Surgical Procedures in the Medical Office Part 1

Surgical Procedures in the Medical Office The medical assistant might have various roles while assisting the provider with minor surgical procedures. They must ensure the comfort and safety of the patient and be knowledgeable enough about the procedures to assist during surgery with little or no direction, if required. Maintaining sterile technique, being knowledgeable about the provider’s preferences and of the surgery being performed are critical. Table 48–1 lists some of the common surgical procedures performed in the medical office along with some general information about each. Table 48–1 In-Office Minor Surgical Procedures PROCEDURE GENERAL DESCRIPTION Laceration repair Closing a wound or laceration by placing suturesto unite parts by stitching them together.or stitches or staples in the skin to hold the edges of the wound together for proper healing. Sebaceous cyst removal Excisionthe surgical removal of a foreign body or of tissue.of a small, painless sac containing a buildup of sebum, the secretion from a sebaceous gland. Incision and drainage (I&D)cutting into for the purpose of providing an exit for material, usually a collection of pus. Incision into a localized infection, such as an abscess, to drain the exudate from the area. Biopsy Excision of a small amount of tissue for microscopic examination. Specimen must be preserved in a solution of 10% formalin until transported to the laboratory and prepared for examination. Needle biopsy Fluid or tissue cells aspirated through a needle into a syringe for microscopic examination. This specimen must also be properly preserved. Cryosurger ythe use of a substance at subfreezing temperature to destroy or remove tissue. Destruction of tissue and skin lesions by using extremely cold temperatures. Electrocaut eryan apparatus used to cauterize tissue with heat from a current of electricity. Removal of benign skin lesions, such as warts and skin tags, by use of electric current. This procedure is performed when a biopsy is not required and to control bleeding during a procedure. Chemical destruction Tissue destroyed by applying silver nitrate to the area. Laser surgery A concentrated laser beam (intense light beam) destroys a target area without harming the surrounding tissue. Loop electrosurgic al excision procedure (LEEP) A thin, low-voltage, electrified wire loop removes abnormal cervical tissue. A vinegar (acetic acid) or iodine solution can be applied to the cervix prior to the procedure to help make abnormal cells more visible. Vasectomy The vas deferens is cut, separated, and then sealed by electrocautery or clamping. This prevents sperm from entering the semen, thus making a man sterile. Circumcision The removal of some or all the foreskin (the skin that covers the tip of the penis) from the penis. Debridement Excision of lacerated, dead, or contaminated tissue and removal of foreign matter from a wound. Outpatient, or ambulatory, surgery in recent years has become more acceptable than ever before for a number of reasons. Local anesthetics are used for many of the surgical procedures performed in the clinic. Additionally, general anesthesia has been significantly improved and causes fewer side effects in patients following surgical procedures, so patients awaken faster and easier. Also, the required time for many surgeries has decreased due to improved techniques and instruments such as the scopes used in laparoscopic surgeries. For example, an abdominal laparoscopy requires two to three very small incisions for insertion of the scope, suction, and possibly a third instrument. The gallbladder, growths, and tumors can be removed with this advanced technology. Because patients naturally feel more comfortable at home following the same-day surgery, most patients of all ages are sent home to recover and do so more rapidly than when in the hospital. Postsurgical infection rate has also declined in those patients who go home immediately following surgery. All this is highlighted by the reduced cost from the elimination of a hospital stay. Tray Setup for Common Surgical Procedures As discussed previously, a variety of surgical procedures are being performed in the medical office. Some procedures require very specific instruments to be used, so having a base knowledge of tray setup for a variety of the common procedures can be to your advantage. Although the types and sizes of instruments may vary from provider to provider and you should always check with their specific wants, Table 48–2 lists the instruments and supplies needed for a few of the more common procedures. Table 48–2 Tray Setup for Common Surgical Procedures Laceration Repair ITEMS PLACED DIRECTLY ON STERILE FIELD ITEMS PLACED OFF TO THE SIDE Sterile drapes Sterile gloves Needle holder Bandage scissors Appropriate suture material Bandage material (gauze, tape) Surgical scissors Antiseptic solution Tissue forceps Sterile water or saline Sterile gauze pads Anesthetic Needle/ syringe PPE Sterile cups/basins Antibiotic ointment Cotton-tipped applicators