Posted in Procedures

Lipoma Removal

Equipment List

  1. Sterile gloves (1 pair)
  2. 15 Blade Disposable Scalpel (1)
  3. Iris Scissors, Straight (1 pair)
  4. Needle Driver (1 pair)
  5. Toothed Pickup (1)
  6. Suture: Assorted (if specific suture not requested by provider)
    • 3-0 Vicryl (1)
    • 4-0 Ethilon (1)
  7. 10 ml syringe (1)
  8. 18 gauge 1.5 inch needle (1)
  9. 27 gauge 1.25 inch needle (1)
  10. ChloraPrep 3mL stick (1)
  11. Alcohol Swabs (4)
  12. Sterile 4×4 gauze (5)
  13. Sterile 2×2 gauze (2)
  14. Paper Medical Tape (1 roll)
  15. Exam-room sheet (1 sheet, when necessary due to location of area to be excised)
  16. Chux Pads (1)
  17. Formalin cups (as many cups as specimens)
  18. 1% or 2% lidocaine: If fingers, toes, penis, or nose – then without epinephrine. Otherwise it is ok to have epinephrine. (1 vial with minimum 20 mL remaining)

Procedure Note

LIPOMA REMOVAL

The procedure was explained in detail and informed consent was obtained from the patient.  The area was prepped and draped in a sterile fashion, and infiltrated with _ mL of _% lidocaine with_ epinephrine for local anesthesia.  The lipoma was palpated superficially under the dermis.  An incision was made directly over the lipoma, and gentle blunt dissection was performed to free and then remove the lipoma.  The specimen was placed in specimen jar and sent for analysis.  Closure was performed with _ simple interrupted sutures using _ type of suture.  Petroleum ointment and a bandage were applied.  EBL was less than 1 ml.  Good hemostasis.  There were no complications.  Patient instructed to follow up for fever, erythema, swelling, pain, or purulent discharge from the wound.  The patient voiced understanding.  Suture removal in _ days.
Posted in Procedures

Skin Biopsy

Equipment List

  1. Nitrile Exam Gloves (1 pair)
  2. Sterile Gloves (1 pair)
  3. 15 Blade Disposable Scalpel (1)
  4. Iris Scissors, Straight (1 pair)
  5. Needle Driver (1 pair)
  6. Toothed Pickup (1)
  7. Suture: Assorted (if specific suture not requested by provider)
    • 3-0 Vicryl (1) – absorbable for deep or layered repair
    • 4-0 Ethilon (1) – for skin closure
  8. Sterile Medium Drape (1)
  9. ChloraPrep 3 mL stick (1)
  10. Alcohol Swabs (4)
  11. Sterile 4×4 gauze (5)
  12. 1% or 2% lidocaine: If fingers, toes, penis, or nose – then without epinephrine. Otherwise it is ok to have epinephrine. (1 vial with minimum 20 mL remaining)
  13. 10 ml syringe (1)
  14. 18 gauge 1.5 inch needle (1)
  15. 27 gauge 1.25 inch needle (1)
  16. Exam-room sheet (1 sheet, when necessary due to location of area to be excised)
  17. Chux Pads (1)
  18. Formalin cups (as many cups as biopsy specimens)
  19. Paper Medical Tape (1 roll)
  20. Sterile 2×2 gauze (5)

Procedure Note

EXCISIONAL/INCISIONAL BIOPSY

The procedure was explained in detail and informed consent was obtained from the patient.  The area was prepped and draped in a sterile fashion, and infiltrated with _ ml of _% lidocaine with_ epinephrine for local anesthesia.  An elliptical cision was performed to remove the lesion, and the specimen was placed in specimen jar and sent for analysis.  Closure was performed with _ suture material.  Petroleum ointment and a bandage applied.  EBL less than 1 ml.  Good hemostasis.  There were no complications.  Patient instructed to follow up for fever, erythema, swelling, pain, or purulent discharge from the wound.  The patient voiced understanding.  Suture removal in _ days.

Suture Removal Period

Face: 5-7 days

Neck: 7 days

Scalp: 10 days

Trunk & Upper Extremities: 10-14 days

Lower Extremities: 14-21 days

Sutures in wounds under greater tension may have to be left in place slightly longer.

