EVALUASI PREOPERATIF DAN TATALAKSANA PASIEN

Dr Sri Lestari SpKK

SMF/ Bagian Ilmu Kesehatan Kulit dan Kelamin
RS Dr M DjamiV Fakultas Kedokteran Universitas Andalas, Padang
Dalam

Lokakarya dan Workshop Bed,ahKulit Dasar 2008

Modan, 24 -26 April2008

PREOPERATIVE PREPARATIOI\
Sri Lestari
D ermatol o gy-V enereolo gy D epartment, Dr M Dj amil Ho spital,
\le dical Faculty of of Anadals University, Padang, West-Sumatra, Indonesia

L\IVERSAL PRECAUTIONS, STERILIZATION, ANd MEDICAL EVALUATION

\lan1' dermatologic surgical procedures are so uncomplicated that extensive patient
evaluatron is unnecessary. But physicians should not be lulled into complacency because
of the apparent simplicity of the surgery. Patient evaluation, appropriate to the surgery, is
a necessity to reduce the possibility of surgical complications. Patient evaluation can be
viewed in terms of general considerations, as well as those more relevant to the surgery
being contemplated. During the evaluation of the patient, it is also an ideal time to
establish a rapport and to discuss possible complications and expectations pertinent to the
anticipated surgery. Possible side effects should be documented and be a part of the
patient consent form (1).

Any medical history evaluation or questionnaire will satisfy every dermatologic surgeon,
but all such inquiries should explore elements of general health, allergies to systemic and
topical agents, current medications, bleeding tendencies, and wound healing (poor
healing, keloids, or hypertrophic scars) (1,2), atheroscierosis hearl disease, hypertension,
cardiac pacemaer, renal disease, diabetes, immunosupression, and pregnancy (2).
As with any surgery, there should be an appropriate review of the patient's history prior

to any procedure. Any allergy to local anesthetics, antibiotics or dressings should

be

established and made clear at the head of the clinical notes (2,3).
Special care should be taken to assess patients with diabetes and peripheral vascular
disease (2) prior to distal limb surgery (3).
Because of the necessity for leg bandaging, it is advisable for wor,nen to stop taking oral

contraseptives 4-6 weeks prior to having varicose vein injection. It is imporlant to ensure
an alternative form of contraseption during the time. Cessation of oral contraseptives in
not necessary for other forms of minor surgery (3).
Most patients will need reassurance that the operation will be free from pain after the
initial anaesthetic injection. It should be mentioned that the local anesthetic will only
numb the operative site and that the surrounding skin will retain normal sensation (3).
It is important to re-examine and mark the site of any subcutaneous lesion prior to the
injection of local anesthetic, as the volume of the injected fluid can make the lesion
difficult to define (3).
The practice of skin surgery in the physician's office requires familarity

1.

2.

3.
4.
5.

Surgicai technique
Careful planning
Instruction of ancillary personnel
Patient education
Proper preparation of the surgical site

with

6.
,-.

The surgical instruments

The patient (4)

Unir.ersal precautions to prevent the transmission of infectious diseases are paramount to

protecting the physician, the medical staff, and the patient (4).

L\IVERS AL PRE,CAUTIONS
The first prerequisite for the proper maintenance ofuniversal precautions is education of
all office staff who may potentially be exposed to infextious material, particularly blood
:

.
e
r
.

All presonnel who may come in contact with blood should be vaccinated

agains

hepatitis B.

We usually recommed testing the patient for serologic evidence of potential

infectious disease.
The use of surgical gloves and the use of barrier clothing, such as gowns, face
masks, and eye protection.
Propel disposal of sharp, disposal surgical instruments, such as needles, scalpel
blades, in speciai puncture-proof containers (4).

