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CHAPTER6 Minorsurgery
Basictechniques
• Never attempt a procedure if you are unsure about it— know the
boundaries of your experience and abilities.
Localanaesthesia
• 0.5– 1% lidocaine is the most commonly used preparation due to its
rapid onset of action and relatively short duration of eect
• Adrenaline/ epinephrine (1:200,000) added to local anaesthetic
epinephrine in areas supplied by end arteries (i.e. ngers, toes, penis,
ear, nose), as vasoconstriction may cause ischaemia
• Safe maximum dose of lidocaine in adults is 20mL of 1% solution (less in
the elderly/ children)— overdose causes ts or cardiac arrhythmia
Administering localanaesthetic
• Pre- warn patients local anaesthetic stings before numbing and that
they will still be able to feel pressure— but not pain. If pain is felt, more
anaesthetic is needed
• Clean the skin, insert a small needle intradermally, and raise a small
bleb before infusing more deeply; always pull back on the syringe
plunger before injecting to check that you are not in a blood vessel—
IVadministration can result in ts and cardiac arrhythmia
• Anaesthetic must be infused all around the excision site. This may
require several needle insertions— try to do this through an already
numb area to d discomfort for the patient; allow the anaesthetic to take
eect (2– 5min) before proceeding
Further information
Primary Care Dermatology Society Skin surgery— local anaesthetic.
Mwww.pcds.org.uk/ p/ skin- surgery- local- anaesthetic
Suturing Various techniques for suturing and knot tying can be used (e.g.
interrupted, continuous, mattress, subcuticular). Suture and needle types—
E p. 136.
• Make a careful record of number of sutures and when they should be
removed; usually, sutures need removal after 3– 5d on the face, 7– 14d
on the back and legs, and 5– 7d elsewhere
• Skin closure strips can be used instead of or in addition to sutures in
some circumstances
Cautery Chemical (silver nitrate) or electrocautery are used alone, or in
combination with other methods (e.g. curettage), to secure haemostasis or
destroy tissue. Suitable conditions:nose bleeds, telangiectasia.
• Do not use electrical cautery for patients with a cardiac pacemaker.
Implants Subcutaneous implants are prescribed for several conditions
(e.g. prostate cancer). Most implants come pre- packaged with an insertion
cannula and information leaet— always read and follow the instructions if
administering a new product and ensure position of implant and timing of
administration is correct.
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BASICTECHNIQUES
Contraceptive implants E p. 739
Joint and soft tissueinjection Steroids have potent anti- inammatory
eects and can dramatically improve certain musculoskeletal problems. Specic
joint injections E p. 138. Most joint injections are straightforward and can be
undertaken in general practice. Hospital rheumatology departments usually
have a joint injection clinic and often allow GPs to watch to gain experience.
Generalrules
• Always use an aseptic, no- touch technique
• Never inject into the substance of a tendon— this may cause rupture (in
tenosynovitis steroid is injected into the tendon sheath)
• Injections should not require pressure on the syringe plunger— if so, the
needle is not correctly located (tennis elbow is an exception)
• Undertake as few injections as possible to settle the problem— often 1
is sucient; if no improvement after 2, reconsider the diagnosis
• Do no more than 1– 2 injections/ patient/ appointment and no more
than 3– 4 injections/ y in any single joint at intervals ≥3mo— more than
this i risk of systemic absorption and joint damage
• Do not inject if Allergy to steroid or LA, local skin sepsis (e.g. cellulitis),
any possibility of fracture or joint infection, prosthetic joint, severe joint
destruction or unstable coagulopathy. If on warfarin, ensure INR <4.5
prior to the procedure; joint injections are safe for patients taking direct
oral anticoagulants, e.g. rivaroxaban— avoid injecting during peak drug activity i.e. for 2– 4h after drug administration
Preparation fortheprocedure
• Take a history, examine, and have a clear diagnosis before injecting
• Gather needles, syringes, a sterile container if needed (for sending
aspirated uid), steroid, local anaesthetic, skin preparation uid (e.g.
chlorhexidine or surgical spirit), cotton wool, and adhesive spot plaster
• Make sure the patient is comfortable and has given informed consent
• The joint should be rested for 2– 5d after injection
Steroid preparations (i order of potency) hydrocortisone acetate,
methylprednisolone acetate, triamcinolone acetonide.