Posted in Procedures

Endometrial Biopsy

Consent Forms

Ensure Patient is Not Pregnant

Equipment List

  1. Sponge forceps (1)
  2. Nitrile exam gloves (2 pair each)
  3. Exam-room sheet (1 sheet)
  4. Chux pads (4)
  5. Speculum (3 total: 1 white, 1 green, 1 blue)
  6. Lubricant gel packet (5)
  7. Pipelle (1)
  8. Os finder (1)
  9. Formalin cup (1 cup)
  10. Foxtail swabs (at least 5 or more)
  11. Sanitary pad (1)
  12. Iodine swab sticks (3)

Procedure Note

ENDOMETRIAL BIOPSY

Procedure was discussed with the patient including indications, risks, benefits, and alternatives.  The patient opted to go forward with procedure.  Timeout completed and documented on paper chart.

After visualization of the cervix with a clean speculum the cervix was prepped with iodine swab sticks, a single tooth tenaculum was used to stabilize the cervix, then an endometrial biopsy pipelle was inserted through the cervical os.  Uterus measured _ cm on the pipelle markings.  Tenaculum removed.  Pipelle plunger was withdrawn completely and a spiral motion of the pipelle was performed to sample the endometrial lining.  A total of _ passes were performed until  adequate sampling obtained.  Pipelle removed.  Tenaculum site was hemostatic.  Minimal bleeding noted from cervical os.  Patient tolerated procedure well.  Return precautions given.

Followup per pathology results.
Posted in Procedures

Newborn Circumcision

Consent Form

Post Procedure Handout

Equipment List

  1. Gomco circumcision clamps:
    • 1.1 bell + 1.1 base (1 each)
    • 1.3 bell + 1.3 base (1 each)
    • 1.45 bell + 1.45 base (1 each)
    • 1.6 bell + 1.6 base (1 each)
    • Yoke (2 yokes)
    • Nut (2 nuts) 2, because these are easy to drop
  2. Mosquito forceps, curved (2 pair)
  3. Mosquito forceps, straight (1 pair)
  4. Iris scissors, straight (1 pair)
  5. 18 gauge 1.5 inch needle (1)
  6. 27 gauge 1.5 inch needle (1)
  7. Safety pins (2 pins)
  8. 15 Blade disposable scalpel (1)
  9. ChloraPrep 3 ml stick (1)
  10. 1% Lidocaine (withOUT epinephrine) (1 vial)
  11. EMLA Cream (1 tube), if EMLA cream is not available, then 2% Lidocaine hydrochloride jelly is acceptable replacement
  12. Petroleum ointment (Vaseline) (1 tube)
  13. Circumstraint papoose board (1 board) + Leg Straps (1 pair)
  14. Exam-room sheet (1 sheet), or baby blanket (2 blankets)
  15. Nitrile exam gloves (1 pair)
  16. Sterile gloves (2 pair)
  17. Plastic sterile drape with fenestration (1)
  18. Blue sterile drape (1 drape)
  19. Sterile 2×2 gauze (5)
  20. Sterile 4×4 gauze (5)
  21. Alcohol swabs (4)
  22. 1 ml syringe (1)
  23. Xeroform sterile petrolatum gauze dressing (1 package)
  24. Sweet-ease® Sugar Water (1)
  25. Bulb suction device (1)

Pre Procedure Preparation

Sterile Area:

In sterile fasion, place Gomco, sterile gauze, scalpel, safety pins, and all sterile surgical equipment (hemostats, scissors, etc…) on a blue sterile drape.

Non-Sterile Area:

In the 1 ml syringe, draw up 1 ml of 1% lidocaine WITHOUT epinephrine. Label the syringe with the contents (write: 1% lido w/o epi). Keep all remaining equipment unopened in the non-sterile area. Prepare the Papoose board with the leg restraints. Have the Sweet-ease and bulb suction at the head of the board for easy access.

Procedure Note

CIRCUMCISION, GOMCO TECHNIQUE

Parents of infant were counseled on the procedure, and all questions answered.  Parents voiced their desire to proceed with the circumcision.  Infant was placed on the Papoose board, legs secured with restraining straps, and infant's upper torso and upper extremities were secured by swaddling with a baby blanket.  Timeout performed.  After cleansing skin with alcohol swab, 1 mL of 1% lidocaine without epinephrine was injected with a 27 gauge needle in a combination dorsal penile/ring block. Surgical site was sterilized with ChloraPrep and draped in sterile fashion.  The foreskin was grasped at 3 and 9 o'clock with the curved mosquito hemostats.  The preputial opening was stretched and the synechial adhesion were broken with a straight hemostat.  The midline foreskin was clamped for 30 seconds, then a midline dorsal slit was made.  The bell-shaped plunger was placed over the glans covering the entire glans. The shaft skin below the corona remained relaxed and supple. The plate of the clamp was applied at the level of the corona. Once in proper alignment the clamp was tightened and a circumferential incision was made with a cold knife. The clamp was left in place for 5 minutes to allow for clotting and coagulation to occur. The clamp was then removed and iodoform gauze was placed at the crush line. Good cosmesis and hemostasis was obtained.  Size of Gomco: _.  Amount of bleeding: < 1mL.  Complications: none.

