DR. ARLENE P. PAVO, M. D.
MINOR SURGERY
 Is any surgical procedure that does not involve
anaesthesia or respiratory assistance during the
surgical procedure.
 Many conditions can be treated quickly and
easily with minor surgery that requires a local
anaesthetic and a few minutes of your time.
 Is usually carried out as a day case or an output
basis in the GP Surgery.
 Prior to any surgery the doctor will conduct an
initial consult to confirm a diagnosis and a plan
for the procedure and gain informed consent.
MINOR SURGERY PROCEDURES CAN BE USED TO
TREAT:
 Skin tags
 Skin cyst
 Incision and drainage of an abscess
 Warts
 Mole removal
 Biopsy of growths
 Verrucae’s
 Leg vein treatments
 Joint injections
AFTER MINOR SURGERY:
 Should you have a wound, your doctor will give
you instructions on how to look after it in order to
keep it clean and free of infection until it has
healed.
 You may also need to take painkillers to relieve
any discomfort or antibiotics to prevent infection.
 After some minor surgery you may feel a little
faint or uncomfortable and may need someone
to take you home.
 You will be given a follow-up appointment so the
doctor can check that the procedure was a
success and ensure the wound is healing, you
may also need to have stitches removed.
*For some procedures it is normal to send off a tissue
sample for histology and please insure there is follow up
with the results.
SURGERY
 Surgery is a term traditionally used for
treatments that involve cutting or stitching tissue.
 However, advances in surgical techniques have
made the definition more complicated.
 The only part of minor surgery that may hurt is
when the anaesthetic is administered, after this
the procedure is pain free.
 The length of time the procedure will take is
dependent on the condition being treated and
can range from 10-15 minutes to a half hour or
more.
 Your doctor will also advise if more visits are
required to treat your condition.
 Sometimes lasers, rather than scalpels are used
to cut tissue, and wounds may be closed without
stitches.
 In modern medical care, distinguishing between
a surgical and medical procedure is not always
easy.
 However, making that distinction is not important
as long as the doctor doing the procedure is well
trained and experienced.
 Is a broad area of care and involves many
different techniques. In some surgical
procedures, tissue is removed.
 In others, blockages are opened. In still others,
arteries and veins are attached in new places to
provide additional blood flow to areas that do not
receive enough.
 Grafts. Sometimes made of artificial materials,
may be implanted to replace blood vessels or
connective tissue, and metal rods may be
inserted into bone to replace broken parts.
 A diagnosis is sometimes accomplished by
doing surgery.
 A biopsy, in which a piece of tissue is removed
for examination under a microscope, is the most
common type of diagnostic surgery.
 In some emergencies, in which there is no time
for diagnostic tests, surgery is used for both
diagnosis and treatment. For example, surgery
may be needed to quickly identify and repair
organs that are bleeding from a gunshot wound.
 The urgency of surgery is often described by
three categories:
 Emergency
 Urgent
 Elective
EMERGENCY SURGERY
 Such as stopping rapid internal bleeding is
done as soon as possible because minutes
can make a difference.

URGENT SURGERY
 Such as removal of an inflamed appendix is
best done within hours.
ELECTIVE SURGERY
 Such as replacement of a knee joint, can be
delayed for some period of time, until
everything has been done to optimize a
person’s chances of doing well during and
after the surgical procedure.
ANESTHESIA
 Because surgery is generally painful, it is always
preceded by the administration of some type of
anesthetic.
 Anesthetics block the perception of pain.
 Anesthesia may be local, regional, or general.
 Anesthetics are typically given by heath care
practitioners specially trained and certified in
providing anesthesia.
 These practitioners may be doctors
(anesthesiologist) or nurse practitioners (nurse
anesthetists).
 Nurse anesthetists practice under the direction
of an anesthesiologist.
LOCAL AND REGIONAL ANESTHESIA
 These types of anesthesia consist of injections
of drugs (such as lidocaine or bupivacaine) that
numb only specific parts of the body.
 In local anesthesia, the drug is injected under
the skin of the site to be cut, numbing only that
site.
 In regional anesthesia, which numbs a larger
area of the body, the drug is injected around one
or more nerves and numbs an area of the body
supplied by those nerves. For example, injecting
a drug around certain nerves can numb fingers,
toes, or large parts of limbs.
 One type of regional anesthesia involves
injecting a drug into a vein (intravenous regional
anesthesia).
 A device such as a woven elastic bandage or
blood pressure cuff compress the area where
the limb joins the body, trapping the drug within
the veins of that limb. Intravenous regional
anesthesia can numb an entire limb.
 During local and regional anesthesia, the person
remains awake.
DR. ARLENE P. PAVO, M. D.
 However, doctors sometimes give antianxiety
drugs intravenously to calm and relax the
person.
 Rarely, numbness, tingling, or pain can resist in
the numbed area for days or even weeks after
the surgical procedures.
 Spinal anesthesia and epidural anesthesia are
specific types of regional anesthesia in which a
drug is injected around the spinal cord in the
lower back.
 Depending on the site of the injection and
position of the body, a large are (such as from
the waist to the toes) can be numbered.
 Spinal and epidural anesthesia are useful for
operations of the lower body, such as hernia
repairs and prostate, rectal, bladder, leg, and
some gynecologic operations.
 These types of anesthesia also can be useful for
childbirth.
 Headaches occasionally develop in the days
after spinal anesthesia but usually can be
treated effectively.
GENERAL ANESTHESIA
 In general anesthesia, a drug that circulates
throughout the bloodstream is given, rendering
the person unconscious.
 The drug can be given intravenously or inhaled.
Because a general anesthetic slows breathing,
the anesthesiologist inserts a breathing tube in
the windpipe (a ventilator breathes for the
person if the operation is long).
 For short operations, however, such a tube may
not be necessary.
 Instead, the anesthesiologist can support
breathing by using a handheld breathing mask.
 General anesthetics affect vital organs, so the
anesthesiologist closely monitors the heart rate,
heart rhythm, breathing, body temperature, and
blood pressure until the drugs wear off. Serious
side effects are very rare.
MAJOR and MINOR SURGERY
 A distinction is sometimes made between
major and minor surgery, although many
surgical procedures have characteristics of
both.
MAJOR SURGERY
 Major surgery often involves opening one of
the major body cavities:
= the abdomen (laparotomy)

= the chest (thoracotomy)
= the skull (craniotomy)
 And can stress vital organs.
 The surgery usually is done using general
anesthesia in a hospital operating room by a
team of doctors.
 A stay of at least one night in the hospital
usually is needed after a major surgery.
MINOR SURGERY
 In minor surgery, major cavities are not
opened.
 Minor surgery can involve the use of local,
regional, or general anesthesia and may be
done in an emergency department, an
ambulatory surgical center, or a doctor’s
office.
 Vital organs usually are not stressed, and
surgery can be done by a single doctor, who
may or may not be a surgeon.
 Usually, the person can return home on the
same day that minor surgery is done.
SURGICAL RISK
 The risk of surgery (that is, how likely
surgery is to cause death or a serious
problem) depend on the type of surgery and
characteristics of the person.
TYPES of SURGERY that have the HIGHEST RISK
include:
 Heart or lung surgery
 Prostate gland removal
 Major operations on the bones and joints
(for example, hip replacement).
Generally, the poorer the person’s overall health, the
higher the risk of surgery. Some particular health
problems that increase surgical rick include:
 Severe chest pain (angina)
 Recent heart attack
 Severe heart failure
 Undernutrition (common among older people
who live in institutions)
 Severe disorders of the lungs or liver
 Chronic kidney disease
 Chronic lung disease (often smoking-related)
 Weakened immune system (for example,
because of long term corticosteroid treatment)
 Diabetes (especially if poorly controlled)
DR. ARLENE P. PAVO, M. D.
 Risk are often higher among older people (see
Spotlight on Aging).
 However, risks are determined more by general
health than by age.
 Chronic disorders that increase surgical risk and
other treatable disorders, such as dehydration,
infections, and imbalances in body fluids and
electrolytes, should be controlled with treatment
as well as possible before an operation.
SECOND OPINION
 The choice to undergo surgery is not always
clear.
 There may be nonsurgical options for treatment,
and there may be several possible surgical
procedures.
 Thus, a person may seek the opinion of more
than one doctor.
 Some health insurance plans require a second
opinion for elective surgery. However, experts
may disagree on which doctor should give the
second opinion.
 Some experts advise obtaining a second opinion
from a doctor who is not a surgeon to eliminate
any bias toward surgery when nonsurgical
treatment is an option.
 Others advise that another surgeon give the
second opinion, believing that a surgeon knows
more about the advantages and disadvantages
of surgery than would a doctor who is not a
surgeon.
 Some experts recommend establishing up front
that any surgeon giving a second opinion will not
do the surgical procedure, so that there is no
conflict of interest.
PREPARING for the DAY of SURGERY
 Various preparations are made in the days and
weeks before surgery.
 It is often recommended that physical
conditioning and nutrition be improved as much
as possible because good general health helps
a person recover from the stress of surgery.
 Valuables should be left at home.
ALCOHOL and TOBACCO use:
 Eliminating or minimizing alcohol and tobacco
use before undergoing surgery that involves
general anesthesia can increase safety.
 Recent tobacco use makes abnormal heart
rhythms more likely to develop during general
anesthesia and impairs lung function.

 Excessive alcohol consumption can damage the
liver, causing heavy bleeding during surgery and
unpredictably increasing or decreasing the effect
of the drugs used for general anesthesia.
 Alcohol consumption should be decreased
gradually, however, because a sudden decrease
before undergoing general anesthesia can have
harmful effects, such as fever and abnormalities
of blood pressure or heart rhythm.
DOCTOR’S EVALUATION
 The surgeon does a physical examination and
takes a medical history, which includes:
 The person’s recent symptoms
 Past medical conditions
 Past reactions to anesthetics (if any)
 Use of tobacco and alcohol
 Infections
 Risk factors for blood clots, problems
pertaining to the heart and lungs (such as
cough or chest pain)
 Allergies
 The person is also asked to list all drugs
currently being taken
 Nonprescription as well as prescription
drugs must be disclosed because serious
health problems could result
 For example, the use of aspirin, which a
person may consider too trivial to mention,
can increase bleeding during surgery.
 Additionally, the use of supplements or
medicinal herbs (for example, ginkgo biloba
or St. John’s wort) should be mentioned as
well because they may have effects during
or after surgery.
 The anesthesiologist may meet the person
before the operation to review test results
and identify any medical conditions that
might affect the choice of anesthetic.
 The safest and most effective types of
anesthesia may be discussed as well.
TESTS:
 Tests done before surgery (preoperative
testing):
 May include blood and urine test, an
electrocardiogram, x-rays, and tests of lung
capacity (pulmonary function test).
 These tests can help determine how ell the
vital organs are functioning.
 If organs are functioning poorly, the stress of
surgery or anesthesia can cause problems.
DR. ARLENE P. PAVO, M. D.
 Preoperative tests occasionally also reveal
an inapparent temporary illness, such as an
infection, which requires the postponement
of surgery.
BLOOD STORAGE for TRANSFUSION
 People may wish to store their own blood in
case a blood transfusion is needed during
surgery.
 Using stored blood (autologous blood
transfusion) eliminates the risk of infections and
most transfusion reactions.
 A pint of blood can be withdrawn from the
person and preserved until surgery.
 Blood should be withdrawn no more often than
once weekly, and the last donation should
probably be at least 2 weeks before surgery.
 The body replaces the missing blood during the
weeks after the blood donation.
DECISION MAKING
 Sometimes before the surgery, the surgeon
obtains the person’s permission to perform the
operation, a process called informed consent.
 The surgeon discusses risk and benefits of the
operation, as well as alternative treatments, and
answers questions.
 The person reads and signs a form documenting
consent. In cases of emergency surgery in
which the person is unable to provide informed
consent, doctors try to contact the family.
 Rarely, emergency surgery must proceed before
the family is contacted.
*A durable power of attorney for health care and a living
will should be prepared before surgery in case the
person becomes unable to communicate or becomes
incapacitated after surgery.
PREPARING THE DIGESTIVE TRACT
 Because some of the drugs given during
surgery may cause vomiting, people should
generally not eat or drink anything for at least 8
hours beforehand.
 For outpatient surgery, people should not eat or
drink anything after midnight.
 Specific guidelines should be given and vary
depending on the kind of surgery.
 People should ask the doctor which of their
regularly prescribed drugs should be taken
before surgery.
 DR. ARLENE P. PAVO, M. D.

