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Keeping up to date with minor surgery

Roger Kneebone
PhD FRCS FRCSEd MRCGP
General Practitioner
Lovemead Group Practice
Trowbridge
Wiltshire
Honorary Senior Lecturer
Department of Medical Sciences
University of Bath
E:r.kneebone@bath.ac.uk

Minor surgery is now an established component of primary care throughout the UK. Most GPs and team members provide a range of such services to their patients, from joint and periarticular injections to removal of skin lesions. In addition, some offer more complex procedures, such as vasectomy.

At whatever level it is provided, minor surgery must be performed to the highest clinical standards. Each doctor or other healthcare professional who undertakes such procedures has a responsibility to remain up to date with current techniques, to audit their own work and to subject their performance to rigorous self-criticism.

Minor surgery is commonly seen as an exercise in technical skill. Competence in the procedural aspects of minor surgery is just one facet of safe practice, however. Competence in diagnosis is equally important, since without a diagnosis it is impossible to decide on the best course of treatment. Of course it may not always be possible to diagnose a lesion with certainty, so an awareness of one's own limitations and a knowledge of when and how to refer patients for specialised advice is vital.

On many occasions, more than one clinical management option may be available to patients. Typically this may involve a choice between undergoing a procedure or not. An open consideration of alternatives, frank discussion of possible complications, and a patient-centred discussion of treatment options are key.

The need for regular practice
Many GPs nowadays have attended an intensive formal training course on minor surgery. Such courses typically last for two days and provide a combination of didactic teaching and group discussion with the opportunity to gain hands-on practice using simulated tissue models or dead animal tissue, such as pigs' trotters.

Immediately after attending such a course, most GPs will have gained a range of new skills or, at the very least, have refreshed their existing knowledge. However, the literature on skills acquisition makes it very clear that regular practice is crucial if recently gained skills are not to be lost.(1,2) Such practice, moreover, must be highly focused and aimed at productive learning - simple repetition is not enough.(3) The skills of minor surgery are especially vulnerable to attrition in primary care, where opportunities for regular practice may be few.

Workload in general practice is unpredictable, and it may be many months before a doctor is required to carry out a particular surgical procedure. Without regular practice, the doctor's skills may dwindle significantly, but without the doctor being aware that this has happened. This can pose obvious dangers to clinical care. Formal tuition is therefore best seen as a way of regularly topping up knowledge and skill, rather than a single one-off episode.

Although regular practice using simulated tissue can help to consolidate recently learned skills, such practice can only be an adjunct to clinical experience. The value of undertaking procedures under the guidance of a more experienced colleague cannot be overemphasised. Such a colleague may be a hospital specialist or a GP with a special interest in the field.

Developing expertise within the practice
It can be misleading to consider minor surgery as a single field. In group practices there will often be some doctors who have a special interest in a particular area - joint injections, say - while others may feel more drawn to "surgical" procedures, such as excision of lipomas and other lesions. There are clear benefits to developing specific areas of expertise, both in diagnosis and in performing technical procedures. A system of internal consultation and referral within and between practices often works very well.

Of course, doctors are not the only primary care professionals who carry out procedures, and many roles traditionally associated with GPs are now being carried out by practice nurses. There seems no reason why nurses should not play an increasing role in offering minor surgery too, provided they receive adequate training coupled with continuing support within their practice. Developing a lead role within minor surgery is one of many opportunities for expanding the nurse's ambit. Training courses designed specifically for minor surgery nurse practitioners are becoming available, and it seems likely that this area will grow in the future.

Constructive self-criticism
Minor surgery is a satisfying area of practice, and mishaps are uncommon. There is always the danger of encountering complications, however, and an awareness of one's own limitations is key to safe practice.

Audit has an important role to play in developing such self-awareness. Successful audit is underpinned by good record-keeping, a key component of professionalism in any clinical discipline. As well as being good practice, however, maintaining meticulous records can provide invaluable information in minor surgery. By making the effort to examine critically the results of one's own surgical procedures, one is forced to confront actual outcomes,rather than relying on wishful thinking and assuming that all is well.
Suitable outcomes to review may include cosmetic appearance, patient satisfaction and the incidence of recurrent symptoms. The use of a digital camera can be extremely revealing, allowing comparison between appearances before and after a minor procedure.

