Dermatology Online Journal

Surgical pearl: the temporary assistant
Aleda A Jacobs MD, Ida F Orengo MD
Dermatology Online Journal 14 (4): 12

Baylor College of Medicine, Houston, TX. ajmd14@yahoo.com

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Abstract

A simple maneuver is presented which simultaneously facilitates both adequate surgical site exposure and sufficient traction. A single suture with high tensile strength can be utilized to this end. This technique is especially helpful when the cutaneous surgeon is operating alone.

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One of the principal governing tenets of surgery is to assure that adequate exposure is provided within an operating field for the operating surgeon. There is a time-tested adage: "You cannot cut, what you cannot see." At times, however, a surgeon is without the benefit of an assistant during portions of or throughout an entire surgical procedure. It may be a challenge to obtain adequate exposure. At times, this dilemma may present itself as a particularly difficult problem, as in the case of operating on the helix or posterior aspect of the ear.

A second principle in surgery lies in achieving both adequate traction and counter traction of tissue, so as to assure optimal conditions for a surgeon to precisely manipulate the scalpel through the tissue during an operation. Eliminating either of these forces instantly increases the difficulty of an operation in almost all cases.

Presented here is a "surgical pearl" for consideration when confronted with the dual challenge of meeting both the need for adequate exposure, while simultaneously providing adequate traction and counter traction, when a surgeon chooses or is left to operate alone. The most common skin cancer, basal cell carcinoma, as well as squamous cell carcinoma and other tumors often arise on sun-exposed areas of the face, very commonly on the ear. The benefit of an assistant is obvious. In the absence of a readily available assistant, we instituted the use of a temporary suture to serve as a "temporary assistant," and were able to achieve both goals of exposure and traction.

Figure 1

A single suture with high tensile strength (such as 5-0 PROLENE™), was used to deflect the patient's helical rim anteriorly, in order to remove a squamous cell carcinoma on the posterior aspect of the ear (Fig. 1). To achieve adequate tensile forces, a single knot was placed in non-diseased tissue, just above the superior margin of the ellipse containing the neoplasm, prior to excision. The helical rim of the ear was then gently pulled anteriorly, and the other end of this same suture, was then anchored to a sterile drape on the patient's upper chest, with a hemostat (Fig. 1). Implementing the above tactic provided both adequate exposure–as well as the counter traction force–and allowed for the entire operation to be conducted, without the aid of an assistant. The surgeon was free to provide necessary traction where needed with the non-dominant hand, while the other was free to hold the scapel and excise the neoplastic tissue. Once the ellipse was removed in toto, this traction also allowed for exposure during the undermining of tissue on the posterior face of the ear and during primary closure. When the operation was completed, the anchoring stitch was removed.

Although a suture (temporary assistant) is not superior to the aid of a good assistant, an alternative method toward achieving the same ultimate goals must occasionally be employed. In our opinion, the above technique utilizing an anchoring suture to help meet specific intraoperative challenges, also achieves the goals of attaining ease and precision during surgery by providing both necessary exposure and appropriate forces on tissue.

© 2008 Dermatology Online Journal