Lighting

Simple surgical procedures can be performed in almost any office if the lighting is adequate. Standard office lighting is often too dim to allow proper visualization of the operative field. When setting up a new facility, it is worth spending time to research the ceiling lights. Consider doubling the number of fixtures to have clear lighting. For many clinicians, this will provide adequate lighting for performing simple surgical procedures.

Headlamps can also be used to illuminate the operative area. When used in conjunction with loupes, headlamps are valuable when performing finely detailed procedures. A good penlight or otoscope can be helpful to illuminate a specific area during an exam.

Surgical Lamps

Adequate lighting is best achieved by using surgical lamps that are either ceiling mounted or on a rolling base. There are many lamps from which to choose. We are pleased with the Burton Outpatient II light in our main procedure room (Figure 2-1A). It is very bright but does not get hot. This is Burton’s number one surgical light and is shadow free, can be focused, and is guaranteed to have a no-drift arm. We have found the light to be too bright at times so we have taped photo diffuser sheets over the lights. Another option is to put in a dimmer so you can control the light output. This light focuses with a central handle. The central handle can be covered with a sterile cover, but we just ask our medical assistant to reposition the light when needed. Many other lights are available, but it is worth getting a good one.

FIGURE 2-1 (A) Ceiling-mounted surgical light. (B) Exam room with Mayo stand, lift chair, Burton SuperNova exam light, and poster of the skin.

(Copyright Richard P. Usatine, MD.)

If you get a better quality light in your main procedure room, it will be easier to see for more complex surgeries. A floor lamp may be used in your other exam rooms, but if you count on it in your procedure room, you may have lower quality light and need to deal with the inconvenience of the stand taking up floor space.

Floor Lamps

You should have at least one good-quality movable floor lamp for your exam rooms. One per room is optimal but one good movable lamp is a good start. Look for a lamp that provides excellent illumination, ease of movement, and stability in a small exam light for the floor. The Burton SuperNova exam light (Figure 2-1B) is one lamp that works well for us, but many other floor lamps are available that provide similar features. A gooseneck lamp with a bare incandescent light bulb gets hot and the light is not optimal for skin procedures.

Woods Lamp

The Woods lamp (Figure 2-2) uses an ultraviolet light and is useful for diagnosing or evaluating fungal infections including Microsporum canis and Malassezia furfur. It is also helpful for identifying the coral red fluorescence of erythrasma. It can be used for accentuating the hypopigmentation of vitiligo. In melasma, it is used to see if the hyperpigmentation is within the epidermal or dermal layer. Outside of dermatology the Woods lamp helps to diagnose corneal abrasions.

FIGURE 2-2 Woods lamp. Ultraviolet light for the diagnosis of fungal infections, erythrasma, vitiligo, and melasma.

(Copyright Richard P. Usatine, MD.)

We use the Burton ultraviolet light. It uses fluorescent bulbs that produce UV-A at an approximately 360-nm wavelength. This is not harmful to the eyes or skin. It has a magnifier lens with three power magnifications and a focal length of 8 in.

Surgical Table, Stools, and Mayo Stands

It is essential to have at least one good surgical table with a height adjustment. The best tables have preset positions that move the table to the optimal height for your work. Also, make sure that you find a table that allows the back and foot adjustments to move simultaneously. If not, it can take a long time to get the patient in the proper position for procedures. It may also help to have a table that spins on a center axis for positioning the patient at the best angle in the room. Make sure that the table has stirrups. Even if you do not do gynecologic exams, stirrups can be helpful for skin procedures performed in the inguinal or genital area. Consider obstetrical knee supports (crutches) with the table if you will be doing colposcopy or long procedures in which patients remain in the lithotomy position.

Individual preferences will determine if a clinician performs most procedures while sitting or standing. It is best to avoid bending over the surgical table for the health of your back and neck. It helps to adjust your table and stool for good body ergonomics. An easily adjustable pneumatic stool is advantageous. Ideally, the stool has foot-actuated controls that allow you to change the height while you are scrubbed in. Otherwise a large hand control for the height adjustment is better than a small one.

Each room should have a Mayo stand to hold surgical instruments during surgery (Figure 2-1B). Make sure these stands are stable and that the height can be adjusted. We prefer the ones with four or five wheels, rather than those with only two wheels.

Elaborate operating room facilities are not necessary to do any of the procedures described in this book, although one might wish to perform most procedures in a “clean” room that is not also being used for “dirty” procedures such as sigmoidoscopies.

Hand Instruments

Small surgical instruments can be categorized by their purpose in surgery, such as the following:

• Cutting: scalpels, razor blades, scissors, punches, curettes

• Tissue holding: forceps, skin hooks

• Undermining: scissors

• Hemostasis: hemostats or mosquitos

• Suturing and wound closure: needle holders, scissors, staplers.

