UBC Objectives: Surgical + Procedural Skills & Procedures: I&D, wound care, suturing, biopsy, cryo, cautery, skin scraping/paring, subungual hematoma + paronychia drainage, toenail excision, foreign body removal, local anesthesia
By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
While in clerkship, and so far in residency, I have had the opportunity to perform minor surgical procedures and wound closures on multiple occasions. My reference of choice is Procedures Consult.
Abscess Incision & Drainage
An abscess is a walled off collection of pus, relatively impenetrable by antibiotics floating in the bloodstream. For this reason, to treat it, it often needs to be incised and drained, to remove the bulk of the gunk and allow the body to heal the remainder. If the abscess is located in the dermis, the layer of the skin just deep to the superficial skin layer (aka epidermis), this is typically an in-office procedure that can be done in any general practitioner's office. In a purulent skin abscess, the causative agent is usually MRSA (methicillin-resistant Staphylococcus aureus), though in patients who are immunocompromised it is possible that there are other microbial culprits. Consider taking a culture of the abscess fluid in unusual circumstances.
After the procedure is done, the patient should be advised to watch for, and seek medical attention, if any of the following signs develop:
To debride a wound means to remove dead tissue and foreign material from it. It is an important aspect of proper wound care to prevent infection, restore function, and improve cosmesis. All wounds must be examined for the need for debridement; depending on the history and physical exam, this need can be not at all or extremely compelling, with higher suspicion if wounds have a more traumatic or dirty mechanism of injury.
Skin is made up of 3 layers: the epidermis, the dermis, and the subcutaneous tissue. Below the subcutaneous tissue lie the fascia, bones, muscles, tendons, etc. This is a diagram from Procedures Consult showing the different layers of the skin, and a very well clean wound that has either already been debrided or that appears as though it doesn't need any debriding.
Insertion of sutures; simple, mattress, and subcuticular
Sutures are the most common way of closing wounds, and the closest I'll ever get to being a good housewife. Before beginning to suture, proper wound debridement needs to be done (as above). We suture skin to restore it's function and improve cosmesis (less scar tissue compared to healing by secondary intent). We do not suture skin closed if there is significant risk for contamination, because this increases the risk of infection, but usually this can be mitigated by good debridement.
Anatomy of wound healing, completed quoted here from Procedures Consult because I don't like to make my life harder than it needs to be:
Laceration repair; suture and gluing
There are some situations in which a laceration can instead be repaired with a tissue adhesive (aka, skin superglue). When this is a feasible option and there are no contraindications, this can make closing a wound a super easy task, and it also typically means less scar formation. It is also pain-free and super cheap. Pretty much, when it can do the job, it is to everyone's advantage to use it over other methods of wound closure.
So, when can we do this already? UpToDate recommends it for lacerations that are clean, that can be well-approximated, that are under low tension, and that are under 4-5 cm in length. It is particularly useful for fragile skin that cannot be sutured easily, common in the elderly patient. In wounds that are under too much tension such that the wound could dehisce using adhesive alone, deep subcutaneous sutures can be employed to relieve tension and allow the adhesive to close the superficial tissue (something to consider in cosmetically important areas).
The contraindications, per UpToDate, of using tissue adhesives for laceration repairs are:
Procedure: The basics of the procedure are similar to the above procedures, in that the following elements must be included: consent, personal protection, patient positioning, wound irrigation +/- debridement, neurovascular examination, and documentation. The procedure itself is extremely simple, easily demonstrated with this UpToDate figure:
Aftercare is very simple. The sealed off laceration does not require a dressing, as it serves as its own water-resistant bandage. If glue gets on non-lacerated skin, it can be wiped off rapidly or if on the skin for greater than 10 seconds, it can be removed with the help of petroleum jelly. It usually peels off as the tissue heals over the next 5-10 days. Just like with placement of sutures, patients should return for medical care if any signs of infection develop, or if there is wound dehiscence. Otherwise, no further followup care is needed. Easy peasy lemon squeezy.
Skin biopsy; shave, punch, and excisional & Excision of dermal lesions, ex: papilloma, nevus, or cyst
Skin biopsy procedures can be useful for for diagnosing and treating various skin lesions. There are various techniques to select from, most commonly being shave, punch, or excisional approaches. The least traumatic method is the shave biopsy, as it only removes tissue protruding above the epidermis, removing epidermis and ideally limited dermis in the process. Naturally, then, this is insufficient for lesions that extend into the dermis, and it is absolutely contraindicated if the lesion being biopsied could possibly by melanoma (in which case the pathologist needs a deep dermal sample). If a shave biopsy won't "cut" it, then there is the option to do a punch biopsy, which is an easy way to gather a deep biopsy/tissue removal. These can remove between 2 and 5 mm in diameter of tissue, based on the size of the punch that is selected. These are great because they are just super easy to perform and if less than 4 mm, and sometimes if less than 5 mm, suturing the site closed is usually unnecessary. If neither of those two options suffices, using a good old-fashioned scalpel to perform an excisional biopsy is always a dependable technique.
