Minor surgery, major risks

Dr David Coombs, a GP with a special interest in dermatology, explores the risks of performing minor surgery in primary care

Minor surgery has long been an important element of the service provided by many GPs, and it is something that is rewarded in the current GP contract. Providing local, high-quality minor surgery services is something that patients value but, like all areas of primary care, there are inherent risks in providing it. However, with sensible forethought, audit and an understanding of the minor surgery risk areas, the dangers can be minimised.

What procedures?

Consideration needs to be made as to whether any procedure is actually necessary

Practices undertaking minor surgery need to initially consider what procedures they are going to undertake. From a contractual viewpoint, will it be simply to provide “Additional Services”, such as cautery, curettage and cryotherapy, or "Enhanced Services”, including excisions, incisions, aspirations or injections.

Some practices may wish to offer more complex services, such as vasectomies. It is important that those performing minor surgery have the training and skills to perform the procedures and to offer appropriate alternatives.

Consideration needs to be made as to whether any procedure is actually necessary – for example, skin lesions do not require removal simply because they exist; could a lesser procedure be used, such as shave excision or curettage rather than formal excision?

Training

GPs will have undergone basic minor surgery training as GP registrars, or will have been performing minor surgery for many years and have been approved by their PCO. The GMS enhanced service (DES) states GPs should have: “skills in-line with those of a GPwSI”. ^{1 2}

It is important for GPs to maintain their skills by regularly updating or enhancing their training. Courses are available from a variety of sources, including the:

Royal College of General Practitioners (RCGP)
Primary Care Dermatology Society (PCDS)
British Society for Dermatological Surgery (BSDS).

Facilities

It is important that premises are adequate and there is enough space to work around the patients. Appropriate equipment should be provided to allow the procedures to be performed satisfactorily. Guidance states that facilities for resuscitation should be available.³

Infection control

The DH provides guidance on the prevention and control of healthcare associated infections and sets out how providers of healthcare can meet current health standards.⁴

Being aware of infection control guidelines is vital. Practices can get advice from their PCO or local consultants in communicable disease control. You should:

ensure there is a clean dedicated area without carpet
provide elbow-operated taps, liquid soap and alcohol hand gel
provide protective clothing, including aprons and sterile gloves (bear in mind the necessity for health and safety assessment if using latex gloves)
use protective covers for cautery or hyfrecator handles
be aware that some procedures, such as excision of sebaceous cysts and lipomas, may be exposure-prone procedures, so the practitioners should ensure that their hepatitis B immunity is up-to-date.

To be compliant with HSC 2000/032 and follow decontamination guidance, many practices have moved to complete use of disposable instruments, rather than using in-house autoclaves or CSSD supplies.⁵

Health and safety

Practices should have undertaken a general COSHH assessment, but there may be particular issues relevant to minor surgery.

Case 1 – False reassurances

Nineteen-year-old Olivia consulted her GP, Dr P, about a small lump on her upper chest, which felt tender at times and had developed a brown mark around it. She thought it may have started as an insect bite, but was now worried that it could be skin cancer. She was also concerned as the lump was visible unless she wore high-neck clothing.

Dr P did not think the small lesion was a skin tumour of any sort. In view of Olivia’s anxiety he offered to excise the lesion in his next minor surgery clinic. The lesion was duly excised and the histology report confirmed a benign dermatofibroma.

Twelve months later, Olivia returned complaining that she now had a red raised itchy scar at the site of her minor op and wished she hadn’t had the lump removed.

Dr P was sure he had warned Olivia that there would be some visible scar, but couldn’t recall the precise advice given. His computer records stated “Informed consent for procedure given”. He prescribed a very potent topical steroid to try and flatten down the scar, but is worried that a solicitor’s letter may be on its way.

Learning points

Was excision necessary for reassurance? If Dr P was uncertain he could have referred to a dermatologist or, if available, a GPwSI.
There will always be a scar with any excision. The risk of hypertrophic scarring is greater in certain areas of skin and in certain patients.
The medical records did not give sufficient detail as to whether informed consent was obtained. A signed consent form with risks outlined and/or the provision of an information leaflet would be supportive evidence in the event of a claim.

Management of low-risk basal cell carcinomas in the community

Since the publication of NICE guidance on managing skin cancer in 2006, there have been suggestions that minor surgery is no longer being encouraged in primary care. The guidelines contained specific requirements for the management of basal cell carcinomas (BCCs), which would have restricted the number of GPs likely to continue treating these cases themselves.

Following a consultation with stakeholders, NICE will be producing new guidance specifically in relation to how low-risk BCCs can be treated and how skin cancer services can be commissioned. NICE is reviewing the definition of low-risk BCCs and is due to publish advice on training, quality assurance, clinical governance, commissioning, models of care, data collection and communication in May.

Those practices providing cryotherapy need to specifically look at issues around the use, storage, decanting and transport of liquid nitrogen. It is not unusual for practices to collect small volumes of liquid nitrogen from secondary care and transport flasks/cryo-guns by car. It is far safer to use larger dewars on site topped up professionally, or make arrangements for commercial delivery when required.

Safe disposal of sharps and used instruments is important, yet it is surprising how frequently practices place sharps bins in accessible places, overfill them or do not store them safely when they become full.

Histology

Take the attitude that all samples removed should be sent for histological analysis. Clinical assessment cannot be 100% accurate. I am surprised how often when visiting practices it becomes clear they do not send all samples. Following this, practices should have robust systems for handling the histology results and ensuring they are actioned, if necessary, and patients informed of the results.

Audit

Minor surgery activities should be regularly audited. The minor surgery DES specifies that practices audit clinical outcomes, infection rates and unexpected or incomplete excision of malignant lesions. To do this, practices do need to keep a log of all minor surgical procedures and also undertake significant event analysis when required.

Patient satisfaction questionnaires can also be helpful in improving services and hopefully provide some rewarding feedback.

Consent

Adequate consent is essential and practices should ensure that the patient’s consent to a minor surgical procedure is always recorded in the patient’s medical record. You should ensure that:

The nature and purpose of the procedure has been fully explained.
The patient has been warned of the risks involved.
A patient information leaflet was given (if available).
Alternatives to the procedure were discussed.

It may be a contractual obligation to obtain a signed consent form, but it is more important that the above issues have been fully addressed and documented.

Last year, the DH published guidance on obtaining consent, along with advice on amending consent forms to reflect the Mental Capacity Act, the concept of parental responsibility and other legal judgments.⁶

Practices are poor at recording any potential risks; risks are often recorded as “informed consent”. Often there is no record of consent for joint and soft tissue injections or for cryotherapy. It is reasonable to take formal consent at the start of a course of cryotherapy, but you must discuss any specific concerns at each attendance.

Case 2 – A case of liquid nitrogen

Dr C held a monthly wart clinic where she treated viral warts with liquid nitrogen cryotherapy. Each month the practice nurse would drive to the local hospital to collect the liquid nitrogen from the dermatology department. She would decant one litre from a large dewar into a small flask, which was then placed in a cardboard box surrounded by towels for the return to the practice.

One day, on returning to the practice, a truck pulled out, causing the nurse to brake hard. The flask toppled over, releasing a cloud of nitrogen gas. The car was stationary by then and the nurse quickly opened the door and jumped out, having first placed the flask upright.