Biohazard and sharps container Sebaceous Cyst Removal ITEMS PLACED DIRECTLY ON STERILE ITEMS PLACED OFF TO THE SIDE FIELD Sterile drapes Sterile gloves Needle holder Bandage scissors Appropriate suture material Bandage material (gauze, tape) Iris scissors Antiseptic solution Hemostatic forceps Sterile water or saline Sterile gauze pads Anesthetic Needle/ syringe PPE Sterile cups/basins Packing gauze Scalpel with blade Biohazard and sharps container Alcohol wipes Incision and Drainage Procedure ITEMS PLACED DIRECTLY ON STERILE FIELD ITEMS PLACED OFF TO THE SIDE Sterile drapes Sterile gloves Scalpel with blade Bandage scissors Tissue forceps Bandage material (gauze, tape) Needle/ syringe Antiseptic solution Dissecting scissors/Hem Sterile water or saline ostat Sterile gauze pads Anesthetic Sterile cups/basins PPE Packing gauze (iodoform or plain) Biohazard and sharps container 48-3 Assisting with Minor Surgery Some providers prefer to perform minor surgical procedures themselves and have the medical assistant prepare the patient, the room, and the equipment only. However, other providers like to have the medical assistant directly involved in assisting with the procedure, and those providers usually have their own preference of how the instruments are set up and what duties the medical assistant is expected to perform. When assisting with a surgical procedure, it is critical to maintain strict sterile technique. A break in sterile technique or a breach of the sterile field can result in an infection for the patient. 48-3a Anesthetics Most in-office minor surgical procedures are performed under local anesthesiawithout sensation, with or without loss of consciousness., which the provider administers. Local anesthesia causes a loss of sensation in a specific area of the body (the area in which the procedure will be performed) as opposed to general anesthesia, which causes a loss of sensation over the entire body (unconsciousness). Quick Tips Practical Application When assisting the provider with minor surgical procedures, it is likely that you will encounter blood and other body tissue. This has been known to cause an uneasy feeling for some and even has triggered a vasovagal syncopefainting occurs when your body overreacts to certain triggers, such as the sight of blood or extreme emotional distress.episode, which is one of the most common causes of fainting. Vasovagal syncope occurs when your body overreacts to certain triggers, such as the sight of blood or extreme emotional distress. The episode causes a sudden drop in your heart rate and blood pressure, which leads to reduced blood flow to your brain and causes a brief loss of consciousness. Although vasovagal syncope is usually harmless and requires no treatment, it is possible that you may injure yourself during an episode. Therefore, if you start to feel light-headed, it is best to excuse yourself from the room, ask for assistance, sit down, and put your head between your knees until the feelings pass. The most common local anesthetic agents are Xylocaine (lidocaine hydrochloride) and Novocain (procaine hydrochloride). The provider is the one to inject the anesthetic into the area, but you might be asked to hold the vial while the provider draws up the medication (Figure 48– 1). The anesthetic usually begins to numb the area within approximately 5 to 15 minutes and will keep the area anesthetized for up to three hours. Some providers prefer to use an anesthetic with epinephrine additive to help constrict the blood vessels in the area, which prolongs the effect of the anesthetic. Figure 48–1 Hold the anesthetic solution in a convenient position so the provider can fill the syringe without contamination. 48-3b Specimen Collection In procedures requiring a biopsy for analysis, carefully labeling and handling the specimen are vital. The laboratory provides a formalin solution container for preservation of the tissue specimen. This container is sterile, and the specimen must be placed directly in the solution with sterile transfer forceps. A completed lab request form must accompany the specimen for analysis. In certain surgical procedures, such as the removal of warts or polyps, an electrocautery device may be used (Figure 48–2). Often, this controls bleeding of the surgical site by electrocoagulation. Controlled high-frequency current is applied by the provider to the surgical area to coagulatelessening of the fluidity of a liquid substance; clotting or curdling.the blood to close the incision. If the reusable tips are preferred by the provider for surgical procedures, they must be autoclaved to prevent possible cross-contamination. Disposable tips are available. Figure 48–2 An electrocautery unit. Courtesy of Bovie Medical Corporation. Another method for removing skin tags, warts, and other skin disorders and growths such as seborrheic keratosis, molluscum contagiosum, and dermatofibroma is by cryosurgery. Often, certain gynecologic treatments and surgical procedures are performed with this method. This process uses subfreezing temperature to destroy