Minor Surgery in Primary Care - Procedures Under a Direct Enhanced Service

There is evidence from around the world and in the UK that minor surgery procedures carried out by general practitioners are popular with patients and highly cost-effective.^1,2 Since 1990 general practitioners on Health Authority minor surgery lists have been eligible to undertake a range of procedures and receive payments for doing so. Since 2003 a directed enhanced service (DES) can be commissioned by every Primary Care Organisation with the aim of expanding the range and extent of minor surgery in primary care.

See also the companion record - Minor Surgery in Primary Care - Basic Procedures.

Cryotherapy along with curettage and cauterisation are procedures commonly undertaken at a primary care level but not part of the DES.¹ Procedures that are covered in the DES include the following:

• Injections into muscles tendons and joints
• Invasive procedures:
  • Incisions
  • Excisions
• Injections of varicose veins and piles
• Other procedures which the practice is deemed competent to carry out

Eligibility requires:

• Partner, employee or subcontractor with the necessary skills to carry out contracted procedures as well as:
  • Competence in resuscitation
  • Regular update of skills
  • Ability to demonstrate a continuing and sustained level of activity
  • Conducting regular audits
  • Participation in appraisal of minor surgery activity
  • Participation in supportive educational activities
• Satisfactory facilities:
  • Appropriate equipment for procedures undertaken
  • Appropriate equipment for resuscitation
  • Appropriate premises³
• Nursing support:
  • Appropriately trained and competent
  • Professionally accountable to their professional body
• Sterilisation and infection control compliance (see below)⁴
• Appropriate clinical waste disposal
• Consent:
  • After information on treatment options and treatment details
  • Should be in written form and filed in patient record
• Pathology services:
  • All specimens to be sent for histology unless exceptional reasons not to do so
• Audit:
  • Full accessible records
  • Regular audit- for example clinical outcomes, infection rates, incomplete excision rate
  • Regular peer review
• Patient information:
  • Proper written record
  • Inform own GP in writing if not registered with the practice

Making an incision

The example here uses the excision of a small skin lesion to show the basic techniques required to minimise the scar and the chance of complications. It uses a spindle-shaped incision either following the direction of skin creases or designed to minimise skin tension in joint areas.⁵ The following steps are involved:

• Draw the incision line, allowing at least 2mm margin from the lesion. The length of the incision should be at least 3 times its width to help with producing a neat closure.
• Clean and sterilise the skin then anaesthetise the area and wait for it to take effect
• Stretch the skin at 90° to the incision with two fingers of your left hand and, holding the scalpel vertical to the skin, cut outside the line. On hairy skin cut at the angle the hairs exit the skin.
• You should try to cut down to the subcutaneous fat in one stroke but avoiding reaching the deep fascia. Remember that skin varies in thickness over the body. Try not to 'fish-tail' at the ends of the wound.
• Take special care in those areas where important structures lie close to the surface, e.g.:
  • Side of the face near the ears
  • Neck
  • Axillae or Popliteal fossa
  • Wrist or palmar aspect of fingers
  • Femoral or inguinal triangle
  • Shins

Performing skin biopsy

• Area of skin needs to be removed with minimum damage for optimum examination results:
  • By using either a skin hook or a silk suture at a corner of the specimen instead of forceps
  • By gently dissecting skin away from subcutaneous fat using blunt-tipped scissors using “separate and snip”
• The specimen is then placed in 10% formalin in saline and sent to the laboratory²

Suturing

• For small wounds not under tension, the edges can held together with adhesive closure strips or enbucrilate glue.
• Skin suturing is usually performed with monofilament nylon or polypropylene and a curved or half-circle cutting needle.
• Subcutaneous suturing is no longer performed with absorbable chromic catgut and synthetic absorbable materials are now used.
• A reverse cutting needle is used when the sutures are unavoidably near to the edge of the wound or the wound is under tension.
• All knots should be reef knots with an additional third throw and 5mm tails left for easy removal.
• Superficial wounds should be closed with the finest suture material available using entry and exit points that equally spaced both either side of the wound and along its length.
• With deeper wounds, subcutaneous tissue needs to be closed first using either interrupted deep sutures or vertical mattress sutures, cut to the knot.

Intra-operative complications

Fainting

Incidence can be reduced by having patient lie down during the procedure. If syncope does occur, put the patient in a head-down position. May need to insert an airway if breathing is at all compromised. Patient should soon recover so that the procedure can be quickly finished. If bradycardia does not resolve consider giving atropine.

Bleeding

Significant haemorrhage is not normally a difficulty in minor surgery but if it does occur the normal haemostatic measures are usually effective, e.g. apply firm pressure with a dressing for 2 minutes and raise the affected areas above the heart. If this fails, introduce a little of the adrenaline-containing anaesthetic or an haemostatic agent (aluminium chloride or ferric sulphate) into the wound. Physical methods include squeezing bleeding points with fine forceps and ligaturing small blood vessels with absorbable sutures.

Resuscitation

This should be conducted when required according to the appropriate guidelines.⁶ Regular training in resuscitation is necessary for medical and nursing staff involved in minor surgery.¹

Dressing the wound

Small wounds generally just need a plaster and more extensive areas should be covered with an absorbent, non-adherent dressing held in place with a Micropore tape or a bandage depending on the site. Opsite spray is a convenient alternative in difficult areas.

Aftercare

Patients should be told to rest the affected area and raise any leg involved. Arms can be placed in a sling and fingers or toes immobilised by strapping together with the adjacent digit. Sutures are removed at between 5 and 12 days depending on the site, with the hands and feet requiring the longest interval. This gives an opportunity to also inspect the wound for any problems, such as infection or failure to heal.

See separate article Infection Control and Instrument Sterility for Minor Surgery.^7,8 From 31 March 2007 the Department of Health requires that all instruments used must comply with the Medical Devices Directive. This directive is backed by the Health Act (2006) with the associated Code of Practice for the Prevention and Control of Healthcare Associated Infection. Enforcement of this code will be by the Healthcare Commission who will have the power to make improvement recommendations and serve improvement notices.⁴ It is envisaged in the light of these changes that many practices, particularly small practices, will opt to comply by using disposable instruments.