Local anaesthetic (LA) (e.g. lidocaine 1%) can be injected rst or mixed with
the steroid for some injections— LA eect occurs immediately and lasts
2– 4h. The patient may then experience some return of symptoms (pain)
before the steroid takes eect— warn the patient.
Follow- up
• Some injections are painful at administration— this is normal for tennis
elbow and plantar fasciitis
• Steroid injection may cause temporary ushing (mainly in ♀), menstrual
irregularity, and worsening of blood sugar control in patients with DM
• Severe or increasing pain ~48h after injection may indicate sepsis—
advise the patient to seek medical attention urgently if this occurs
• If steroid is injected close to the skin surface (as in tennis elbow), skin
dimpling and pigment loss can occur— warn the patient
Further information
Silver T (2018) Joint and Soft Tissue Injection:Injecting with Condence
(6thedn). Boca Raton, FL:CRC Press. ISBN 9781138604179.
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CHAPTER6 Minorsurgery
Removal ofskinlesions
• Rules forremoving skinlesions
• Ensure that you have had formal training in all techniques required—
learning by experience is much better than from a book. There are
many courses available
• Only remove benign lesions (unless you have specic training to excise
low- risk basal cell carcinomas)— refer suspicious lesions to a specialist
for expert management
• Only remove lesions that you are condent you can cope with. Take
special care with children, and lesions on the face or lip margin— the
scar may be very noticeable
• Send all excised lesions for histology— place in formalin; label carefully
Surgical excision ofskinlesions Gain written consent— ensure that
you have warned the patient about the likely size of the scar and the possibility of keloid (especially if the lesion is on a risk area, e.g. upper back and
chest). Work out the direction of the skin contour lines, clean and anaesthetize the area (E p. 134). An elliptical incision ~3× as long as it is wide is
suitable for most lesions. Place the incision in the skin contour lines if possible (marking the incision line can be helpful). Cut through the skin at right
angles to the surface with a smooth sweep of the blade. Use a skin hook
to lift the skin from one end of the ellipse. Use the scalpel blade to remove
the skin from the subcutaneous fat. Save the excised specimen for histology.
Close the wound by carefully opposing the edges (slightly everted) using
non- absorbable sutures. Avoid tension in the sutures and knot securely.
Large wounds may benet from the use of deep absorbable sutures to reduce skin tension. Suture types— Box 6.1
Box 6.1 Suturetypes
Suturematerial
• Absorbable e.g. catgut, Dexon, Vicryl— used to stitch deep layers to
help d tension on the skin sutures
• Non- absorbable e.g. silk, Prolene, nylon— used for closure of skin
wounds after minor surgery
Needle type Straight, curved, cutting, or round- bodied. Surgical site and
personal preference dictate which to use— a cutting needle is usually
used for skin.
Suture thickness (gauge) Indicated by a number (10/ 0 is ne and 2/ 0
thick). For skin closure:6/ 0 or 5/ 0 is usually used for the face, 3/ 0 on
legs and back, and 4/ 0 elsewhere.
Curettage Useful for seborrhoeic keratoses, pyogenic granuloma,
or single viral warts. Not suitable for naevi. Use only if the diagnosis is
certain— scrapings can be sent for histology but architecture of the lesion
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REMOVAL OFSKINLESIONS
is lost. Clean the area, then numb with local anaesthetic Remove the lesion
with gentle scooping movements using a curette spoon. Finally cauterize
the base of the lesion.
Punchbiopsy Allows histological examination of the skin for diagnostic
purposes. Do not biopsy pigmented lesions in primary care. Choose biopsy
site to include the skin changes of concern and minimize cosmetic impact.
Clean and anaesthetize the area. Sterile, disposable punch biopsy tools 2–
4mm diameter are suitable for use in primary care. Using aseptic technique,
hold the tool perpendicular to the skin and gently rotate until a ‘give’ is felt
as the tool enters the subcutaneous fat. Withdraw the punch and remove
the specimen with forceps to send for histology. If needed, close the skin
with skin closure strips or a suture.
Shaveexcision Suitable for removal of supercial benign skin lesions in
primary care, e.g. prominent moles or skin tags. Clean and anaesthetize the
area. Using aseptic technique, remove the lesion using a razor blade, scalpel,
or shave excision instrument skimmed parallel to and on the surface of the
skin. No skin closure is required. The excision site heals with a scab over
several days. Send excised tissue for histology.