Equipment (varies depending on the technique):
Procedure (in general, technique varies depending on specific method): Consent, positioning, clean or sterile technique, personal protection, planning biopsy (ex: for an excisional biopsy, plan to excise parallel to lines of minimal skin tension, outline area to be biopsied), anesthesia, remove tissue, control bleeding +/- suture, wound aftercare (as above).
*Note that the picture under the "Wound debridement" section above is what an excisional biopsy would look like after the tissue has been removed.
Cryotherapy of skin lesions
I debated even including this procedure in this section as a minor surgical procedure, but I opted to include it because it's useful to consider as an alternative strategy to surgical lesion removal, if appropriate for the type of lesion. It is much less invasive, almost always pain-free, and convenient to do in the clinic. It is commonly used instead of surgical biopsy for removal of the following sorts of lesions: warts, molluscum contagiosum, skin tags, papular nevi, and seborrheic keratoses. One of the downsides of this technique is that it can leave scars on people if they have darker skin pigment (but not in fair individuals), and you should think twice about doing it in patients who have chronic infection or who are otherwise immunocompromised because they may have more cryoglobulins floating around in their blood, and through some mechanism, this can lead to greater scar formation. You also want to make sure you're not freezing an area with a high degree of cutaneous nerves (may damage the nerves and lead to a permanent loss in sensation) or in which there is not the greatest source of blood supply to promote good healing (ex: lower legs in a patient with long-standing poorly controlled diabetes mellitus).
Equipment = freezing agent
*Note that for common warts, the combination of patient-applied salicylic acid and physician-applied cryotherapy is standard practice. While this could also be done for genital warts, generally different strategies are employed. Good first-line options include
Electrocautery of skin lesions
Although I've only seen cautery being done in the operating room, this is a modality that can be employed in the office setting. It can be useful to remove moles, with the advantage of better hemostasis and so can be a good option when there is a greater risk of significant bleeding. It is also useful for getting rid of annoying spider veins and telangiectasia.
Procedure: Proper technique will depend in part on knowing how to use the device you will work with. Basic settings range from "cutting," "cutting and coagulating" or "cut and coag," and "coagulation." Basically, there is more hemostasis toward the coagulation setting side, but also more scarring (although if too low for the tissue being worked on, this could lead to less smoothness in the cut, and a more unsightly scar). The intensity of the electricity can also be adjusted to modify the power of the instrument, so it can be tuned for the procedure to be effective while also limiting any excess force. This is a procedure that requires proper training and practice. Preparation before and care after the procedure is much the same as for other lump and bump procedures (see above).
Skin scraping for fungus determination
This wannabe procedure involves a scalpel, so I'd say it "makes the cut." It was also lovely to encounter the description for this simple yet useful procedure in the Canadian Family Physician, the journal I read the most. The article is called, "Microscopic Potassium Hydroxide Preparation" and it was published in 2014 as part of a series called, "The Top Ten Forgotten Diagnostic Procedures," an initiative to teach family medicine residents about useful diagnostic procedures that are on the brink of extinction. Makes sense, I have only seen this procedure being done very rarely despite the multitude of times there's a diagnostic dilemma regarding yeast vs something else. I think the thinking is that empiric treatment with antifungals is of such little harm, it's okay to just give it a go without really knowing. But this can lead to treatment failure, onerous application and cost of antifungal therapies, and a delay in resolving the problem if it is not in fact a fungal infection. Of course, some fungal infections will clinically be very convincing of this, in which case this procedure would not need to be done. But, for those times in which there is diagnostic uncertainty, it makes a lot of sense to me to check a scraping for fungus under the microscope in real-time to inform clinical decision-making. Note that the use of a Wood's lamp is an alternative procedure that can be done before opting to do a scraping.
As always you start with obtaining consent, and then gather equipment, position and drape the patient, and don personal protection. There is no aftercare needed for this procedure, but if the procedure does not reveal evidence of fungal infection, you should send the scrapings for fungal culture in case the sample collected is just not representative. Here is the meat in the middle:
The article provides this photo of a positive finding under the microscope:
Subungual hematoma release
Subungual hematomas aren't a significant concern, at least by themselves, but they can hurt like a B and if large, could suggest a fracture of the underlying bone in the finger or toe. For any significant hematoma, getting an xray before trephination would be the way to go. It's also only really helpful if a patient presents within 48 hours of when it began, as there is no evidence to show that trephination after this time makes a difference at all. Trephination should also not be done by the general practitioner if there are any complicating features, such as signs of infection, extensive nail-bed injury, or evidence of fracture. These patients should extend get a referral to a hand surgeon. Here is an example of a subungual hematoma that could be safely decompressed by the general practitioner, ideally from the distal end of it so as not to risk damage to the lunula (part of the nail bed matrix).