 People undergoing surgery involving the
intestines are given laxatives for a day or two
before the operation.
FINGERNAILS
 Because the device that monitors the level of
oxygen in the blood is attached to a finger, nail
polish and artificial nails should be removed
before going to the hospital.
 Then, this device can perform more accurately.
THE DAY OF SURGERY
 The operating room typically contains a
monitor that displays vital signs an
instrument table, and an operating lamp.
 Anesthetic gases are piped into the
anesthetic machine.
 A catheter attached to a suction machine
removes excess blood and other fluids,
which can prevent surgeons from seeing the
tissues clearly.
 Fluids given by vein, started before the
person enters the operating room, are
continued.

 Before most operations, a person removes all

clothing, jewelry, hearing aids, false teeth, and
contact lenses or eyeglasses and puts on a
hospital gown.
 The person is taken to a specially designated
room (the holding area) or to the operating room
itself for final preparation before surgery.
 The skin that will be cut (operative site) is
scrubbed with an antiseptic, which minimizes the
number of bacteria and helps to prevent
infection.
 A health care practitioner may shave the
operative site.
 A plastic tube (catheter) is inserted in one of the
veins of the hand or arm.
 Fluids and drugs are given through the catheter.
 A drug may be given intravenously for sedation.
 If an operation involves the mouth, intestinal
tract, lungs or respiratory tract, or urinary tract,
people are given one or more antibiotics within
 If the final preparations are done in the
the hour before the operation to prevent
infection (prophylaxis). holding area, the person is then taken to the
operating room.
 This therapy also applies to people undergoing
 At this point, the person the person may still
some other operations in which infections are
particularly problematic (for example, joint or be awake, although may groggy, or may
heart valve replacement. already be asleep.
 The person is moved to the operating table,
IN THE OPERATING ROOM lit by specially designed surgical lights.
 Doctors, nurses, and other personnel who
*The operating room provides a sterile environment in will be near or touching he operative site,
which the operating team can do surgery. The operating thoroughly scrub their hands with antiseptic
team consist of the following: soap, which minimizes the number of
 Chief surgeon, who directs the surgery bacteria and viruses in the operating room.
 One or more assistant surgeons, who help  For surgery, they also wear scrub suits,
the chief surgeon caps, masks, shoe covers, sterile gowns,
 Anesthesiologist, who controls the supply of and sterile gloves.
anesthetic and monitors the person closely.  Before surgery begins, a time out is held
 Scrub nurse, who passes instruments to the during which the surgical team confirms the
surgeon following:
- The person’s identity
 Circulating nurse, who provides extra
- The correct procedure and side (if
equipment to the operating team.
applicable)

- Availability of all needed equipment
- Prophylaxis to prevent infection or blood
clots (if needed)
 Local, regional, or general anesthesia is
used.
AFTER SURGERY
 After the operation is completed and
anesthesia begins to wear off, the person is
taken to a recovery room to be closely
watched for about 1 or 2 hours.
 Most people feel groggy when awakening,
particularly after major surgery.
 Some people are nauseated for a short
while. Some feel cold.
 Depending on the nature of the surgery and
the type of anesthesia, a person may go
home directly from the recovery room or be
admitted to the hospital, sometimes in an
intensive care unit (ICU).
DIRECT DISCHARGE HOME
*A person being sent home must be:
 Thinking clearly
 Breathing normally
 Able to drink fluids
 Able to urinate
 Able to walk
 Free of severe pain
*People who have been given sedatives and then
discharged need to be accompanied home by someone
else and are not permitted to drive themselves. The
operative site should be free of bleeding and unexpected
swelling.
HOSPITALIZATION
 People who are admitted to the hospital after
surgery may awaken to find many tubes and
devices in and on them
- For example, there may be a breathing
tube in the throat.
- Adhesive pads on the chest to monitor
the heartbeat.
- A tube in the bladder.
- A device attached to a finger to measure
the level of oxygen in the blood.
- A dressing on the operative site.
- A tube in the nose or mouth, and one or
more tubes in the veins.
*Pain is expected after most operations and can almost
always be relieved. Drugs that relieve pain (analgesics)
DR. ARLENE P. PAVO, M. D.
can be given intravenously, by mouth, or by injection into
the muscle or can be applied to the skin as a patch. If
epidural anesthetic was used, the plastic tube used to
give the anesthetic may be left in the person’s back.
Opioid analgesics, such as morphine, can be injected
through the tube.
*People staying in the hospital may be given a device
that continuously injects an opioid analgesic into a vein,
which also can deliver a small additional amount of
analgesic when people press a button (patient-controlled
analgesia). If pain persists, additional treatment can be
requested. Repeated use of opioid analgesics often
causes constipation. To prevent constipation, doctors
may give the person stimulant laxative or stool softener.
*Good nutrition is critical for rapid healing and minimizing
the chance of infection. Nutritional needs increase after
major surgery. If surgery makes eating possible for more
than several days, an alternative source of nutrition can
speed recovery and prevent problems. People whose
digestive tracts are functioning but who are otherwise
unable to eat may be given nutrients through a tube
placed into the stomach. Such a tube may be passed
through the nose, mouth, or an incision in the abdominal
wall. Rarely, people who had surgery of the digestive
tract and cannot eat for extended periods may be given
nutrients through a catheter inserted in one of the body’s
large veins (parenteral nutrition) – see intravenous
feeding).
COMPLICATIONS
 Complications such as fever, blood clots, wound
problems, confusion, difficulty urinating or
defecating, and muscle loss can develop during
the days after surgery.
 Fever has several common causes, including an
inflammatory response to the trauma of an
operation; a high metabolic rate that occurs with
the stress of an operation, which causes the
body to burn more calories and generate more
heat; and infections at the operative site.
Pneumonia may be prevented by periodically
breathing forcefully in and out of a handheld
device (incentive spirometry) and coughing as
needed.
 Blood clots in the legs or pelvic veins (deep vein
thrombosis) can develop, particularly if people
lie immobile during and after surgery or have
had surgery on their leg, pelvis, or both. The
clots can dislodge and travel through the
bloodstream to the lungs, where they can block
blood from circulating through the lungs (causing
pulmonary embolism). As a result, the oxygen
supply to the rest of the body maybe decreased,

and sometimes blood pressure may fall. For
operations that make blood clots particularly
likely and for people who are likely to have to lie
still without much movement, doctors give drugs
that keep blood from clotting (anticoagulants),
such as low-molecular-weight heparin, or put
compression stockings on the person’s legs to
improve blood circulation. However,
anticoagulants may be recommended for
operations in which these drugs may
substantially increase bleeding. People should
begin moving their limbs and walking as soon as
it is safe for them to do so.
 Wound complications may include infection and
separation of the wound edges (dehiscence). To
decrease the risk of the infection, doctors put a
dressing on the surgical incision after surgery.
The dressing includes a sterile bandage and
usually includes an antibiotic ointment. The
bandage keeps bacteria away from the incision
and absorbs fluids that ooze from the incision.
Because these fluids can encourage bacteria to
grow and infect the incision, the dressing is
changed often, usually daily. The wound is
examined whenever the dressing is changed,
sometimes more often. Occasionally, infection
develop despite the best wound care. An
infected site becomes increasingly painful 1 or
more days after surgery and can become red
and warm or drain pus or fluid. Fever can
develop. If any of these symptoms develop the
doctor should be seen as soon as possible.
 Delirium (confusion and agitation) can develop,
particularly among older people. Drugs with
anticholinergic effects (such as confusion,
blurred vision, and loss of bladder control),
opioids, sedatives, or little oxygen in the blood.
Drugs that can cause confusion should be
avoided in older people when possible.
 Difficulty urinating and difficulty defecating
(constipation) can develop after surgery. Factors
that contribute can include use of drugs with
anticholinergic effects or opioids, inactivity, and
not eating or drinking. Urine flow may become
completely blocked, stretching the bladder.
Blockage can lead to urinary tract infections.
Sometimes pressing on the lower abdomen
while trying to urinate relieves the blockage, but
often a catheter needs to be inserted into the
bladder. The catheter may be left in place or
may be removed as soon as the bladder is
emptied. Frequently sitting up may help prevent
blockage. People who develop constipation and
whose surgery did not involve the intestinal tract
can be given laxatives that stimulate the
DR. ARLENE P. PAVO, M. D.
intestines, such as bisacodyl, senna, or cascara.
Stool softeners such as docusate do not help.
 Loss of muscle (sarcopenia) and strength occur
in all people who need bed rest for a long time.
With complete bed rest young adults lose about
1% of their muscle per day, but older people
lose up to 5% per day because they have lower
levels of growth hormone, which is responsible
for maintaining for recovery. Thus, people
should sit up in bed, move, stand, and exercise
as soon as and as much as is safe for them.
DISCHARGE HOME AFTER HOSPITALIZATION
 Before leaving the hospital, people are
responsible for:
- Scheduling a follow-up visit with the
doctor
- Knowing what drugs to take
- Knowing what activities to avoid or limit
 Examples of activities that may need to be
avoided temporarily include climbing stairs,
driving a car, lifting heavy objects, and having
sexual intercourse. A person should know what
symptoms necessitate contacting the doctor
before the scheduled follow-up visit.
 Resuming normal activity during recovery from
surgery should occur gradually. Some people
need rehabilitation (see see rehabilitation),
which involves special exercises and activities,
to improve strength and flexibility. For example,
rehabilitation after hip replacement surgery can
involve learning ways to walk, stretch, and
exercise.
CONTRAINDICATIONS TO MINOR SURGICAL
PROCEDURES:
 Minor surgery connotes surgical therapy of
lesions offering little or no immediate or potential
threat to life, which maybe treated with the
patient on an ambulant status.
- Patients with diabetes, blood
dyscrasias, severe heart disease are
poor subjects for office surgery.
- If patient must stay in bed for one- or
two-days post-operative.
- If no nursing care at home.
- If lesions maybe malignant or require
wide excision.
- If extent of the lesion cannot be
determined pre-operative.
PRE-OPERATIVE CARE

*IMPORTANT: patient must be fully aware of the need
for and scope of the operation and type of anesthetic to
be used.
 If post-op disability is likely, the patient should
be prepared for it.
 If patient is reluctant to undergo surgery –
DON’T PROCEED
 Always do schedule operations
 Advise patient to use or wear clothing which will
permit wide exposure to the part
 Advise patient to omit meal immediately
preceding operation
CONDUCT OF OPERATION
 The surgeon must make certain that the
instruments and supplies needed for the
procedure are properly prepared and at hand.
 The patient position during the operation should
afford maximum exposure and accessibility of
the part and should afford maximum exposure
and accessibility of the part and should be
capable of being maintained comfortably.
 Operative field should be shaved.
 Clean area by friction sponging several times
with ether-soaked sponges then paint with
colored antiseptic OR use hexachlorophene.
 Gowns not necessary but surgeon’s cap and
mask is a must.
 Surgical scrubbing.
 Drapes.
POST- OPERATIVE CARE
 Patient’s require detailed instructions regarding
care of minor operative wounds.
 The surgeon should anticipate complications
and should instruct the patient in the proper
precautionary measures to be taken to avoid
them.
 The patient should be kept in the office or clinic
until sufficiently recovered from anesthetic and
operation.
ASEPTIC SURGERY
 Principles of Aseptic Surgery:
- This is a topic which embraces three
stages:
1. pre-operative sterilization of
instruments, materials, and drapes
to be used during the operation.
2. precaution to prevent infection of the
operative field during the operation
DR. ARLENE P. PAVO, M. D.
3. protection of the wound from
infection after the operation until it
has healed.
DEFINITION OF TERMS
ASEPSIS - the absence of infection or septic material.
ANTISEPSIS - the prevention of sepsis (putrefaction) by
destroying bacteria and infective material.
STERILIZATION - process by which all forms of bacteria
are destroyed.
DISINFECTION - process by which only all the infective
bacteria are destroyed.
ANTISEPTIC – a substance that will inhibit the growth of
bacteria without necessarily destroying them.
DISINFECTANT – is an agent, usually a chemical that
kills pathogenic bacteria.
GERMICIDE or BACTERICIDE – any agent that kills all
germs or bacteria.
METHODS OF STERILIZATION
 Mechanical methods – thorough scrubbing with
soap and water. By this method, no absolute
sterilization can be attained however, it is done
because a large number of bacteria may be
removed.
- DEBRIDEMENT – this is the removal of
devitalized tissues from a traumatic
wound. The removal of the necrotic and
devitalized tissues carries with it the
contaminating bacteria and foreign
bodies that may be present.
 Thermal methods
- DRY HEAT
1. NAKED FLAME – used in
emergency cases to sterilize
needles, other sharp instruments
like scalpels, kidney basins, etc.
= hypodermic needles may be
sterilized by heating it to a point red
heat over an alcohol flame from a
lamp or a burning piece of cotton
wet with alcohol.
2. HOT AIR OVEN – in this form of
sterilization, the materials are
subjected to high temperature (300
to 320 F for 120 minutes) in a hot
oven.
= it is used especially to sterilize
Vaseline, vaselinized gauze, oils,
bone wax, and talcum powder.
= hot air destroys microorganism by
means of oxidation.
3. MOIST HEAT
= BOILING WATER – this is one of
the commonest methods of
 DR. ARLENE P. PAVO, M. D.