Cryotherapy Liquid nitrogen can be used to treat viral warts, and seb-
orrhoeic and solar keratosis. Local arrangements for delivery of liquid nitrogen dier— often a clinic session to treat all suitable lesions at the same
time is helpful. If diagnosis is uncertain excise the lesion, or take a biopsy
prior to freezing. Acotton wool bud or nitrogen spray gun can be used to
apply liquid nitrogen for approximately 10 seconds until a thin frozen halo
appears at the base of the lesion. Ablister forms <24h after treatment—
the lesion then falls o with the blister. Repeat treatment may be needed
after ≥4wk. Side eects include pain, failure to remove the lesion, skin
hypopigmentation, and ulceration of lower leg lesions (especially in elderly
patients).
Furtherinformation
Primary Care DermatologySociety Skin surgery series:
• Curettage M www.pcds.org.uk/ p/ skin- surgery- curettage
• Elliptical excision M www.pcds.org.uk/ p/ skin- surgery- elliptical- excision
• Epidermoid (sebaceous) cyst removal M www.pcds.org.uk/ p/
skin- surgery- epidermoid- sebaceous- cyst- removal
• Lipoma M www.pcds.org.uk/ p/ skin- surgery- lipoma
• Mattress suturing M www.pcds.org.uk/ p/ skin- surgery- mattress- suturing
• Punch biopsy M www.pcds.org.uk/ p/ skin- surgery- punch- biopsy
• Shave excision M www.pcds.org.uk/ p/ skin- surgery- shave- excision
• Subcutaneous suturing M www.pcds.org.uk/ p/
skin- surgery- subcutanous- suturing
• Subcuticular suturing M www.pcds.org.uk/ p/
skin- surgery- subcuticular- suturing
• Surface suturing M www.pcds.org.uk/ p/ skin- surgery- surface- suturing
• Suture knot M www.pcds.org.uk/ p/ skin- surgery- suture- knot
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(a) (b)
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CHAPTER6 Minorsurgery
Commonly performedinjections
Theknee Joint eusions are common (e.g. trauma, ligament strains, OA,
RA, gout). Aspirated uid should be clear/ slightly yellow and not purulent.
Send any uid aspirated for analysis. Aspiration of uid can:
• Help make a diagnosis, e.g. gout
• Be a therapeutic procedure— draining a tense eusion can relieve pain
• Precede administration of steroids, e.g. RA are
• Any sign of infection within the joint prohibits steroid use.
Technique foraspiration and jointinjection
• Lie the patient on couch with knee slightly bent— place a pillow under
the knee as this relaxes the muscles
• Palpate the joint space under the lateral or medial edge of the patella
and inject/ aspirate just below the superior border of the patella with
the needle horizontal— Figure 6.1
• Use a green (21- gauge) needle
• If aspirating and then injecting steroids, maintain the needle in position
and swap the syringe
• Normal doses of steroid are triamcinolone acetonide 40mg or
methylprednisolone acetate 40mg
• In pre- patellar bursitis, aspiration and injection of hydrocortisone 25mg
into the bursa can help settle inammation
Figure6.1 Knee joint injection or aspiration
Trochantericbursitis Tender area overlying the greater trochanter of
the hip. Steroid injection can alleviate pain.
Technique
• Lie the patient on one side with both hips and knees bent, so that the
painful hip is uppermost; draw up triamcinolone acetonide 40mg and
5mL of 1% lidocaine
• Ask the patient to show you the most tender spot and mark it; then
clean the skin and insert the needle (green, 21-gauge) perpendicular to
the skin at the marked spot
injection point
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COMMONLY PERFORMEDINJECTIONS
• Insert as far as the needle allows or to bone, withdraw 3– 5mm and
inject 1mL; without taking the needle out, move the needle in a circle
injecting 1mL in each direction— try to inject all the tender area
Plantarfasciitis Painful area in the middle of the heel pad. Steroid in-
jection (e.g. triamcinolone acetonide 10– 40mg) into the most tender spot
can help. Injection hurts, so advise analgesia. Mixing lidocaine 1% with the
steroid can help.
Technique Two methods are commonly used (Figure 6.2):
• Injection through the tough skin of the sole (more accurate), or
• Lateral approach (less painful)
Rest the foot for several days afterwards and use an in- shoe heel pad.
Rupture of the plantar fascia is a rare complication.
Plantar
fascia
Alternative
Figure6.2 Injection of plantar fasciitis
Tenosynovitis Causes pain and stiness in the line of the tendon and
crepitus over the aected tendon. The most common site is the base of the
thumb (de Quervain’s tenosynovitis). Injecting steroid and LA (e.g. hydrocortisone 25mg + 1mL 1% lidocaine) into the space between tendon and
sheath can help.