Drainage acute paronychia
The information in this post gets credited to a fabulous Emergency Medicine website called Life in the Fast Lane. Some gold nuggets by the Emergency Medicine Nurse who wrote the post:
Equipment: Whatever you need to perform a digital anesthetic block (procedure to be explained, stay tuned), a scalpel, gauze, saline, a syringe and any associated supplies for irrigation, and a bandage +/- antibiotic ointment.
Procedure: All the usual, and then following:
Now just imagine this was a patient who came to you, and you can do something to make it better right away! Brilliant.
Partial toenail removal; Wedge excision for ingrown toenail
For whatever reason, these are listed as separate procedures under the list of core procedures that I am expected to be able to perform as a family physician, although the latter is really a reason (and probably the most common one) to do a partial toenail removal, so I have lumped them together here. The other common reason would be to clip nails shorter when trying to debride a toenail of onychomycosis (toenail fungus), but in this setting, the procedure is as simple as trimming a nail as short as possible (the part with fungus doesn't have as much sensation, and you basically trim the nail as far back as you can while not causing pain). Another less common reason to trim a nail back is in the setting of trauma and partial traumatic nail avulsion. In this setting, you would want to trim the nail back just until it is not likely to catch (if the nail is oriented in a funny direction).
For all the visual learners:
Removal of foreign body, ex: fish hook, splinter, or glass
If there's something alien that is penetrating your skin, it's best to eject it from the mothership. Foreign bodies can obviously be painful, but they can also pose a serious risk for infection. Naturally, living in Canada means lots of splinter injuries with all the lumberjacks hard at work (:D), but now that I'm out on the West coast, fish hooks are also a thing (and beware of the ones with barbs on the end, tricky little buggers). Being in the downtown East side means I also need to be on the lookout for shattered glass. Okay I'm being lame, but these are three common types of foreign bodies that can inadvertently get under the skin from trauma. This year, I pulled out a piece of tree from a snowboarder who crashed into the bush while carving his way down Cypress mountain. He came into his family doctor's office for this, not the emergency department, so you just honestly never know what might walk in the door.
Really, foreign body removal is part of the process of good wound debridement (see above), so I won't belabour the topic here. It is important to highlight the need to ensure tetanus prophylaxis whenever a wound is penetrated by a foreign object. As well, if a patient complains that a wound feels as though something is in it, heed that sensation; if nothing can be seen, a plain xray can be your friend - even glass is radiopaque as long as the shards are larger than 2 mm. And while xrays are friendly, anesthesia is even friendlier - a digital ring block can make all the difference to ensure proper wound exploration under proper lighting +/- magnification. Irrigating with drinkable tap water is just as good as saline, and better in the possible dirty wound (per the mechanism of injury on history) because the pressure with saline syringe irrigation can further embed foreign material.
...Sorta worth a splinter or two.
Pare skin callus
Calluses and corns and common benign skin thickenings on the feet that are physiologic adaptations increased pressure to that region of the body. Often, they arise because or poor-fitting shoes, abnormal gait, or underlying bony problems (commonly neuropathic joints as a complication of long-standing and poorly controlled diabetes). Sometimes corns in particular can be a bit difficult on first glance to differentiate from a wart, but you'll notice that warts obscure the natural skin lines ("toe prints" if you will), while these lines tend to be more pronounced with purely hyperkeratotic skin. After paring them down, you'll also see an absence of the dark specks normally within the central area of a wart (these are punctate capillary thromboses; the wart virus basically causes small clots in the surrounding capillaries).
Infiltration of local anesthetic
Finally, I will now go over the basics of how to provide local anesthesia. The only absolute contraindication to giving a patient local anesthesia is a history of previous allergic reaction to anesthetic, which is extremely rare, but you should always ask, just as when prescribing any other medication.
*Although highly unlikely, it may be useful to know that phentolamine is an antidote and can be used to reverse the effects of lidocaine if ischemic complications develop. This would be extremely rare. I have never heard of this being done, and have never even been taught that this is something I should know by any attending physicians with whom I have trained to give local anesthesia.
Digital block in finger or toe
Performing a digital block is an alternative method of providing local anesthesia when performing procedures on fingers or toes. It is a method of providing sufficient anesthesia to an area that is limited for space to deposit enough anesthetic agent for sufficient freezing. The procedure and equipment needed is much the same as for providing standard local anesthesia.
The technique for performing a digital ring block using the two-injection dorsal technique is as follows:
Incise and drain thrombosed external hemorrhoid
Left until the "bottom" of this post, this is a variation of the I&D for abscesses, only it is an I&D for a blood clot rather than a collection of pus. Hemorrhoids are common, and thrombosed external hemorrhoids (painful, tender, swollen, bluish lump at the anal orifice) can be a source of significant pain, although are easily "rectified" with an in-office I&D procedure, usually done within 48 hours of onset of pain because after this the pain starts to subside anyway. In the same "vein," perianal skin tags can also be excised, although this is mostly done for cosmetic purposes as they are asymptomatic (on occasion patients may experience pruritus from them). Patients should generally be advised that this procedure, like any, is not without risk, and so is generally not recommended.