Skin biopsy techniques

Skin biopsy techniques 

 

Types 

1. Shave biopsy 

2. Punch biopsy

3. Incisional biopsy

4. Excisional biopsy  

 Steps common to all minor procedures

 

SHAVE BIOPSY 

1. Stabilize the lesion between the thumb and forefinger in a direction perpendicular to Resting skin tension lines

2. A vertical cut is put at the periphery of the lesion using 11 or 15 No. scalpel blade attached to No. 3 BP handle

3. Blade is held parallel to the skin surface and then passed through the lesion through the cut that is already made at the periphery 

4. The blade is advanced through the lesion by a smooth sweeping stroke rather than a sawing motion while grasping the lesion with forceps

5. Hemostasis is achieved by firm pressure or with the chemicals
   

6. The procedure can also be performed by using halved razor blade or curved scissors.

7. Antibiotic cream applied and a gauze dressing is given

 

 

PUNCH BIOPSY  

1. Routinely a 3-4 mm punch is chosen

2. Traction given in a direction perpendicular to long axis of resting skin tension lines  

3. Punch is held vertically, and a steady pressure is applied

4. Punch is rotated in a clockwise manner till the punch reaches the subcutis. At this stage there is feeling of give away

5. Punch is withdrawn

6. Tissue cast is lifted with fine forceps while avoiding crushing and damage to epidermis. It is then cut at the base with scalpel blade as shown in figure

7. On releasing the tension, the circular biopsy defect relaxes into ellipse

8. The wound may be sutured for better healing with interrupted sutures for cosmetically important regions, but otherwise only dressing is generally done

 

PRACTICAL TIPS AND TRICKS: 

 Approximately, ½ of the blade of skin punch should be visible when it reaches the subcutis. 

 

  

INCISIONAL BIOPSY 

1. In this type, biopsy is performed from active edge of the lesion in a wedge shape including the normal skin. Alternatively, it can be performed by using biopsy punches of size 5 mm and above 

2. Area is kept taut and scalpel with No. 15 blade is held like a pencil

3. Begin the incision at the apex holding the blade perpendicular to the skin 

4. As the incision progresses blade is angled to 45° to cut the tissue with the belly of the blade

5. At the end of the incision again the scalpel is lifted vertically to prevent the excision from extending beyond the end point 

6. Wedge of tissue separated from underlying tissue with scalpel or dissecting forceps

7. Interrupted suture taken for larger and deeper defects suturing is done in two layers

 

 

EXCISIONAL BIOPSY Different techniques are been used to excise lumps from different parts of the body and different types of the lump. Separate document for the same has been sent.

 

Written by our guest authors Mohit Jain and Kritika Bhatia

Illustration by Devi Bavishi
#Ae(ONE)INTERN

 

Skin tag removal

 

Acrochordon (Skin tag) removal

METHODS

• Cryotherapy

• Surgical removal (Usually done)

• Electrosurgery

SURGICAL EXCISION

 

REQUIREMENTS: 

Written informed consent, 2 ml syringe filled with local anesthetic and attached to a needle, scissors, toothed forceps, sterile gauze pieces, ethanol

PROCEDURE:

• Area over and surrounding the lesion is cleaned with ethanol

• Local anaesthesia with 2% Lignocaine with or without adrenaline is given

• Acrochordon is held with the forceps and the base is cut using a snip scissor or blade

• After achieving hemostasis (by applying pressure or aluminium chloride), antibiotic ointment applied

  
  
  
   
  
  Written by our guest author Kritika Bhatia
  

  Illustration by Devi Bavishi
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Preoperative patient preparation

Pre-op washing: 

Using soap to physically remove dirt and remove transient microorganisms from the surface of the skin.

A regular soap is enough for cleaning, patient is not required to use costly antiseptic soaps.

Pre-op hair removal: Hair should be clipped not shaved

INTRA-OP SKIN DISINFECTION:

SCRUB AND PAINT

Things to keep in mind while cleaning:

• Clean the areas in a circular motion going outside from the center

• Always prep from "clean to dirty" areas, starting with the incision site

• Pour the antiseptic on the gauze

• After contact with peripheral or contaminated areas of the prep site, discard the sponge/applicator and use new sponge/gauze to clean new sites (e.g. cleaning the umbilicus, inside the vagina)

• Do not "back track" over an area that has already been prepped with the same prep sponge/gauze

• Prepped area should extend to an area large enough to accommodate:

1) The potential extension of the incision 

2) The potential for additional incisions 

3) All potential drain sites

 

 

DRAPING:

The purpose of draping is to eliminate the passage of microorganisms between nonsterile and sterile areas.

