At a recent workshop in sydney conducted by Maurice he summarized his observations.
There were participants from all over Australia with different skills levels but who are generally quite experienced and working in a variety of situations. A common theme was doctors wanted to refresh there skills, get a few tips on knot tying, suturing, management of wounds and lacerations. Some wished to address specific topics such digital block whilst many wanted to compare and enhance their procedural skills.
C.M.E demands a certain amount of theory. It appears they appreciated however, going back to the basics regarding such topics as the properties of local anaesthesia.
We attempted to impart principles we feel are important in carrying out office surgery.
This included managing the types of haemorrhage that may occur during and following a procedure. The methods to reduce and control bleeding by utilizing tissue planes, pressure with packing, artery forceps and deep suturing were discussed. Some use diathermy, others don’t.
The types of wound healing, primary, delayed primary closure and healing by second intention were discussed. Examples of how these were appropriate were demonstrated.
A session on excision of lumps and bumps included diagnoses and surgery of in particular lipomata and sebaceous cysts.
From a diagnostic point of view outliers such as malignancies, liposarcoma and secondary melanoma were mentioned. The inflammatory changes can give an overlying erythema.
There was the opportunity to practice excisions. For the large infected cyst drainage alone may be appropriate. If totally excised the doctors practised a method of dealing with the dead space by inserting a pack which is removed in a couple of days.
In these workshops we attempt to share the learning experiences as we also made our own way in surgical practice. Feed back has shown that doctors learn from the problems we have encountered. An example I cited were the problems encountered with haematoms or infection which may develop in large dead spaces and the measures taken to reduce the problem.
With a definitive plan based on matching aetiological or pathological processes with physical signs a diagnoses is usually possible. It could even help in identifying unusual conditions such as a neurofibroma or leiomyoma where mobility is usually only in the one direction.
We discussed informed consent including the rare case of sympathetic ophthalmia in the second eye and its consequences – comparing this to the possibility of testicular damage in hernia repair when there is only a single normal testis on that side.
We also pointed out that each area of the body has its specific characteristics to consider in diagnosis and surgical risk e.g. keloid scar in skin over sternum. Or an infected cyst over the glabella requiring urgent treatment to reduce risk of cerebral spread of infection.
The location of the lump, in skin, attached to skin and deeper could all be used to help in diagnosis. This is then used in an assessment of the pros and cons of carrying out surgery in the office setting .
POSITION, POSITION, POSITION
Why the surgeon can be compared to a real estate agent.
Thus we discussed the diagnosis, suitability for office procedure, the surgical equipment, the local anaesthetic and the theory behind their use.
Lignocaine, being an acidic solution stings. We mentioned that sodium bicarbonate can be used to reduce the sting and speed up the onset of action. 2 ml of 4.8% concentration would be added a 20 ml solution of 1or 2% of lignocaine. I have no experience with it.
Suture materials could be
- absorbable or non absorbable
- natural such as catgut or silk
- monofilament or multi (- braided )
Correct knot tying was practiced. Many now appreciate the importance of locking the suture after the first double throw.
A variety of suturing techniques were practiced. The emphasis was on the everting suture.
There was the interrupted, vertical and horizontal mattress, deep and sub-cuticular Many were interested in the subcuticular suture using absorbable suture with a buried Aberdeen knot (a crochet stitch).
The use of and management of vertical and horizontal mattress suture was practiced. These helped evert the skin edge and could be placed deeper helping with obliteration of deep space instead of deep suturing.
We did provide some flyers but we are sending you some online which you are welcome to share with your colleagues.
Here we attempted to use our judgment in deciding to manage injuries such as clean or dirty wounds
- To suture or not
- To freshen edges
- Too a debride
During the course of the workshop we discussed, sometimes to individual groups, anal conditions such as perianal haematoma, pilonidal abscess and warts. We also spoke about the diagnosis and treatment of plantar warts and callouses as well as mentioning briefly a few other types of blocks. All these could be topics for future workshops.
Presented on behalf of the specialists at THE MELBOURNE HERNIA CLINIC
– by A/Prof. Maurice Brygel surgery for presentations was also conducted by Charles Leinkram
www.hernia.net.au. Tel.03 95259077 at
Masada, Mitcham & Sir John Monash Private hospitals
A/Prof. Maurice Brygel