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Step-by-Step Approaches
Step-by-Step Approaches
Hemostasis with monopolar electrocautery
- Defer hemostasis until the lesion is completely excised and appropriately
undermined.
2. In order to achieve complete hemostasis, visualization of the wound bed and
undermined surface should be achieved via skin hooks and ample gauze.
3. For electrocoagulation to work effectively, the operative field must be dry, as blood
diffuses the current flowing from the electrode. A dry field is best achieved utilizing a two-handed technique. With the nondominant hand, use forceps and a piece of gauze to dry the field and visualize the source of bleeding. With the dominant hand, cauterize the source of bleeding with the active electrode. If possible, an assistant should hold gauze at the dependent area of the wound to absorb any dripping blood.
4. It is easiest to achieve hemostasis by operating in the direction of gravity. For
instance, if operating on the neck, work from the superior to the inferior pole.
Achieving hemostasis with bipolar electrocautery
- Dry the field to visualize the sites that are bleeding.
- Clamp the tines of the bipolar electrode, shut and touch it to the areas that are
bleeding.
Achieving hemostasis of a bleeding vessel
- Use gauze to dry the field and visualize the bleeding vessel.
- Using fine-toothed forceps or a hemostat, grip the vessel, then touch the active
electrode to the forceps or hemostat and apply monopolar current through it.
3. If using a bipolar electrode, simply grip the vessel between the two tines and apply
current.
4. If a popping sound is heard or a spark is seen, current flow should be stopped and
the area re-evaluated to ensure satisfactory hemostasis. In order to optimize hemostasis, the surgical field should be dry, as blood will diffuse the current flowing from the electrode.
5. Only small vessels should be cauterized in this fashion; larger or arterial vessels
would benefit from direct suture ligation.
How to perform electrodesiccation & curettage
- Anesthetize the area with a mixture of 1% lidocaine with epinephrine.
- With the sharp end of the curette pointing down toward the skin, scrape the affected
area to the base, which can be identified by the gritty sensation of the dermis. In the setting of a skin cancer, the cancerous area is more friable compared to normal skin.
3. Dry the base with gauze, then fully electrodesiccate the base with electrosurgery.
4. Recurette the base in a different direction and once again desiccate the base. Repeat
for a total of three passes.
Another consideration to take into account when deciding upon whether or not to treat a lesion by ED&C is cosmesis. On the trunk and extremities, ED&C most often results in residual dyspigmented patches, though atrophic, hypertrophic, or keloidal scars can occur. On the face, ED&C often produces a fine white macule or patch, while indurated or depressed circular scars are a risk. For many patients, ED&C offers a cosmetically acceptable scar.47,49
Electrosurgery for the treatment of benign epidermal lesions
Benign skin lesions such as seborrheic keratoses or warts can be treated with superficial coagulation by using a fine-tip electrode or electrofulguration with very low power. After a quick, gentle treatment, the lesion should be wiped off. If there is any residual lesion left, a subsequent pass of superficial electrocoagulation can be performed. If there is spark formation, this is an indicator of deeper injury. This can be avoided by reducing the voltage, power, or contact time.
CONCLUSIONS
Electrosurgery is a universal staple of the dermatologic surgery practice, whether used for hemostasis, treatment of nonmelanoma skin cancer, or benign lesion desiccation. A comprehensive appreciation of the underlying principles behind electrosurgery helps the dermatologic surgeon better decide on optimal techniques and approaches for a variety of applications.