Out-patient surgery

Out-patient surgery is a primary link, the right flank of surgical aids to community. A lot of patients apply to an out-patient surgeon with various problems. A surgeon has to make diagnosis quickly and help a patient. The majority of patients have different suppurative disorders (infected wounds, furuncles, ingrown nails, skin tumors etc.). Lately out-patient surgery has reached the summit of its popularity as having several advantages:

• The help is quickly obtained;
• A patient does not need to go to hospital, and may move around without limitations;
• Bandaging may be performed in an ambulatory or at home;
• A patient may plan to visit a doctor himself;
• Costs of out-patient managements are much lower than of in-patient one;
• There is no danger of hospital infection.

 Out-patient surgery in “Real Health” clinic provides:

• Small operations on suppurative disorders (dissection and drainage of furuncles, carbuncles, suppurative ateromas, abscesses)";
• Large operations on suppurative disorders (dissection and drainage of mastitis, diffuse suppurative lesions, large abscesses) under anesthesia with knowledge of all modern technologies and rules of suppurative surgery;
• Control over the course of the wound healing process and application of aseptic bandages after all types of operations and, in particular, those that have been made in other medical institutions;
• Puncture biopsy with anesthesia under control of Ultrasound Doppler;
• Puncture of joints if inflammatory collections are present;
• Blockades with modern local anesthetics in musculoskeletal system disorders;
• Surgical treatment of wounds of different locations and sizes with application of negligible cosmetic suture using modern dissolving ligating materials;
• Excision of alien bodies of soft tissues using anesthesia;
• Excision of different soft tissue masses (warts, papillomas, moles) in a conventional way as well as using coagulator (no blood);
•  Excision of benign tumors of soft tissues (lipoma, atheroma, fibroma) – without pain, bleeding, with the best cosmetic effect, with use of coagulator and further application of an intracutaneous cosmetic suture of modern dissolving material;
• Treatment of ingrown nail by electrocoagulator – without bleeding, sutures and repeats of the problem, early return to work, 1 or2 bandaging.

Clinical advantages are in minimal post-surgical discomfort, minimal production of cicatricial tissue, improved healing and the best cosmetic results. Unbounded facilities to perform in-patient operation.

Skin masses

Three groups of skin masses can be determined in clinic.

1. Benign: papilloma, adenoma, fibroma, lipoma, ateroma;
2. Pre-cancer: senile keratoma,skin horn, Pedget disease, Bowan disease, leukoplakia.
3. Malignant: epitelioma, melanoma, sercoma.

There also exist so called secondary (metastatic) tumors of skin. They may be observed in patients who are being treated for tumors of internal organs (lungs, breast etc.). At present lymphomas of skin are distinguished – they are caused by malignant proliferation of lymphoid cells in skin.

Skin cancer represents about 4-10 % all malignancies of a human. It is encountered equally in both genders, predominantly elderly. In many cases several skin changes precede skin cancer. These changes are self-limited disease entities which create the background of cancer  for a long time. These changes are called pre-cancer changes. Factors of predilection to skin pre-cancer are physical (injury, insolation, irradiation) and cancerogenic toxins; chronic specific inflammatory lesions of skin (tuberculosis, lupus erythematosus) and non-specific lesions such as trophic ulcers, fistulas, burn scars etc.). The third group is aging-related factors (senile keratoma,skin horn, Pedget disease, Bowan disease, leukoplakia), as well as inborn abnormalities and constitutional features.

Beningn mass lesions of skin

WARTS are such a mass lesions of skin that are caused by human papillomavirus. It is believed that virus permeates the skin through small wounds and in transmitted by a contiguous way. Warts may develop in any age, but more frequently in children and adolescents. In 25% of cases warts disappear themselves within half a year, in 70% - within 2 years. Protean, planar, plantar warts and sharp-end condilomas are distinguished. Filiform and finger-shaped warts are also distinguished. Filiform warts are thin elongated  masses on skin and neck, and finger-shaped warts are thick elongated masses on the scalp.

Surgical treatment

HYPERTROPHIC SCAR develops due to excessive formation of cicatricial tissue at the site of injury, it never expands beyond the bounds of initial wound and becomes planar with time.

DERMATOFIBROMA (histiocytopma) is a tumor that originates from connective tissue elements of derma. Mild injury often precedes its occurrence. Dermatofibroma may be multiple and hyperpigmented. The tumor represents a node with following typical features:

• Thick node with well-celineated borders, round- or oval-shaped, 3-10 mm in size;
• The node is easily displaced in relation to adjacent tissues and forms an eminence above the skin;
• The color is pink or purple;
• Typical invagination occurs when skin id pressed above the node;
• Itching is common

Surgery is not required as usual. If a tumor is localized in a place where it is exposed to injury, excision is indicated.

IMPLANTATION CYST is a small painful node that forms in sites of stabbed wounds (on fingertips) and is frequently seen in hair dressers and  tailors.

KELOID SCAR  in contrast to hypertrophic one expand beyond the bound of the initial wound. Inherited predilection exist.

Typical features of keloid scar :

• It is thick irregular-shaped mass lesion of purple color elevated above the skin;
• It may occur even after minor trauma, for instance, after piercing of an ear);
• Pain, burning, itching.