sterilization used in medical = the concentration of a solution usually

practice. Its use however, is limited influences the efficiency of the agent.
to emergencies and for sanitizing = an increased temperature accelerates
equipment. Except for instruments the rate of disinfection.
(like cotton balls, gauze, catgut, = the composition and structure of the
etc.) that are damaged by wetting, object or instrument will influence the
this process of sterilization has wide kind of chemical to be used.
range of utility. Its main  Physical methods
disadvantages is that it dulls cutting
instruments like scissors, scalpels, GROUP OF ANTISEPTICS
etc. and may form deposits like  The Phenol Group
scissors, scalpels, etc. and may  Salts of heavy metals
form deposits of lime on the surface  The dye group
or joints of metallic instruments and  The chlorine group
utensils. Time of exposure is usually  Oxidizing group
20 minutes.
 Compound antiseptics
= STEAM UNDER PRESSURE –
 Miscellaneous group of antiseptics
this is the best method of sterilizing
PHENOL GROUP
most if not all surgical supplies. The
- The most commonly used are phenol
autoclave, which is the apparatus
and Lysol.
used for this purpose, is built to
- PHENOL or CARBOLIC ACID – this is
withstand increased steam
colorless crystalline compound obtained
pressure. Exposure is for 15 to 20
by distillation of coal tar. When dissolve
minutes at 250 F.
in a little amount of water to produce a
95% strength, it is generally called pure
ADVANTAGES of pressure steam sterilization
phenol or pure carbolic acid.
(PERKINS):
- USES – to cauterize and subsequently
- Rapid heating power and rapid
sterilize the cut edges of intestinal
penetration of materials
mucosa. This is best exemplified by
- Destruction of most resistant non-
practically every surgeon who paints the
pathogenic and pathogenic spores in s
appendiceal stump with phenol followed
short period of exposure
by neutralization with alcohol.
- Characteristics and power easily
- to cauterize and destroy the
controlled for all packages in the
capsule linings of various growths
sterilizer.
like sebaceous cysts. Immediate
- Automatic controls practically excluding
neutralization with alcohol is done to
human error in operation.
prevent destruction of surrounding.
- Accurate measures to test efficiency of
SALT of HEAVY METALS
the methods used.
- In watery solution the germicidal activity
 Chemical methods – this is done by the use of
of these salts is great. However, the
antiseptics and germicides. In general, the vital
activity becomes much reduced on
parts of the cells are destroyed by coagulation or
coming in contact with soaps, alkalis,
blocked by combination with the chemical.
proteins, etc., example is silver nitrate.
- The efficiency of a disinfectant to
- Silver nitrate is powerful antiseptic which
destroy microorganisms is influenced by
easily decomposes when exposed to
the following factors:
light.
= the selection depends on the types of
- USES – one half to 5% of aqueous
bacteria to be destroyed
solutions are used as antiseptics to
= the surface of the objects must be free
mucus membranes like the eyes,
from blood, pus, oil, or grease, so that
urethra, bladder, etc.
the chemical agent can contact the
- “Lunar caustic” or fused silver
bacterial cells.
nitrate prepared in cones or pencils are
= the time required to destroy bacteria is
often used as caustics.
influenced by the types of bacteria to be
DYE GROUP
destroyed, the construction and design
- This group of antiseptics is more
of the item.
commonly seen in wards, dispensaries

and they are just effective if not better
than the other antiseptics. Examples are
gentian violet and merthiolate.
- GENTIAN VIOLET – antiseptic for most
common skin lesions and wounds of the
mucosa.
- MERTHIOLATE – used for the
preparation of the site of operation.
THE CHLORINE GROUP
- This group derives its antiseptic capacity
from the giving off chlorine when
brought into contact with protein
materials of the tissues or bacteria.
Example is DAKIN’s SOLUTION which
is hypochlorite solution used in wounds
especially the pungent ones.
THE OXIDIZING GROUP
- This group liberates oxygen when
brought into contact with the tissues.
Examples are hydrogen peroxide and
potassium permanganate.
- Potassium permanganate may be used
as antiseptic solution for sloughing
wounds in the vagina and urethra, and
as deodorant for foul wounds and
necrotic tissues.
COMPOUND ANTISEPTICS
- These are those whose action as
antiseptic is enhanced by combining
them with other drugs.
- Example is the ABC antiseptic douche
(Alum, Boric Acid, Carbolic Acid).
MISCELLANEOUS GROUP of ANTISEPTICS
- ALCOHOL or ZEPHIRAN are good
examples.
- ALCOHOL – this is one of the most
useful.
o USES – in 70% solution is
frequently used in pre-operative
and post-operative sterilization
of the surgeon’s hands and the
patient’s skin.
o For sterilization of cutting
instruments which cannot be
boiled.
- ZEPHIRAN – is a 1.1000 aqueous
solution is a very useful antiseptic for
sterilization of cutting instruments,
delicate scopes, etc.
PHYSICAL METHOD of STERILIZATION
- Although used sparingly, it should
deserve mention.
- Examples are the following:
o Sunlight
o Ultraviolet rays
o X-rays
DR. ARLENE P. PAVO, M. D.
- These are indicated in the treatment of
sluggish wounds as in bedsores, and
also in carbuncles.
PRE-OPERATIVE STERILIZATION
- This stage covers the sterilization of the
following:
o All the materials to be used
during the operation
o The surgeon and his assistants
o The operative area (patient’s
skin)
o The surgical materials include
all the instruments like forceps,
scalpel needles, sutures,
operative sponges, gowns,
linen, gloves, and any other
things that are going to come in
contact with the operative field.
DURING the OPERATION
- The operating team must not touch
anything that is not sterile and vice
versa, non-sterile members must not
come into contact with anything that has
been rendered sterile.
- Special precautions should be taken to
prevent sweat to fall into the operative
field as this is one way that
contamination may occur.
POST-OPERATIVE PROTECTION
- After operation, the wound is usually
painted again with an antiseptic and
covered by sterile dressing to prevent
infection.
- The dressings are held in place with
adhesive plaster or roller bandage.
General accepted methods of sterilization of
materials used in operation:
- Linen, gowns, gauze, gloves, powder,
cotton balls, and other supplies are best
sterilized by autoclave.
- Surgical cut – tubes containing non-
boilable gut must be disinfected by
chemical – 1:1000 aqueous solution of
zephiran.
- Basins or other containers for use in an
operation are best autoclaved.
- Brushes are disinfected by immersion in
germicide.
- Cytoscopes, thoracoscopes, and
peritoneoscopes are best sterilized by
soaking in 1:1000 aqueous solution
zephiran.
- Majority of instruments except the
cutting instruments are best sterilized by
autoclave.

- Cutting-edge instruments as scalpels
and scissors are best sterilized by
soaking in 1:1000 solution (aqueous)
zephiran.
- Plastics are best sterilized by soaking in
chemicals.
- Utensils, operating room tables, floors,
paints, etc. are best sterilized by
scrubbing.
- Surgeons and assistants’ hands,
forearms, and elbows are best prepared
by mechanical scrubbing with soap and
water.
- The patient’s skin upon which the
operation is to be performed is
preferably cleansed first with soap and
water to remove to remove dirt and oily
substances which may be present; then
application of either with a piece of
gauze to further remove fat; followed by
the application of an antiseptic
(betadine).
- Application of antiseptic will begin over
the site of incision then moving outward
circulatory without going back from the
point of origin. A large area around the
site if incision is prepared.
- The surgeon and his assistants,
including the sterile nurses, and other
operating room personnel should not
wear their street clothes or their ordinary
hospital uniforms in the operating room.
- They should be provided with a surgical
helmet or cap, which should be clean
and should fit the person’s head.
- The person should apply it so that all his
or her hair is covered.
- A facemask should be worn in order to
filter bacteria as the person talks,
laughs, and sneezes.
- The face mask should be made of
preshrunk double ply cotton and should
be designed to fit the contours of the
face so that it covers the nose and
mouth.
- Once properly attired as above, the
surgeon and assistants may proceed to
scrub.
TECHNIQUES OF SCRUBBING
 All fingernails should be short and clean
 Turn on the faucet. Wet the hands and apply
soap, then mix with water, make a good lather
and scrub the hands and forearms to 3 inches
above elbows.
DR. ARLENE P. PAVO, M. D.
 Take a sterile brush and saturate with soap,
scrub the nails and hands for one minute. Then
rinse the hands and brush.
 Apply liquid soap on each hand and water to
make suds, then scrub each forearm for 2
minutes. Start the scrub above the elbows,
working downward over the hands and covering
all surfaces with plenty of suds. To conserve
energy during the scrub, relax the wrists and
make straight short strokes or small circular
motions.
 Rinse the suds from the hands and forearms,
heeding the hands downward to allow the water
to run off the fingers.
 Keep the hands higher than the flexed elbow to
allow the water to drip off them and to prevent
the water from running on to the forearm.
 Soak the hands and forearms for one minute in
an antiseptic.
 Keeping the hands up and in front of the body,
with the elbow slightly flexed, prepare to put on
the sterile gown or to dry the hands.
PUTTING on a STERILE GOWN
 The scrubbed person dries hand and forearms
with sterile towel.
 Then he grasps the folded gown, steps back
from the table, and extends the arms at level
with the upper chest to prevent the gown from
touching an unsterile object.
 Keeping the arms extended and elbows slightly
flexed, grasp the ends of the neck band with
both hands and shakes the gown slightly to
open it.
 Then he introduces each hand into armhole,
keeping the arms extended and making sure the
sleeves do not touch an unsterile object.
 To introduce the forearms into the upper portion
of the sleeves, the person flexes the elbow.
 The circulating nurse places each hand on the
inner side of the gown at each shoulder seam
and pulls the gown over the person’s shoulder.
 To close the gown, the circulating nurse grasps
the ends of the tapes and tie them together. The
scrubbed person should keep the arms in front
with the elbow flexed.
PUTTING on STERILE GLOVES
 The gowned person takes one glove (right or
left) from envelope by placing the fingers of the
opposite hand on the fold of the everted cuff at a
 DR. ARLENE P. PAVO, M. D.

point in line with the glove’s palm, and pulls the

glove over hand, leaving the cuff turned back.
 Then he takes the second glove from the
envelope by placing the gloved fingers under the
everted cuff.
 When with the arms extended and elbows flexed
slightly, introduces the free hand into the glove.
 Then with the fingers under cuff of the glove,
draws it over the cuff of the gown.
 When the cuff of the gown is loose, the gowned
person makes a pleat at the bottom of the
wristlet of one sleeve, holds the pleat with the
gloved thumb of one hand, places the fingers of
the same hand under the turned-back cuff, and
brings it over the pleat, making sure to remove
the thumb as soon as the bottom part of the
pleat is secured.
 Then he brings the cuff of the glove over the
upper part of the wristlet by easily separating the
fingers under the turned-back cuff and by
rotating the arm externally and internally.
 The procedure is repeated in the other hand.