Instruments used to perform excisions include scalpel handles with blades, forceps, skin hooks, hemostats, scissors, and a needle holder. High-quality instruments that will last and perform well during surgical procedures should be purchased. A high-quality needle holder is important because a poorly manufactured one will not hold needles properly. The best surgical instruments are often made in Germany, England, and the United States. Some of the less expensive surgical instruments are manufactured in Pakistan, and the quality is comparable to the cost. Poorly made disposable hand instruments should be avoided.

Cutting

Scalpels

A scalpel has two parts, the handle and blade. The four most useful blades (Figure 2-3A) for skin surgery are:

FIGURE 2-3 (A) Scalpel blades used in skin surgery. (B) Scalpel handles with ruler markings. Note the round handle was designed by a surgeon for increased dexterity during more challenging surgeries (Siegel handle).

(Copyright Richard P. Usatine, MD.)

• No. 15 blade: most commonly used blade for skin surgery.

• No. 15C blade: shorter and thinner blade with a finer point than the traditional No. 15 blade. It is useful for fine plastics work on the face.

• No. 11 blade: sharply pointed with a cutting blade on both sides, making it useful for incision and drainage of an abscess or cyst.

• No. 10 blade: larger than a No. 15 blade with the same shape. It is useful for doing a shave biopsy of a large lesion or for cutting a thick callus on the foot. Some surgeons prefer it for large skin excisions on the back because the skin is so thick in this location.

Blades are disposable and can be purchased separately or preattached to disposable plastic handles. The advantage of a totally disposable scalpel is that it eliminates the risk of being cut while attaching or removing a disposable blade from a nondisposable metal handle. The risk of being cut is low with good dexterity and experience. A needle holder or hemostat is helpful when placing a blade on the handle or taking it off. Blade-removal instruments can also be purchased. Although disposable scalpels are convenient, they are not as stable or as sharp as a metal scalpel handle with a disposable blade. For elliptical excisions and flaps, I prefer the sharp blades on a nondisposable metal handle. Special scalpel handles have been designed by surgeons for increased dexterity during more challenging surgeries (Figure 2-3B). Most metal scalpel handles come with a ruler marking for measuring the size of your surgical cuts (Figure 2-3B).

Personna Plus Microcoat blades are particularly sharp Teflon-coated blades. However, sharp disposable blades are also available from Bard-Parker, Cincinnati Surgical, and Swann-Morton. It may be worthwhile to try out more than one type to determine which one meets your personal needs and budget.

Razor Blades

The full range of razor blades (Figure 2-4) is discussed in detail in Chapter 9, The Shave Biopsy. The DermaBlade is a particularly easy and sharp blade to use for the novice and the expert. The Personna super double-edge blade is very sharp and can be broken in half for easy use. Although these do not come in sterile packaging, they can be used for shave biopsies without putting them through the autoclave. At pennies a blade, these are the most cost-effective tool for shave biopsies. They can be broken in half within their paper container to avoid cutting your hand prior to use.

FIGURE 2-4 Razors and scalpels for shave biopsies. The DermaBlade is the blue-handled blade in the bottom right corner.

(Copyright Richard P. Usatine, MD.)

Scissors

Figure 2-5 shows different types of scissors used in skin surgery. The most versatile and affordable scissor for snip excisions and cutting the base of a punch biopsy is the iris scissor, a small, sharp-tipped scissor that may be straight or curved. Use of the straight or curved iris is a matter of personal preference. The curved scissor is a bit more expensive and may allow the operator to get under a punch biopsy specimen with some ease. Scissor length varies from 3 to 5 in. The iris scissor can be used for suture removal and cutting sutures, but the ones used for this purpose should be kept separate from tissue-cutting scissors to avoid dulling your best surgical scissors. The iris scissor can also be used for blunt dissection and undermining. Scissors need periodic sharpening, but properly cleaned and treated instruments will generally last a long time and are worth the investment.

FIGURE 2-5 Assorted scissors for skin surgery: Supercut iris scissor, gold-handled iris scissor, Gradle scissor, and a tissue undermining scissor.

(Copyright Richard P. Usatine, MD.)

Gradle scissors have very small blades for fine cutting and undermining. These scissors can be invaluable with a punch biopsy of the nail matrix in which the tissue is friable and would be easy to crush if a less fine pair of scissors were used. Gradle scissors are more expensive than standard iris scissors.

Many companies make specific undermining scissors with sharp or blunt tips and sharp blades. Some of these are tenotomy scissors or Metzenbaum scissors. These could be used instead of the all-purpose iris scissor. New technologies are being used to make the blades of scissors sharper. For a premium price you can now buy scissors that are as sharp as a scalpel (e.g., Supercut scissors). Endarterectomy scissors, which have a longer handle with blunt tips, also provide excellent control and precision for delicate work, but at a somewhat higher price.¹

Punches

Punches come in sizes ranging from 2 to 10 mm. Clinicians may choose between disposable, one-use punches and reusable steel punches (Figure 2-6). Disposable punches are presterilized and need no maintenance. Reusable punches require cleaning and sterilization between procedures and must be sharpened periodically. We use disposable punches only because they are always sharp and convenient.