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Biopsy Techniques

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Title: Biopsy Techniques


1
Biopsy Techniques
2
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

3
  • 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)

4
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

5
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

6
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

7
Local Anesthesia
8
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9
Scissor Snip Removal
10
Scissor Snip Supplies
  • Clean gloves
  • Antiseptic solution
  • /- Anesthetic
  • Tissue, iris or skin tag scissors or blade
  • Hemostasis agent or compression
  • Topical antibiotic
  • Band-Aid

11
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)

12
  • Apply hemostatic agent (will sting if anesthetic
    not used) or compression
  • Topical antibacterial or vaseline
  • Band-Aid or dressing

13
Shave Biopsy
14
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

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

16
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

17
Punch Biopsy
18
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

19
  • 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

20
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

21
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22
  • 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

23
Elliptical (Fusiform) Excision
24
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

25
  • 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

26
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

27
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28
  • 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.

29
  • 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.

30
  • 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.

31
  • G Electrodesiccation is used to address small
    actively bleeding vessels to achieve hemostasis.
    H The subepidermal space is closed with buried
    stitches.

32
  • I The epidermal edges are opposed by simple
    interrupted stitches.

  • (Bolognia, Jorrizzo Rapini, 2008)

33
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

34
Choosing Suture Materials
  • Nonabsorbable polyester, nylon, polybutester,
    polypropylene, silk.
  • Absorbable polyglycolic acid, polyglactin
    (vicryl), polydioxanone, catgut

35
Guidelines for Suture Size and Removal
36
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

37
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38
Simple Interrupted Sutures
39
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

40
  • 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

41
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
  • Slide knot to one side of the suture line

42
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

43
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

44
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

45
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

46
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

47
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

48
Contact Information
  • Margaret J. Constante MSN, FNP-BC
  • mconstante_at_comderm.com
  • Commonwealth Dermatology, PC
  • 7001 Forest Avenue, Suite 300
  • Richmond, VA 23230

49
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

50
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.

51
  • 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.
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