Universal precautions
1. A1l workers should routinely use appropriate barrier precautions to prevent skin
and mucous-membrane exposure when contact with blood or other body fluids of
any patient is anticipated. Gloves should be worn for touching blood and body
fluids, mucous membranes, or non-intact skin of all patients. Gloves should be
changed after contact with each patient. Masks and protective eyewear or face
shields should be worn during procedures that are likely to generate droplets of
blood or other body fluids to prevent exposure of mucous membranes of the
mouth, nose, and eyes. Gowns or aprons should be worn during procedures that
are likely to generate splashes of blood or other body fluids.
2. Hands and othe skin surfaces should be washed immediately and thoroughly if
contaminated with blood or other body fluids. Hands should be washed
immediately after gloves are removed.
3. Ali workers should take precautions to prevent injuries cause by needle, scalpels,
and other sharp instruments or devices during procedures; when cleaning use

instruments; during disposal of used needles; and when handling

4.
5.

sharp

instruments after procedures. To prevent needle-stick injuries, needle should not

be recapped, purposely bent or broken by hand, removed from disposable
syringes, or otherwise manipulated by hand. After they are used, disposable
syringes and needles, scalpel blades, and other sharp item should be placed in
puncture-resistant containers for disposal.
To minimrze the need for emergency mouth-to-mouth resuscitation, mouthpieces, resuscitation bags, or other ventilation devices should be available for use
in area in which the need for resuscitation is predictable.
Health-care workers who have axudative lesions or weeping dermatitis should
refrain from all direct patient care and from handling patient-care equipment until
the condition resolves.

6.
SL-np1e

Pre-qnant-health-care workers should be especially familiar

ad.here to precautions to minimizes the risk of HIV transmission

(4).

surgical procedure, such as shave or punch biopsies :

o Need no special scheduling.
. These procedure can be done rapidly as the need arise (4).

\lore compiex surgical procedures in the office will benefit from

.
.

with and strictly

Carelul
Deliberate considration of how best to integrate the surgeries into the office
schedule.
To do more complex surgeries at the begiming of the week and avoid surgery on
Friday so patients can be seen the day after surgery for a postoperative check (4).

COMPONENTS OF THE PREOPERATIVE CONSULTATION :

1. Medical history
2. Surgical history with an emphasis on past dermatologic and/

or

cosmetic

procedures

3.

Complete medication list including use of over-the-counter (OTC) drugs, vitamins

and nutritional supplements

4. Problem-focused physical examination

5. Social history
6. Detailed explanationof the proposed procedure, treatment alternatives, and
informed consent (5).
Universal precautions are one aspect of the planning required before surgery. Other
aspects include the following :
. Preoperative medical evaluatlon
. Informed consent
o Standby medications and equipment
o Sterile technique
o Sterilization of instruments
r Preoperative patient preparation (slcin, hair, drapes)
. Preoperative medications (e.g., antibiotic prophylaxis to prevent skin infections,
endocarditis prophylaxis) (a)
PREOPERATIVE MEDICAL EVALUATION
MEDICAL HISTORY
A complete medical history and review of system before minor skin surgery may not
be necessary. Item that should be include in the history include the following :
o Current medications, especially piatelet-inhibiting agents such as aspirin,
nonsteroidal antiinflammatory drugs Q.,lSAIDs) and dipiridamole;
coagulation-inhibiting agents such as Coumadin; beta-blocking agents
(2,4); phenothiazines; tricyclic antidepressants; thyroid hormones; and
monoamine oxidase inhibitors (2).

.
.
.
e
..
.

Allergies, especially to antibiotics, tapes/ adhesives, iodine, latex, local

anesthetics, surgical wound dressings, pain medications (2,4,5).

Cardiac disease (e.g., any condition requiring endocarditis prophylaxis

(e.g., valve disease), uncontrolled hypertension, epinephrine sensitivity,
angina, pacemaker, ( electrosurgery precautions) (2,4,5)
Other ilinesses and medical conditions (e.g., seizure disorder, hematologic
disorder or bleeding diathesis, joint replacement (endocarditis
prophyiaxis), high-risk groups (injection drug users), diabetes (2,4).
Pregnancy (2,4,5).
Keloids or hypertrophic scars (2,4).
Infectious diseases (e.g,, hepatitis, AIDS, tuberculosis) (2,4)

Local anesthetics can cross the placental barrier and may accumulated preferentially in
the fetus. Potential complications from use of local anesthetic during pregnancy include
both fetal bradycardia and central nervus system toxicity. Several studies examining the
use of liidocain during pregnancy have shown no increase in adverse fetal events or
teratogenicity, Epinephrine is frequently combined with lidocaine, should be used
caustiously. Appropriate pregnancy antibiotics include penicilline, cephalexin and
erythromycin base (5).
The blood pressure and pulse rate should be part af all preoperative dermatologic surgical
evaluations. A history of hyperlension, angina, a previous myocardial infarction, and
some arrhytmias may restrict the use of epinephrine. Electrosurgery may interfere with
some cardiac pacemakers but, with careful usage, should present little problem (1,5),
Epinephrine should be used with caution in patients taking beta-blocking agents, tricyclic
anti depressant, thyroid hormones, and monoamine oxidase inhibitors because of the risk
of severe hypertension (2).

