Chapter contents

The Patient History

551

Skin Preparation

551

Bites

551

Immunizations

552

Procedure Room

552

Anesthesia

553

Sedation

555

Wound Irrigation

555

Debridement

555

Principles of Healing

556

Stages of Healing

556

Keloids

556

Hypertrophic Scars

558

Wound Dressings

558

Nonhealing Wounds

558

Principles of Skin Closure

558

Skin Tension Orientation

559

Skin Tension on Closure

559

Tissue Adhesive

559

Suture Placement

560

Z-Plasty

561

Complications

561

Excisions

562

Atypical Moles and Pigmented Lesions

562

Basal Cell Cancer

563

Cryotherapy

563

Indications and Contraindications

563

Equipment and Technique

564

Complications

564

Incision and Drainage of Cutaneous Abscess

564

Lipomas

565

Surgery of the Nail and Digits

565

Ingrown Nail (Onychocryptosis)

565

Nail Plate Avulsion for Onychomycosis

565

Paronychia

565

Evacuation of Subungual Hematoma

566

Anorectal Disease

566

Anoscopy

566

Hemorrhoids

566

Anorectal Abscess

568

Anal Fissure

568

Pilonidal Cyst and Abscess

569

Gynecologic Office Procedures

569

Contraceptive Devices

569

Bartholin's Gland Abscess or Cyst

571

Colposcopy

571

Endocervical Curettage

572

Cervical Biopsy

572

Endometrial Biopsy

572

Cervical Polyp Removal

573

Uterine Aspiration for Biopsy or Miscarriage Management

573

Breast Mass

573

Breast Cyst Aspiration

574

Fine-Needle Aspiration Cytology or Biopsy

574

Neonatal Circumcision

574

Musculoskeletal Office Procedures

575

Aspiration of Knee Joint (Arthrocentesis)

575

Shoulder Injection

576

Safe approaches to common surgical procedures can be performed by primary care providers in an outpatient setting without significant sedation. This chapter provides the foundation to build skills of competency in common procedures, including adequate preparation, appropriate setup, informed consent, good technical skills, and knowledge of how to handle potential complications. Discussions of the basic surgical skills and setup required, patient consent, and local anesthesia are followed by a review of common office procedures in family medicine, with tips to perform these successfully and methods to prevent complications.

As the U.S. health care system grapples with medical home concepts, family medicine providers must develop proficient skills to carry out common procedures in primary care clinics. The health care system may continue to provide high remuneration for procedural medicine but may change to a system driven by outcomes, competency, and ability to provide competent procedural services in the medical home. Comprehensive patient care will return to the primary care realm, where it is more cost-effective.

For a brief history of surgery, see the online discussion at www.expertconsult.com.

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