In addition, it is important to monitor the reliability of the practice's system for ensuring that specimens are sent for histological examination and reports checked, as well as auditing adequacy of excision and the incidence of expected and unexpected malignancy. Problems may highlight wider issues within the practice and are often suitable for discussion with other members of the practice team at a significant event audit.

Radiosurgery - an underused technique
It is important to remain aware of alternative approaches to minor surgery that may improve the quality of care. Radiosurgery is a relatively new technique that is especially suited to primary care, although many GPs have never encountered it. It is now well established in other medical fields, including gynaecology, dermatology, cosmetic surgery and ophthalmology, where it produces excellent results with minimal discomfort. Many superficial lesions can be successfully treated under local anaesthetic within a primary care setting using this technique.(4)
 
Radiosurgery describes the removal or destruction of tissue by using electrical energy via a metal electrode. Radiofrequency energy at 3.8MHz causes vaporisation of cells, allowing tissues to be divided with great precision and without causing collateral damage to surrounding structures. Unlike conventional electrocautery, the electrode remains cold and heat is only generated within the actual tissues. Healing is usually rapid, and cosmetic results are excellent.

The equipment consists of a power generator, a dispersive plate that is placed under the patient, a treatment handle (with a variety of electrodes designed for cutting or coagulating tissue), and a control switch operated either by hand or by a pedal. A range of techniques for treating skin lesions includes formal excision (using the radiosurgery electrode instead of a scalpel), snaring of pedunculated lesions (using the wire-loop electrode), shave excision (again using the wire-loop electrode), and obliteration of telangiectasia. Radiosurgery can also be used for treating ingrowing toenails, using a nail matrixectomy electrode for selective destruction of the nail bed's germinal epithelium.

Learning the technique
Removing a lesion by radiosurgery requires a different technique from conventional excision. Unlike a scalpel blade, a radiosurgery electrode requires no pressure - indeed, applying pressure will prevent it from working at all. Moreover, adjusting the settings on the machine allows the operator to choose between a filtered waveform (which produces a pure cutting effect, like a scalpel blade) and a fully or partially rectified waveform (which provides varying degrees of coagulation as the tissues are divided). This unfamiliar approach means that existing skills have to be set aside and new ones learned.

Although mastering this new technique is not difficult and can usually be achieved in a half-day session, specific training is required. Preliminary practice in fine motor control, tracing geometrical patterns in a thin line with a fine paint brush, allows learners to develop the required lightness of touch. Once this is achieved, a structured programme of exercises using fresh steak provides experience in techniques of incision, coagulation and haemostasis. Finally and most importantly, learners should spend as much time as possible observing an experienced colleague performing clinical sessions before applying the technique themselves.

Possible problems
Most of the dangers of radiosurgery come from inadequate training, insufficient practice and lack of supervision by an experienced colleague in the early stages. Provided the principles and application of the technique are clearly understood, radiosurgery offers an excellent alternative to conventional methods for many patients.
Its major drawback is the high cost of equipment, but this can be overcome by collaborative arrangements, where one machine is used to provide a population-based service shared by a number of practices.

References

  1. Ericsson KA, Krampe RT,Tesch-Römer C. The role of deliberate ­practice in the acquisition of expert performance. Psychol Rev 1993;100:363-406.
  2. Arthur W, Bennett W, Stanush PL, McNelly TL. Factors that influence skill decay and retention: a quantitative review and analysis. Hum Performance 1998;11:57-101.
  3. Guest CB, Regehr G, Tiberius RG. The life long challenge of expertise. Med Educ 2001;35:78-81.
  4. Brown JS. Minor Surgery. A text and atlas. London: Arnold; 2000.

Resources
Ellman International Inc- radiosurgery equipment manufacturer
W:www.ellman.com/medical
Medical Skills- runs training programmes in minor surgery
W:www.medicalskills.com