For minor skin surgery under local anesthesia, blood pressure does not need to be
monitored unless the patient has a history of hypertension that is not controlled (4).
Uncontrolled hypertension may lead to increased bleeding during surgery (4,5). It is
prudent to be more careful with fragile patients, such as the elderly, and to be particulariy
careful with the use of epinephrine-containing anesthetics in patients with a history of
angina, cardiac disease, or a sensitivity to epinephrine. It may help to warn patients that
they may develop an increased heart rate or a feeling of anxiety after injection of
lidocaine with epinephrine (4).
SURGICAL HISTORY
Targeted questions can be used to identify patients at high risk for perioperative
complications. Once identified, patients at risk for particular surgical complications can
be counseled appropriately (5).
COMPLETE MEDICATION LIST
PREOPERATIVE MEDICATIONS
The most important part of medication history is to find out if the patient is taking aspirin
NSAIDs, and warfarin increase excessive bleeding in the intraoperative or postoperative

period (2.4-5). The patient stop taking aspirin at least 1-2 weeks before any surgical
procedure, Aspirin and NSAIDs that can also have an effect on platelet function
(1.2.4,5). The effect of aspirin is irreversible inhibition of platelet function (2). NSAiDs
and n'alfarin need to be stopped 2 -7 days before a procedure because the effect of
NSAIDs on platelets is reversible (2,4,5). The effect of aspirin on hemostasis in a patient
with an otherwise normal hemostatic sysmtem is usually minor, with prolongation of
template bleeding time increasing from a control4.18 min to 5,83 mtn2 hr after ingestion
of 300 mg of aspirin (30) (1). Aspirin has an irresible effect on platelets (1,2,4), and its
use requires that the patient wait 2 weeks after discontinuing use for new platelets to
replace the old ones (4).

Minor procedures, such as skin biopsy, may not require stopping aspirin use (4).
Coumadin can also be a potential cause of excess bleeding (4,7),but it does not cause the
same degree of excess bleeding as aspirin. For minor skin procedures, Coumadin does
not need to be stopped before surgery (4). If the procedure is complex, stopping the
Coumadine about 2 to 4 days before surgery (2,4). However, the risks of stopping the

Coumadin (thrombosis, embolism, and stroke) must be weighed against the benefit of
surgery. Coumadin can be restarled about 2 days after surgery when the chance of
hematoma formation decrease. Pressure dressings can help minimize the risk of
hematoma. In general, rather than stopping oumadin we prefer to take exceptional care in
using electrosurgery for hemostasis, which does not require interruption of
anticoagulation (4).

A history of an antibiotic allergy may be relevant if prophylactic antibiotics are given.

Antianxiety medications such as triazolam, diazepam, or lorazepam can be useful in the
very anxious patient. If these medications are administered sublingually (under the
tongue), the onset of action can be quicker than when they are administered orally. These
medications should not be given to a patient who will be driving home. All patients
given introperative or preoperative sedatives must be accompanied by an adult, must be
counseled not to drive on the day of the surgery, must be observed postoperatively until
the sedative effect has diminished (a).
Nutritional supplements (garlic, ginseng, ginger, gingko) have also been shown to have
anticoagulant effects, although their impact on dermatologic surgery is unknown.
Vitamin E or o,-tocopherol as a potential anticoagulant. All nutritional supplements,
including multivitamins, are to be discontinued 7 days before the surgical procedure (5).
Tobacco use may adversely effect dermatologic surgery by enhancing cutaneous
vasoconstriction, impairing wound healing, and increasing wound infection (5). The
patient will discontinue tobacco use I - 2 weeks before and after surgery (2,5).
Alcohol is to be avoided for 2 days before the surgical procedure (2,5).
ROBLEM-FOCUSED PHYSICAL EXAMINATION
It is not advisable to do skin surgery on patients who have unstable angina because the
epinephrine in the local anesthetic can precipitate angina. It is worth having nitroglycerin
in the office to deal with this potetial situation. Patients who have uncontroled diabetes

inellitus ma1. have impaired wound healing. Closer follow-up after surgery may help
ar,'oid potential problems with these patients (4,5).

