Thirteen Shortcuts in Office Surgery

Symposium on Surgical Techniques

Thirteen Shortcuts in Office Surgery

George Crile, Jr., M.D.*

Since surgeons rarely write articles about simple minor operations that are easily performed in the office, most of us rely on techniques that we learned in medical school or from other surgeons. Some of these techniques are cumbersome and make relatively major procedures of operations that can be performed quite simply. The techniques described here are doubtless already in use, and it is with no claim to originality that I report them. Acute Pilonidal Cyst It is now established that there are no hair follicles in a pilonidal cyst and that the hair that causes the inflammation grows in from the outside. 5 In essence, the cyst is merely a complication of an ingrown hair. All that is necessary to cure most acute pilonidal cysts is to freeze the skin with ethyl chloride and incise them exactly at the midline dimple, even if they seem to point laterally. 2 A small mushroom catheter is then stretched over a probe to flatten the bulge, and is inserted through the incision. The catheter is cut off close to the skin and kept from falling into the cyst by transfixing it with a safety pin. The catheter is shortened to skin level in 1 week. Since the cavity by then has collapsed and there is no further danger of the catheter's falling into it, the pin can be removed. The patient is urged to wear no dressings and to carry on his usual activities. After a month, the catheter is withdrawn, and the cavity, which is now no larger than the mushroom of the catheter, is searched for hair, and any hairs that are found are removed. The hair around the sinus is shaved or removed by application of a depilatory cream. Usually, within a few days the sinus is firmly healed. If drainage persists as a result of a lateral extension or tunnel, the operation required to correct it is similar to that for a pilonidal sinus. *Emeritus Consultant, Department of General Surgery, The Cleveland Clinic Foundation, and The Cleveland Clinic Educational Foundation, Cleveland, Ohio Parts of this article are reprinted from Postgraduate Medicine, February, 1957, with the permission of the Editors.

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Pilonidal Sinuses Since there are no hair follicles in most pilonidal sinuses, all that is necessary to cure the uncomplicated ones is to remove the hair from the sinus and keep the hair of the buttocks from growing back in. In very small sinuses, the hair sometimes can be removed with operation by curetting the sinus with a tiny crochet hook. The patient is then instructed to shave the buttocks frequently or to use a depilatory cream to keep the hair from growing back in. Injection of an iodized oil such as Lipiodol or Telepaque may hasten the closure of the sinus. In cases of more extensive and branching sinuses and in cases in which sinuses persist after catheter drainage of a cyst, it may be impossible to remove all of the hair. When this happens it is usually necessary to lay the entire sinus open. The most important factor in postoperative care is elimination of the hair by shaving or by use of a depilatory cream. Nonspecific Sinuses and Fistulas Most sinuses and fistulas have a definite cause, such as a foreign body or persistent drainage from a hollow viscus, but in some cases a sinus may become chronic and continue to drain even after the original foreign body or causative agent has been removed. Fo; some unexplained reason, injection of an iodized oil (such as Lipiodol or Telepaque) often causes immediate and permanent closure of such a sinus or fistula. 1 Bartholin's Cyst or Abscess Obstruction of the duct appears to be the basic cause of a Bartholin cyst or abscess. If the area is frozen with ethyl chloride and a stab wound is made into the cyst or abscess, a tiny mushroom catheter can be inserted. This provides good drainage, and if it is cut short and left in place for 2 to 3 weeks, epithelization of the tract appears to occur; after withdrawal of the catheter, the cyst does not recur. 6 Removal of Sutures When nonabsorbable suture material causes draining sinuses, a tiny crochet hook is helpful in locating and removing the offending sutures. Ingrown Toenails Although ingrown toenails sometimes require surgical removal, most patients, if instructed in the use of a stout pair of nail clippers (not scissors), can cut out the medial ingrowing part of the toenail and keep themselves comfortable. There seems to be little validity in the concept of cutting ingrown toenails square. Seborrheic Keratosis Seborrheic keratosis is often a source of concem to patients who fear that they may have a melanoma. Usually, the clinical diagnosis is clear and after injection of procaine the lesion can be lightly cauterized and then wiped off with a piece of gauze, which leaves intact the un-

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derlying deep layers of the skin. Little or no scarring ensues, and- the necessity of an incision and sutures is avoided.