The basic surgical instruments used for surgical

procedures are as follows:
 Peritoneals or Halstead forceps
 Kelly curved forceps
 Ochsner or Kocher forceps
 Allis forceps
 Babcock’s forceps
 Tissue forceps
 Thumb forceps
The basic surgical instruments used for most
procedures are as follows:
 Towel clips
 Sponge forceps or holders
 Retractors
 Scalpel handles and blades
 Surgical scissors (Mayo)- curved and straight
 Needle holders
 Suture needles

CONTENT
 Dressing and Bandages
 Technique of dressing and suture removal
 Ligatures and Sutures
 Knots
BANDAGES AND DRESSING
 Dressing and Bandages in general are classified
into three main groups:
1. Those which main purpose for wound
covering. (When dressing or a bandage is
applied to a wound until there is a complete
healing or it absorbs the secretion of an
infected wound)
2. Those which give support and
immobilizes part
(when dressing or bandage is applied to
immobilize and support wounds or injuries,
like fracture of extremities)
3. Those which have use as a special
therapeutic agent. (Warm compress,
Unna’s paste boot, and dressing of its
curative properties)
 Requisites of a successful bandage:
1. It should efficiently hold dressing or splints in
place
2. It should be comfortable
3. It should not come off
4. It should have a neat appearance
 Types of Bandages according to materials used
1. Gauze: most commonly used either as
gauze squares or roller bandages
2. Muslin: are not used very much except for
making T-binders of the perineum and for
traction in the treatment of certain fractures
3. Flannel: used for many years for traumatic
lesions of the extremities and especially of
joints.
4. Elastic: very much used at present for many
purposes. It may be used over and over
again since it is washable.
DR. ARLENE P. PAVO, M. D.
5. Elastic Adhesive: are cotton webbing
bandages in which adhesive is overlayed on
one side.
KINDS OF BANDAGE
TRIANGULAR BANDAGE
- Can be improvised from any kind of cloth, large
handkerchief, etc. Unbleached muslin is
generally used in making one
Uses:
As open or unfolded triangular bandage:
a. Head-especially to keep a dressing in place on
scalp or forehead when extensive
b. Hand/foot- useful in extensive injuries as in burn
cases
c. Chest/back-also to hold dressings in burns or
wounds of the chest and back, breast binder or
to hold compresses on breast
d. Shoulder or hip bandage
e. Face bandage
f. Arm sling
TRIANGULAR BANDAGE FOLDED AS A CRAVAT
a. Head or ear-useful especially to control
hemorrhage of scalp or forehead
b. To hold dressings in the eye
c. Neck bandage
d. Arm/forearm, thigh/leg bandage
e. Elbow/knee bandage
f. Pressure bandage of the palm
g. Support sprained ankle
ROLLER OR PLEATED GAUZE BANDAGE
- Are strips of gauze rolled into tight rolls or folded
(pleated) for convenient packing. They are
variable width, varying from 1-inch, 2-inch, and
4-inch; and the length may usually be five or ten
yards
Uses:
a. Hold padding in place
b. Make compression
c. To bandage injuries of fingers, toes, limbs,
hands, wrists, foot, ankle, joints
FOUR-TAILED BANDAGE
- Maybe a piece of cloth about 3ft long and 3-8
inches wide, split down the middle from each
and thus creating four tails
Uses:
a. Best bandage for wounds of the chin and lower
jaw, but not for fracture of jaw
b. May be used for wounds of nose, likewise for
the head
c. To hold dressing in perineum
CLASSIFICATION OF BANDAGING (as to the way
a roller bandage is applied)
CIRCULAR

- Simple circular turns are taken about the part.
- bandage is fixed by 2 or 3 turns about the part
- it is then advanced up or down the part by
successive circular turns, each of which
overlaps the one preceding by 0.5 inch (1.3cm)
to 1 inch (2.5cm), depending upon the width of
the bandage.
SPIRAL
- each turn covers about one-half of the preceding
one.
OBLIQUE
- applied with oblique turns
SPIRAL REVERSE
- best applied if the extremity or limb increases in
size from elbow upwards. This can be done by
fixing the bandage with the thumb or reversed
so that the inner surface becomes the outer
each turn. The reverse is made preferably along
line.
- Bandage is fixed by 2 or 3 circular turns. Then
one each succeeding turn, the roll is rotated
counterclockwise 180 degrees as the bandage
is advanced along extremity.
RECURRENT
- The turns recur successively to the same point,
used over the hand, amputation stump, and of
DR. ARLENE P. PAVO, M. D.
fingers or fist. It should be carefully fixed to
prevent displacements of recurrent loops
- Several circular turns are made. About the
extremity
- While an assistant fixes the bandage, its
direction is changed 90 degrees, and it is carried
back and forth across the end of the stump until
stump is covered
- Several more circular turns are then made to
complete the bandage
- This type of bandage may also be used for head
dressings
FIGURE-OF-EIGHT
- Applied in the form open loops, interdigitating in
the figure of “8” form. Included in this, we have
the descending figure of 8 bandage and spice-
bandage
- Several circular turns are made
- The bandage is then carried obliquely across the
part above the joint and another circular turn
taken, thus completing a figure-of-eight
- The process is repeated, overlapping each turn,
until pan is covered.
SPECIAL TYPES OF BANDAGES
HEAD BANDAGE
- Applied by first making several turns around the
head at the base of the skull, so that is firmly
applied to both the inion and the glabella
- Bandage should extend low enough to include
external occipital protruberance
- Back and forth layers of bandage are then
applied and held at the ends by assistants until
the entire head is covered, then the circular
bandage described above is repeated
- Transverse or circular strips of adhesive plaster
are used to reinforce the head bandage
FINGER BANDAGE
- The fingertips may be covered by making
several back and forth turns, and then this is
held in place by subsequent circular turns.
VELPEAU B.
- This is applied as follows:
-The arm in affected side is positioned in
such a way that the hand is upon the

opposite shoulder and the elbow near
the xiphoid process
- A pad is preferably placed in the axilla
of the affected side. Starting from
opposite axilla, the bandage is carried
across the back to the affected
shoulder, over it to reach the anterior
portion; from here, it is carried pver the
middle of the arm and curved behind the
elbow to reach the anterior chest and
carried back to the starting position.
- the horizontal turn is made at the level
of the affected elbow.
- The vertical and horizontal turns are
alternated until the whole arm and
forearm including the elbow are covered
- The horizontal turns are allowed to
ascend progressively until the shoulder
is reached, while the vertical turns
descend to the elbow
- In each, the subsequent turns overlap
the preceding ones.
FIGURE-OF-8 BANDAGE TO SUPPORT BREAST
- this starts at the shoulder, is passed down under
the breast of the opposite side, under that axilla,
over that shoulder, then down in front of the
chest under the opposite breast, under that
axilla, over that shoulder, and so on.
FIGURE-OF-8 BANDAGE TO SUPPORT CLAVICLE
- In this bandage, pelt pads are placed on the
front of both axilla.
The bandages are crossed on the back so as to
form a figure of 8, the loops of which include the
shoulders to hold them back.
- This is useful to immobilize fractures of the
clavicle.
STIFF, FIXED OR IMMOVABLE BANDAGE
- At times for better support and protection the
bandages used are hardened.
- The materials used therefore, should be capable
of hardening after application.
- To achieve this, the hardening substance is
incorporated in the fabric used.
- Examples are starch, plaster of Paris or gypsum,
silicate of soda or water glass, dextrin, flour,
glue, gum or wax.
- When these are applied, the bony prominences
should be protected with pads
SPLINTS
- These are used to give support to the bony
framework or joints of the body.
DR. ARLENE P. PAVO, M. D.
- The materials used may either be rigid,
flexible, or provided with hinges.
- In cases of emergencies, one may use
provisional splints.
- This may be any material available at the
moment as strips of wood or board, canes,
umbrellas, etc.
- There are many forms of splints available, their
names varying according to their shape or
adopting the name of the individual who devised
the same.
- Examples are: simple straight splint which
consists of padded thin wooded board. Angular
splints consist of two boards united at an angle.
o Molded splints - molded to fit the part,
usually formed of a plaster of Paris roller
bandage.
- Wire splints consist of very heavy wire or metal
rod as in the Thomas splint.
BRACES
- These are specially made supporting devices
designed for more permanent use.
- They are usually made of steel and leather, with
or without hinges.
- Braces are especially useful for support of the
spine, neck, hip, or extremities.
TECHNIQUE OF DRESSING AND SUTURE
REMOVAL
- Immediately after a clean surgical operation,
the wound is covered with several sterile
gauze squares and may be with a top
dressing.
- These should not be bulky and are fastened
to the skin by means of adhesive plaster with
but a minimum amount of pressure.
- If hemostatic is incomplete or uncertain, and if
dead spaces are present in the wound, then
the thickness of the dressings over the
incision is increased and the adhesive or
bandage applied with a greater amount of
pressure.
- Hairy regions should be shaved especially at
the spot where the adhesive will come into
contact with the skin.
- In clean wounds, redressing is not necessary
until the time for suture removal.
- However, if the top dressings became soiled
or the patient complains of pain around the
wound indicating infection, then the wound is
inspected and treated accordingly.
- Soiling of top dressing requires only its

change but not of the layers underneath
which should not be disturbed at all.
- The redressing of wounds with or without
removal of sutures should be carried out
under relative sterile conditions.
- Mayo tray is overlaid with sterile towel upon
which sterile gauze squares and cotton balls
are placed.
- With a pick-up forceps, needed instruments
like dressing forceps, hemostats, suture
scissors and probe are removed from the
instrument tray as needed.
- These are picked-up in such a manner that
the part of the instrument to come in contact
with the wound is not contaminated.
- The outer layer or top dressing is lifted off by
the hand after the adhesive plaster has been
loosened by ether or benzene.
- From then on, the other dressings and the
wound are touched only with sterile
instruments and supplies.
- If the dressings are adherent to the wound it
is loosened up by means of hydrogen
peroxide or alcohol.
- Then the wound and surrounding skin are
painted with alcohol or any colored antiseptic.
- In removing the sutures, we should attempt to
cut them as close to the skin as possible and
extracted by pulling the free ends towards the
incision in order to avoid gaping of the edge of
the wound.
LIGATURES AND SUTURES
Definitions:
a. Ligature- materials used for ligation of blood
vessels
b. Suture- material used for the approximation of
tissues together.
KINDS OF SUTURE MATERIAL
1. ABSORBABLE SUTURES - materials that are
dissolved when left in the tissues of the body for
a short time (1 to 4 weeks).
- All of them are of animal origin. Examples are:
from tendons of kangaroo or rat, aorta of the ox,
intestinal wall of sheep, etc.
- Of these, only catgut has remained in use thus
replacing all other
kinds of absorbable sutures.
 Catgut - this is made from the submucous layer
of the intestinal wall of the sheep.
DR. ARLENE P. PAVO, M. D.
 Catgut is prepared in different sizes, namely:
000, 00, 0, 1, 2, 3, 4, 5, 6,7.
 Catgut may also be subdivided depending upon
the method of chemical treatment into:
a. Plain Catgut
b. Chronic Catgut
Plain Catgut- this has not been treated with any reagent.
Chronic Catgut- a plain catgut suture which has been
treated by chromium trioxide with the object of rendering
it more resistant to tissue fluids and thus delay its
absorption. Sometimes by the number of days
necessary for the catgut to be absorbed, chromic catgut
is named as "ten-day", "twenty-day", "twenty-day", or
"forty-day".
2. NON-ABSORBABLE SUTURES- these stay
indefinitely in the a tissues as they do not dissolve when
left in the body.
There are several types:
- Inorganic
- Organic (Animal Nature Synthetic Origin)
A. Inorganic Nature
 Metallic sutures - these were extensively used
before, later discarded, especially useful for
closure of the skin and for use as tension-
sutures.
The different metals used are:
a. Metal clips - used for closure of the skin of the
abdomen. Usually made of combination of
different metals (alloy).
b. Stainless steel wire - this is expensive, non-
irritating and less brittle than silver or bronze
wire. Used for closure of the skin and as tension
sutures.
B. Organic Natures
 Vegetable Nature:
a. Linen - this is used extensively and is an
excellent suture material. Much stronger than
silk of the same diameter, can be easily
disinfected by boiling, and it is much cheaper.
b. Cotton - has met wide use in recent years.
- It possesses pliability, adequate tensile
strength and stability on exposure to heat and
moisture.

