Transcript curretage and cautery

Curettage and Cautery
Curette
From the Latin curare, to care for or to cure.
Then to the French curer, to cure.
Bronze curettes have been found in Egyptian
tombs!
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Cautery
From the Latin cauterium, a branding iron.
An old usage is a cauterant, a chemical used to
burn!
Used for several thousand years
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Cautery
One of the earliest
surgical techniques and
one that is still very
useful especially in a
general practice setting.
It is often quick to
perform and provided
simple precautions are
observed it is safe and
effective.
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Cautery
As a additional incentive the "Minor surgery"
scheme allows most forms of cautery to be a
claimable "minor op".
The regulations are not specific as to what
constitutes claimable cautery so the
interpretation can be fairly broad.
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Cautery
There are 3 types of cautery relevant to general
practice, the use of specialist operating theatre
type equipment is out side the normal scope of
general practice.
These are Cryocautery, Chemical cautery and
Electro cautery [ hot wire - DC types ].
All have uses in general practice.
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Cautery
By definition cautery does not produce a tissue sample
for histology ( unless used as a adjuvant in another
procedure) so it must Never be used if there is any
doubt as to the nature of the lesion.
Medical records must be meticulous as to the procedure
and the diagnosis of the lesion concerned.
As in all things there is no substitute for practical
experience, Good sources of practical training are
Dermatology outpatients, ENT outpatients, A&E and
gynae - but your training practice may the best bet!
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Cryocautery
Works by causing cellular
lysis after freeze thaw cycle,
relatively painless with liquid
nitrogen but stings with
warmer techniques.
There are 4 different
techniques, carbon dioxide
snow(now rarely used), liquid
nitrogen, nitrous oxide and
commercial freezing mixtures
(e.g. Histofreeze).
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Liquid Nitrogen
Very cold and causes lots of tissue destruction can be
over applied and cause full thickness skin loss.
Only one application usually needed. Applied with
cotton wool buds or proprietary sprays.
Can be kept in a Dewar flask(fancy thermos) for 2 days.
BOC won't sell small amounts so need to arrange
supply from local hospital or industry.
This means saving up suitable patients and arranging a
special session.
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Nitrous Oxide
Used to cool special heads via gun.
Difficult to over treat lesion, may need 2-3 goes
to clear thicker lesions - about 10-14 days apart.
Always to hand from cylinder, gas prescribable
on FP10.
Convenient and to hand but more painful and
needs more treatment, less skill needed.
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What for?
Suitable for surface skin lesions of known type,
e.g. viral warts, seb. warts, small moles,
Keratoacanthoma, solar keratosis etc.
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Warnings to Patients
The patient should be warned that the treated lesion will
throb for up to 12 hours, paracetamol may be suitable.
The lesion will blister, the blister should not be "popped"
if possible but allowed to dry off as "natural" dressing.
This area of dead skin will slough off 7-14 days after
treatment leaving a red area.
The red area will fade to normal colour after up to 12
weeks - usually 6.
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Electro-cautery
Works by simple burning
of tissue via DC current.
Needs local anaesthesia.
Cheap machines readily
available.
Quick to use.
Very easy to cause
marked scars, good
haemostasis.
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Electro-cautery
Unsuitable for viral warts as highest recurrence
rate of any wart therapy.
May be useful adjuvant to straight scalpel
surgery for stopping bleeding.
Needle point tips available for the treatment of
spider naevi and capillary flares.
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Chemical Cautery
The chemical destruction
of a surface lesion.
Usually employs silver
nitrate.
This comes in the forms
of pencils - sold to the
public (!) for shaving
cuts, but a simple cheap
source for certain
applications.
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Chemical Cautery
It is also available on sticks - looking like a very
long match with a black head.
These are very cheap.
They need storage in a dry dark place.
Silver nitrate stains clothing, worktops and skin,
WARN the patients and always wear gloves
when handling.
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Chemical Cautery
The stain will go as the top layer of skin is shed.
The lesion or the head of the stick needs to be
moist to work, it is usual to dip in a galipot with
some water and knock off excess water before
use.
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Nasal Cautery
Cautery to Little's area
for recurrent nose bleeds
is a quick and simple
procedure, well within
the remit of general
practice.
It should only be done
when the practitioner has
had supervised prior
experience.
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Nasal Cautery
The area needs to well visualized with good
lighting.
It should also only be done if a obvious vessel is
seen to cauterise - one is not trying to burn the
whole nasal septum!
The technique is not suitable when there is
active bleeding.
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Nasal Cautery
The area needs to be free of debris and large
clots, washing the area with Adrenaline diluted to
about 1 in 10,000 from a syringe without a
needle will remove debris and will usually
temporarily stop bleeding.
The upper lip should be covered with Vaseline to
prevent chemical burns to the upper lip - medicolegally important
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Nasal Cautery
And the patient warned to leave the Vaseline on
over night.
The procedure may need to be repeated.
It is unsuitable for nasal bleeding other than from
Little's area.
After preparation the area is simply touched with
the stick using a rolling movement.
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Granuloma cautery
Post op, bits of
granuloma tissue in
wounds can be simply
touched to induce
involution.
Pyogenic granuloma can
be easily and quickly
treated. The pressure
required on the lesion
may be quite painful.
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Adjuvant
Can usefully be employed to
stop bleeding from a raw
area, particularly useful after
a shave excision.
MUST not be used to stop
bleeding if the treated area is
in a wound - the silver nitrate
incorporated into deeper
layers will cause
considerable damage.
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Curettage
Allowable under the minor
surgery scheme.
Usually needs some sort of
anaesthetic.
Produces tissue for cytology,
NOT histology.
Quick and simple.
Surface lesions only.
Often blunt.
Possible to sharpen them!
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Curettage
Disposable curettes cost £2-3 each. Very sharp!
– A joy to use!
– 4mm and 7mm ring sizes available.
Any surface skin lesions that one is pretty sure
of!
May need to apply haemostatic.
Avoid on possible carcinomas!
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Curettage
Specially good for:
–
–
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Seborrhoeic warts
Kerato-acanthomas
Skin tags
Facial warts
Pyogenic granuloma
• (Chalazions)
If it extends beyond the dermis – excise it!
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Curettage
Basal cell carcinomas.
– Said to be good.
– 90% cure with selected
lesions.
– Maybe a place in elderly
and infirm.
– I don’t do it intentionally!
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