Technique
• Insert the needle along the line of the tendon just distal to the point of
maximum tenderness
• Advance the needle proximally into the tendon (felt as a resistance)
and then slowly withdraw until the resistance disappears. The tip of the
needle is then in the tendon sheath
• It is now safe to inject— the tendon sheath may swell
• Advise the patient to rest the aected area for several days and avoid
the precipitating activity
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n
Flexor digitorum
supercialis
Flexor tendon
sheath
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CHAPTER6 Minorsurgery
Carpal tunnelsyndrome E p. 460
Technique
• Sit the patient with hand resting on a rm surface, palm up. Palmaris
longus tendon can be seen by wrist exion against resistance
• Insert the needle at the distal skin crease, at 45° to the horizontal,
pointing towards the ngers, just ulnar (little nger) side of the palmaris
tendon (Figure 6.3). If palmaris longus is absent (10%), inject between
exor digitorum supercialis and exor carpi radialis tendons
• Use a blue (23- gauge) needle. Advance it to half its length. If sudden
pain in the ngers, you have hit the median nerve— withdraw the needle
and reposition it
• Inject steroid, e.g. 10mg triamcinolone acetonide— if there is resistance
the needle is not in the right place. Do not use LA as it causes nger
numbness
• Rest the hand for several days afterwards
Palmaris longus tendo
Flexor carpi radialis
Flexor retinaculum
Figure6.3 Injection of the carpal tunnel
Elbow
Technique fortennis/ golfer’s elbowinjection
• Sit the patient with the elbow exed to 90°
• Palpate the most tender spot and insert the needle into that spot
• Inject 0.1– 0.2mL of steroid (e.g. hydrocortisone 25mg/ mL). There will
be resistance. Without taking the needle out, move the needle in a fan
shape injecting small amounts of steroid— try to inject all the tender
area. Warn about the possibility of skin dimpling or pigment loss
• Pain of injection may last 48h— warn the patient in advance, advise
resting the arm and analgesia
For tennis elbow, steroid injection has signicantly better eects in
the short term (~6wk) but poorer outcome long- term compared to
physiotherapyR.
(c)
Acromion
Coracoid process
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COMMONLY PERFORMEDINJECTIONS
Shoulder injection May help rotator cu problems, impingement,
frozen shoulder, subacromial bursitis, and RA. Use an anterior or posterior approach for shoulder joint injection and lateral approach for the
subacromial space.
Technique:anteriorapproach
• Sit the patient with the arm relaxed at the side, slightly externally rotate
• Insert the needle (green, 21-gauge) horizontally into the gap between
the head of humerus and the coracoid process, ensuring the needle
is lateral to the coracoid process— Figure6.4(a). Insert the needle for
most of its length to reach the joint space
• Inject 1mL steroid, e.g. triamcinolone acetonide 40mg + 5mL 1%
lidocaine
• There should be no/ little resistance to injection— if there is, the needle
is wrongly positioned
Technique: lateral approach to subacromial space Sit the patient with arm
hanging down to the side. Palpate the posterolateral corner of the acromion.
Insert the needle horizontally into the space under the acromion—
Figure6.4(b). Inject 40mg triamcinolone acetonide + 5mL 1% lidocaine.
Subacromial bursa
(b)
Long head of
biceps synovial
sheath
Medial border
of deltoid
Lateral end of
clavicle
(a)
141
Figure6.4 Shoulder joint injection
Technique:AC joint injection Can help the pain of OA.
• Palpate the joint space— insert the needle anteriorly or superiorly— if
you go too far, you may enter the shoulder joint— Figure6.4(c)
• Only 0.2– 0.5mL of steroid can be injected as small joint space. Use a
blue (23- gauge) needle and do not add LA
• Warn patients that pain may worsen for up to 48h after injection before it improves.
Patient information
Arthritis Research UK Patient information:‘Local steroid injections’.
F0800 5200 520 M www.arthritisresearchuk.org
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Chapter7
Healthyliving
Prevention and screening 144
Prevention of travel- related illness 146
Diet 148
Obesity 152
Exercise 154
Smoking 156
Alcohol 158
Management of alcohol misuse 160
Assessment of drugs misuse 162
Management of drugs misuse 166
Insomnia 168
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