(1) Handle the drapes as little as possible

(2) Hold the drapes high enough to avoid touching nonsterile area but avoid touching the overhead light

(3) Hold the drape high until it is directly over the proper area, then drop (open fingers and release sheet) it down where it is to remain. NEVER ADJUST ANY DRAPE. If the drape is incorrectly placed, leave it in place and place another drape over it

(4) Do not let the gloved hand touch the skin of the patient

(5) If a hole is found in a drape after it is laid down, cover the hole with another drape or discard the entire drape

(6) If the end of a drape falls below waist level,or gets contaminated,do not handle it further. Drop it and use another drape. If in doubt about sterility, discard the drape

Written by our guest author Swapnil Bhagat

Illustrations by Anveshi Nayan
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Slab application

 Plaster of Paris Slab Application

 

BELOW ELBOW BACKSLAB 

The plaster slab extends from a point about 5 cm below the top of the olecranon to the level just proximal to the knuckles in the dorsum of the hand and the distal crease in the palmar aspect. 

• Apply a layer of dry gauze bandage around the forearm to just below the elbow

 

 

• 6-8 layers of 15cm width PoP is unrolled to the appropriate length as measured above

 

• Hold the folded plaster slab in the folded position and immerse it in water for about 5 seconds (until bubbles stop)

• Take it out of the water and gently squeeze out the excess water

• Apply the slab on the dorsal aspect of the forearm and the dorsolateral aspect of the wrist and rub it smooth so that the lower end of the radius is gently gripped by the slab

• Take a roll of 10 cm broad gauze bandage, soak it well in water and squeeze out the excess water

• Apply 10cm diameter wet bandage around the forearm, starting from the distal end to fix the slab

 

• The forearm is held with the elbow in a 90° flexed and the wrist in the position of function of 25° dorsiflexion

• The fingers should be free to move fully at the metacarpophalangeal joints and check capillary refill at the end of the procedure

VIDEO LINK: https://youtu.be/pGxxKH4wSqs 

**Stocky nets may not available in hospital supply

BELOW KNEE BACKSLAB  

• The below knee plaster slab is applied in cases of injuries to the ankle and foot. 

• Extends from the level of the tibial tuberosity, posteriorly down the calf, ankle, heel and sole to the toes. Cover the area with a soft cotton roll

• Keep the foot in neutral position (ankle MUST be kept at 90°) 

• The rest of the procedure is similar to 'Below Elbow Slab'

VIDEO LINK:

https://www.youtube.com/watch?v=NdcD8qqSil8 

ABOVE ELBOW BACKSLAB 

• The patient's forearm is held in mid prone position with the elbow in 90° flexed position

 

• A layer of soft cotton roll is applied around the elbow

• A layer of dry gauze bandage is applied from the hand up to the middle of the arm

• A slab equal to the length extending from the middle of the upper arm to the point just proximal to the knuckles in the dorsum of the hand is prepared dry as described in 'Below Elbow Backslab' using a 15 cms PoP roll

• The slab is applied along the posterior aspect of the arm, elbow and the forearm down to the knuckles

• Make slits (about 5 cm) across the slab at the inner and outer aspects of the elbow joint crease. Overlap the cut edges and smooth out the bend without "dog ears"

• To strengthen the slab, at the elbow joint level, another slab of 5 layers is made and applied starting on the medial aspect at the top end of the first slab crossing around the point of the elbow and going upwards on the lateral aspect to the top end

Smoothen the edges (particularly around joints) and place in triangular sling

VIDEO LINK: https://www.youtube.com/watch?v=8jnCDQDzbAc 

ABOVE KNEE BACKSLAB 

This type of plaster slab is applied in cases of injuries around the knee and fractures of the tibia and fibula. It extends from the middle of the thigh along the back of the leg and heel to the base of the toes.

• Prepare a dry plaster slab to the above length (8 layers from a 15 cm PoP roll). Prepare two side slabs of length 10 cm shorter than the posterior slab, each with 6 layers. The patient lies on his back. An assistant holds the leg about 25 cm above the couch with one palm under the knee and the other hand holding the toes. The knee is held in 5° flexion and the foot kept at neutral position

 

 • Cover the patient's knee with a layer of soft cotton roll; apply another pad around the ankle and heel

• Apply a layer of dry gauze bandage firmly from the base of the toes to the middle of the thigh

• Apply the first slab after moistening, starting over the sole of the foot and along the posterior aspect of the leg and thigh and mold it to the leg by rubbing and smoothening it

• Apply the side slabs on the medial and lateral sides of the limb and covering the heel. Mold the slabs over the leg by smoothing the slabs