or remove tissue. Generally, the most common substance used is liquid nitrogen. Skin lesions often can be treated in a single session, although some require several treatments. Some advantages of this treatment include low risk of infection, minimal wound care, and no anesthesia. Potential side effects include bleeding, blister formation, white skin where applied, and sometimes scarring. Cryosurgery is also used as a surgical treatment to freeze and destroy abnormal tissue in the cervix that causes precancerous conditions of the cervix known as cervical intraepithelial neoplasia or abnormal cell changes in the cervix that may develop into cervical cancer. This is accomplished by the provider inserting a device called a cryoprobe into the vagina and placing it firmly on the surface of the cervix, freezing the abnormal tissue and killing the abnormal cells. Generally, the freezing is done for three minutes, the cervix is allowed to thaw for five minutes, and then the freezing is repeated for another three minutes. It is sometimes referred to as cryotherapy. Quick Tips Practical Application A careful medical history must be taken from the patient to determine possible allergic or adverse reactions. It is imperative to know of any reactions to anesthesia both local and general prior to any surgical procedure where it would be used. Ask about current medications and any over-the-counter, herbal, or diet supplements taken. This helps avoid complications during and after the procedure. If the patient discloses any significant medical history or abnormality, such as hemophiliahereditary condition, transmitted through sexlinked chromosomes of female carriers; affects males only, causing inability to clot blood.(a serious blood-clotting disease in which the absence of one of the necessary blood-clotting factors prevents blood from coagulating), you should bring it to the provider’s attention immediately. This information should be clearly documented in the patient’s EHR. Hemophilia is a sex-linked hereditary trait that occurs mostly in males. Patients who have this diagnosis must have surgery of any type only at a completely equipped, well-staffed medical-surgical hospital to protect their safety and well-being. 48-3c Bandaging Patients will present with skin sensitivities to various materials; the type of bandage the provider orders will vary and should be appropriate for the wound and for the patient’s skin. For patients who are very active or who are employed in activities that could further injure or cause the wound to become dirty or wet, the wound should be wrapped in a very thick dressing to cushion and protect it and allow it to heal. Make sure you advise the patient to keep the dressing clean and dry. Remind the patient to place a plastic bag over the extremity to keep it dry during showers or baths. If the wound is on the trunk of the body, taking a shower or bath should be discouraged unless the provider has approved it. Usually, a sponge bath is preferred until the bandage comes off. This is important in minimizing the possibility of infection. If an infection should occur, you might be asked to obtain a specimen for laboratory analysis and culture. Procedure 48–1 explains wound collection procedures. Simply use a sterile swab and insert the tip into the center of the infected area of the wound. Then transfer the swab with the specimen into the culture medium. Provide patient education regarding care of the site and when to return for a follow-up appointment. In addition, providers advise using an elastic bandage to offer more protection and support of surgical areas of the extremities, especially for pediatric and physically active patients. Application of an ACE wrap increases circulation of the area, which hastens the healing process. Refer to Chapter 54 for more information on bandage types and techniques. Procedure 48–1 Perform Wound Collection Purpose: To collect a wound culture while maintaining sterile technique. Equipment: Appropriate personal protective equipment as required by procedure, sterile gloves, sterile instrumentation, and culture swab with transport media. Skill: Instruct and prepare a patient for a procedure or treatment Skill: Perform wound collection procedures Procedure Steps Detailed Instructions and/or Rationales 1. Assemble all necessary supplies. 2. Introduce yourself and identify the patient. 3. Verify the provider’s orders. 4. The patient can be identified by asking their name and date of birth and checking the information in the chart. Explain to the patient the rationale for performance of the procedure. Criteria: Say “Today we are going to clean your wound so the doctor can get a better look at it.” 5. Remove the sterile swab from the container. 6. Collect a sterile specimen. Roll the sterile swab in the exudate. 7. Insert the sterile swab back into the culture swab container and crush the media ampule. 8. Record the patient information on the container. 9. Document the procedure in the patient’s chart. The swab should not touch any part of the wound except the exudate.