Excision of skin tumor

The risk of complications such as hematoma and infection is very small with excision of skin tumor.

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Excision of skin tumor

Indication

• In case of suspicion of malignancy or in case of need for histological diagnosis
• For functional or aesthetic problems

Contraindication

• Bleeding disorder (relative)
  • It will often be time for a regulation of this problem
  • Minor surgical procedures in the skin can easily be performed even if the patient is in AK treatment
• Compromised wound healing
  • May be a relative contraindication

Patient preparation

• Consider possible previously similar tumors or malignancy
• Consider possible drug treatment
• Clinical examination of the skin, possibly regional lymph nodes on suspicion of malignancy
• Biochemical assessment is usually not relevant

Information for the patient

• The procedure is performed under local anesthesia, the injection causes short-term burning and then gives pain relief. The patient will be able to feel that you are touching the skin
• In areas with tightly bound skin (eg nose and big toe) injection of local anesthetic may be uncomfortable
• Postoperative limitations, e.g. keep one extremity still and elevated
• The risk of complications such as hematoma and infection is very small with excision of skin tumor
• The procedure may leave a visible scar

Equipment

• Lidocaine, mepivacaine or bupivacaine
  • Resolution 1-2%
  • Added vasoconstrictor to reduce bleeding and prolong the effect of the anesthetic
  • Vasoconstrictor, often adrenaline, is permissible under local anesthesia in all regions incl. ear, penis, fingers / toes, which is a change from the more cautious attitude of the past
• Surgical equipment
  • Scalpel, surgical forceps, scissors and needle holder
  • Electrical coagulation if possible
• Anaphylaxis prophylaxis
  • There should be easy access to sufficient equipment to treat any. anaphylactic shock or more frequently: vasovagal seizures

Procedure

• The patient is positioned so that there is a good overview of the surgical field and it is easily accessible. The patient should also lie down comfortably – and thus calmly
• The skin is disinfected several cm outside the surgical field
• Ideally, cover with sterile covers or a hole
• Draw the planned incision lines on the skin in the slit direction of the skin. It gives the nicest scar and least tightening when closed
• An elliptical excision with a length of approx. four times wide, “donkey ears” are avoided
• Anesthesia
  • Infiltration anesthesia is placed in the recorded incision lines
  • Possibly. wiring block is laid as early as possible as it only works after a few minutes. The same goes for vasoconstrictors
  • Check that the local anesthetic works by gently poking into the recorded area
• Radicality
  • At excision biopsy, a 1-2 mm incision of normal skin around the tumor is made
  • If malignant melanoma is suspected, up to 5 mm normal skin is taken, depending on the location
  • In the radical treatment of benign tumors, a maximum of a few mm of normal tissue is included
  • In non-melanoma skin cancer, ie keratinocyte carcinomas, a 5-10 mm border is taken, depending on the type and location
• Reference
  • Patients with malignant melanoma, dermatofibrosarcoma protuberans and other highly malignant tumors should be referred for radical treatment in plastic surgery wards
• The incision
  • The incision is placed perpendicular to the surface down into the upper subcutis with a sliding motion along the entire length of the incision so that it becomes a smooth incision.
  • Then cut sharply to the appropriate depth and remove the specimen in one piece
  • If the diagnosis is known, cut to the appropriate depth
  • The procedure should be made as traumatic as possible. The tissue is manipulated as gently and gently as possible, and tissue handling instruments are used
• The preparation
  • When removing several separate elements, the marking must be clear, so that any. pathology is unique
  • If it is important, the preparation should be marked with e.g. a suture to make the orientation unique
• Closure
  • Coagulate significant sources of bleeding
  • Close the subcutis if there will otherwise be a cavity
  • The dermis is closed separately if there is a large pull on the wound lips, the risk of scar tissue formation in the skin is reduced.
  • The skin is closed with single nodules or continuous suture, intra- or percutaneously at the surgeon’s assessment
  • Use as thin sutures as possible – on the head (except the scalp), neck and hands are used 5-0 to 7-0; otherwise 3-0 to 4-0
  • Use as few sutures as possible – so close that the wound does not yawn, often 2-3 mm for 6-0, 5-6 mm for 3-0
  • Tighten as little as possible – the wound edges are approximated, they are not laced together
• Removal of sutures
  • In the head-neck region in adults, sutures of 3rd-6th are removed. day
  • On trunk and upper extremities on 7.-10. day
  • On lower extremities on 10.-14. day
  • Sutures should be removed early if suture marks are to be avoided. Possibly. the wound can be relieved the following days with transverse patches
• Bandaging?
  • If the wound can be kept dry and clean, there is really no need for bandaging
  • For practical reasons, a bandage should be applied, which seals the wound for a minimum of 24 hours
  • A piece of paper patch that remains for suture removal is usually sufficient, but an occlusive bandage increases the rate of epithelialization and thus reduces scarring.
• Drain?
  • Not usually needed
• Prophylactic antibiotics?
  • Is only indicated by increased risk of infection and is then given as a one-time prescription immediately before the procedure

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