The infant was observed after the procedure, no further bleeding was noted.  One time dose of 10 mg/kg oral baby acetaminophen (160 mg/ml concentration) was given.  Handout on circumcision care given to parent, all questions answered.  Infant allowed to return to care of parents with return precautions.

References

Newborn Circumcision Techniques – American Family Physician

Posted in Procedures

Vasectomy

Consent

Patient Information

Equipment List

  1. Vasectomy ring clamp (2)
  2. Vasectomy dissector (1)
  3. Mosquito forceps, curved (2 pair)
  4. Mosquito forceps, straight (1 pair)
  5. Iris scissors, straight (1 pair)
  6. Needle driver (1 pair)
  7. Nitrile exam gloves (1 pair)
  8. Sterile gloves (3 pair per provider)
  9. Sterile medium drape (3)
  10. Suture: 4-0 vicryl (2)
  11. Sterile towels (5 towels)
  12. Cautery pen (1)
  13. ChloraPrep 26 ml stick (1)
  14. Foam tape (1 new roll)
  15. Sterile 4×4 gauze (20)
  16. 1% lidocaine without epinephrine (1 vial with minimum 20mL remaining)
  17. 10 ml syringe (2)
  18. 18 gauge 1.5 inch needle (2)
  19. 27 gauge 1.5 inch needle (2)
  20. 15 Blade disposable scalpel (1)
  21. Exam-room sheet (1 sheet)
  22. Chux pads (2)
  23. Formalin cups (2 cups)

Room Preparation

  • Remove any unnecessary items from the room (stool, vitals machine)
  • Clean the room: wipe down all surfaces and wait the appropriate amount of contact time. Vacuum the floor.
  • Ensure the room temperature is set to 70 degrees Fahrenheit.
  • Turn on the surgical light.
  • Prepare a surgical tray in sterile fashion:
    • Medium drape
    • All sterile tools
    • Suture material, cautery pen, ChloraPrep stick, 10 cc syringes, 18 and 27 gauge needles (1 each)
  • Have all other equipment available on top of a chux pad, on top of the equipment drawers.

Patient Preparation

  • Check the patient in, and bring them to an exam room to review and sign the consent form. Once they have had a chance to ask any questions, bring them into the procedure room.
  • Make sure a chux pad is on the procedure table. Have the patient remove pants and underwear, and cover themselves with the sheet.
  • Have the patient apply foam tape to penis securing it against the abdomen.
  • Once provider enters, ensure TIMEOUT occurs.
  • Put on non-sterile gloves. Once provider starts, assist by elevating the scrotum while the provider sterilizes the skin with ChloraPrep. Provider will then place blue towels under and around the region, and finally cover the entire area with a a medium sterile drape to create a sterile field.

After the Procedure

  • Assist the patient with placing gauze over the scrotum and securing it with tape.
  • Answer any last questions, and assist the patient back to the waiting area, ensuring their driver is available or on the way.
  • If specimens were collected, check that they are labelled correctly and bring them to lab.

Procedure Note

VASECTOMY

Pre-procedure counseling completed, including risk discussion of bleeding, infection, need for repeat procedure, chronic pain, failure of sterilization.  Timeout completed and documented on paper chart.

An examination of the genitals is normal; both testes normal without tenderness, masses, hydroceles, varicoceles, erythema or swelling.

Shaft normal, meatus normal without discharge. No inguinal hernia noted. No inguinal lymphadenopathy. Anatomic landmarks were confirmed

Under sterile conditions, a 1-2 cm wheal was made at the desired incision site with 1% lidocaine without epinephrine, administered to provide local skin anesthesia. The needle was then advanced through the wheal parallel and adjacent to the _left vas and toward the external inguinal ring. After gentle aspiration to ensure the needle is not in a blood vessel, _ cc of 1% Lidocaine without epinephrine was injected into the external spermatic fascia.

