Surgery - Puch Skin Biopsy Indications • Punch biopsy is widely used for diagnosing lesions and rashes • It is less helpful to confirm deep processes or for conditions that may be difficult to confirm histologically such as mycosis fungoides. Here, a larger incisional biopsy can be a better choice. Contraindications • Adrenaline-containing anesthetic should not be used on the fingers, toes, or penis, due to a potential risk of occluding an end-artery • © Punch biopsy should usually be avoided if melanoma is suspected (excision biopsy is required • © It is inadvisable to biopsy a patient if platelets < 50 × 10°/L or INR >3. Risks • Take particular care when taking a punch biopsy from an area with important structures just beneath the skin. For example, the tendons on the dorsum of the hand, the facial nerve crossing the zygoma or temple: • The risk can be reduced by raising a large bleb with the anaesthetic to put more depth between the surface and deeper structures • D Patients should be warned that punch biopsy will always leave a scar • In a patient prone to keloid scarring, try to avoid biopsying keloid-prone areas such as the upper trunk and back of the neck • Infection • Haemorrhage. Procedure Tips • Punch biopsy implements range in size from 3-8mm. For most diagnostic purposes, 4mm is appropriate; an 8mm punch biopsy defect requires a buried subcuticular suture in addition to surface sutures • > Choice of biopsy site is very important for some lesias Land rashes, as the diagnostic histological features may only be press ten lesions, or in a particular part of a lesion. If in doubt, consult ologist • D Always mark the site of the biopsy. It can be surprise ricw, after blanching the skin with adrenaline and rubbing to clean the area, the obvious red, scaly plaque completely disappears! • I Bulla: take the specimen across the edge of a fresh blister • Ulcer: take the specimen from the edge of the lesion • If for any reason suturing the wound is going to be difficult (e.g. very tight skin on the leg, markedly indurated lesion or patient won't keep still), the defect can be left to heal by secondary intention. Equipment • Surgical pack including sterile drape, gauze, small bowl • Isopropyl alcohol swab • Skin marker • Non-sterile gloves • Local anaesthetic (1 mL 1% lidocaine is usually plenty) • 2mL syringe and fine bore (blue) needle • Sterile gloves • Sterile towel • Sterile cleaning solution (e.g. iodine) • Disposable punch biopsy implement (usually 4mm) • Toothed forceps • Scissors • Histology pot • Vaseline® or similar • Plaster or other dressing. Procedure • Introduce yourself, confirm the patient's identity, explain the procedure, and obtain written consent if possible • Mark the exact area to be biopsied with the skin marker • Wipe the site to be biopsied with the alcohol swab • Draw up the local anaesthetic (e.g. lidocaine 1% with adrenaline 1:200,000): • If using anaesthetic containing adrenaline, warn the patient that the injection will sting • Wearing the non-sterile gloves, inject the anaes around and beneath the biopsy site (into dermis and subcutis) to raise up a bleb: • Keep gauze to hand to catch any drips. • Wash hands using surgical scrub technique. • Cleanse the area around the biopsy site with the cleaning solution and some gauze • Position the sterile drape(s) • Have gauze handy to mop up any bleeding: • It can be helpful to place some adiacent to the biopsy site in the direction that any blood will flow • Place the punch biopsy over the mark and push it through the skin with a rotating motion... penetrate through to subcutis, at which point a reduction in resistance can be felt • Put down the punch biopsy implement • Pick up the specimen without compressing it with the toothed forceps • Harvest the specimen by cutting with the scissors through the connecting subcutaneous fat strands (sometimes this is unnecessary as the fat may just fall away) • Place the specimen in the histology pot • Place a smear of Vaseline® over the wound and cover with the plaster or dressing. Documentation • Date, time, indication, informed consent obtained • Type and volume of local anaesthetic used • Note the site and method of the biopsy (it can be helpful to draw a diagram) • The type of suture used • Instructions on the time for suture removal • The pathology request form should provide the pathologist with information on the date, site, size type of biopsy. • A brief history, description of the problem an differential is essential (lesion' or 'rash' does not • Signature, printed name, and contact details.
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