• Fix the slab with wet gauze bandage, holding the limb in the correct position described above

Rest the leg on two sand bags, one behind the knee and a smaller one behind the ankle

VIDEO LINK: https://www.youtube.com/watch?v=KSgyEUgLQg 

POP INSTRUCTIONS : http://emed.ie/PatientInfo/Docs/AdvicePOP_20161123.pdf

Written by our guest author Pratyush Patowary

Illustrations by Anveshi Nayan
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Reduction of anterior dislocation of shoulder

What to see: 

Xray shoulder joint: Head of humerus not in the glenoid cavity 

How to treat: 

1.Kocher's method 

2.Milch technique 

3.Stimson's method

KOCHER'S METHOD

• Flexion of the elbow to a right angle

• traction in the line of the humerus

• external rotation of the arm: this brings the head of the humerus to face forwards 

• the elbow is pulled across the body: this adducts the humerus and disengages the humeral head 
• internal rotation of the arm: this lets the humeral head fall back into the glenoid

MILCH METHOD 

• Have the patient lie on a stretcher; the patient can be either supine or prone based on his or her comfort

• Have the patient abduct the affected arm to place their hand behind their head, if they are able, and then straighten the arm at the elbow

• If the patient cannot do this unassisted, then grab patient's arm at either the elbow or the wrist and guide arm into full abduction

• With the arm fully abducted, apply gentle longitudinal traction and gentle external rotation to achieve reduction

 

 

• If reduction does not occur quickly, apply gentle cephalad pressure to the humeral head while continuing to hold traction

STIMSON'S METHOD 

• The patient is placed in the prone position on an elevated stretcher/bed

• The affected shoulder should be off the edge of the stretcher/bed, hanging downward in 90° of forward flexion

• The stretcher/bed should be high enough to allow the patient's arm to dangle without touching the floor

• To prevent the patient from sliding off the stretcher, he or she is tightly strapped down with a sheet, and 2-10 kg of weight is securely fastened to the wrist of the affected arm to provide continuous traction

• If weights are unavailable, two to four 1L containers of normal saline can be used

• The patient is instructed to maintain this position for at least 15-20 minutes or until reduction is accomplished

Written by our guest author Swapnil Bhagat

Illustrations by Anveshi Nayan
#Ae(ONE)INTERN

 Mantoux Test

 

REQUIREMENTS: 

Cotton, spirit, 26G needle, Tuberculin syringe, PPD-RT with Tween-80, scale 

PROCEDURE: 

 ▪ Select the preferred site of injection

- Non-dominant hand forearm, flexor surface (but can be given on either side) - 4 inches below elbow joint. 

▪ Ensure adequate lighting

▪ Select healthy skin which is free from intracath &/or injectable drug administration or any test dose, hairs, veins, sores, scars

▪ Take all aseptic precautions

▪ With the help of 26G needle, draw 0.1 ml of 5 TU PPD-RT with Tween-80 solution, without trapping any air bubble (for that don't vigorously shake the vial)

▪ Inject the PPD intra- dermally on volar of forearm. Position the syringe at 10-15 degrees to the forearm and insert just below the epidermis

▪ An elevation of the skin (a wheel) 6 to 10 mm in diameter should be produced. (If not produced, repeat the injection, on the other forearm or 2 inches away from the original site on the same forearm) 

▪ Patient should be instructed to keep the test site clean, uncovered, not to scratch the area or rub the area.

▪ Record the time and date of administration of test

 

▪ The test should be read between 48-72 hours after administration

 

▪ For this, measurement of induration horizontally across the arm is measured by drawing a line over it using a pen

▪ Exact measurement of the induration in millimetres(mm) should be measured. Erythema should not be measured

VIDEO LINK: https://youtu.be/F08U1DNSFy8   

Written by our guest author Manpreet Kaur

Illustration by Anveshi Nayan
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 Toe nail removal

 

1. The patient is placed in the supine position, with the knees flexed (foot flat on the table) or extended (foot hanging off the end of the table). The physician wears sterile gloves. 

 2. The toe is prepped with povidone-iodine solution followed by spirit

 3. A standard digital block is performed with 1 percent lidocaine (without epinephrine), using a 5 mL syringe and a 22-24 G needle. About 2 to 3 mL of lidocaine on each side of the toe is usually sufficient for adequate anesthesia. Wait for some time allows the block to become effective

 

4. After checking the effect of anesthesia, slide one tip of an open artery forceps between the nail plate and the underlying nail bed (till the base of the nail plate). Grasp the nail firmly between the jaws of the artery forceps and clamp the artery forceps. 

