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Library of Congress Cataloging-in-Publication Data
Names: Mohan, Helen, 1983- editor. | Winter, Desmond, 1969- editor.
Title: Minor surgery at a glance / edited by Helen Mohan, Desmond Winter.
Other titles: At a glance series (Oxford, England)
Description: Chichester, West Sussex : John Wiley & Sons, Ltd,
2017. | Series: At a glance series | Includes bibliographical references
and index.
Identifiers: LCCN 2016019921 (print) | LCCN 2016020560 (ebook) | ISBN
9781118561447 (pbk.) | ISBN 9781118561423 (pdf) | ISBN 9781118561430 (epub)
Subjects: | MESH: Minor Surgical Procedures--methods | Perioperative Care |
Handbooks
Classification: LCC RD111 (print) | LCC RD111 (ebook) | NLM WO 39 | DDC
617/.024–dc23
LC record available at https://lccn.loc.gov/2016019921
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Cover image: © Getty/image source
Tan Arulampalam, Chapters 2, 3
Robert Baigrie, Chapter 36
Ishwarya Balasubramanian, Chapters 26, 28
Andrew J Beamish, Chapter 39
Dara Breslin, Chapters 14, 16
Michelle Carey, Chapter 13
Michael Chung, Chapter 24
David J Clark, Chapter 47
Maura Cotter, Chapter 8
Denis Cusack, Chapter 1
Joana Ferrer Fábrega, Chapter 34
Christina Fleming, Chapter 27
Charlotte Florence, Chapter 47
Jessica J Foster, Chapter 39
Greg Fulton, Chapter 37
Olivier Gié, Chapters 9, 21, 22, 23
Amy Godden, Chapter 33
Graeme JK Guthrie, Chapter 30
Hanafiah Harunarashid, Chapter 17
Masakazu Hasegawa, Chapter 38
Anna Heeney, Chapter 37
Paul Horgan, Chapter 30
Steve Hornby, Chapters 13, 46
James Horwood, Chapter 47
Michael Hu, Chapter 43
Jeong Hyun, Chapter 32
Farrah-Hani Imran, Chapter 17
Anand Alister Joseph Ramachandran, Chapter 15
Josep M Grau Junyen, Chapter 34
Mortimer Kelleher, Chapters 14, 16
Genevieve Kelly, Chapters 25–28
Michael Kelly, Chapter 35
Rory Kennelly, Chapter 45
Brian Kirby, Chapters 25–28
Walter Koltun, Chapters 19, 20
Nik Ritza Kosai, Chapter 17
Stavros Koustais, Chapter 31
David Lo, Chapter 18
Michael T Longaker, Chapters 18, 24, 32, 38, 42, 43
Marie-Laure Matthey, Chapters 9, 22
Adrian McArdle, Chapters 18, 24, 32, 38, 42, 43
Frank D McDermott, Chapters 5–7, 33
Keno Mentor, Chapter 36
Helen Mohan, Chapters 4, 23, 25, 31, 37, 41, 48
Nigel Noor, Chapters 2, 3
Maeve O'Connor, Chapter 14
Peter Radford, Chapter 29
Meenakshi Ramphul, Chapter 12
Rish Sehgal, Chapters 19, 20
Kshemendra Senarath-Yapa, Chapter 42
Rishi Sharma, Chapter 29
Neil Smart, Chapters 5-7
Abel Wakai, Chapters 10, 11, 45
Derrick Wan, Chapters 18, 24, 32, 38, 42, 44
Rory Whelan, Chapters 10, 11, 45
Adam Williams, Chapter 40
Des Winter, Chapters 4, 23, 31, 35, 41, 43, 44
This title is also available as an e-book.
For more details, please see
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Minor surgery is a generic term encompassing a variety of elective and emergency procedures. The term minor surgery can be misleading, as these operations are far from trivial and serious consequences can arise. Therefore, minor surgery requires due care and consideration. This book provides an overview of minor surgical techniques and common minor surgical procedures.
The first half of the book deals with general principles of minor surgery. These include non-technical factors, for example, how to deal with patients and their families, consent, and technical considerations such as asepsis, wound closure and choice of suture material. The second half of the book covers common minor procedures in both the elective and emergency setting.
This book does not attempt to provide an exhaustive review of minor surgery, but rather to provide a useful starting point to adjunct clinical learning for those embarking on minor surgery, including surgical trainees, GPs and emergency medicine physicians.
Helen Mohan
Des Winter
This medico-legal summary is based on current laws in Common Law jurisdictions (those which have their roots in the English legal system). The principles are, however, applicable to medical practice across other legal systems.
A doctor is obliged to obtain a patient’s prior agreement to any proposed treatment, intervention or procedure. This respects the patient’s right to be involved in their healthcare decisions. Consent may be implied from the conduct of the patient or circumstances of the consultation. But where there is an intervention or procedure with potential side effects or adverse outcome, then express consent, either verbal or written, must be obtained. Allegations of clinical negligence in cases of adverse or unexpected outcome now frequently include an allegation of failure to obtain proper informed consent in addition to allegations of negligent performance standard.
The patient should be given information regarding:
The patient must also be told that they are free to refuse treatment or to withdraw their consent at any time prior to the treatment.
