Using technology tools

Transcription

1 Using technology tools S008: Dermatologic Surgery Pearls: Optimizing Safety, Satisfaction, Efficiency February 16, 2018 Jayne Joo, MD Director of Mohs surgery, Sacramento VA Medical Center Assistant Clinical Professor, Department of Dermatology, University of California, Davis

2 Disclosure I have no relevant relationship with industry.

3 Outline Efficient undermining Adhesive strip skin closure Negative pressure device Phone based apps

4 Undermining techniques Cold steel Sharp Blunt Electrosurgery

5 Electrosurgical Undermining Advantages Decreased operative time Decreased bleeding Disadvantages Collateral tissue damage Wound edge necrosis Vascular compromise Chen DL, Carlson EO, Fathi R, Brown MR. Undermining and Hemostasis. Dermatol Surg Oct;41 Suppl 10:S

6

7 Undermining with bi-terminal electrosurgical unit

8 Surgical smoke Health risk Particulate matter Toxic chemicals Infectious agents Lewin JM, Brauer JA, Ostad A. Surgical smoke and the dermatologist. J Am Acad Dermatol Sep;65(3): Patient dissatisfaction Yonan Y, Ochoa S. Impact of Smoke Evacuation on Patient Experience During Mohs Surgery. Dermatol Surg Nov;43(11): Golda N, Huber A, Gole H. Determining the impact of intraoperative smoke evacuation on the patient experience during outpatient surgery: A Randomized Controlled Trial. J Am Acad Dermatol Nov 11. pii: S (17)

9 Surgical smoke Ablation of 1 gram of tissue produces a smoke plume with an equivalent mutagenicity to 6 unfiltered cigarettes On average the smoke produced daily in plastics OR was equivalent to 27 to 30 cigarettes Hill DS, O'Neill JK, Powell RJ, Oliver DW. Surgical smoke - a health hazard in the operating theatre: a study to quantify exposure and a survey of the use of smoke extractor systems in UK plastic surgery units. J Plast Reconstr Aesthet Surg Jul;65(7):911-6.

10 1,000 Mohs cases/year = 50 hours of continuous smoke exposure Oganesyan G, Eimpunth S, Kim SS, Jiang SI. Surgical smoke in dermatologic surgery. Dermatol Surg Dec;40(12):

11 Chemicals identified in surgical smoke Acetonitrile Furfural (aldehyde) Acetylene Hexadecanoic acid Acroloin Hydrogen cyanide Acrylonitrile Indole (amine) Alkyl benzene Isobutene Benzaldehyde Methane Benzene 3-Methyl butenal (aldehyde) Benzonitrile 6-Methyl indole (amine) Butadiene 4-Methyl phenol Butene 2-Methyl propanol (aldehyde) Formaldehyde 3-Butenenitrile Methyl pyrazine Carbon monoxide Phenol Creosol Propene 1-Decene (hydrocarbon) 2- Propylene nitrile 2,3-Dihydro indene Pyridine Ethane Pyrrole (amine) Ethene Styrene Ethylene Toluene (hydrocarbon) Ethyl benzene 1-Undecene (hydrocarbon) Ethynyl benzene Xylene Hill DS, O'Neill JK, Powell RJ, Oliver DW. Surgical smoke - a health hazard in the operating theatre: a study to quantify exposure and a survey of the use of smoke extractor systems in UK plastic surgery units. J Plast Reconstr Aesthet Surg Jul;65(7):911-6.

12 The distribution of pulmonary function test results was identical among deployed and nondeployed veterans. Findings did not confirm the hypothesis that deployment to the Gulf War in resulted in an increased prevalence of clinically significant pulmonary abnormalities 10 years later. Karlinsky JB, Blanchard M, Alpern R, Eisen SA, Kang H, Murphy FM, Reda DJ. Late prevalence of respiratory symptoms and pulmonary function abnormalities in Gulf War I Veterans. Arch Intern Med Dec 13-27;164(22):

13 American Journal of Respiratory and Critical Care Medicine 2014;189:A Gulf War veterans approximately 20 years post-deployment Significantly higher rates of small airway obstruction (5x) and restrictive lung physiology (2x) at 20-years postdeployment compared to at 10-years postdeployment Falvo MJ, Osinubi O, Klein JC et al. Durbin D, Kallan M, Elliott M. Late Prevalence of Pulmonary Function Abnormalities In Iraq/Afghanistan Veterans. Paper presented at: 2014 American Thoracic Society International Conference. May 2014; San Diego.

14 Adhesive strips Quicker than sutures for closing surgical wounds Reduces wound care burden Barrier function No risk of sharps injury

15 Yang S, Ozog D. Comparison of Traditional Superficial Cutaneous Sutures Versus Adhesive Strips in Layered Dermatologic Closures on the Back-A Prospective, Randomized, Split-Scar Study. Dermatol Surg Nov;41(11): Gkegkes ID, Mavros MN, Alexiou VG, Peppas G, Athanasiou S, Falagas ME. Adhesive strips for the closure of surgical incisional sites: a systematic review and meta-analysis. Surg Innov Jun;19(2): Lazar HL, McCann J, Fitzgerald CA, Cabral HJ. Adhesive strips versus subcuticular suture for mediansternotomy wound closure. J Card Surg Jul;26(4):344-7.