-It produces less tissue reaction than silk, linen,
or catgut.
-Three sizes of spool cotton are adequate; size
no. 6-0; for ligature of small vessels and for
suture of wounds.
- Where the cosmetic result is important: size 4-
0; for closure of peritoneum, suture of gastro-
intestinal tract, subcutaneous suture and skin:
size 2-0 for suture of fascia and ligation of large
vessels.
- Cotton is also prepared in the following sizes:
000000 up to 7.
Most surgeons using cotton recommend the use of
interrupted sutures and even warns that it should not be
used as a continuous suture.
It has been shown that wounds closed with spool cotton
have less induration edema and tenderness as
compared with wounds closed with other suture material.
 Animal Nature:
a. Silk, braided or twisted
- this is strong, easily sterilized, pliable, does
not swell when placed in the tissues and
does not irritate them.
- It is easy to tie; the knots are tight and have
little tendency to slip.
- However, its capillarity makes silk
unsuitable for skin closure, since it may act
as a wick to carry infection into the deeper
tissues.
b. Silkworm gut
- prepared from silk-forming glands of
silkworm,
- Easily sterilized by boiling which softens it
and renders the tying easy.
- Used for tension sutures but should never
be used as a buried suture.
c. . Dermal
- pure silk threads carefully spun from
selected silk fibers and finished by special
processes.
- Has greater tensile strength than horse hair.
- It can be boiled for sterilization purposes.
- Is preferable to horse hair for suturing the
skin.
d. Kal-dermic
- used for skin and tension sutures.
DR. ARLENE P. PAVO, M. D.
- It is a silk thread which has been subjected
to special treatment by chemical to render it
resistant to the action of the body fluids.
 Synthetic Origin:
a. Nylon
- synthetic substitute for silk.
- It can be boiled or autoclaved.
- It may be multi-filament or braided, and mono-
filament.
- It produces minimal tissue reaction but is
objected to because of allergic reactions and the
tendency for the knot to slip.
b. Vinyon
- a polyvinyl resin with all the qualities of nylon.
- It cannot be sterilized by boiling.
c. Plastigut
- it is similar in appearance to catgut.
- Maybe used as interrupted or continuous suture
in the peritoneal cavity
KINDS OF SUTURE WITH REFERENCES TO
APPLICATION IN TISSUES
1. Interrupted - each stitch is tied separately.
2. Continuous - where tissues are sewed together
with one long thread and only the first and last
stitches are tied.
3. Buried - there are those taken in any tissue
under the skin.
4. Purse-string - like an ordinary gathering string.
5. Subcuticular- stitches taken under the skin,
leaving only the line of incision visible.
Especially nice where no scar is wanted on face
or exposed areas.
6. Tension or Stay Suture - usually silkworm gut
to hold wound together.
7. Through and through suture - going through
all layers of abdomen, usually used in
emergency where a patient is in poor condition
and needs to be out of the operating room table
quickly.
8. Tier - each layer sutured by itself.
9. Button - where skin sutures are tied over a
button so that they will not bury themselves in
the skin.
SUTURE NEEDLES
- Shape may be straight, full curved, or half-
curved. Straight needles are used when the
suture is to be placed at an accessible site.
- Curved needles are preferred when the suturing
is in a deep or inaccessible location.
 DR. ARLENE P. PAVO, M. D.

Types - needles may be classified under two headings: GRANNY KNOT

1. Cutting edge:
a. Hagedorn
b. Spear point
c. Trocar point
Cutting needles are used for the skin or any
dense tissue, such as the cervix of the uterus.
2. Round point needles - used for operations on
the intestines, brain, mucous membranes,
nerves and such delicate structures such as
blood vessels, etc.
SLIP KNOT
 Size - needles come in varying sizes and
caliber; usually the smallest number indicate the
largest needles, although sometimes just the
reverse of this is true depending upon the maker
of the needles.
- In this knot, each of the vertical limbs passes in
front of one of the horizontal limbs and behind
the other horizontal limb.
- This is not only a little less dependable than the
square knot;
- however, the ends can be more easily untied
than can the square knot, probably because
they are not bent so sharply back upon
themselves in the same place as they are in a
square knot.
- produced by pulling tightly on one end of the
thread while making a loop with the other and
around the taut end as around an axis and
failing to cross ends in the opposite direction
when each half-hitch of the knot is made.
- It is a very unreliable knot.

KNOTS
SQUARE KNOT
- AKA reef knot; sailor’s knot
- it has one vertical limb in the loop which passes
in front of the other vertical limb behind the
horizontal limbs.
- This is the most reliable knot with no tendency
to untie:
- It resists pressure from inside more than any
other knot (with the exception of the surgical
knot).

SURGEON’S KNOT
- (Surgical Knot) it differs from the above in that
when the first half-hitch is made, the ends are
not pushed away from each other but another
half- hitch is made in the same direction.
- Then the ends of the thread are pushed away
from each other.
- This constitutes the first half of the surgeon's
knot.
- The second half of the knot is made by turning
the ends in the opposite direction so as to make
it a square knot.
- This knot, unlike square knot, does not slip away
before it is completed.
- It is however, more bulky.
- This is seldom used now. Its usefulness is only SURGICAL INSTRUMENTS
in cases when a blood vessel has to be tied 1. Minor Surgery tray
deep in the field, when even the point of ligation 2. Basic Pack
is not well seen. • Scalpel:
• Forceps: thumb forceps, thump forceps,
toothed/non-toothed forceps, rat tooth, adsons, twisors,
 DR. ARLENE P. PAVO, M. D.

Russian forceps, DeBakey, long/short, grasping, allis, - Size of the blade does not change the
babcock, kocher, sponge forceps, homeostatic forceps, technique of use
Kelly/mosquito, curved/straight, arterial forceps/artery
clips
• Scissors: curved/straight mayo scissors,
Metzenbaum, bandage, suture, Littauer suture
• Retractor: farabeuf, spay hook, zenn, army
navy, weitlaner, gelpi
• Curettes
• Needle holder: Olsen hegar, mayohegar
• clamps

MINOR SURGERY TRAY

SCALPEL HANDLE

a. #4 Handle- for larger blades (#20)

BARD-PARKER #4 HANDLE

• Minor Surgery Instruments

- Lesions for minor surgery are generally small
and readily accessible, thus minor surgery
instruments are small.
- Although use of fine instruments does not
ensure meticulous operative technique, it
- Quantity of each instruments required b. #3 Handle- for smaller blades (10, 11, 12, 15);
depends largely upon the number of minor commonly used in plastic surgery
surgical operations performed. c. #7 handle- ends of which are similar to #3 handle;
• Basic Pack commonly used in eye, ear, nose and throat work
- Good quality instruments, and no cheap
instruments

SCALPEL
- Best instrument for division of tissue
- Less traumatic to surrounding tissues
- Should be held in a way that will permit full
control of the instrument and freedom of
movement
- Composed of blade, and the blade handle
- Blades come in different sizes and shape

d. Blades #10 is the most commonly
used blade
e. #15 is a smaller version of 10 and is
used for more delicate incisions. It is
used in most procedures, especially
plastic surgery , allowing more precise
turns when making the incision.
f. Blade #11 (stab/bayonet)- is used for
draining collections of pus by driving
the point directly into the abscess and
then sweeping the blade up through
the tissue in an arc. It may be used in
removing sutures
g. Blade #12 (bistoury)-looks like a hook
and used for draining infection of the
middle ear; the tip sweeps through
the drum in an arc. It can also be used
in
removing sutures
DISPOSABLE SCALPEL
Disposable scalpel and instruments can be
used if there is no available autoclave (An
autoclave is used to sterilize surgical equipment,
laboratory instruments, pharmaceutical items, and
other materials. It can sterilize solids, liquids,
hollows, and instruments of various shapes and
sizes)
FORCEPS
DR. ARLENE P. PAVO, M. D.
THUMB FORCEPS
- Consist of two tines held together at one end
and with a spring device that holds the tines
open
- Dressing forceps have smooth or smoothly
serrated tips
- Tissue forceps have teeth to grip tissue; it is
used to pick up tissue between the apposed
surfaces
- when teeth are present in the apposing
surfaces, the forceps can hold tissue without
slipping and
without exerting undue pressure
TISSUE FORCEPS
- Used for precision holding
- Used to pick up delicate tissues for suturing
- It may either have many teeth or a single tooth
- Thumb forceps are used to grasp tough tissues
- Single tooth forceps are aka “rat tooth
forceps”
NO -TOOTHED
N FORCEPS
- Used in handling vital sutures, those which
should not be perforated, should have no teeth;
additional grasping strength is provided for a
wider head
- Many forceps bear the name of the originator
of the design, such as Adson tissue forceps
TOOTHED TISSUE FORCEPS
A. TISSUE FORCEPS
TISSUE F.

- Has teeth which prevents it from slipping
- Only a small amount of pressure is required to
grasp tissue firmly
- Teeth vary in number from one to a dozen and
in size from very fine to fairly large
- Always used when handling skin
B. RAT TOOTH (THUMB) TISSUE FORCEPS
RAT TOOTH
- Interdigitating teeth to hold tissue without
slipping
- Used to hold skin/ dense skin
DRESSING AND TISSUE FORCEPS
A. ADSONS TISSUE FORCEPS
- Smaller serrated teeth on edge of tips
- Has delicate serrated tips designed for light,
careful handling of tissues.
DR. ARLENE P. PAVO, M. D.
B. ADSON FORCEPS WITH TEETH
- Used for any heavy duty clasping such as
with the skin and suturing Adson pick ups
are either:
- smooth; to grasp delicate tissue
- with teeth: to grasp skin (dura forceps)
THUMB FORCEPS
- Used in handling vital sutures, those which
should not be perforated, should have no teeth;
additional grasping strength is provided for a
wider head
DRESSING FORCEPS
- Has blunt end with coarse striations to give
additional grasping power
- Used routinely in applying and removing
dressings
- Also used to handle hollow viscus which might
be punctured by a sharply pointed forceps
- Not used to grasp the skin when putting in skin
structures ; since there are no teeth on grasping
edges the force required to hold the skin firmly
may be enough to cause necrosis
DISSECTING FORCEPS (TWISORS)
-the forceps is held between thumb and middle
fingers of either hand (like a pencil); not held
like
a knife
RUSSIAN FORCEPS
- They have serrations up the tip, following a
better grasp of tissue with minimum trauma.
- Used for smaller holds
- Long smooth pick ups are called dressing
forceps
- Short smooth pick ups are used to grasp
delicate tissues
 DR. ARLENE P. PAVO, M. D.

- Its tip consists of apposing serrated edges with

fairly short teeth
- Slightly traumatic
- Used for grasping fascia or breast tissue
- Used for traction on the skin; it is not applied
RUSSIAN FORCEPS directly to the skin; it is not applied directly to
the skin rather on the tissue immediately
DeBakeyFORCEPS
beneath the skin
- Are used to grasp delicate tissues particularly in - May also be used to hold wound drapes in place
cardiovascular surgery BABCOCK FORCEPS

DeBakey

BABCOCK

- More delicate than allis, less directly traumatic

- Broad, flared ends with smooth tips
- Used to atraumatically hold viscera (bowel and
LONG & SHORT PLAIN FORCEPS bladder)
- Forceps that help to move tissue during surgery KOCHER FORCEPS
and hold tissue for suture placements - The blades have transverse serrations running
along the full length and long sharp points are
GRASPING FORCEPS found at tips
- Designed primarily to take hold of tissues and
allow one to exert traction
- The apposing surfaces of the individual heads
vary a great deal depending on the specific
purpose
- All have a set of finger rings and a locking
mechanism
ALLIS FORCEPS

ALLIS
 DR. ARLENE P. PAVO, M. D.

KELLY AND MOSQUITO HOMEOSTATS

tissue is unlikely to pull free when grasped with

this forceps

KOCHER
KELLY

KELLY HOMEOSTATIC FORCEPS

(CURVED/STRAIGHT
)

SPONGE OVUM
( ) FORCEPS
- Has considerable grasping power and allows
one to exert a considerable amount of tension
on tissues
- Commonly used on heavy fascia or bone; the
- Both are transversely serrated
- Mosquito homeostats are more delicate, have
smaller and finer tips than Kelly.
- Kelly forceps can either be straight and curved

MOSQUITO

SPONGE FORCEPS

- Can be straight or curved

- Can have smooth or serrated jaws
- Used to atraumatically hold viscera (bowel and
bladder)
- Used to hold the sponge when prepping
HOMEOSTATIC FORCEPS
- Hinged (locking) mechanism
- May bear the name of the designer (Kelly,
holstead, crile)
- Used to clamp and hold blood vessels
- May be curved or straight

CURVED/STRAIGHT KELLY
CARMALT HOMEOSTATIC FORCEPS
(CURVED/STRAIGHT)
- are characterized by the longitudinal
serrations that run the length of the blade
with crosshatching at the tip. These large,
crushing hemostatic forceps are a choice
instrument for clamping blood vessels
and large tissues or ligating pedicles.
(https://www.wpiinc.com/)
SCISSORS
CARMALT
ARTERY CLIPS
ARTERY CLIPS
- Artery forceps are used to compress an
artery to stem bleeding, because of this they
belong to a group of surgical instruments
called hemostats.
(https://www.surgicalholdings.co.uk/)
GRASPING FORCEPS
- To manipulate, the thumb and the 4 th fingers
are inserted through the rings and the rings are
apposed to lock
DR. ARLENE P. PAVO, M. D.
GRASPING FORCEPS
- Grasping Forceps device is intended to be used
to grasp tissue, retrieve foreign bodies,
and remove tissue from within the
gastrointestinal tract.
(https://mtendoscopy.com/)
- For division of tissues
- Also used to cut sutures and dressings
- Tissue scissors are usually lighter, have a finer
cutting edge and smoother points than the
suture scissors
- Straight scissors are used for work on the
surface; curved scissors are used deeper in the
wound
- Usually on the tip is used for cutting
- When a tough suture must be cut, the heel or
the back portion of the blade is used so as not
to spoil the blade near the tip.
- To avoid injury of vital structures, the scissors
should never be closed unless the tips of the
blades can be seen clearly, as in cutting sutures
- In cutting sutures, never attempt to cut a
suture unless :
- you are in good position
- you have a full control of the scissors
- you can see the suture to be divided - you can
see that you are not likely to cut any other
structure - To hold the scissors, the
thumb and the 4th fingers are inserted
through the rings , the middle finger is
rested in front of the ring finger and the
index finger is set against the blades. -
the index finger placed well forward on
 DR. ARLENE P. PAVO, M. D.

the scissors provides more control of - Have longer handle to blade ratio
instrument - the instrument should
remain at the tips of the fingers for the
METZ
maximum control.

