Biopsy Techniques

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Biopsy Techniques
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Medications

• Antiseptic solutionalcohol betadine hibiclens
• Anestheticlidocaine (Xylocaine) with or without
  epinephrine bupivicaine (Marcaine) mepivacaine
  (Carbocaine) or diphenhydramine (Benadryl)
• Sodium bicarbonate to buffer the acid
• Topical anestheticEMLA or LMX or spray coolant
  anesthetic

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• Hemostatic agents Aluminum chloride (Drysol
  Xerac AC) ferric subsulfate (Monsels soln)
  silver nitrate electrocautery pressure
  oxidized cellulose (Oxycel or Surgicel) gelatin
  sponge (Gelfoam)
• Topical antibacterials bacitracin polysporin
  neomycin mupirocin triple antibiotic ointment
  OR plain vaseline aquaphor
• Contact dermatitis to neomycin (neosporin)

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Using Lidocaine

• Epinephrine- reduces bleeding prolongs
  anesthesia (never use on fingers and penis
  caution on nose and earlobes)
• Avoid in patients with cardiac arrhythmias
• Large doses (more than 10 ml) can produce
  hypertensive episodes
• The usual adverse reaction is vasovagal
• Place patient in comfortable supine position
• To decrease pain with administration
• Slow infiltration small bore needle pinch site
  buffer with sodium bicarbonate topical
  anesthetic or ice

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Administering Anesthesia

• Instill deeper for larger/deeper excisions-will
  take 5-10 min for anesthesia on the surface of
  the skin
• Punch or shave biopsy requires little agent
  superficial instillation can be used- more
  painful quick onset
• Epinephrine requires 15 minutes to produce
  maximum vasoconstriction

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Lidocaine Allergy

• True lidocaine allergy is very rare
• Diphenhydramine
• no more than 50 mg (5 ml of 1 solution)
• Readily available weak anesthetic slow onset
• Saline Water
• Probably due to benzyl alcohol used as
  bacteriostatic agent in sterile solutions
• Discouraged may have irreversible effect on
  nerve conduction
• Saline without benzyl alcohol
• Small procedures
• Inject to produce a wheal
• Distilled water
• Painful injection

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Local Anesthesia
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Scissor Snip Removal
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Scissor Snip Supplies

• Clean gloves
• Antiseptic solution
• /- Anesthetic
• Tissue iris or skin tag scissors or blade
• Hemostasis agent or compression
• Topical antibiotic
• Band-Aid

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Scissor Snip Procedure

• Prepare the lesion and surrounding skin with
  antiseptic
• Mark the area with sterile marker if needed
• /- infiltrate the area to be removed with
  anesthetic. Wait 3-5 minutes
• Holding scissors flush with surrounding skin
  stabilize lesion and snip. Traction on the skin
  can help vs. using pick-ups (careful no to crush
  the specimen)

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• Apply hemostatic agent (will sting if anesthetic
  not used) or compression
• Topical antibacterial or vaseline
• Band-Aid or dressing

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Shave Biopsy
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Shave Excision Supplies

• Clean and sterile gloves
• Chux
• Antiseptic solution alcohol
• Anesthetic drawn in a syringe with extra thin
  needle
• Gauze pads
• Sterile marking pen
• Sterile barrier
• Fenestrated drape

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• Betadine
• Surgical blade (15) or Dermablade
• Formalin or sterile saline gauze
• Cotton-tip applicators
• Hemostatic agent
• Topical antibacterial or vaseline
• Band-Aids or dressing

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Shave Procedure

• Position for comfort (patient and provider)
• Prep area with antiseptic
• Using ring block infiltration anesthetize area
  OR anesthetize directly under lesion to produce a
  wheal
• Using scalpel or flexible blade remove lesion by
  using sawing motion back and forth (flush with
  skin or scooped)
• Apply pressure and/or cauterize use aluminum
  chloride
• Apply antimicrobial and cover with dressing

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Punch Biopsy
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Punch Excision Supplies

• Clean and sterile gloves
• Chux
• Antiseptic solution alcohol
• Anesthetic drawn in a syringe with extra thin
  needle
• Gauze pads
• Sterile marking pen
• Sterile barrier
• Fenestrated drape

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• Betadine
• Biopunch
• Suture material
• Needle holder
• Suture scissors
• Forceps with teeth
• Surgical blade or tissue scissors
• Formalin or Sterile saline gauze
• Cotton-tip applicator
• Electrocautery (check pace maker status)
• Topical antibacterial
• Dressing

