Introduction

Minor surgery in primary care has long been held to be cost-effective and popular with patients.^1,2
Following the new NHS GP contract of April 2004, minor surgery procedures in general can be divided into 2 groups:

• Those provided under additional services which do not attract an item of service fee:
  • Cryotherapy
  • Electrocautery
  • Curettage
• Those provided as part of a directed enhanced service (DES) which do attract an item of service fee:³
  • Therapeutic Injections used in a variety of conditions. These include, for example:
    • Injections into joints (steroids but also perhaps viscosupplementation)
    • Aspiration of joints
    • Injection of tennis and golfer's elbow, or carpal tunnel injection
    • Injection of varicose veins and piles
  • Excisions
  • Incisions
  • Other procedures which the practice is deemed competent to carry out

This article will focus mainly on the first group. See also the separate companion article Minor Surgery in Primary Care - Procedures Under a Direct Enhanced Service.

Deciding what level of service to offer

• A practice may decide to opt out of doing all minor surgery procedures. What procedures to offer patients will depend on a number of factors. Eligibility to offer a directed enhanced service (DES) for minor surgery is covered in the separate article (see above) dealing with minor surgery procedures in primary care, but will involve:³
  • Availability of a suitably competent partner, employee or subcontractor
  • Satisfactory facilities
  • Nursing support
  • Sterilisation and infection control compliance
  • Appropriate clinical waste disposal
  • Consent
  • Pathology services
  • Audit
  • Patient information
• If the practice has not opted out of doing the basic minor surgery procedures then these should be provided. Provision of these services again requires the surgery to have appropriate equipment and competence in the techniques.

Basic minor surgery

The following will need to be considered:

• Contractual issues:
  • What procedures are involved? Clause 81 of the new General Medical Services (GMS) contract states that 'the Contractor shall make available to patients, where appropriate, curettage and cautery and, in relation to warts, verrucae and other skin lesions, cryosurgery.'
  • Does it apply to Personal Medical Services (PMS) practices? Although it is called the new GMS contract and it was signed by all principals providing GMS, there is almost nothing in the new GMS contract that is not equally applicable to PMS.
  • Does it apply to all doctors in the practice? All doctors in a practice are not obliged to perform these procedures. The contract is with the practice as a whole; however, someone in the practice has to provide the service. Training may be required and many courses are available.⁴
  • Can practices opt out of all minor surgery? Practices can opt out. Also, clearly the service may be declined in individual cases if the doctor feels treatment is clinically inappropriate. In such circumstances the doctor is obliged to refer for further management. It may be inappropriate because of the size of the lesion, the site (near the eye or on the eyelid) or the nature of the lesion (for example, very vascular lesions or when there is a suspicion of malignancy). The referral may be to a GP or consultant colleague.
• Equipment and accommodation:
  • Most surgeries have a dedicated treatment room in which such procedures are performed but cryotherapy, electrocautery and curettage can be performed in a normal consultation room, provided that there is adequate lighting and space.
  • A clean area is not as important as for 'cutting' surgery but it is desirable and creates a favourable impression of a professional service.
  • Equipment should be appropriate to the job and of adequate specification:
    • A curette can be sharp or blunt. A sharp curette is more frequently employed, although it can cause more damage if used without skill. A range of sizes adds versatility. Disposable instruments are now recommended. A hot water boiler is inadequate and even pressurised autoclaves can no longer be recommended.^5,6,7 If there is any uncertainty about the adequacy of equipment, the Clinical Governance team of the local primary care trust (PCT) should be able to give advice.
    • Appropriate infection control measures should be in place. National Institute for Health and Clinical Excellence (NICE) guidance is available.⁸
    • Electrocautery is provided by a hot wire. This apparatus usually works on about 12 volts. This may be provided by a battery but a transformer plugged into the mains is more usual. There is a button on the handle to switch the current on and off. There may be a number of heads of various shapes and sizes for various jobs. They can be removed to be cleaned and sterilised but letting them glow red will provide a much higher temperature than any autoclave, although not for so long.
    • Cryosurgery requires a cold source and the most common is liquid nitrogen. It can usually be bought by special arrangement from a local hospital or directly from a supplier if a storage vessel is purchased. It is essential to remember that it is exceptionally cold with a boiling point of -196ºC and so requires appropriate precautions for use and storage. Thick gloves and goggles must be worn when decanting or transferring liquid nitrogen.
• Organisational issues. These procedures can be carried out:
  • In normal consultations. Most people do not perform minor surgery during the course of normal consultations except perhaps the injection or aspiration of joints and such techniques.
  • At a dedicated session. It can be better to get the patient to return to a dedicated session in a specific room with the equipment set up and, in the case of liquid nitrogen, with a fresh supply of the material to hand.
• Consent:
  • The question of informed consent is discussed in the separate article Medical Ethics. Clause 82 of the new GMS contract states: 'The Contractor shall ensure that its record of any treatment provided pursuant to clause 81 includes the consent of the patient to that treatment.'
  • Getting signed consent is good practice, as is making a record of consent in the notes (written or electronic). Informed consent requires full information on the proposed treatment, alternatives and possible complications including, for example, a measured opinion about the cosmetic result. Standardised information sheets can be useful.