Wens There is no necessity to shave the hair in order to remove a wen. Infection of the scalp almost never occurs. The hair and the scalp around the wen are moistened with 70 per cent alcohol or some colorless disinfectant. Bleeding can be minimized if, after procaine hydrochloride is injected over the wen, an assistant presses firmly with his finger tips on each side of the wen. A small (not larger than 1 em) stab incision is then made into the center of the wen; the opening in its capsule is stretched by inserting and opening a hemostat; the contents are squeezed out, and subsequently the sac can usually be popped out in a single piece or pulled out with hemostats. Sometimes a suture is required to control bleeding, but usually a few moments of pressure suffice. Paronychia A paronychia originates as an infection under the tough dead skin of a hangnail. From here, cellulitis spreads around the nail. When pus forms it causes swelling of the soft tissues of the finger several millimeters away from its point of origin. The horny tissue adjacent to the nail is too hard to swell, and masks the spot where the abscess is trying to point. Surgeons are tempted to incise and drain a paronychia at the sensitive and vascular spot where the swelling is, and they often are disappointed in not encountering pus at this point. Most paronychias can be cured by picking with a stilet at the hard insensitive cuticle of the hangnail until it is incised and a drop of underlying pus is obtained. No anesthesia is necessary. To maintain drainage a 2 em length of a small rubber band may be slid into the opening and secured with adhesive tape. A large dressing is applied, and to facilitate drainage the patient is instructed to keep this dressing moist for 48 hours. The drain can then be removed, and the infection usually subsides. Lipomas Lipmnas of the abdomen or of the extremities are easy to remove in the office under local anesthesia. It is not necessary to make the incision the full width of the tumor. A small incision is made over the center of the lipoma and a forceps is inserted and opened to stretch the skin. The capsule of the lipoma is then incised and firm pressure on the sides of the tumor causes the soft contents to be extruded, capsule and all. Lipomas of the back, back of the neck, and shoulders are usually multilocular and weave in and out through strands of fibrous tissue so that these are hard to remove completely by the above technique. Aspiration Biopsy of the Breast Aspiration biopsy of breast cancers saves the time and trouble of open biopsy and gives a positive diagnosis in 85 per cent of the cases. The skin is anesthetized by freezing and a 20-gauge needle is inserted

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down to the tumor. While strong suction is exerted through a 5 or 10 cc syringe, the needle is run back and forth through the tumor two or three times. The suction is then released and the needle withdrawn. The needle is then taken off the syringe and a little air is aspirated into the syringe. The needle is then put back on the syringe and its contents are forcibly squirted out on a slide, where it is spread thin, fixed instantly as in a Pap spread, and sent to the pathologist. 4 If the smear is negative the possibility of cancer is by no means excluded. Open biopsy should always be done. If the smear is positive and correlates well with the clinical diagnosis, no further biopsy is needed. When there is lack of correlation between clinical or cytologic diagnosis or when the findings are equivocal, a Silverman needle or open biopsy should be taken. If the nodule is cystic, and disappears after aspiration of the fluids, no furtber treatment is needed. Needle Biopsy of the Thyroid As a result of the striking development of cytologic diagnosis, it is now possible for a pathologist, well versed in cytologic techniques, to diagnose the majority of thyroid nodules. The skin is anesthetized by freezing or by a drop of procaine and an 18- or 15-gauge needle is inserted into the thyroid nodule. The nodule is squeezed and at the same time the plunger of the syringe is withdrawn to produce strong suction. The needle is run back and forth two or three times through the nodule and is then withdrawn. The fixative (Zenker's solution) is then sucked up into the syringe and expelled, with the fragments of tumor, into a little jar. This fixes the tumor fragments and keeps them from sticking to the sides of the syringe. The syringe should be rinsed two or three times by sucking up the fixative or else the plunger will tend to stick. The Zenker's is then spun down and a cell block is made. About 90 per cent of thyroid nodules can be definitively diagnosed on the basis of these findings. About half of the 10 per cent that are indefinite or suggest carcinoma will indeed be malignant. If more precise diagnosis is desirable, a Silverman or, better yet, a "True-Cut" needle biopsy usually gives it. Seeding of cancer cells into the needle tract almost never occurs. In the benign colloid nodules that the Silverman needle fails to obtain a core, the "True-Cut" needle usually will. Sometimes the aspiration biopsy gives so much material that the nodule almost disappears. When the nodule is cystic, as is the case in about a third of the cases, aspiration often cures the cyst. If the cysts recur and are aspirated several times, more than 90 per cent of them can be permanently obliterated or maintained at a size much smaller than before treatment. Usually thyroxin is given to suppress the thyroid. 3 Abdominal Pain of Unexplained Origin When there seems to be no organic cause for abdominal pain, it is often relieved by injection of procaine followed by hydrocortisone. The most effective test for determining whether the pain is neuromuscular ·

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is to ask the recumbent patient to tighten the abdominal muscles by raising his legs. If the abdominal wall is still tender when the muscles are tense, injection of the tender area with cortisone usually gives temporary and often lasting relief. If any relief is afforded, it does much to relieve the anxiety of the patient, who usually had thought that he was suffering from some disease of vital internal organs.

REFERENCES 1. Crile, G., Jr.: Injection of iodized oil as aid to closure of draining sinuses. U.S. Nav. Med.

Bull., 46:1174,1946. 2. Crile, G., Jr.: Definitive ambulatory treatment for infected pilonidal cysts. Surgery, 24:677, 1948. 3. Crile, G., Jr., and Hawk, W.: Aspiration biopsy of thyroid nodules. Surg. Gynec. Obstet. (February) 1973. 4. Crile, G., Jr., et al.: A new look at biopsy of the breast. Am. J. Surg., 126:117, 1973. 5. Hurston, J. T.: Aetiology of pilonidal sinuses. Brit. J. Surg., 41:307, 1953. 6. Krieger, J. S., and Crile, G., Jr.: Bartholin's cysts. Cleveland Clin. Quart., 19:72 (April) 1952. Department of General Surgery The Cleveland Clinic Foundation 9500 Euclid Avenue Cleveland, Ohio 44106