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Punch Procedure

• Position for comfort (patient and provider) lie
  flat if using epinephrine
• Prep area with antiseptic
• Cover with fenestrated drape
• Anesthetize using ring block infiltration
• Using thumb and forefinger apply tension
  opposite skin lines
• Holding the punch apply direct pressure over the
  area to be excised and turn clockwise

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• Lift and remove punch device
• Using forceps or needle lift piece of skin and
  clip
• Place specimen in container of formalin (check
  barrel)
• Hemostasis or suture wound closed
• Apply antimicrobial and cover with sterile
  dressing

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Elliptical (Fusiform) Excision
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Elliptical Excision Supplies

• Clean and sterile gloves
• Chux
• Antiseptic solution alcohol
• Anesthetic drawn in a syringe with extra thin
  needle
• Gauze pads
• Sterile marking pen
• Sterile barrier
• Fenestrated drape

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• Betadine
• Surgical blade (15)
• Blade holder
• Undermining scissors
• Suture material absorbable and nonabsorbable
• Needle holder
• Suture scissors
• Forceps with teeth
• Formalin or sterile saline soaked gauze
• Cotton-tip applicators
• Electrocautery
• Topical antibacterial
• Pressure dressing

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Elliptical Procedure

• Position for comfort (patient and provider) lie
  flat if using epinephrine
• Prep area with antiseptic
• Cover with fenestrated drape
• Anesthetize using ring block infiltration
• Mark and make an elliptical incision around the
  lesion using a handled blade
• Length to width ratio is 31
• Parallel to the skin tension lines

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• A After the margins are marked the site is
  anesthetized prepared with an antibacterial
  cleansing agent and draped with sterile cloths.
  B Stabilizing the site with traction the
  epidermis on one side of the fusiform design is
  scored using a no. 15 blade.

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• C The epidermis on the opposite side is then
  scored. D The incision is completed into the
  appropriate plane in the subcutaneous tissue and
  the specimen then sits up in the middle of the
  wound like an island.

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• E The base of the specimen is dissected with
  scissors or a blade. F The wound edges are then
  undermined in the same plane as the base of the
  wound.

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• G Electrodesiccation is used to address small
  actively bleeding vessels to achieve hemostasis.
  H The subepidermal space is closed with buried
  stitches.

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• I The epidermal edges are opposed by simple
  interrupted stitches.
• 
  (Bolognia Jorrizzo Rapini 2008)

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Wound Closure

• Secondary intention
• Wound is repaired by granulation tissue
  formation epidermal cell migration and
  contraction
• Primary intention
• Closure of wound by suturing
• Same repair as above although reduced since wound
  edges are opposed

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Choosing Suture Materials

• Nonabsorbable polyester nylon polybutester
  polypropylene silk.
• Absorbable polyglycolic acid polyglactin
  (vicryl) polydioxanone catgut

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Guidelines for Suture Size and Removal
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Placing Buried Sutures

• For layered closure in wounds supports wounds
  and reduces tension on wound edges facilitates
  healing allows better epidermal approximation
  eliminates dead space
• Insert needle parallel to epidermis at the
  junction of the dermis and subcutis
• Needle curves upward and exits the papillary
  (upper) dermis and is inserted on the opposing
  edge of the wound curves down through the
  reticular (lower) dermis and exits at the base of
  the wound.
• The two ends are tied in a knot at the BASE of
  the wound

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Simple Interrupted Sutures
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Simple Interrupted Sutures

• Performed to approximate wound edges to allow
  wound to heal without infection and with minimal
  scarring
• Procedure
• Using needle holder grasp the needle at the
  distal portion of the body. Tighten the needle
  holder by squeezing until the first ratchet
  catches.
• Stabilize skin to be sutured with tension or
  forceps

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• Start sutures at center of wound
• Insert needle at a right angle into the skin 1-3
  mm from the wound edge depending on skin
  thickness
• Penetrate through the dermis
• Follow needle to the subcutaneous wound on the
  other side and bring the needle up through the
  dermis the same distance from the wound edge
• Approximate the tissue

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Knot Tying

• Pull needle and suture through so short end
  protrudes from where you began
• Rotate the needle holder clockwise around the
  long end of the suture material for 2 complete
  turns
• Use the tip of the needle holder to grasp the
  short end of the suture and pull through the
  loops you just created
• The needle holder is then rotated
  counter-clockwise once around the long end of the
  suture the short end is grasped using the needle
  holder tip and pulled through again
• Repeat the above step 2 more times to complete
  you knot before cutting your excess suture
  material and starting your next knot
• knot to one side of the suture line