Techniques

The following techniques form the basis of minor surgery provision under additional services:

Local anaesthesia

• Sometimes lesions are so superficial that they can be removed without any need for local anaesthetic. It is required for cautery but should not be used with cryotherapy.
• Lidocaine 1% is the most commonly used local anaesthetic and it can be used for these procedures. It is most conveniently administered using a dental syringe with a fine dental needle and cartridges made for the syringe.
• A lidocaine/adrenaline mixture is often used. This prolongs the duration of action, and increases the total dose that can be used; however, its greatest asset is that it induces vasoconstriction and so reduces bleeding. It must not be used on fingers, toes or the penis.
• If analgesia is required on a mucus membrane it is possible to apply lidocaine directly via a piece of gauze and this numbs the surface so that injection is less painful. It does not cross the horny barrier of keratinised epithelium in the skin and so is of no use to numb skin. For topical use, a 2% or 4% solution is acceptable but otherwise a maximum of 1% is recommended.
• Remember that after injection of local anaesthetic it is necessary to allow a few minutes for the injection to have its effect.
• Another way to obtain superficial topical analgesia is to 'freeze' the skin with an ethyl chloride spray. This is a highly volatile liquid that comes in a large ampoule with a spring-loaded rubber stopper. It is inverted over the lesion and vapour pressure of the liquid ensures that when the cap is opened a fine spray of ethyl chloride is directed at the lesion. Usually it takes about 15 to 40 seconds for the area to turn white before beginning the procedure. Although it is a convenient, it is not very effective and the duration of action is very limited. It may be necessary to stop and spray again a number of times. It is used by some for superficial curettage but use is probably not widespread.
• Ethyl chloride is highly inflammable and must not be used in association with electrocautery. It should not be used close to the eyes, nose, ears or other orifices.

Curettage

• Curettage is reserved for superficial lesions like seborrhoeic keratosis and solar (actinic) keratosis, which are usually so superficial that removal does not leave a scar.
• Keratoacanthomas can also be removed by curettage but it tends to be deeper and often leaves a scar.
• Ethyl chloride can be used for analgesia but if the lesion is thick and horny it may not penetrate and so infiltration under the lesion with lidocaine is preferable.
• Hold the neighbouring skin firmly with the non-dominant hand and, with the curette in the dominant hand, use a firm motion to get under and elevate the lesion. Sometimes a rather raw area below the lesion oozes blood. Firm pressure with a piece of gauze for several minutes should stop this. Alternatively a superficial electrocautery can seal the vessels (but not if ethyl chloride has been used).
• Removal of a keratosis often just produces a cornified lesion that is of no value for histology but, wherever possible, excised tissue should be sent for histology (to confirm the clinical diagnosis and to exclude malignancy).