SOCL{I HISTORY
sicians should try to assess the suitability of a particular patient for a given
procedwe. is the patient able to comply with the postoperative care instructions? Is a
caretaker (spouse, relative) available to assist with wound care? (5)
Phr

NFORMED CONSENT
Thorough discussion with the patient regarding the benefits and risks of the plarured
surgical procedure and the alternatives to surgery that are avilable is essential before
surgery, and all of the patient's questions can be answered (2,4,5). If the patient is
mentally incompetent or younger than age 18 years, from the patient's legal guardian
(2). For many routine minor procedures, such as skin biopsy, a written consent may
not be needed. However, written consent is always obtained for procedures that may
have more significant adverse consequences, such scarring or functional effects (4).

STANDBY MEDICATIONS AND EQUIPMENT

It is helpfui to have injectable Benadryl and epinephrine available for subcutaneous
injection in case of an anaphylactic reaction to anesthesia, latex, or othe medication. It
may also be helpful to have an Ambu bag, an insertable airway, oxygen, a cardiac
monitor, and a defibrillator in the office, but these items are not absolutely necessary
(4)

STERIL TECHNIQUE
Absolut sterile technique is not necessary for many of the minor skin surgical procedures
performed (e.g., cryosurger/, electrosurgery, shave biopsy, curettage, incision and
drainage, and other small surgical procedures in which the wounds are left open to heal
without suturing. Although all instruments must be sterile before use for these
procedures, the physician may use nonsterile gloves (4). Gloves should be worn for
surgical procedures and whenever there is any risk of coming into contact with blood or
body fluids (3,5). Sterile drapes are not needed. We use single-use scalpels and nqedles
that are disposed of at the end of the procedure (a). No hat or mask or speciai ciothing for
minor pracedures. For simple skin surgery ordinary clothing may be protected by a
disposable plastic apron (3).
Sterile technique is necessary when performing surgery in which the wound will be
closed, such as with suturing or staples. Careful instruction of ancillary surgical personnel
in sterile technique is necessary (4).
Protective glasses

Fine blood spots can be commonly found on surgeon's protective glasses even after
simple skin surgery. Consideration should therefore be given to the routine wearing of
protective glasses for all routine minor surgery (3).

STEzuLIZATION OF INSTRUMENTS
Belore sterilization, instruments must be cleaned of blood and debris. The instruments
should be placed in sterilization bags with indicator strips to ensure the sterilization
process is effective. Gauze, cotton-tipped, applicators, electrosurgery tips, and glass
containers can all be steam sterilized by putting them in the sterilization bags (4).
PREOPERATIVE PATIENT PREPARATION
Preparation of the skin.
There is no need to scrub up for most minor surgical procedures. The hands can be
srmply washed using 4o/o chlorhexidine (Hibiscub) detergen solution or 7 .5o/o povidone
iodine (Betadine) detergen solution. Dried with clean paper towels and gloves worn.
Some doctors prefer to use only soap and water, A formal scrub should be undeftaken
prior to more involved or length procedures (3).
The most common preoperative preparations to be used on the skin include alcohol,
Betadine (povidone-iodine), and Hibiclens (chlorhexidine) (3,4). Hibiclens are that it has
ionger-lasting antibacterial effect than Betadine and the risk of contact sensitivity may be
less, but it is more toxic to the eye if it accidentally drops into it. Caution must be taken
when using alcohol or Hibiclens tincture to be sure that all of the alcohol has evaporated
before any cautery is performed in the area. This eliminates the possibility of ignition of
the solution, the surrounding drapes and gauze, and the physician (4).
The most important part of the preoperative preparation of the skin is the mechanical
rubbing of the antiseptic onto the skin with a sterile gauze. The goal of the preoperative
preparation of the skin is to reduce the bacteria on the skin surface by scrubbing the skin
with a good antiseptic such as Betadine or Hibiclens. Betadine must be allowed to dry on
the skin for its effect to be optimal (4) When contaminated lesions such as
keratoacanthoma or ulcerated basal cell carcinoma are excised, it is advisible to leave a
cotton wool ball soaked in antiseptic solution directly on the lesion for several minutes
prior to the surgery (3).
Preparation of hair
The best method of hair removal over a surgical site is to use scissors to cut the hairs.
Using scissors is preferable to using a disposabl e razor when the hair is long enough to
interfere with the operation or the application of dressing (3,4), and because a close
shave causes minute abrations and cuts into the skin that can increase the chance of
infection. For elective procedure, the site can be shaved by the patient 2 days before
sugery. The scalp is the area of the body in which the hairs can most interfere with
surgery. Plestering down the hair with water, petrolatum, or ointment can decrease the
number of hairs that interfere with surgery without causing a noticeable loss oh hair
during the postoperative period (4).
Drapes
The use