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Wound Care with Sutures

• Keep dressing dry and intact for 24 hours
• If blood soaks through reinforce with more gauze
• Call office if bloody seepage doesnt stop with
  bandage change or pressure
• After 24 hours shower let water run over
  stitches pat dry with a clean towel
• Apply topical antibiotic or vaseline and a clean
  band-aid
• If the skin becomes wet wrinkled and soggy
  underneath the band-aid remove it for a few
  hours and continue to apply the ointment
• Continue to shower daily as above and apply new
  band-aid until sutures are removed

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Wound Care without Sutures

• Keep original dressing dry and intact until
  following morning
• Following morning remove bandage and shower
  letting water run over the wound pat dry with
  clean towel
• Apply antibiotic ointment or vaseline and a clean
  band-aid
• If the skin becomes wet wrinkled and soggy
  underneath the band-aid remove it for a few
  hours and continue to apply the ointment
• Continue above until re-epithelialized (2-3
  weeks)
• Call the office if the sore has not healed in 3-4
  weeks

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Wounds and Swimming

• Do not swim with sutured wounds for at least 5
  days
• After 5 days short periods okay waterproof
  band-aid
• Suture line can dehisce if the skin gets too
  soggy
• For wounds not sutured use antibiotic ointment
  or vaseline and a waterproof band-aid.
• Soggy wounds do not heal well
• Swimming with wounds may be frowned upon by pool
  staff
• Bathing usually requires longer contact with
  water running the risk of the skin getting soggy
  and not healing well
• For children who cannot shower have them stand
  in the tub and rinse

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Wound Care Pearls

• Better results with pressure dressings
• Better results when a crust is not allowed to
  form on the suture lineplus it hurts when
  sutures are removed
• Better results when a crust or scab is not
  allowed to form on the woundalso less irritation
  and itching
• Best if wound is kept clean with ointment
  appliedwounds heal in a clean moist environment
• Soggy wounds dont heal well

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More Pearls

• Let patients know that it may take 2 weeks for
  the pathology to come back.
• Have nurse contact patients of normal results
• Contact patients yourself if the diagnosis is
  cancer or the plan is more complex
• Patients appreciate some form of communication
  whether good or bad news
• Avoid phone calls on Fridays. If you dont get
  in touch with them theyll be worried all
  weekend

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Safety

• Scope of practice/practice agreement
• Patient consent
• Syncope protocol in place
• Universal precautions/eye protection
• Sharps precautions
• Trust and communicate with your
  dermatopathologist discuss results with
  physician know who to refer to

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Contact Information

• Margaret J. Constante MSN FNP-BC
• mconstante_at_comderm.com
• Commonwealth Dermatology PC
• 7001 Forest Avenue Suite 300
• Richmond VA 23230

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Hands-on Workshop

• Margaret Constante MSN FNP-BC
• Donna Jarvis MSN ANP-BC
• Amy Black MSN ANP-BC
• Rosie Taylor MSN ANP-BC
• Kathryn H. Scribner RN MSN RNFA CNOR FNP-BC

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References

• Anderson KN Anderson LE and Glanze WD.
  (1994). Mosbys medical nursing allied
  health dictionary (fourth edition). St. Louis
  MO MosbyYear Book Inc.
• Bennett RG. (1988). Fundamentals of cutaneous
  surgery. St. Louis MO The C.V. Mosby Company.
• Bolognia JL Jorrizzo JL Rapini RP et. Al.
  (2008). Dermatology (second edition). Spain
  MosbyElsevier.
• Collette PL. (2006). Medical encyclopedia
  skin biopsy on-line. Available
  www.anwers.com/topic/skin-biopsy
• Hill MJ. (2003). Dermatologic nursing
  essentials a core curriculum (second edition).
  Pitman NJ Dermatology Nurses Association.

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• MacKay-Wiggan J Ratner DR. (2007).
  Suturing techniques on-line. Available
  http//www.emedicine.com/derm/topic828.htm
• Robertson J Shilkofski N. (2005). The
  Harriet Lane handbook (seventeenth edition).
  Philadelphia PA Elsevier Mosby.
• Wolf K Johnson RA Suurmond D. (2005).
  Fitzpatricks color atlas synopsis of clinical
  dermatology (fifth edition). New York NY
  McGraw-Hill Medical Publishing Division.
• Wright W Blasen L (2005). The midatlantic
  regional conference common dermatological
  procedures. Unpublished manuscript.