Excision of Sebaceous cyst/ Dermoid cyst

EXCISION OF SEBACEOUS CYST/ DERMOID CYST

  

 

Steps common to all minor procedures 

REQUIREMENTS: Written informed consent, local anaesthetic in a 2 or 5 ml syringe with needle, sterile gauze pieces, povidone-iodine, ethanol, sterile drape, scalpel with curved no. 15 blade, artery forceps, toothed forceps, needle holder, suture, dressing material

• Palpate the cyst and surrounding area to confirm its exact location and punctum
• Curved no. 15 blade is used to make an incision
• The longitudinal direction of the ellipse should be along Langer’s lines (vertical in limbs and horizontal on trunk)
• The width of ellipse = approx. 1/3 rd diameter of cyst and length considerably longer
• First incise the skin up to the subcutaneous tissues
• Then, using blunt and sharp dissection, identify the plane between the cyst and surrounding subcutaneous tissues
• Then, separate the superficial 25% of the circumference of the cyst with blunt dissection
• Now press the normal surrounding skin and soft tissues on both sides gently with the thumbs, first in
one direction, then at 90 degrees to the previous direction
• Around 80-90% of the cyst emerges from the incised area
• Gently lift up the incised ellipse of skin and attached cyst with forceps, and separate the deep pole of the cyst from underlying tissues using blade

  

 

GANGLION CYST EXCISION

It is similar to the above procedure, while bearing following in mind:
1. Careful dissection away from the tendons should be done
2. Feeding vessels to the ganglion need to be ligated
3. Special care should be taken not to injure major vessels like radial artery
4. The stalk of ganglion cyst should be traced and if arising from joint capsule, some part of joint capsule will have to be excised

PRACTICAL TIPS AND TRICKS:
1) While infiltrating, try to elevate the lesion by raising a wheal which allows the lesion to prop up
2) Keep a formalin filled pre-labelled container ready for putting the specimen in after its removal
3) Incisions should be made with the belly of blade

VIDEO LINK:
Excision of sebaceous cyst/ dermoid cyst: https://youtu.be/On9iKyDmtk8
Excision of ganglion cyst: https://youtu.be/KqOSb0TC8Ss

 

Written by our guest authors Anveshi Nayan and Shrishti Patil

Illustrations by Devi Bavishi
#Ae(ONE)INTERN

 

Pap Smear

PAP SMEAR

Pap smear should be obtained before per speculum/ per vaginum examination done by the doctor.

Although there exist guidelines regarding cervical cancer screening, in most of the government hospitals in India, pap smear is done for every female who visits the Gynecology O.P.D. 

It should be avoided in a female who is menstruating or has copious vaginal discharge.

PROCEDURE

- Take verbal consent of the patient and follow aseptic technique

 

- Any vaginal speculum can be used. Insert the closed speculum with its blades facing the lateral vaginal wall. Then rotate it by 90 degree and open it

- Use Ayre’s spatula OR Cytobrush to obtain the sample from inside the external os. Also obtain one sample from ectocervix using opposite end of Ayre’s spatula

        - Take a pre- labelled slide and make 1 smear each of the two samples (one obtained from inside the external os and one from ectocervix) as follows:

 

 

- Place the slide in a jar containing fixative (generally 95% Ethyl alcohol) and fill the required forms

VIDEO LINK:

https://youtu.be/PlAoDirRqC8

Written by our guest author Hemant Kadam

Illustrations by Devi Bavishi
#Ae(ONE)INTERN

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
  #Ae(ONE)INTERN
  
  
  
  

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
#Ae(ONE)INTERN

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
#Ae(ONE)INTERN

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
#Ae(ONE)INTERN