of sterile fenestrated aperture (drape with a hole) is necessary when suturing is

performed so that the sutures do not drag over nonsterile skin (4). Sterile drapes are not
necessary for small procedures (3), such as a shave biopsy, where suturing is not

performed (4). A medium-sized disposable paper towel with a central window can be
used for larger cases (3).
Premedication
Premedication is usually unnecessary for minor procedures in adults, but may be used in
children, anxious adults and for more complicated or lengthy surgical procedures.
Keeping a relaxed, reassuring and jovial atmosphere is more important than a sedative. A
simple regime in adult is to use Temazepam 10 - 30 mg t hour before surgery. In
children, diazepam 2.5 - 5 mg or trimeprazine 3- 4 mglkg I-2 h before surgery. The
trimeprazine is liable to cause postoperative restlessness when pain is present (3).

Antibiotic prophylaxis
Preoperative antibiotic such as oral cephalexin, dicloxacllin, or clindamycin may be
recommended for use with the patient who has a higher risk of infection, contaminated
or infected lesions; a lesion in an area of increased bacteria, such as the axilla, ear, or
mouth; a lesion on a hand or foot, especially in patients with peripheral vascular disease;
the operation might take more than t hour or if the wound was open for more than 1
hour, diabetic patient, patient with neutropenia (4).
However, more extensive procedures such as
. Dermabration
. Hair transpiantation
. Flaps
. Nail surgery
May require more comprehensive evaluation (1)

DERMABRATION
Herpes simplex may disseminated on the denude skin of a dermabraded site during the
healing phase. Acyclovir has been used as treatment and also prevent this occurrence
inpatient with history of recurrent herpes simplex. Acyclovir is given 1-2 days prior to
dermabration and continued during the time of healing.
Skin refrigerants are used in dermabration for anesthesia, hemostasis, and to establish a
firm surface. Some of the refrigerants have been associated with increase scaring. This
may be due to the loss of natural depth landmarks an also because the surgeon freezes
or dermabrades too deep, or cryonecrosis. The margin of safety of new agent,
Cryoesthesia (-30 - -60; containing Freon 11 and 12).
Isotretinoin has been associated with unusual postoperative scaring after rmabration, and
the mechanism is not known (l).

HAI R TRANPLANTATION
The main concern for preoperative evaluation of patients to undergo hir transplantation is
bleeding problems. Therefore, a careful personal and family history of bleeding diatheses
should be elicited as well as evaluating drugs that affect hemostasis, such aspirin. The
tests prior to hair transpl4ff grr:gery : (1) platelet count, (2) thromboplastin time, (3)
prothrombin time, (4) bleeding time (1).