KERATOACANTOMA  is a node forming an eminence above the skin with crater-shaped invagination in the center, filled with keratin masses. Rapid growth is typical.

Keratoacantoma usually develops on open parts of human body at the age above 50. Spontaneous recovery within half a year with scar is typical. Malignant transformation is possible. It is hard to make differential diagnosis between keratoacantoma and planocellular skin carcinoma.

Surgical treatment. Early excision with histological study is the tactic of choice.

ANNULAR GRANULOMA is often seen in children and young people and in patients with diabetes mellitus. Typical features are:

- annular papulas having a shape of necklace;

- location on dorsal and lateral surfaces of fingers, wrists, elbows and knees.

Treatment is effective when blood glucose, dose of corticosteroids and infection are controlled.

SOFT FIBROMA  is a mass lesion originationg of skin, frequently seen in elderly. Malignant transformation is uncommon. Soft fibromas is often localize on neck, in subaxillar and groin regions, on the trunk. They usually produce only a cosmetic discomfort. After repeated injuries fibromas become painful.

Surgical treatment or no treatment.

EPIDERMAL CYST  is a round-shaped mass lesion that is usually localized on scalp, sometimes on neck or trunk. The cyst can be easily displaced with skin and contains curdle-like masses , with frequent inflammation.

If the epidermal cyst is small and produces no discomfort, it may not be excised. In other cases surgical treatment is indicated.

Surgical treatment is proceeded under local anesthesia.

RANULA  is a cyst that forms after obliteration of a salivary gland. It usually localizes on the mucous membrane of lips and chicks, is round-shaped and smooth surface, yellow of blue color. It contains transparent and sometimes viscous liquid.

Surgical treatment.

SUN KERATOSIS is a pre-cancer disorder. It appears as thick squamas on a papula or a part of skin with hyperemia. Squamas are thick and resemble rough emery, they are tightly tied with skin. Exfoliation of squamas are not painful. Moist surface stays after exfoliation. Squamas are located on open places of the body, on the face, ears, scalp (in case of alopetia), on forearms, dorsal surfaces of wrists and heels. Spontaneous recovery is possible.

Treatment. To avoid sun. Criodectruction. 5% ftoruracil cream every day within 4 months. If You hesitate in diagnosis and suspicion of malignant transformation arises (especially when exulceration is present) excision with histological study is indicated.

SENILE KEARTOMA (seborrhea keratoma, senile wart) is a brown or bronze mass lesion with well-delineated borders, resembling a raisin pressed into the skin. It is a widely distributed disease among people aged above 40. Senile keratomas are often multiple, and they frequently locate on the face and trunk in elderly. They are usually asymptomatic, self-amputation is common. Malignant transformation is uncommon. This mass should be differentiated from melanoma.

Surgical treatment, especially if a cosmetic defect is marked. Electrocoagulation is used for small papulas on the face. Liquid nitrogen can make papulas lose their color. If You hesitate in diagnosis it is better to excise papula and make a histiological sstudy.

INGROWN NAIL

There are a lot of factors causing ingrowing of a nail, sometimes it is a hereditary predilection, sometimes it develops due to uncomfortable shoes, loose care for nails, application of several drugs (anti-psoriatic drug acytretin or protease inhibitors used to treat HIV infection), arthritic bone changes, proliferation of tissue under a nail, plantar hyperhydrosis.

Who is under the risk of ingrown nail occurrence?

• Infants who start to walk
• Adolescents and adults with “typical” or “juvenile ingrowing”
• Elderly with onychogriphosis, in whom proliferation of tissue under a nail develops.

Treatment using electrocoagulator

After an injection of local anesthetis into the base of a finger and application of ligature to stop bleeding a surgeon excises a margin of ingrown nail. After that using electrocoagulator a surgeon eliminates the part of skin of which ingrown nail originates. Sutures are unnecessary.

Advantages of this techniwue:

• Sutures are unnecessary
• No pain
• Early return to work
• Minimal number of residual cases
• 1 -2 control bandaging

ABSCESS  is a suppurative inflammation of tissue with formation of delimited focus of debris.

Staphylococci and Streptococci are the most frequent pathogens of soft tissue abscesses. In other locations the pathogen depends on the causes of abscess and the local flora (for instance, in appendicular abscess the pathogen is usually Escherichia coli) in combination with non-clostridial anaerobic flora and cocci.

CELLULITIS is a suppurative inflammation off tissue with tendency to progression.

Depending on slices afflicted by cellulitis, subcutaneous, subfascial and intermuscular cellulitis are distinguished. Cellulitis may develop in mediastinum, in retroperitoneal fat, in pectoral and abdominal walls.

The pathogens are Streptococci, anaerobic microbes.

CARBUNCLE is  a suppurative inflammation of several hair follicles and subcutaneous fat around. The most frequent location is occipital area and back.

Carbuncle transforms into furuncle if diabetes mellitus is present or injury occurs.

FURUCNCLE is a suppurative inflammation of a hair follicle and surrounding subcutaneous fat. The most frequent pathogen is Staphylococcus.

Predisposing factors are poor hygiene, unnoticed small injuries of skin, especially during shaving, hyperhidrosis, diabetes mellitus.

Frequent locations are face, occipital area, groin, buttocks and hands.