Chapter 25 Small Soft Tissue Operations
ADVANTAGES OF WALANT VERSUS SEDATION AND TOURNIQUET IN SKIN CANCER EXCISION
The large volume of tumescent local anesthetic used in this technique actually hydrodissects the tumor off the paratenon for you. This promotes the take of a skin graft and creates a nice tissue plane, permitting you to get under the cancer for complete excision of the tumor.
Many of these patients are older and may have problems with general anesthesia and sedation because of medical comorbidities. With WALANT, they will simply get up and go home after the procedure, just like after they have a dental procedure.
You can educate patients during surgery about how important it is that they keep their hand elevated and “on strike,” doing absolutely nothing with it for the next week while the skin graft takes. At the end of the procedure, patients can sit up and elevate their hand with total understanding of what to do. If patients are sedated or undergo general anesthesia, they may not understand what to do and may be too groggy during postoperative recovery to grasp patient teaching. They may well keep their hand dependent and may even have problems with vomiting, which could lead to further hematoma under the graft. They may require hospital admission for the procedure to get safe general anesthesia and monitoring.
See Chapter 8 for a clip on giving a patient advice while excising skin cancer from the hand.
All of the general advantages listed in Chapter 2 apply to both the surgeon and the patient.
WHERE TO INJECT THE LOCAL ANESTHETIC FOR SKIN CANCER EXCISION
SPECIFICS OF MINIMALLY PAINFUL INJECTION OF LOCAL ANESTHETIC IN SKIN CANCER EXCISION
We inject the anesthetic solution a minimum of 30 minutes before surgery to allow the epinephrine to take optimal effect and provide an adequately dry working field, as outlined in Chapters 4 and 14.
We inject supine patients on stretchers in a waiting area outside the procedure room to decrease the risk of their fainting (see Chapter 6). We then operate on other patients while waiting for the epinephrine to work.
To minimize the pain of injection, start with a fine 27-gauge needle (not a 25-gauge) into the most proximal injection point. This point is marked at least 1 cm proximal to the most proximal place you are likely to dissect.
Ask the patient to look away. Press with a fingertip just proximal to the injection site before you put in the needle to add the sensory “noise” of pressure to decrease the pain.
Insert the first needle perpendicularly into the subcutaneous fat. Stabilize the syringe with two hands to avoid needle wobble pain until the skin needle site is numb. Inject the first visible 0.5 ml bleb and then pause. Wait 15 to 45 seconds until the patient tells you that all needle pain is gone. Inject the rest of the first 10 ml slowly (over 2 minutes) without moving the needle.
Reinsert the needle farther distally into skin that is within 1 cm of clearly vasoconstricted white skin that has functioning lidocaine and epinephrine so that needle reinsertion is pain free.
Continue injecting from proximal to distal, blowing the local anesthetic slowly ahead of the needle so there is always at least 1 cm of visible or palpable local anesthetic ahead of the sharp needle tip that the patient would feel if you advanced it into “live” nerves. “Blow slow before you go.” (See Chapter 5 for further tips on how to inject the local anesthetic with minimal pain.)
Do not insert the needle in the tumor itself. Blow all around it first, from proximal to distal. You will elevate the tumor off the tendons with the large volume of tumescent local anesthetic.
The more volume that you inject, the greater the loose tissue between the epitenon and the cancer will be elevated so that you will be able to retain epitenon and yet completely excise the cancer.