The vas was maneuvered to the desired location, and vas clamp was applied to isolated vas.  The soft tissue was then bluntly dissected with a fine cured hemostat. The left vas was elevated and exposed.  The vas was hemi-transected.  Thermal cautery applied to a 1 cm length inside the lumen of the prosthetic end of the cut vas until blanching occurred.  The vas was then completely transected and facial interposition achieved with a metal clip over the prostatic end and the testicular end. The area was inspected thoroughly and good hemostasis was noted before the vas was reduced back into the scrotum. The procedure was repeated on the right vas. The estimated blood loss was <2 cc.  Petroleum jelly applied over areas of dissection to provide barrier protection.  The patient tolerated the procedure well.

Patient instructed to return 8-12 weeks post procedure for semen analysis, after minimum of 25 ejaculations.  Patient agreed and voiced understanding that sterility not confirmed until lab evaluation shows no sperm.
Posted in Procedures

IUD Removal

Consent Form

Equipment List

  1. Chux pads (3)
  2. Exam-room sheet (1 sheet)
  3. Sanitary pad (1)
  4. Speculum (1 each size)
  5. Speculum light (1)
  6. Sponge forceps (1)
  7. Cytobrush (1)
  8. Foxtail swabs (10)
  9. Surgical lubricant (2)

Procedure Note

IUD REMOVAL

Pre-procedure counseling and consent completed, all questions answered.  A timeout was performed and time  documented on paper consent form.

The speculum was inserted and the cervix was identified.  The IUD strings were identified and grasped with a sponge forceps and the IUD was removed without difficulty.  The patient tolerated the procedure well.  No complications.  IUD inspected by myself and patient, complete IUD and attached strings present.  IUD disposed of appropriately.  Standby present throughout exam: _.
Posted in Procedures

Skin Tag Removal

Consent

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. Toothed pickup (1)
  3. DermaBlade (1)
  4. ChloraPrep swab 3 ml (1), or Alcohol swabs (many)
  5. Sterile 4×4 gauze (10)
  6. Band-Aid (as many as tags to be removed)
  7. DrySol (Aluminum chloride) (1)
  8. Sterile cup for DrySol (such as urine specimen cup) (1)
  9. Sterile cotton tipped applicators (CTA) (10)

Optional Items (may not be needed):

  1. 1% or 2% lidocaine (with epinephrine) (1 vial with minimum 20mL remaining)
  2. 10 ml syringe (2)
  3. 18 gauge 1.5 inch needle (2)
  4. 27 gauge 1.25 inch needle (2)
  5. Exam-room sheet (1 sheet, when necessary due to location of area to be excised)
  6. Chux pads (3)
  7. Formalin cups (if needed for suspicious tags to be sent for pathology)

Procedure Note

SHAVE BIOPSY

Before the procedure began the risks and benefits were discussed, including the risk of bleeding, scarring, infection, or need to repeat the procedure.  Patient voiced understanding and desire to proceed.  Timeout performed (time documented on paper form).  

Acrochodon was grasped with pickups, then thin stalk was excised flat with DermaBlade.  Per patient request no anesthetic was used.  Aluminum chloride immediately applied to area to stop bleeding, then BandAid applied.  This was repeated for _ acrochordon which the patient desired removed.  Good hemostasis.  There were no complications.  Wound care and post-procedure warning signs were discussed.  Patient voiced understanding.
Posted in Procedures

IUD Replacement

Consent Form:

Equipment List

  1. IUD device
  2. Sterile gloves (2 pair)
  3. Chux pads (3)
  4. Exam-room sheet (1 sheet)
  5. Sanitary pad (1)
  6. Pipelle (1)
  7. Os finder (1)
  8. Speculum (1 each size)
  9. Speculum light (1)
  10. Sponge forceps (1)
  11. Cytobrush (1)
  12. Curved scissors (1)
  13. Tenaculum (1)
  14. Iodine swabs (5)
  15. Foxtail swabs (10)
  16. Surgical lubricant (2)

Procedure Note

IUD REMOVAL AND INSERTION

Before the procedure began the risks and benefits were discussed, including the risk of bleeding, device failure or expulsion, device migration, uterine perforation or insertion in the uterine wall, and infection.  Patient voiced understanding and desire to proceed.  Timeout performed (time documented on paper timeout form).  

The speculum was inserted and the cervix was identified.  The IUD strings were visualized and grasped with sponge forceps.  The IUD was removed without difficulty.  

IUD inspected by myself and patient, complete IUD and attached strings present.  IUD disposed of appropriately.