 5. Gently rotate the artery forceps along its long axis 360 degrees, removing the nail in the process

 6. Clean the nail-bed and apply antiseptic sterile dressings

7. Any infection or abscess of nail bed should be cleaned or drained

VIDEO LINK: (**The separation of nail may be done as shown in video by cuticle separator, but is usually not done so here) https://www.youtube.com/watch?v=E6jp5bBXA04 

Written by our guest author Varun Bansal

Illustrations by Anveshi Nayan
#Ae(ONE)INTERN

Tube Thoracostomy (ICD insertion)

 

Procedure:

1. Position of Patient:

 

2. Site:

 

 

3. Apply antiseptic solution to a wide area of the chest wall and drape

4. Local anesthesia: 

-Use the 25-G needle to inject 5 mL of the local anesthetic solution into the skin overlying the region of initial skin incision

-Use the longer needle to infiltrate about 5 mL of the an subcutaneous tissue superior to the expected initial incision

-Redirect the needle to the expected course of the chest tube (following the upper border of the rib below the fifth intercostal space), and inject approximately 10 mL of the anesthetic solution into the periosteum (if bone is encountered), intercostal muscle, and the pleura

-Aspiration of air, blood, pus, or a combination thereof into the syringe confirms that the needle entered the pleural cavity

 5. Steps to insert the tube: 

• The skin incision is made in between the midaxillary and anterior axillary lines over a rib that is below the intercostal level selected for chest tube insertion with the help of 11 no. blade. The incision is made 4 cm long

• Use a hemostat or Kelly clamp to bluntly dissect a tract in the subcutaneous tissue by intermittently advancing the closed instrument and opening it

• Palpate the tract with a finger as shown, and make sure that the tract ends at the upper border of the rib above the skin incision. Insertion of the chest tube as close as possible to the upper border of the rib (minimize the risks of injury to the nerve and blood vessels that follow the lower border of each rib)

• Use a closed large Kelly clamp to pass through the intercostal muscles and parietal pleura and enter into the pleural space

• It should be done in a controlled manner so that instrument does not enter too far into the chest, which could injure the lung or diaphragm

• Upon entry into the pleural space, a rush of air or fluid should occur. Use a sterile, gloved finger to appreciate the size of the tract and to feel for lung tissue and possible adhesions. Rotate the finger 360º to appreciate the presence of dense adhesions that cannot be broken and require placement of the chest tube in a different site

• Measure the length between the skin incision and the apex of the lung to estimate how far the chest tube should be inserted

 

• Grasp the proximal (fenestrated) end of the chest tube with the large Kelly clamp and introduce it through the tract and into the thoracic cavity as shown. Clamp the distal end of the tube with a hemostat

7) Connect the chest tube to the drainage device as shown (the distal end of the chest tube can be cut to facilitate its connection to the drainage device tubing). Release the cross clamp that is on the chest tube only after the chest tube is connected to the drainage device

8) Secure the chest tube to the skin using 0 or 1-0  silk or nylon stitches. For securing sutures, two separate through and through, simple, interrupted stitches on each side of the chest tube are recommended

This technique ensures tight closure of the skin incision and prevents routine patient movements from dislodging the chest tube

Each stitch should be tightly tied to the skin, then wrapped tightly around the chest tube several times to cause slight indentation, and then tied again (but not piercing the tube) 

9) Create an occlusive dressing to place over the chest tube by turning regular gauze squares (4 x 4 in)  into Y shaped fenestrated gauze squares and using 4-in adhesive tape to secure them to the chest wall. Make sure to provide enough padding between the chest tube and the chest wall

10) Obtain a chest radiograph to ensure correct placement of the chest tube

VIDEO LINK: https://youtu.be/kEc8fn6ownc

 

Written by our guest author Mohit Singla

Illustrations by Anveshi Nayan
#Ae(ONE)INTERN

 

 Suturing Techniques

SIMPLE INTERRUPTED SUTURES

REQUIREMENTS: 

• Needle holder 

Needle holders should be held with your dominant hand

 

 

 

• Toothed forceps 

 Hold the forceps with your non-dominant hand in the same way you would hold a pen

Be gentle when using toothed forceps to manipulate skin, do not grip it too tightly or you may damage the wound's edges

 

• Scissors (to cut the sutures) 

• Written Informed Consent 

PROCEDURE: 

1. Load your needle holder by placing the needle in the tip of the holder. Needle should be held at the junction of 2/3rd distance from tip

Plan the entry and exit of your suture on either side of the wound such that on a cross-sectional view, the final suture, once tied, should appear square