Different levels of detail are required to be given depending on the nature of the intervention. In all cases, the standard is what a reasonable person would expect to be told in order to make a fully informed decision. The standard level of information given to the patient must include an explanation of any frequent minor risks and of major risks (even if infrequent), which are sometimes referred to as ‘material risks’. In the case of medical necessity for the procedure there is a general and approved practice not to disclose minimal risks that might cause unnecessary anxiety and stress or might deter the patient from undergoing necessary treatment, but this must be the exception rather than the rule. When the procedure is not a medical necessity (sometimes called ‘elective’), the required standard of information provision is higher and tends towards full disclosure. Disclosure must also include direct and full response to specific questions raised by the patient about the procedure, including any complications. It is the substance of the disclosure that is critical to the validity of the consent rather than the mere formulaic existence of a written and signed consent form.
The legal analysis of the meaning of material risk by the Courts has changed in recent times. The question of risk is no longer solely determined by the standards of the medical profession but is judged by the significance a reasonable patient would attach to the risk of the proposed treatment or intervention. What constitutes material risk involves consideration of both the severity of the potential consequences and the statistical frequency of the risk.
A competent adult patient must make the decision about a treatment or intervention themselves. No one else is entitled to make that decision for them. If not competent, then other persons may be in a position to contribute to such a decision using a combination of tests of substituted judgment (as if standing in the shoes of the patient) and ‘best interests’ of the patient. In the event of a dispute between next-of-kin and/or health carers over such a decision, the Courts may ultimately be asked to make the decision.
In the majority of Common Law jurisdictions, statute laws are in place by which a child under 18 years but who is 16 years or over is considered legally competent to give consent to medical, surgical or dental treatment. However, doctors should be familiar with local, national or state legal provisions that provide for varied age thresholds (e.g. from 14 to 18 years). The parents or legal guardians of a child under the relevant legal age are considered entitled to give consent on behalf of the child. A mature child under that age may in certain defined circumstances be considered competent. The Courts will have the ultimate decision where a dispute arises or where the refusal of treatment is considered potentially detrimental to the child.
Great care must be taken in circumstances where the capacity of the adult patient to make decisions is in doubt. In cases of dispute or in the absence of clear agreement or legal authority, the Courts will be the ultimate decision maker.
When a doctor is faced with a situation where there is doubt about the validity of the consent of the patient or where there is disagreement about treatment or intervention when a patient is not considered competent to make such a decision, the doctor is advised to seek immediate expert medico-legal advice from their medical indemnity organisation. The only exception in this scenario is in circumstances of medical emergency where there is an immediate danger to the health or well-being of the patient, when the doctor may have to act in the patient’s best clinical interest. Doctors should also seek such expert advice if in doubt in any specific consent situation.
Minor surgery should ideally be conducted in an environment specifically designed for that purpose. Minor surgery services may be separated from the inpatient hospital environment in favour of hospital-integrated units or community-based free-standing units (often referred to as Treatment Centres or Ambulatory Care and Diagnostic Centres (ACADs) in the UK). There are several advantages and disadvantages to hospital-based versus community-based units (Table 2.1). Patient selection is key if using a community-based unit, as the same backup is not present as in the hospital environment.
Minor surgery facilities can be configured in a number of ways but generally require a day ward or waiting area to receive patients, operating theatres or procedure rooms and a recovery area for rehabilitation. In the hospital setting, anaesthetic rooms are often also used. Modernisation of medical practice has led to the replacement of beds in favour of trolleys and chairs to reduce space requirements and also to promote earlier mobilisation to aid recovery.
For general practitioners setting up a minor operating facility, it is important to be aware of health and safety legislation and to ensure that sterilisation of equipment, sharps disposal and use of chemicals such as liquid nitrogen complies with relevant health and safety legislation.
The physical layout of the operating suite can be variable; however, recognition of the importance of reducing contamination to reduce wound infection has led to the delineation of clean, hazardous and contaminated areas as seen here.
Unrestricted – contaminated
These include the patient receiving area, dressing rooms, lounges and office.
Semi-restricted – hazardous
These include hallways, instrument and supply processing area, storage areas and utility rooms.
Restricted – clean
These include the operating theatre, scrub sink areas and sterile supply rooms.
The surgery-operating suite must be spacious to allow scrubbed personnel to move around non-sterile equipment without contamination. In addition, it must be easy to clean – uncluttered and simple so that dust is not trapped in areas that would be difficult to clean. Surfaces must be durable and easy to clean to reduce contamination.
Guidelines for the design of new operating theatre facilities advocate positive pressure ventilation of 25 exchanges per hour of filtered air. Windows should not be opened. However, a facility with natural ventilation is acceptable for most minor surgical procedures. If using natural ventilation, windows can be opened but only if they have an adequate fly screen. Humidity is controlled to 50–53% to achieve minimal static and reduce microbial growth. Temperature is maintained at 20–24 °C.
It is important to have appropriate lighting – both in terms of overhead room lights and surgical spotlights for the operative site. The operating table should be adjustable for height, degree of tilt in all directions, orientation in the room, articular breaks and length.
It is important to have a telephone to contact outside assistance. Emergency numbers should be clearly displayed.
Anaesthesia equipment and monitoring as appropriate to the surgery must be present and in good condition. Anaesthetic machines must be checked at the start of every case.
Fire safety is crucial and the theatre should be designed in keeping with fire regulations.