16 Soni A, Narula R, Kumar A, Parmar M, Sahore M, Chandel M. Comparing cyanoacrylate tissue adhesive and conventional subcuticular skin sutures for maxillofacial incisions--a prospective randomized trial considering closure time, wound morbidity, and cosmetic outcome. J Oral Maxillofac Surg Dec;71(12):2152.e1-8. Krishnamoorthy B1, Najam O, Khan UA, Waterworth P, Fildes JE, Yonan N. Randomized prospective study comparing conventional subcuticular skin closure with Dermabond skin glue after saphenous vein harvesting. Ann Thorac Surg Nov;88(5): Buchweitz O, Frye C, Moeller CP, Nugent W, Krueger E, Nugent A, Biel P, Juergens S. Cosmetic outcome of skin adhesives versus transcutaneous sutures in laparoscopic port-site wounds: a prospective randomized controlled trial. Surg Endosc Jun;30(6):

17 Dumville JC, Coulthard P, Worthington HV, Riley P, Patel N, Darcey J, Esposito M, van der Elst M, van Waes OJ. Tissue adhesives for closure of surgical incisions. Cochrane Database Syst Rev Nov 28;(11):CD

18 Coulthard P, Esposito M, Worthington HV, van der Elst M, van Waes OJ, Darcey J. Tissue adhesives for closure of surgical incisions. Cochrane Database Syst Rev May 12;(5):CD

19 Combination closure with adhesive strips and buried interrupted subcuticular suturing was not significantly associated with improved overall scar assessment compared with buried interrupted subcuticular suturing alone when evaluated by blinded observers or the patients themselves. Our results do not support the use of adhesive strips as a means to improve cosmetic outcomes or reduce scar width. Custis T, Armstrong AW, King TH, Sharon VR, Eisen DB. Effect of Adhesive Strips and Dermal Sutures vs Dermal Sutures Only on Wound Closure: A Randomized Clinical Trial. JAMA Dermatol Aug;151(8):862-7.

20 PICO NPWT Dressing Pocket device for negative pressure wound therapy (NPWT)

21

22 Wound dressings

23 Indications Chronic wounds Acute wounds Traumatic wounds Subacute and dehisced wounds Partial-thickness burns Ulcers (such as diabetic or pressure) Flaps and grafts Closed surgical incisions

24 Benefits of Negative Pressure Accelerates wound healing Promotes moist wound healing milieu Decreases complications, such as surgical site infection, dehiscence, seroma/hematoma, and wound edge necrosis Ingargiola MJ, Daniali LN, Lee ES. Does the application of incisional negative pressure therapy to high-risk wounds prevent surgical site complications? A systematic review. Eplasty Sep 20;13:e49. ecollection Scalise A, Calamita R, Tartaglione C, Pierangeli M, Bolletta E, Gioacchini M, Gesuita R, Di Benedetto G. Improving wound healing and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature. Int Wound J Dec;13(6):

25 Mechanism of NPWT Decreases interstitial edema Removal toxic inflammatory mediators Increases cutaneous blood flow Promotes angiogenesis Splints against tensile forces across wound Ingargiola MJ, Daniali LN, Lee ES. Does the application of incisional negative pressure therapy to high-risk wounds prevent surgical site complications? A systematic review. Eplasty Sep 20;13:e49. ecollection Scalise A, Calamita R, Tartaglione C, Pierangeli M, Bolletta E, Gioacchini M, Gesuita R, Di Benedetto G. Improving wound healing and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature. Int Wound J Dec;13(6):

26 Relative Contraindications Adhesive tape reaction Ischemia Excessive exudative wounds Inadequate hemostasis Cellulitis Open/dehiscent surgical wounds [Profuse perspiration]

27 High complication risks Surgery-related Location Surgical site contamination Technique Operative time Patient-related Morbid obesity Comorbidities Nicotine abuse Drugs (systemic steroids, immunosuppression) Scalise A, Calamita R, Tartaglione C, Pierangeli M, Bolletta E, Gioacchini M, Gesuita R, Di Benedetto G. Improving wound healing and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature. Int Wound J Dec;13(6):

28 Webster J, Scuffham P, Stankiewicz M, Chaboyer WP. Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention. Cochrane Database Syst Rev Oct 7;(10):CD

29 Coding and Reimbursement CPT code Surface area 50 cm 2 CPT code Surface area 50 cm 2 Includes: Provision of exudate management collection system Topical application Wound assessment Instructions for ongoing care 2016 Medicare national average payment $225.55

30 Apps Haiku Tiger Text Doximity dialer Evernotes VisualDx Appointment reminder Photo collage

31

32

33

34

35

36 Best Note-taking apps of

37 Peripheral Brain

38

39

40

41

42

43 Appointment reminders

44

45

46 Photo Collage Editor

47 Thank you for your attention Questions?