Preparations Prior to Surgery

Preparations Prior to SurgeryTable 6. Common inauspicious reactions during administration of local anaesthetics and their management 34 thump 2 utilitarian guide line of descents time administering local anesthesia 33Box 3 local anaesthesia in special situations 30,31,32Intradermal test dose is through to check for hypersensitivity to local anaesthesia. 0.5 to 1.0mL of test solution undiluted and containing no adrenaline is injected subcutaneously. The test is negative if no reaction occurs during the 30 minutes adjacent the injection. However, regular subr offine of test dose remains controversial as every(prenominal)ergy to LA has been found to be exceptionally low (0.7%). (43) somewhat(prenominal) oddballs of reported allergy to LA have been attributed to sensitivity to preservatives used in the solution, such as sodium metabisulfite, rather than an allergy to the anaesthetic component itself. (33)In some dermatologic agencys, often uncomplainings atomic number 18 av erse to use of local injections for anaesthesia while use of topical anaesthesia whitethorn not be sufficient to slake their discomfort.. In these patients, vibration potty be used to reduce the pain of injections. It may even be used as a substitute for anaesthesia by pharmacologic agents in certain dermatological procedures desire botulinum toxin injection, laser therapy, cauterization of facial warts, incision and drainage of abcesses, etc.Their action is defined by the gate control theory of pain. The A - nerve fibers which transmit mechanoreceptor signals like touch, vibration, stimulate the inhibitory interneurons in the spinal cord which in second reduce the amount of pain signal l transmitted by A- and C fibers from thes kin. Thus, counter stimulation, akin to stroking or pinching the trim, offer alleviate pain sensation. (44)Cold temperature in the form of ice packs or ethyl group chloride sprays has also been used for these purposes (cryo analgesia)The accountabil ity of a dermatosurgeon towards his patient who requires operating theatre, not entirely lies in performing the procedure well but, actually begins from collecting all the medical information about him, counselling him and chalking out a think that has his best interest in mind.(45)It is prerogative to work up the patient completely beforehand he is taken up for cognitive process to bend all adverse events.The workup should include a complete autobiography and clinical examination, relevant investigations, counseling, and documentation. 46A detailed history of co-morbidities and concomitant medicinal drug is taken. Concurrent conditions like diabetes mellitus, cardiovascular disease, infectious diseases should be inquired upon. History regarding expel tendencies should also be taken. Wound healing is delayed in diabetes out-of-pocket to associated vasculopathy, decrease in the peripheral blood supply and increased lay on the line of infections, hence the blood sugar leve ls should be monitored and brought under control before surgery. Also, these patient should be given a broad spectrum antibiotic prophylactically. 47,48For patients with cardiovascular disease, a sublingual nitroglycerin is kept handy in case of a possible precipitation of angina. Adrenaline maybe avoided in cases of hypertension or peripheral vascular disease.49, 50 Electrooperative procedures ar avoided in patients with pacemakers.51In pregnancy, local anaesthesia is used without adrenaline to avoid chances of uterine arterial blood vessel spasm. Safer antibiotics be prescribed and salicylates and NASIDS are avoided as they can interfere with the return of the foetus. 39A detailed drug history is imperative as certain drugs meddle with the haemostatic, inflammatory and wound healing processes. Hence, these drugs shoot to be stopped for a certain period, after the advice of the physician. 52History of allergy to any drugs, ingested or applied, allergy to adhesive tapes, histor y of keloid formation, scarring tendencies should be asked in detail. Box 4 gives the important drugs to be taken into consideration while proviso a surgeryBox 4 Important drug history that need to be asked for prior to a dermatosurgeryLocal examination of the send to be operated should be done to check the condition of the overlying skin, and to prescript out any infection. The dermatosurgeon should have a thorough knowledge of the cardinal vital structures so as to avoid any trauma while performing the procedure. Thorough examination also provides signs of keloidal tendency, for e.g in pre existing scars.If the lesion to be operated upon is suspected to be premalignant or malignant, then it is prudent to perform a biopsy first to confirm the findings on histopathology and then decide the next line of treatment.To thwart post operative infections check for damaged ,infected skin, diabetes, debilitation, hypogammaglobulinaemia, severe malnutrition, coherent term antibiotic the rapy, corticosteroids, immunocompromised states, emotional stress, poor hygiene, etc. instruction is an important constituent of the management of any