BANDAGE SCISSORS
- Most common type has one blade with a flat
CURVED MAYO SCISSORS blunt prow which can be inserted beneath a
dressing and slid forward without fear of
penetrating the skin
- Used mainly in cutting bandages and rarely used
in operating table

BANDAGE

- Common most surgical trays and used for cutting

dense tissue where metz scissors are too
delicate

MAYO DISSECTING SCISSORS

C. MAYO

STRAIGHT MAYO SCISSORS

- General purpose and suture cutting scissors,
normally not used on tissue

STRAIGHT

MAYO DISSECTING

METZENBAUM SCISSORS
- Used for cutting delicate tissues
 DR. ARLENE P. PAVO, M. D.

METZENBAUM DISSECTING SCISSORS - Aid in exposure of the tissue or lesion being

dissected

FARABEUF RETRACTOR

- Is used during a wide range surgery to draw

back tissues that reside in deep body cavity

METZ DISSECTING

SUTURE SCISSORS (blunt blunt)

FARABEUF

SPAY HOOK
- An instrument curved or bent near its tip,
used for fixation of a part or traction.

SUTURE SCISSORS

LITTAUER SUTURE SCISSORS

LITTAU HAND HELD RETRACTORS

ER - Are usually held by an assistant to aid
the surgeon in the visualization of the
lesion being dissected

SPAY
- used for suture removal. These scissors
have a small hook shaped tip on one blade
that slides under sutures to slightly lift them
A. ZENN
before cutting for removal.
(https://us.vwr.com/) - Blades at each end
RETRACTORS - Blades can be blunt (delicate) or sharp (more
- May be hand held or self-retaining traumatic, used for fascia)
 DR. ARLENE P. PAVO, M. D.

- This instrument is used for skin retraction GELPI

ZENN CURETTES

CURETTES
B. ARMY NAVY

- Blunt edge with different lengths used in most

minor procedures

- A curette is a surgical instrument designed

for scrapping or debriding biologic tissue or
ARMY NAVY
debris in a biopsy, excision, or cleaning
procedure
SELF RETAINING RETRACTORS
A. WEITLANER PERIOSTAL ELEVATOR

- Ends can be blunt or sharp - Periosteal elevators are mainly used to lift
- Has rake tips full thickness soft tissue flaps
- Ratchet to hold tissue apart (https://www.rvc.ac.uk /)

WEITLANER

PERIOSTAL ELEV

NEEDLE HOLDER
B. GELPI - Hinged (locking) instrument used to hold the
needle while suturing tissue
- Has single point tips - Good quality is ensured with tungsten carbide
- Ratchet to hold tissue apar
 DR. ARLENE P. PAVO, M. D.

OLSEN-HEGAR

inserts at the tips of the needle holder CASTRO-VIEJO NEEDLE DRIVER

- Comes in locking and non-locking varieties
depending on the surgeon’s preference
- Used for very fine suture in the 00000 and
smaller range

MAYO-HEGAR
- Heavy, with mild tapered jaws
- No cutting blades ******

PROPER HANDLING OF SCALPEL

MAY
O- - Common to vascular, ophthalmic and delicate
HEGA cosmetic surgeries
R
- Like other ringed instruments, the needle
holder is held with the thumb and the 4 th fingers
inserted through the rings, the middle finger is
rested in front of the ring finger and the index
finger is set against the handle.
- this needle driver is usually “palmed” with the
curved portion of the locking mechanism held
between the thenar and hypothenar eminences
of the thumb and little finger respectively
OLSEN-HEGAR
- Includes both needle holding jaw and scissor
blades
- Disadvantage to having blades within the
needle holder is the suture material may
accidentally
cut
 DR. ARLENE P. PAVO, M. D.

pointed tip
TOWEL
CLAMP

CASTRO-VIEJO
TOWEL CLAMPS
- secure drapes
- may also be used to hold tissue
Backhaus towel clamp: locking forceps with curved,

THE SEBACEOUS CYST

 DR. ARLENE P. PAVO, M. D.

(Wen, Steatoma, Atheroma)

 A typical sebaceous cyst or WEN is a retention cyst formed by occlusion of the duct of a
sebaceous gland in which the continued accumulation of secreted sebum, together with
desquamated cells and cornified detritus, gradually distends the pore or hair follicle which
unless evacuated, may attain considerable size.
The Sebaceous Cyst
 Subcutaneous globular mass protruding slightly above the level of the surrounding skin.
 Demonstrates distinct dimple on the surface of the skin.
 It is attached to the skin at one definite point.
STEATOMA or ATHEROMA is a cyst containing cholesterol crystals.

KERATOMA thought to arise from the duct of sebaceous gland, contains primarily cornified material.

COMPLICATIONS
 Infection
 Malignant change
TREATMENT
 Total surgical excision
DERMOID
 DERMOID CYST represent subcutaneous inclusion of dermal elements which occur from
misplacements of embryonal ectoderm along lines of fusion with other embryonic layers.
 TREATMENT
- EXCISION for cosmetic
- Dermoids above the eyebrow may have a deep attachment to the meninges through a
perforation of the skull, and if caution is not exercised in the dissection, a spinal fluid fistula
may be produced.
- For this reason dermoids above the eyebrow should not be treated in the out patient.
- Sharp dissection with a scalpel under constant vision is usually necessary for total removal
of the lesion.
- The technique of the excision of dermoids is otherwise the same as that of sebaceous
cysts.
EPIDERMOID CYST
 This epithelial lined cavity located in the subcutaneous tissue is usually caused by traumatic
implantation of bits of epithelium below the epidermis, although occasionally the cyst may
originate in embryonic cell rest.
 These lesions usually cause no symptoms, occasionally they maybe become quite tender and
cause considerable inconvenience, especially if they involve the skin of the hands or fingers.
 The tendency to malignant degeneration is slight.
 Epidermoid cysts should also be removed under local anesthesia by the same technique as
described for sebaceous cysts.
WARTS
(Cutaneous Wart, Veruca Vulgaris)
 Warts are papillary, benign growths appearing on the exposed surfaces of the skin,
characterized by hypertrophy of the horny layer in addition to increase length and irregularity of
the papillae.
 DR. ARLENE P. PAVO, M. D.

 They vary in size from pinpoint to more than 1 cm in diameter and maybe sessile or
pedunculated.
 The surface is usually rough and irregular with a shaggy appearance caused by excessive
overgrowth of the papillae.
 Warts usually occur on exposed surfaces on the fingers, hands and face, and most frequently
on persons from 5 to 15 years of age.
 On the fingers they frequently appear in the periphery of the nails or even under the nails and
maybe single, grouped or confluent.
 They may appear and disappear spontaneously without apparent reason.
 Acuminate warts (venereal warts) are fungating lesions which occur on the genitals and
around the anus in both sexes.
 Plantar warts are similar to the common wart in many respects but because of their
characteristic location on the plantar aspects on the foot overlying the metatarsal heads, and
because of their tendency to produce disabling symptoms, they deserve special consideration.
 Plantar warts have a tendency to extend deeply into the hypertrophied skin of the foot forming
lesions painful to touch and to walk on.
 They maybe distinguished from calluses and corns by close examination after the surface of
the lesion is pared away with a scalpel.
 This maneuver will expose the distinguishing feature of this lesions, which is a characteristic
central core.
 On the pared surface freshly bleeding capillaries representing the capillary projections maybe
seen, or these vessels maybe thrombosed, in which case multiple brownish ducts will be
visible.
 In callosities there is no break in the normal capillary lines and in corns, paring of the lesion
exposes a central pearly grey cornified core without capillary vessels.
 Direct pressure over corns and callosities causes pain, whereas lateral pressure upon a
plantar wart is more likely to elicit pain.
 Plantar warts occur usually in patients between the ages of 10 and 40 years and are often
associated with flattened arches and ill-fitting shoes.
 Occasionally, warts are seen growing in corns or callosities.
 The etiology of all warts has not been definitely established, although the theory that implicates
filterable virus is most plausible.
 Warts have been inoculated in human beings and in animals and the effective agent will pass
through a bacterial filter.
 Typical common have been produced by intracutaneous injection of a sterile filter of wart
material.
 The incubation period is usually from 1 to 8 months, depending upon the susceptibility of the
individual.
 Perhaps all warts are caused by a filterable virus, but the size, extent, location and distribution
depend on certain factors which are determined by susceptibility of the host and location of the
inoculum.
TREATMENT
 The methods of treatment of warts are numerous, but only the more effective means will be
considered.
 DR. ARLENE P. PAVO, M. D.

 Many fascinating means of dealing with these lesions have been proposed and used, most of
which represent forms of psychotherapy.
 Good result from such treatments has been vaguely attributed to alterations produced in the
vegetative nervous system or even the endocrine system.
 For example, apparent cures have been forthcoming with hypnotic suggestion of various
types.
 In some instances warts have disappeared following mental suggestions by means of highly
colored liquids magic wands, charms and other devices.
 Also, there is convincing evidences that certain accepted methods of treatment such as
irradiation, bismuth injections, and even electrodessication, are merely variations of
suggestion therapy.
 Systemic treatment consisting mainly of intramuscular injections of bismuth subsalicylate,
continuous to have advocates, and local injections of similar substances sometimes produce a
cure.
 Although these methods of treatment may occasionally be successful, their usefulness is
nevertheless limited.
 Electrodessication offers the most effective means of treatment for warts including the hands
and face.
 After the skin has been cleanse with soap and water, the lesion and in he immediate
surrounding zone is coagulated to destroy the lesion and its cutaneous projections.
 Small scissors may be used to trim away the charred tissue, and if necessary, more adequate
coagulation maybe performed unless it has been demonstrated that the depths of the lesion
have been adequately coagulated.
 In some instances, recauterization is necessary 6 to 8 weeks later if cure has not been
obtained by the first treatment.
 Local application of strong acids or alkalies, such as nitric, chromic and trichloroacetic acids,
phenol and glacial acetic acid in concentrated liquid form, may be effective in some instances.
 Repeated application of those substances may in time entirely remove the wart but their use
must be cautiously controlled.
 The treatment of plantar warts deserves special consideration because of their troublesome
location and their striking tendency to recur after treatment.
 Conservative management consists of paring down the adjacent callus to expose the core of
the wart. Daily applications of a 10% salicylic acid ointment will keep the lesion soft and
relieve pain, which is caused by pressure from the hard core.
 Because weak arches or prominence of the second metatarsal head predispose to plantar
warts. The patient should wear properly fitted shoes with metatarsal arch supports, and in time
the wart may completely disappear.
 If such measures are not successful, electrodessication maybe effective, although
occasionally a painful scar results.
 Electrodessication should be done carefully in order to avoid a severe plantar burn, which
maybe temporarily crippling.
 More obstinate warts require wide local excision under spinal or general anesthesia with
primary suture or skin graft to close the defect.
 Radiotherapy has been widely used and unfortunately, in some instances inadvisably, with
serious consequences.
 DR. ARLENE P. PAVO, M. D.