CRYOSURGERY
For ertensive cryosurgery, such as cryoabrasion, evaluate for cryopathies and diseases in
u'hich cr1'opathy more frequebtly occurs. Measuring cryoglobulins and cryofibrinogens.
if crr-s5u1gery is used in acral areas, then Raynaud's phenomenon and other vasospastic
or peripheral vascular disease should be assessed (1).
ELECTROSURGERY
The electromagnetic emission from electrosurgery may interfere with cardrac
pacemakers. The use biterminal electrode can more safely direct current flow away from
the heart. Some suggest the use of laser surgery for patients with cardiac pacemakers (1).
TOE.NAIL SURGERY
The most specific evaluation is the adequacy of the peripheral vascular system.
Investigation should be directed at assessing vascular disease such as intermittent
claudication or evidence of arteriosclerotic disease in other site as the hearl or the barin.
Peripheral pulses should be palpated before toenail surgery. Cutaneous signs of vascular
insufficiency include thin shiny skin, thickened ridged nails, absence of dorsal dgital hair,
and dependent rubor followed by a pallor with elevation. Approppriate consultation and
vascular flow studies may be indicated (1).
SURGERY IN ANATOMIC DANGER ZONES
Four anatomic areas are commonly referred to as danger zones because the motor nerves
in these areas run superficially. These are the superficiai temporal, zygomatrc, marginal
mandibular branches of the facial nerve, and the spinal accessory nerve as it courses
through the posterior triangle of the neck; Damage to these nerves can result in
significant motor deficits. If surgery is necessary, blunt dissection and minimization of
incisions is important. Prior to undergoing any surgery, the patient must be made fully
aware of the risks and consequences should damage the these nerve occur (1).
SURGERY NEAR THE EYE
Possible complications that can result when doing surgery near the eye range from
ectropion, corneal abrasion, and lacrimal system injury to retrobulbar hemorrhage when
performing a blepharoplasty. When doing extensive surgery near the eye, it is wise to
have the patient obtain a presurgical eye examination to document visual acuity. If the
patient claims to have any change in acuity resulting from the surgery, a comparison
between pre- and postsurgical acuity can be helpful (1).
The operative evaluation of candidates for dermatologic surgery is often as important as
the surgery itself. Fortunetely, the risk and complications of minor skin surgery occur
infrequently. Cosmetic surgery, requires a minimum risk of complications since patients'
expectations are so high. Most dermatologic surgery can be performed under local
anesthesia, even patients who have significant medical problems or are elderly can
undergo these procedures safely. More time should be spent explaining a procedure and
possible risks, because an anxious patient usuaily lacks understanding about what is
going to happen. Patients are more cooperative and relaxed once they understand the
procedure and its expected results (6).

to

undergo treatment as soon as possible

and cosmetic result is usualiy secondary and not the main concern. Cosmetic
dennatologic surgery patients may not have objective disease but are motivated to have
surger)'for a variety of reasons (6).
The preoperatve psychological evaluation of dermatologic surgery patients is difficult to
t.u.h *d is learned through experience. Patient satisfaction is determined not only by the
technical quality of the surgery performed but also by a good physician-patient

Patients g'ith skin cancer are highly motivated

relationship (6).

The preoperative consultaion for patients undergoing cosmetic dermatologic surgery

includes some basic determinations:
1. Patient request,; the patient describes the problem to be corrected.
2. Physical examination; the surgeon evaluates the patient on his/ her request and
plans treatment.
3. Medical evaluation; to determine if there are contraindications to the procedure.
4. Physchological assessment; which begins ta the first meeting and continues
through surgery and during all follow-up visits (6)'
The preoperative psychological assessment includes

1. Motivations for surgery; internal motivations to andergo aesthetic surgery include

a patientt's desire to change his/ her appearance in order to improve self-image or
to meet a personal standard of physical attractiveness. Externally motivated
matients, either respond nto pressure from others (spouse, friend, or relative) to
change their appearance.
2. The patient's expectation; which critically influence the patient's perception of
surgical outcome, should be realistic, and the patient should not believe that
surgery will improve occupational problems, solve financial difficulties, resolve
personal conflicts, or render physical perfection.
3. Understanding of the risk and implications of surgery; the patient needs to
understand the procedure completely. The patients should also understand that the
surgeon cannot predict the final outcome preciesly.
4. Anxiety level; no anxiety indicates denial and a possible faillure of the patient to
fully comprehend the risks of surgery.
5. Ego strength; an individual with normal ego stregth is sable, capable of tolerating
the stress of surgery, and wil not be governed by irrational fears or fantaties (6).
Cosmetic surgery consultations sho[ld be scheduled and be hurried (6).