Betadine was used to clean the cervix.  After cleansing, tenaculum was applied to anterior/superior cervix.  Os Finder was inserted to gently dilate the cervix, and pipelle was used to sound the depth of the uterus.  Depth measured at _ centimeters.  The intrauterine device was inserted and deployed per manufacturer instructions.  The string was cut to 3 centimeters length and a sample of the remaining string was given to the patient for later comparison.  The patient tolerated the procedure well, without significant signs or symptoms of vasovagal responses.  EBL less than _ ml.  Standby present throughout the procedure including any pre-procedure examinations: _.  

The patient was given the patient handout and card for the specific device and lot number of inserted device.  The patient agrees to return for fever, severe lower abdominal cramping, heavy bleeding, or purulent discharge.  The patient was counseled on how to check the strings herself to ensure the IUD has not been displaced, and instructed to return for a post-placement exam if desired.
Posted in Procedures

Cryotherapy

Consent Form

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. Liquid nitrogen (1)
  3. Ear speculums (1 each size)

Procedure Note

CRYOTHERAPY

Procedure was discussed with the patient including indications, risks, benefits, and alternatives.  Local post-procedure care discussed.  Side effects of treatment discussed.  All questions answered.  The patient opted to go forward with procedure.  Timeout performed.  The lesion was treated with light cryotherapy using cryo-cautery. The nozzle of the spray gun was positioned 1.0 to 1.5 cm above the skin surface and aimed at the center of the target lesion.  Liquid nitrogen applied until an ice field encompassed the lesion and the desired margin of _ mm.  Freeze thaw freeze technique was performed with complete thawing between cycles.  A total of _ lesions treated.  Patient tolerated procedure well.

Reference

https://www.aafp.org/afp/2020/0401/p399.html

Posted in Procedures

Nexplanon Replacement

Consent

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. Sterile gloves (1 pair)
  3. Nexplanon
  4. 1% lidocaine with epinephrine (1 vial)
  5. Mosquito curved ridged hemostat (1)
  6. 11 Blade disposable scalpel (1)
  7. Chux pads (2)
  8. Alcohol swabs (6)
  9. 18 gauge 1.5 inch needle (1)
  10. 27 gauge 1.5 inch needle (1)
  11. 5 ml syringe (1)
  12. ChloraPrep 3mL stick (1)
  13. Steri strips (1)
  14. Sterile 2×2 gauze (6)
  15. Coban roll (1)

Procedure Note

NEXPLANON REPLACEMENT

The Nexplanon rod in place was palpated in the patient's _ arm in the appropriate position.  After informed consent was obtained, and time-out completed, the patient's left arm was prepped in a sterile fashion with a ChloraPrep swab.  Approximately 5 cc of 1% lidocaine with epinephrine was infused along the planned incision site, and below and along the palpated rod.  An incision was made, the device brought to the level of the incision. The rod was removed intact and verified by patient and physician.  Patient tolerated procedure well. Minimal bleeding throughout procedure.  Steri-Strips were placed over incision, and covered by sterile gauze and pressure dressing.  Minimal (<1 ml) blood loss during procedure.  Post procedure instructions & precautions were given, including: keep top compression dressing in place for 24 hours, then dressing can be removed but allow Steri-strips to remain in place for 3-5 days.  Keep the area clean and dry until fully healed.  Return or call the clinic if there is bleeding, pus, or increasing redness, or pain at insertion site, or fever or chills.  Patient informed that effective immediately she must use another form of birth control if pregnancy is not desired.  

The needle of the Nexplanon insertion device was inserted into the skin through the newly created incision site.  Upon insertion the needle was brought horizontal and using a tenting - advance motion the needle was advanced to its entire length.  The applicator button was depressed and Nexplanon rod remained in place after the device was removed.  The rod was palpated in place subdermally by both the physician and the patient.  Minimal bleeding.  The patient tolerated the procedure well.  A Steri-strip and gauze dressing was applied over the insertion site and a pressure dressing was applied over the area.  Post procedure instructions & precautions were given, including: keep compression dressing in place for 24 hours, then keep area clean and covered (with Band-Aid or gauze dressing) until healed, usually 3-5 days.  Return or call the clinic if there is bleeding, pus, or increasing redness, or pain at insertion site, or fever or chills, the implant comes out or you have concerns about its location, or you have a positive pregnancy test or suspect you might be pregnant.  Wallet card given.

Patient informed replacement date: _.