 Large warts on the back of the hand maybe effectively removed by electrodessication followed
by administration of x-radiation closely shielded to the edge of the wart.
 In general however, radiotherapy, including roentgen ray and radium, should be confined to
treatment of plantar wart, largely because irradiation and especially radium tends to produce
unsightly telangiectasis.
 A method for treating plantar warts effective in 60 to 80% of cases, is a single application of
1600 r shielded to within 1 to 2 mm of the edge of the wart after the lesion has been pared to
expose its core.
PAPILLOMA
 Like the wart or verruca, papilloma of the skin arises from the superficial layers of the skin
and is a benign lesion.
 The papilloma is also probably caused by filterable virus.
 In general, the papilloma shows no malignant tendencies, but as in order benign lesion
under stimulus of chromic irritation, may develop into a carcinoma depending upon their
location, papillomas should be removed under local anesthesia by excision or fulguration.
KERATOSIS
(Keratosis senilis, Seborrheic Keratosis)
 These are flat, dry, circumscribed lesions with a roughened surface characteristically located
on parts of the body which are usually exposed to actinic rays of sunlight.
 There are several forms varying from simple keratosis, which after reaching a certain radiation
of majority, dropped off the skin, to those which progress rapidly into advancing squamous
carcinoma.
 Keratoid keratosis which is flat and verrucose, is produced by proliferation of the epithelium,
the structure of which may exhibit a loose arrangement with a surface from which flakes of
tissue can be dislodged.
 In some instances exuberant epithelium may have a striking cohesiveness and may form a
yellowish cutaneous horn of cartilaginous consistency.
 Benign forms of ketosis have little evidence of increased vascularity whereas the faster
growing lesions with cancerous tendencies are characteristically surrounded by a narrow zone
of hyperemia.
 About 15% of theses lesions are reported to progress to squamous carcinoma.
 Treatment varies with the location of the keratosis but usually requires a series of local
applications of keratolytics, electrodessication or excision.
 An ointment consisting of 10% salicylic acid and petrolatum base may soften the keratosis and
appear to destroy it, although in many instances, the cells below the skin level continue to
proliferate.
 Healing will occur the most cases without evidence of cicatrisation following fulguration with
the electrodesiccating needle.
 Because of the malignant potentialities in some of these lesions, total excision including a
narrow margin of normal skin maybe indicated when feasible.
 If histologic examination of the margins of the lesions reveals cancer, the margins of excision
must be enlarged.
 In some instance, dermatologists have obtained admirable results with irradiation or radium
application.
 Dermatitis may occur at the site of the lesion and may require subsequent excision.
KELOIDS
 DR. ARLENE P. PAVO, M. D.

 Keloids may be defined as overgrowth of connective tissue arising usually in scars formed
after lacerations, excision, and puncture wounds or in draining sinuses.
 The lesion which is usually raised above the surface of the skin presents a reddened shiny
surface and is sometimes painful.
 It maybe difficult to differentiate a normal degree of scar tissue formation and excessive fibrous
growth in a healing wound, but in some instances the overgrowth of fibrous tissue maybe
extreme, forming small pedunculated growth.
 Microscopically, the fibrosis is located in the layers of the cutis.
 The stimulus to overgrowth of fibrous tissue in a wound or ulcers depends upon several
factors.
 Although the etiology is not definitely known. Keloids more commonly appear in an infected
granulated area such as in the draining sinuses, in tuberculous glands of the neck or in the
granulation of a deep cutaneous burn.
 Keloids are likely to occur on the anterior chest, particularly in women, because of the tension
produced by the breast.
 Certainly individuals appear to have a predisposition of keloid formation and under these
circumstances the tendency maybe hereditary.
 The Negro race is particularly prone to keloid formation.
 There are several stages in the development or maturation of keloids.
 In the initial stage the lesion is reddened, smooth and glistening, with a translucent surface
beneath which small capillary-size vessels are visible.
 After 4 to 6 weeks, a stage of involution begins to appear and the surface of the keloid
becomes wrinkled, indication some subsidence of edema and inflammatory change.
 Final stage in maturation appears, and the surface changes from red to white, edema
completely subsides, an area of brownish pigment become evident of the surface.
 Malignant changes almost never develop in the excessive fibrous tissue of keloids despite the
striking fibroplastic activity.
 The undesirable effects result from the presence of unsightly scars on exposed surfaces of the
body or incapacitation caused by contractures which may follow deep cutaneous burns of the
axilla and antecubital or popliteal space.
 Surgical treatment of keloids is generally not satisfactory, partly because the etiology is
unknown and partly because of an apparent tendency to keloid formation which is present in
some individuals.
 During the first 6 to 8 weeks of healing, the appearance of scar may strongly suggest keloid
formation, but after a longer period of time has elapsed the scar may be satisfactory enough to
require no treatment.
 Thus, it is advisable to postpone treatment for 4 to 6 months before surgical excision of a scar
is considered.
 In special cases, particularly in young women who may express considerable concern over the
lesion, treatment maybe instituted earlier.
 Usually the most satisfactory results are obtained by a combination of surgical excision of the
lesion and irradiation.
 Particularly in persons who are susceptible to keloids, meticulous technique must be employed
in excising the lesion to avoid unnecessary operative trauma.
 DR. ARLENE P. PAVO, M. D.

 Extensive lesions require general anesthesia, whereas smaller ones may be removed after
infiltration with procaine solution.
 The edges of the wound are approximated carefully with fine nylon sutures, if an extensive
excision has been necessary, a spilt thickness graft maybe utilized.
 Small doses of irradiation for the first 4 to 5 days post operatively may be beneficial,
particularly if primary closure had been done.
 Despite this, recurrences are common.
 Surgical treatment of extensive keloids causing contractures of the axilla, popliteal space and
neck are strictly major surgical problems and are considered in a separate section.
FIBROMAS
 Fibromas are benign tumors of fibrous tissue origin which may appear anywhere on the body
surface.
 They arise in the deeper layer of the skin and frequently contain other mesodermal or
epithelial elements; hence such terms as fibrolipoma, myofibroma, and neurofibroma have
been applied to them.
 A fibroma with a gelatinous type of stroma is referred to as a fibromyoma.
 Under ordinary circumstances, the tendency to malignant changes is relatively slight, but any
lesion exposed to constant trauma may ultimately become malignant.
 Thus, excision may be indicated in a small fibroma in constant contact with a man’s collar or
belt, whereas the same kind of lesion in a location not subjected to constant trauma may
require no treatment.
 Neurofibromas in the thorax and with in the abdomen are particularly susceptible to the
development of malignant change.
 Surgical excision is also indicated if the lesion is painful, or for cosmetic reasons, and removal
for biopsy may be indicated.
 The technique of excising such cutaneous tumors is simple.
 As for epidermoid cysts, the line of incision is planned to conform to the natural creases of the
skin.
 Following infiltration of the surrounding area, the lesion is removed with a small margin of
normal tissue.
 The skin edges are re-approximated with fine sutures of nylon.
 Neurofibromatosis (von Recklinghausen’s disease) is an easily recognized systemic condition
which is usually hereditary in origin.
 It is characterized by the presence of multiple tumors of varying sizes, areas of cutaneous
pigmentation, and café au lait patches.
 The tumors are sometimes painful and are usually visible, projecting above the cutaneous
surface, but they are palpable under the skin.
 The fibrous tumors arise on the nerve sheath or neurilemma.
 In some instances, the neurofibroma involves primarily the axis cylinder and then causes
thickening, tortuosity and elongation of the nerve.
 This type of tumor is referred to as the plexiform neurofibroma.
 Neurofibromas may occur in many sites other than the skin surface, including bone, central
nervous system, and pelvis.
 They vary in size from that of pea to that of a large grapefruit, and though usually painless,
occasionally these tumors may cause considerable discomfort.
 DR. ARLENE P. PAVO, M. D.

 Pigmentation is an important diagnostic feature of this disease.

 Patches of light brownish pigmentation (café au lait) on the skin surface may suggest the
diagnosis when cutaneous lesions are absent.
 Some neurofibromas become sarcomatous and unless completely removed may be fatal.
 Malignant degeneration should be suspected if lesions attain unusually large size or show
recent tendency to rapid growth and if paresthesia, hyperesthesia or motor changes appear
spontaneously.
 Under such circumstances excision is indicated.
 It is usually impractical to attempt excision of multiple lesions of neurofibromatosis because of
their widespread distribution.
 In general, the tumors on the face and other exposed parts of the body probably should be
excised, but no attempt should be made to remove lesions of generalized distribution.
 The nature of the disease should be explained to these patients so that they may be
reassured and learn to tolerate their disfigurement.
LIPOMAS
 Lipomas are benign tumors originating in fatty tissue and varying in size from several
milliliters in diameter to several pounds in weight.
 Lipomas located deeper in the body, as in the mesenteric or retroperitoneal tissues, tend to
become immense before removal.
 On the cutaneous surface these tumors are located and usually the lobules are surrounded
by a fibrous capsule, but as they slowly grow, they may cause discomfort by compressing
surrounding structures.
 Although they rarely become malignant, in doubtful cases surgical excision is indicated.
 The common sites of lipomas on the body surface are in the subcutaneous tissues of the
shoulders, back, upper arm and buttocks, particularly in obese person.
 The tumors are usually not tender and the lobulations are easily palpated.
 In some instances, there maybe difficulty in differentiating lipomas from sebaceous cyst; the
tendency for fibrous trabeculae to cause multiple dimpling of the skin on movement of lipoma
may assist in differentiation.
 The skin overlying the lipoma may have an “orange skin” appearance produced by the deep
fibrous attachments.
 Lipomas have a fluctuant feel and resemble on palpation a fluid-containing cyst.
 A large tumor or one pressing on nerves may cause pain. But usually multiple, painful
lipomas in obese persons indicate the diagnosis of a rare disease known as adiposis
dolorosa (Dercum’s disease).
 The pain is probably related to the proximity of the lipoma to the cutaneous nerve endings.
 Treatment of lipoma is usually surgical excision.
 Local infiltration of procaine solution may provide sufficient anesthesia or small tumors.
 General anesthesia is preferable for excision of large lipomas, particularly those situated on
the back where there are dense fibrous attachments to the underlying fascia, and where
rather large vascular tributaries may be encountered during the dissection, requiring
considerable operative manipulation.
 Incision over the lipoma demonstrates a thin capsule delineating the various lobulations and
trabeculae.
 By sharp dissection, the tumor maybe completely removed intact.
 DR. ARLENE P. PAVO, M. D.

 The remaining defect is obliterated by insertion of fine, plain catgut sutures attaching the skin
flap to the underlying fascia.
 Of the defect is extensive, it maybe advisable to employ a small soft rubber drains for several
days to prevent postoperative formation of a seroma.
XANTHOMAS
 Xanthomas are small, yellow, benign nodules in the skin thought to be produced by a
disturbance of liquid metabolism.
 They are usually located on the eyelids, and there are called xanthelasma.
 They may be somewhat disfiguring particularly when multiple and maybe carefully excised
under local aesthesia with good results.
THE GLOMUS TUMOR
 The glomus tumor is a rare, benign, painful small neoplasm involving usually the skin and
subcutaneous tissue.
 It is found most often on the extremities.
 The neoplasm arises from the normally occurring glomus body which is a normal end-organ
structure composed of an arteriovenous anastomosis without an intervening capillary bed.
 There is a neuroreticular component associated with the glomus body that is through the
arteriovenous channels and thus to help regulate blood flow to the extremities and, in
consequence, to conserve or dissipate body heat.
 When the glomus apparatus is fully dilated there is a large dispersal of heat due to the greatly
accelerated rate of blood flow.
 When the glomus is closed the heat is conserved by shunting blood through the capillary
network and away from the skin. Pop off found that there were 65 glomus bodies in the large
toe alone, they being especially concentrated in the nailbed and distal phalanx.
 Therefore, it is not unexpected that the terminal phalanges of the toes and fingers should be
the most common location of the glomus tumor, those occurring in the nailbed maybe
excruciating painful.
 Glomus tumors have occasionally been found in the dermis of other body areas, and one case
of a mediastinal glomus tumor has been reported.
 The glomus tumor is small, usually single, and there is little evidence to suggest any racial or
sex variation.
 Neither is there any significant age concentration, of the tumor has been found in the very
young and very old.
 The tumor rarely measures over 1cm. in size and is usually sharp demarcated and clearly
visible.; however, rarely may it be as small as to be impalpable and only an exquisitely tender
“trigger spot” shows the location of the tumor.
 The tumor may vary in color from gray to blue to red and the color may change in extremes of
temperature-blue in cold, reddish pink in the presence of heat.
 Pain of a particularly excruciating type is a characteristic feature of the tumor.
 The pain may be throbbing in character but more usually is lancinating, extending from the
tumor up the entire extremity.
 The slightest touch or temperature change may set off the pain and the patient may be forced
to take marked protective measures in order to carry on normal activities.
 Rarely the glomus tumor may affect the bone od a terminal phalanx, leading to destructive
changes secondary to pressure; however the tumor is benign and does not metastasize.
 DR. ARLENE P. PAVO, M. D.