Good candidates for cosmetic surgery can be grouped as having either major or minor
disfigurements. Patients with minor disfigurements can also be good candidates for
cosmetic swgery. Correction of a specific problem can be very satisfying. Patients with
pesonality disorders, surgery be best avoided in these patients because they will not be
satisfied with the . Referal to another surgeon, when the patient is a good candidate but
has a poor personality (6),

On the da1. of surgery, the surgeon should appear happy, efficient, and organized. The
patient should gret the patient and establish that the surgery is a happy event. The
surgeon's perspective about the operative utcome can strongly influence the patient,s
reactions to the operative results. This important that intraoperative problems be dealt
rith quietly and efficiently (never say "oops" during the procedure) (6).
PREOPERATTVE CONCERNS (7)
I. PRE-OPERATIVE ASSESSMENT GOALS
A. PREOPERATIVE EVALUATION AND PLANNING IS ESSENTIAL TO THE
BEST SURGICAL OUTCOME
1. The nature of the lesion or presenting problem
2. the anatomic structure that may be affected
3. Medical condiition(s) of the patient
4. Factores that may affect wound healing

B. MEDICAL HISTORY
1. Allergies, including anesthetics, antibiotics, topical dressings and latex
2. Medicines, including anticoagulants, immunosuppressive, neurologic and cardiac
agents

3. Use of alcohol and tobacco, and overall nutricional status

4. Patient's overall health

a. In severe coronary artery disease, limitation or omission of epinephrine in local
anesthesia may be appropriate
b. Patients with valvular heart disease or prosthetic valves as risk for bacterial
endocarditis
c, Implanted electrical devices (pacemaker, pumps, defibrillators) require
electrosurgical precautions
d. Raynaud's or vasospastic disease for epinephrine avoidance
e. Edema may delay wound healing in affected extremities
f. Diabetes mellitus
L Delayed wound healing
2. increased risk of postoperative wound infection
3. Small vessel disease with ischemic risks
4. Observe for signs of hypoglycemia during procedure
g. Infectious diseases
1. Hepatitis / HrY I immunosuppressed patients may be predisposed to
postoperative infection and delayed wound healing
2' Herpes Simplex virus - intiviral prophylaxis should be used where appropriate
3. Adherence to universal precautions should be used for all procedures
C. LABORATORY EVALUATION
Blood work and imaging studies will be at the discretion of the surgeon

SOCIAL ISSUES
1. Visiting nurse referral
2. Social services

II. INFORMED CONSENT

A. DETAILED EXPLANATION OF THE PROCEDURE
B. EXPLANATION OF TREATMENT ALTERNATIVES
C. EXPLANATION OF RISKS AND BENEFITS OF THE PROCEDURE
D. BE CER.TAIN THAT THE PATIENT IS COMPETENT TO GIVE INFORMED
CONCENT

CONCLUSION
Outpatient skin surgery requires careful preparation to ensure optimal results and safety
of patient and medical personnel. Universal precautions to prevent the transmission of
contagious disease.Brief medical evaluation by the physician before performing minor
procedures. Sterilization of equipment, steril technique, informed patient consent,
preoperative preparation of the operative site, and preoperative medications

References

1.

Balle MR, Krull EA. Medical evaluation and universal precautions. In : Roenigk
RK, Roenigk HF eds. Roenigk & Roenigk's dermatologic surgery : principles
and practice. 2"u ed. New York; Marcel Dekker, lnc,1996 : 53 - 64.
2. Robinson JK, Hruza GJ. Dermatologic surgery : Introduction and approach. In :
Freedberg IM, Eisen AZ, wolff K, Austen KF, Goldsmith LA, Katz sI. Fitz
Patrick's Dermatology in general medicine. 6th ed. yol2.New york; McGrawHill Medical Publishing Division,2003 :2517.
3. Sodera V K. Preoperative preparation and postoperative care. In : Minor surgery
in practice. Cambridge University Press, 1994 : 4l - 47.
4. Tobinick EL, Moy RL, usatine RP. Preoperative preparation : universal
precautions, sterilization, and medical evaluation. In : usatine RP, Moy RL,
Tobinick EL, Siegel DM. Skin surgery. A Practical Guide. St Louis; Mosby, 1998
: l0 - 19.
5. Fein H, vidimos AT. Patient evaluation, informed consent, preoperative
assessment and care. In : Robinson JK, Sengelmann RD, Hanke cw, Siegel DM
eds. Surgery of the skin. Procedural dematology. Philadelphia; Elsevier Mosby,
2005 :67 -76.
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