SAN DIEGO – If you perform excisional surgery in your dermatology practice, don’t skimp on instrumentation, advised Dr. David E. Kent.
"Spend your money on instrumentation that’s going to get you out of trouble," Dr. Kent said at the meeting, which was sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic.
Dr. David E. Kent
His list of recommended instrumentation includes hemostats to clamp and tie off blood vessels, skin hooks to improve visualization, suction to remove excess blood, cotton tip applicators, and 4-by-4-inch gauze. "Be aware that the least expensive gauze may not have the best quality, so you want to evaluate different vendors," said Dr. Kent, a clinical instructor in the division of dermatology at the Medical College of Georgia, Augusta.
He also recommends having electrosurgical devices on hand, liquid thrombin, Gelfoam, and oxidized cellulose to place in wounds that are going to heal by second intention. Xenografts, "which can be helpful for temporary hemostasis over a wound with exposed muscle, may serve as a very nice scaffold to seal the wound and are easy to apply," he said.
Applying pressure to the wound after surgery is key, he added. "In all of our patients who are on any aspirin products, after any closure, my nurse holds pressure for 10 minutes. We’ve found that to be very helpful."
Photo courtesy Dr. David E. Kent
This image shows a Geiger thermal cautery unit, which is helpful for patients who have implantable cardiac defibrillators.
He finds the Geiger Thermal Cautery Unit useful for patients who have implantable cardiac defibrillators. "We did a study of this unit years ago and found that a setting between 6 and 7.5 is fairly ideal," Dr. Kent said. "It holds its temperature reasonably well in a wet field, compared with handheld units."
For handheld cautery, he recommends the LMA Perfect Temp device for isolated small pinpoint areas of bleeding. For solid state electrosurgical generators, "there are many manufacturers including Valleylab, Bard Medical, and Aaron Medical, to name a few," he said. "When using electrosurgical devices, it is important to avoid skin edges. This can be done by approaching the bleeding site at 90 degrees to the skin edge to avoid epidermal thermal injury. Use the lowest possible setting to control bleeding."
Another worthwhile instrument to have is a hemostatic scalpel, which provides heat energy to seal vessels and tissue. "It's excellent for skeletal muscle and large defects into muscle," Dr. Kent said. "If you're doing a lot of larger cases, it can really help you avoid excessive bleeding. But they are costly," he said. Used hemostatic scalpels can cost as much as $5,000. Blades cost $10 apiece and are not reusable.
If postoperative bleeding occurs after the patient has gone home, see the patient as soon as possible. "The next day is not soon enough," Dr. Kent said. "Have someone there to help you; make sure you have a nurse on call if you need one." On return, make sure the patient's vital signs are stable. Is the bandage soiled? Is there active bleeding? "Consider removing one or two sutures to see if there is brisk bleeding," Dr. Kent said. "Try to establish if it is a single skin edge or something more. If uncertain, you may need to take the entire closure down, inspect, and control what is bleeding."
Dr. Kent said that he had no relevant financial conflicts to disclose.