2. First suture should always be in the centre of the wound

OUT-TO-IN 

3. Gently lift the skin with the forceps and pierce the skin surface with the needle perpendicular (90°) to the skin at approximately 4mm from the wound edge

4. Supinate your wrist so that the needle passes through the dermis and rises out of the middle of the wound

5. Use your forceps to hold the needle whilst you release your needle holder

6. Re-grasp the needle in the same place with your needle holder

IN-TO-OUT 

7. Lift the opposing skin edge gently with your forceps

8. This time the needle has to travel perpendicularly through the dermis from inside to outside. Use the curvature of the needle and supinate your wrist to move the needle through the skin

 9. As a guide, forceps may be kept near the exit point as follows: 

10. Again, use your forceps to grasp the needle and pull it through the skin. You should continue to follow the curvature of the needle as it travels through the skin, pulling the suture through as you go. You should now have a suture crossing perpendicularly to the wound, approximately 4mm from the wound edge

 

KNOT TIE 

11. Put down the forceps. 

12. Pull the suture through so that there is approximately 3cm of length on the opposing side

13. Hold the suture in your non-dominant hand and the needle holder in your dominant hand

14. Loop the suture away from you around the needle holder twice, then grasp the suture end with your needle holder

Tip: To remember which direction to loop in, place the needle holder in between the two limbs of the suture. Then, loop the suture material such that it lies over the needle holder first

15. Pull the needle holder towards you and push your non-dominant hand away to lay the first knot

16.Let go of the suture with your needle holder but keep hold of it in your non-dominant hand

17. Now loop the suture back towards you around the needle holder once and grasp the suture end with your needle holder. Take care not to pull the suture upwards (so that the surgical knot remains tight

 

18. Push the needle holder away from you and bring your non-dominant hand towards you to lay the second knot

19. Finally, loop the suture away from you around the needle holder once, then grasp the suture end with your needle holder. Pull the needle holder towards you and push your non-dominant hand away to lay the final knot

20. Once the knot is tied, use the needle holder to pull the knot to one side so it is not overlying the wound

21. Now cut the suture between 5-6 mm in length (If it is too short the knot will (If it is too long, the suture material will become trapped within other knots and they will come undone)

VERTICAL MATTRESS SUTURE

 PROCEDURE:  

Steps 1-10 as above but take a bigger 'bite' of skin either side, meaning you enter and exit the skin approximately at 5-8mm from the wound edge. (Till A and B step in the figure)

11. Now re-load the needle facing the opposite direction (away from you). The aim is the throw another suture across the wound directly above or superficial to your original throw, taking smaller bites of the skin edge to evert the wound edges. You need to bring your suture back to the side of original entry so that you can tie your knot away from the wound

12. Again, you can remove your fingers from the needle holder handle if you find this increases your dexterity. Gently lift the skin with the forceps, and pierce the skin surface with the needle perpendicular to the skin

13. Because your needle is loaded facing away from you, you will need to pronate your wrist so that the needle passes through the dermis and rises out of the wound

14. Use your forceps to hold the needle whilst you release with your needle holder

15. Re-grasp the needle in the  same place with your needle holder

16. Lift the opposing skin edge gently with your forceps

17. This time the needle needs to travel perpendicular through the dermis from inside to outside. Use the curvature of the needle and pronate your wrist to needle through the skin back to where you started

18. Again, use your forceps to grasp the needle and pull it through the skin. You should continue to follow the curvature of the needle as it travels through the skin. Finally, pull the suture through

KNOT TIE: Similar to above

VIDEO LINK FOR ALL SUTURE TECHNIQUES:
https://www.youtube.com/watch?v=TFwFMav_cpE&feature=youtu.be

 

Time line:
0:48 - Instrument tie and Simple interrupted sutures
04:37 - Simple buried suture (subcutaneous interrupted)
06:17 - Vertical Mattress suture
08:07 - Horizontal Mattress suture, Figure of 8 suture, Half- buried Horizontal mattress suture
10:53 - Simple Running (or Continuous) suture
12:55 - Simple Running (or Continuous) suture with interlocking
15:05 - Subcuticular running (or Continuous) suture

VIDEO LINK for simple interrupted sutures: 

For Right-Handed: https://youtu.be/z8oWv-nVO6g  

For left-handed: https://youtu.be/iuxOv3Y0OX4

 

VIDEO LINK for vertical mattress: https://lacerationrepair.com/techniques/basic-suturing-techniques/vertical-mattress-sutures/  

 

Written by our guest author Akanksha Barnwal

Illustrations by Anveshi Nayan
#Ae(ONE)INTERN