 Local surgical excision leads to complete cure of the glomus tumor; roentgenotherapy, heat,
cold, and symphatectomy are without benefit.
 Under local infiltration, regional nerve block or rarely general anesthesia, the tumor itself can
usually be dissected free with minimal loss of normal tissue; however, when the bone of the
terminal phalanx is eroded, local amputation may be necessary.
CARCINOMA OF THE SKIN
 Carcinoma of the skin is without question the most common form of cancer occurring in the
human body.
 It occurs primary in two forms, the basal cell carcinoma, or so-called rodent ulcer, and the
more malignant squamous cell or epidermoid cancer of the skin.
 Skin carcinoma is also the most easily detected of all cancers and this reflected in the
excellent results that are obtained by intelligently applied therapy.
ETIOLOGY
 Carcinoma of the skin is found predominantly in outdoor workers or people who are exposed
over long periods of time to the sun and wind.
 By far the greatest number of skin cancers occurs on the exposed surfaces of the body
particularly the face, neck, ears and hands.
 Prolonged exposure to solar rays is apparently the most important etiologic factors concerned
in the production of the skin cancer.
 The incidence of the skin cancer is relatively high in farmers, construction workers, sailors,
fishermen.
 Prolonged exposure is necessary for the solar rays to exert their carcinogenic effects for the
disease is rarely seen before the age 40 years and is most commonly found beyond the age
60.
 Men do not seem to be susceptible to the disease than do women, although the fact that the
former are more commonly employed in outdoor activities is reflected in the incidence rate,
some series having reported the disease as 7 times more common in men than in women.
 There is no appreciable sex or racial variants in those skin cancers occurring on the
unexposed portions of the body.
 There is some racial susceptibility in that the races with light skins shows a much higher
incidence of the disease than do the dark-skinned races.
 Individuals with a hereditary hypersensitivity of the skin to the rays of the sun develops a
condition known as xeroderma pigmentosum, which is associated with early development of
multiple skin cancers.
 Characteristically, prolonged exposure to the sun’s rays produces definite patches of
hyperkeratosis which, after a varying length of time, is followed by the development of
carcinoma.
 Other important etiologic factors include previous damage to skin by excessive irradiation, burn
scars, or chronic ulcers such as decubitus and stasis ulcerations of the lower extremities.
 Certain chemical agents have been shown to have the capacity to produce skin cancers,
notable among these being arsenic.
 One of the characteristics of arsenical skin cancer is its frequent.
 Occurrence on the soles of the feet and the palms of hands, locations where skin carcinomas
otherwise do not commonly arise.
 Chronic exposure to nitrites, oils, paraffin and other coal tar products has been implicated as a
cause of the skin cancer.
 DR. ARLENE P. PAVO, M. D.

CLINICAL MANIFESTATIONS
 Skin carcinoma whether basal cell or squamous cell may grow primarily as a polypoid
projection above the skin level as a deeply invasive ulceration or by wide superficial lateral
growth.
 The prognosis of the individual case may be considerably influenced by this particular aspect
of the tumor.
 It has been shown that skin carcinomas which occur at or above the level of the sweat glands
in the skin rarely metastasize whereas those tumors that infiltrate definitely below the level of
the coiled sweat glands may metastasize to the regional lymph nodes in as high as 30% of the
cases.
PATHOLOGY
 Basal cell carcinomas arise from the basal layer of the skin epithelium and may present
various histological patterns.
 They my present as areas of solidly packed cells extending through the basement membrane
into the deeper tissues, or they may be associated with masses of such cells surrounding
cystic areas filled with mucin.
 Occasionally, there may be areas of squamous cells showing keratinization, and this type is
classified as a basosquamous epithelium.
 Basal cell carcinomas most frequently develop from a pre-existing area of hyperkeratosis on
the skin of the scalp, the nose, around the lips.
 The eyelids, the areas and the dorsum of the hands.
 They are usually well circumscribed having a grayish white color and although more
commonly they show an exophytic type of growth, they may be ulcerate and invade deeply
with great destruction of skin, fascia, muscle, cartilage and bones.
 The latter type represents the so-called rodent ulcer.
 Basal cell carcinomas practically never metastasize but may lead to death of the patient
through secondary infection and hemorrhage.
 The rate of growth of these tumors is extremely slow.
 Epidermoid carcinomas of the skin are no different histologically from squamous cell
carcinomas occurring in other organs of the body.
 They show varying degrees of keratinization and pearl formation, depending upon the degree
of anaplasia of the tumor.
 Epidermoid carcinomas usually arise from pre-existing areas of hyperkeratosis and are
commonly found in the skin of the temporal and malar areas of the face and forehead and
more particularly on the dorsum of the hands.
 Epidermoid carcinomas, although rarely found on unexposed surface of the body other than in
areas of previous chemical or physical trauma, are much more likely to be found in these
localities that are basal cell carcinomas.
 These lesions may be either protuberant or ulcerative.
 Those that ulcerate are usually secondarily infected and there may be a considerable zone of
surrounding inflammation and fixation to the deeper structures, making it very difficult to
determine whether the fixation is due solely to infection or to tumor infiltration.
 Carcinomas may also arise in sweat glands and in sebaceous glands; however only a few
cases of each have been reported in the medical literature.
 They tend to grow lowly and to invade locally, and only very rarely metastasize.
DIAGNOSIS
 DR. ARLENE P. PAVO, M. D.

 The diagnosis of carcinoma of the skin can be made clinically in a very great percentage of
cases; however, the treatment of such a lesion should never be undertaken without previously
having obtained a definite diagnosis by means of an incisional biopsy and histologic diagnosis.
 An amelanotic melanoma may grossly appear identical with a nonulcerating basal cell
carcinoma, and since the former lesion is completely radioresistant, the use of x-ray therapy
without histologic diagnosis may lead to tragic results.
 In ulcerating lesions the biopsy should be taken from the edge of the tumor to include a
segment of the normal- appearing skin, for otherwise may mask the underlying tumor and lead
to an erroneous diagnosis.
TREATMENT
 Skin carcinoma offer by far the best prognosis of any type of cancers; however, these tumors
may kill by local destruction by invasion or by distant metastasis just as surely as the most
virulent cancer if they do not receive proper and competent treatment.
 Radiation therapy and surgical excision each give excellent results, and there is not a great
deal to choose between the methods of therapy under usual circumstances; however, each
has specific advantages in particular types of cases.
 Some lesions of the eyelids and those around the inner canthus of the eye, the nose and the
nasolabial folds, and of the ears and lips maybe treated just as successfully by x-ray as by
surgery and actually yield a better cosmetic result.
 In other instance, particularly in skin, carcinomas arising in previously damaged tissue from
either physical or chemical trauma, surgery are the preferred method of therapy.
 Wide surgical excision, with at least a 1cm margin of normal skin at the periphery, should be
done.
 It should be stressed that with the use of surgery the depth of the excision is just as important
as the width of the excision.
 If the process has extended maybe hope of cure or if the patient refuses surgery, x-ray may
offer significant palliation.
 Prophylactic node dissection is rarely indicated in these lesions; however, in those that show
clinical evidence of metastasis to the regional nodes a radical resection of the lymph nodes
should be carried out.
 In those lesions of squamous carcinomas which show deep invasion and a high degree of
anaplasia it maybe worthwhile to do a radical resection of the regional lymphatic drainage area
even in the absence of clinically detectable metastasis.
 Obviously, such node dissections are in patient hospital procedure under appropriate general
spinal anesthesia.
 Not infrequently a combination of therapy consisting of x-ray to control the lymphatic
metastasis maybe used, this being commonly true in cases of carcinoma of the lips.
 In the treatment of carcinoma of the dorsum of the hand, not infrequently a well developed
carcinoma will be present surrounded by an area of numerous hyperkeratosis.
 In such circumstances it is the preferred method of treatment to widely resect the carcinoma
and the surrounding damaged skin and to replace the defect immediately with a split-thickness
skin graft.
 This offers good functional and cosmetic results.
 Carcinoma of the skin offers by far the best prognosis of cancers affecting mankind.
 Intelligent therapy directed towards the lesions should result in a 5 year control rate of better
than 90% in basal cell carcinomas and better than 80% in squamous cell carcinomas and by
 DR. ARLENE P. PAVO, M. D.

earlier and more vigorous treatment of suspicious lesions these figures can be materially
increased.
MALIGNANT MELANOMA
 The malignant melanoma, melanosarcoma or malignant mole is the most dangerous and yet
the most unpredictable of all cutaneous neoplasms.
ETIOLOGY
 There is considerable difference of opinion as to the incidence of this but all agreed that it is
associated with high morbidity and mortality.
 It has been reported to compromise as high as 2% of all malignancies and 20% of all skin
cancers.
 It is also the most common malignancy involving the lower extremities.
 The tumors occur most commonly in the skin, arising from malignant change in a pre-existing
epidermo-dermal or “junctional” nevus.
 However it may arise anywhere in the body; in the eye, at the junction of the skin and mucous
membranes of the body orifices, and in the gastrointestinal tract, although it is extremely rare
in the latter.
 The anatomic sites found to be most frequently involved, in general order of frequency are the
lower extremity, head and neck, trunk, upper extremity and eye.
 Certainly a very small percentage of pigmented nevi represent malignant melanomas;
however, those occurring in the eye, on the soles of the feet and the palms of the hands,
beneath the finger and toe nails and on the genitalia should be strongly suspected of being
malignant.
 Although there has been some disagreement, Soldans and Massons thesis that melanomas
are of neuroectodermal origin has been widely accepted.
 It is felt that the dermo-epidermal, or junction, cell is related to the Schwann cell of nerve tissue
and the corpuscles of Meissner and Ranvier.
 About 95% of all nevi in children have nevus cells in the epidermis and are therefore junction
nevi.
 It has been estimated that about 15% of these remain as junction nevi and it is from these that
most cutaneous melanomas arise.
 The intradermal nevus or common brown nevus very rarely becomes malignant.
PATHOLOGY
 The microscopic picture of malignant melanoma is very variable. In those tumors with large
amounts of melanin and large round or oval cells with round nuclei, large nucleoli and bizarre
mitotic figures, the diagnosis offers no difficulty.
 However, in those melanomas with very scanty pigment, the so-called amelanotic melanomas,
with bizarre cellular patterns, the histologic diagnosis maybe difficult and may require the study
of numerous sections and the aid of the tyrosinase reaction and the Bloch dopa technique of
staining to identify definitely the malignant cells.
 The malignant melanoma may mimic the histologic features of other malignant tumors such as
fibrosarcoma with long spindle-like cells or a very undifferentiated carcinoma with small round
cells, little cytoplasm and small nucleoli.
 An interesting variant of the malignant melanoma is the one occurring in young children prior to
puberty; although it may be histologically indistinguishable from the adult form, biologically it
very rarely shows local extension or metastasis and thus the treatment and prognosis are quite
different in these cases.
 DR. ARLENE P. PAVO, M. D.

DIAGNOSIS
 The clinical diagnosis is usually not difficult to make but it must be stressed that definitive
treatment of this lesion should rarely be undertaken without prior histologic proof by surgical
biopsy.
 Scantily pigmented melanomas occurring in the preauricular area and along the hair lines can
be easily mistaken for a basal-cell epithelioma, and with tragic results if the treatment for the
latter condition is instituted.
 Any of the following changes in a previously quiescent mole should suggest malignant change:
1. Increase in size
2. Change in color
3. Infection
4. Bleeding or ulceration
5. Pain or any irritation
6. Development of a halo or satellite moles.
 The development of regional and nodal enlargement without obvious cause should lead one to
examine carefully the lymphatic drainage area for the presence of a suspicious-appearing
mole. In about 10% of reported cases, clinical evidence or regional node involvement has been
the initial sign of the presence of a malignant melanoma.
 Malignant melanomas may spread by local extension, by the lymphatics to show satellite areas
and nodal metastasis, and more frequently by the blood stream to the lungs, liver, brain and
bone. In the far advanced lesions no organ system or structure may escape metastatic lesions.
In very small suspicious lesions, excisional biopsy using field block or general anesthesia and
including at least 2cm wide skin margins and the full thickness of subcutaneous fat and fascia
should be done. Local infiltration anesthesia under the tumor should not be used for fear or
producing tumor emboli. In the large cutaneous lesion, a small incisional biopsy taken from the
edge of the lesion may be preferable.
 If the diagnosis of malignant melanoma is made, a very thorough search for metastatic spread
and a complete general evaluation of the clinical status of the patient should be made before
further definitive therapy is decided upon.
 The search for metastasis should particularly include the regional lymphatic reservoir, a chest
x-ray for pulmonary metastasis, a skeletal x-ray or any area of bone tenderness or pain, and
 A neurologic examination including particularly a fundoscopy study.
 Any hepatic enlargement should be very suggestive of metastasis and the urine should be
examined for the presence of melanin.
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