dermatosurgical procedure. The problems and needs of the patient are assessed, and all the options are put forward for him to decide. Patients need to have a thorough knowledge of the procedure, the complications, the follow-up, post-operative care, outcome of the surgery, essential be given to the patient. either queries about the procedures duly addressed. Expected results should be explained. Any unrea enumerateic expectations need to be put to rest then and there. Patients with unrealistic expectations should be counselled against the procedureBaseline investigations that should be done before a dermatosurgical procedure are listed in box 5. It is, however, not necessary to do the whole list of investigation prior to a minor dermatosurgical procedure. The investigations that need to be carried out should be based on the results of the clinical examination.Box 5 Investigations to be carried out prior to a dermatosurgical procedure.Complete documentation of the case is a very important part of preoperative preparation. All the relevant clinical notes, photographs should be kept as record for medicolegal reasons. A compose informed consent is of paramount importance. Drugs that are prescribed before a major dermatosurgery are mentioned in box 6. However, this is again not mandate and is based on the patient profile, nature of the surgery and surgeons experienceBox 6 Preoperative drugs prior to a dermatosurgeryDermatosurgeon must undertake strict safety measures in show to prevent wild infections. As mentioned earlier hand hygiene plays a major enjoyment in preventing iatrogenic infections. Right technique of hand washing reduces contaminant and prevents the transfer of infection from one man to another.Personal protective equipment (PPE) is a protective gear that comprises of mask, gloves, gowns, goggle s and shoes. A high quality PPE is the precisely barricade between the surgeon and the infectious material. 23.All the instruments required for the surgery should be kept ready in the instruments trolley car before the surgery. The surgical trolley should also have surgical drapes, adequate amount of veiling pads, cotton swabs and surgical disinfectants in place. The order of keeping the instruments on the trolley should be predetermined and kept uniform for a particular surgery so as to maintain a smooth flow of operation.Also, the indispensability tray should always be ready in order to deal with any critical situation.The field of view to be operated upon has to be cleaned and shaved if required. Disinfection of the surgical area is done by using disinfectants like povidone iodine and methylated spirit. The cleanup position of the area should always be started from the centre extending into the periphery in order to ensure minimum possible risk of contamination of the site o f operation. infertile drapes must then be used to isolate the surgical area. deletion means cutting out a tissue, an organ or a tumour. The ellipse (fusiform excision) is the mainstay and workhorse of cutaneous excisional surgery and reconstructive surgery.Proper homework of the incision should be done before the surgery is started. This results in a least noticeable and well healed scar.A well be after incision line should lean parallel to the favourable lines of closure i.e. the relaxed skin tension lines (RSTL) or the lines of minimal skin tension (natural skin creases or wrinkles). Illustration 31.4 These lines can be made obvious by pinching the skin in all direction. They can also be judged by asking the patient to smile or grimace.57,58 The incision line so planned not only makes the scar inconspicuous but it heals faster and has a high tensile strength. Lines of maximal extensibility are typically at right angles to the RSTL. These lines are important when performing a flap grafting from an adjacent area. Incisions can also be taken along the wrinkle lines, skin folds. another(prenominal) option is to make a circular incision and wait for some time to allow it to turn into an ovate class after undermining the edges. forward final closure the oval shape can be converted into an ellipse. Always respect the cosmetic units of the face. The cosmetic units of the face are chin, perioral region, cheek, periorbital region, nose, forehead, glabella, and temple. Scars limit to single cosmetic unit hide well, than the scar crossing binary units.58 Illustration 31.5Nature of the lesion removed is also an important factor. For benign lesions the surround principle skin excised is minimal, on the other hand for malignant lesion two factors are very important, complete excision of the tumour and to include sufficient surrounding normal looking tissue in the excision to prevent recurrences. ( 59,60)The shape of the lesion also plays important role in decid ing the excision line. For oval shaped lesion the long axis of the incision line must run parallel the long axis of the lesion. This will shorten the length of the scar.61.When pickings incisions near lips or eyes, functional considerations are very important to prevent lip retraction and ectropion respectively.