Electrocautery

• Electrocautery can be a useful technique, especially when a lesion is vascular.
• The equipment used usually has a range of settings, typically from 1 to 10 (for example coagulation between 3 and 4, cutting between 6 and 10).
• Its main disadvantage is that it often burns the tissue beyond recognition so that it is impossible to get histological confirmation of the lesion. Patients sometimes find the smell of burning tissue rather distressing.
• It is useful for removal of skin tags when the diagnosis is usually clear. In obese patients these are often multiple. A little bleb of local anaesthetic is injected into the base of each.
• Remember that ethyl chloride is contra-indicated.
• After giving a few minutes for the local anaesthetic to work, grasp the lesion with a pair of forceps and press the button on the handle so that the tip glows bright red. This usually takes 5 to 10 seconds. Then touch the base of the lesion with the glowing coil and it will cut swiftly though it. The lesion comes away in the forceps and there is usually no bleeding. If there is a little bleeding then touching the area with the glowing tip should seal it.
• A few hours later, when the local anaesthetic has worn off, the patient may feel discomfort in the burned area and this may need simple analgesia.

Cryotherapy⁹

• Local anaesthesia should not be used and is not necessary.
• Cryotherapy works by rapidly freezing tissue cells which then thaw causing lysis of cells.
• Cryospray, cryoprobes or cotton tipped applicators can be used.
• The art of this technique is to apply enough cooling to destroy the lesion without applying too much and causing collateral tissue damage. If in doubt, undertreat, as it is possible to treat again, but overtreatment will destroy healthy tissue.
• The contact with the tip produces a rim of blanching. It may then freeze the lesion to the tip and it can be pulled away but more often it falls away some time later. This means that there is often no tissue for histology.
• It is recommended that the technique be learned by attending a course or from an experienced and appropriately trained practitioner.
• Knowing what to treat and what not to treat with cryotherapy is most important. Cryotherapy can be used very successfully for a variety of lesions. The list below of lesions treatable with cryotherapy is not exhaustive and does not imply that the technique is appropriate for all such lesions. An important part of learning the technique is getting familiar with what can be treated successfully and what lesions require other techniques and possibly referral.
  • Actinic keratoses
  • Seborrhoeic keratoses
  • Warts and veruccae
  • Lentigos
  • Skin tags
  • Superficial spreading basal cell carcinoma
  • Basal cell carcinoma
• It is worth avoiding:
  • Lesions on the pinna (can cause necrosis of cartilage)
  • Lesions close to the eye
  • Treatment of lesions on hands and feet in Raynaud's disease
• Complications can arise after treatment and patients should be warned of these. Blistering and pain occur frequently.

Audit

• It is good practice to audit minor surgery whether being undertaken as a directed enhanced service (DES) or not.
• Audits require accurate record keeping and consistent computer data entry. The following can usefully be recorded:
  • Number and type of procedure
  • The operator (who performed them)
  • Clinical diagnosis
  • Tissue diagnosis (adequate removal - for example, clearance in excisions)
  • Complications

Document references

1. Stainforth J, Goodfield MJ; Cost effectiveness of minor surgery in general practice. Br J Gen Pract. 1992 Jul;42(360):302-3.
2. Finn L, Crook S; Minor surgery in general practice--setting the standards.; J Public Health Med. 1998 Jun;20(2):169-74. [abstract]
3. BMA - Minor surgery - Specification for a directed enhanced service.
4. Primary Care Dermatology Society; Home page.
5. Coulter WA, Chew-Graham CA, Cheung SW, et al; Autoclave performance and operator knowledge of autoclave use in primary care: a survey of UK practices. J Hosp Infect. 2001 Jul;48(3):180-5. [abstract]
6. Scottish Executive Health Department Working Group - decontamination process. 2001.
7. Dept. of Health; The Health Act 2006: Code of Practice for the Prevention and Contol of Healthcare Associated Infections.
8. Infection control, prevention of healthcare-associated infection in primary and community care, NICE (2003)
9. Kuwahara R; Cryotherapy. eMedicine, November 2007.

Internet and further reading

• Primary Care Dermatology Society; Home page.

Acknowledgements