Key Facts

Minor surgery is a core GP skill that provides convenient, cost-effective access to procedures in the community. Appropriate patient selection, consent, and clinical governance are essential.

Common Procedures

• Excision/shave biopsy of skin lesions (sebaceous cysts, lipomas, moles, skin tags)
• Incision and drainage of abscesses
• Cryotherapy (viral warts, seborrhoeic keratoses, actinic keratoses)
• Cautery/curettage
• Joint and soft tissue injections
• Ingrown toenail surgery (partial nail avulsion + phenolisation)
• Wound closure (suturing, skin adhesive)
• Ear syringing/microsuction

Training and Governance

• RCGP minor surgery certificate or equivalent training
• Regular CPD and audit
• Appropriate premises, equipment, and resuscitation facilities
• Written consent for all procedures
• Chaperone policy
• Histology pathway for all excised specimens

Pre-Procedure Assessment

• Clinical assessment of lesion/condition
• Determine whether lesion is suitable for GP excision or requires specialist referral
• Assess suitability for local anaesthesia
• Anticoagulation status (warfarin, DOACs - generally safe for minor procedures; do not stop)
• Allergy history (lidocaine allergy very rare)

Indications for GP Excision

• Clinically benign skin lesions: sebaceous cysts, lipomas (<5cm), benign moles, skin tags, dermatofibromas
• Diagnostic excision of atypical lesions (if not suspicious enough for 2-week-wait)

Lesions Requiring 2-Week-Wait Referral (NOT GP Excision)

• Suspected melanoma (ABCDE criteria, dermoscopic concern)
• Suspected SCC (non-healing ulcerated/keratotic nodule)
• Suspected BCC in difficult anatomical site (nose, around eyes, ears)
• Rapidly growing lesions

Red Flags

• ABCDE criteria for melanoma: Asymmetry, Border irregularity, Colour variation, Diameter >6mm, Evolving
• Non-healing skin ulcer >8 weeks - consider SCC
• Pearly papule with telangiectasia - consider BCC
• Hard, fixed subcutaneous lump - consider malignancy
• Lesion growing rapidly - urgent referral

Pre-Procedure

• Clinical examination and documentation (description, measurements, photograph)
• Dermoscopy if trained (for pigmented lesions)
• INR check if on warfarin (safe to proceed if INR <3.5 for minor procedures)

Post-Procedure

• All excised tissue must be sent for histology - this is a critical safety requirement
• Histology result review and patient follow-up
• Further management based on histology (re-excision if incomplete, referral if malignant)

Documentation

• Consent form
• Description of procedure, anaesthesia used, complications
• Specimen sent for histology (labelled and orientated if appropriate)
• Follow-up plan communicated to patient

Local Anaesthesia

• Lidocaine 1% (10mg/mL): max dose 3mg/kg (200mg in 70kg adult = 20mL)
• Lidocaine 1% with adrenaline 1:200,000: max dose 7mg/kg; longer duration; reduces bleeding
• Adrenaline: safe for digits (evidence supports use; traditional teaching of avoiding is outdated)
• Infiltrate slowly with fine needle (25G or 27G); wait 3-5 minutes for effect

Excision Technique

• Mark lesion with skin marker
• Elliptical excision: 3:1 length-to-width ratio; fusiform shape; long axis along Langer lines
• Excision margin: 2mm for benign lesions
• Achieve haemostasis (cautery, pressure)
• Closure: subcuticular or interrupted sutures; Steri-Strips for superficial wounds
• Dressing and wound care instructions

Joint Injection

• Aseptic technique essential (infection risk approximately 1 in 10,000-77,000)
• Triamcinolone acetonide 40mg (large joints) or 10mg (small joints) + lidocaine 1%
• Post-injection flare: occurs in 2-10%; self-limiting
• Advise relative rest for 24-48 hours
• Maximum 3-4 injections per joint per year

Incision and Drainage of Abscess

• Local anaesthetic (field block around abscess; infiltrating into abscess is painful and less effective)
• Cruciate incision over point of maximal fluctuance
• Express pus, break down loculations
• Pack cavity lightly with ribbon gauze
• Send pus for MC&S
• Antibiotics only if cellulitis, systemic infection, or immunocompromised

Referral Criteria

• Any lesion suspicious for malignancy: 2-week-wait dermatology/plastics
• Incomplete excision of BCC/SCC/melanoma on histology: urgent re-referral
• Lesions in cosmetically sensitive areas: consider specialist referral
• Large or deep lipomas (>5cm or subfascial): surgical referral
• Recurrent or complex abscesses: consider underlying cause

• Minor surgery complications: infection 1-3%, haematoma 1-2%, wound dehiscence 1-2%
• Incomplete excision of BCC: recurrence rate 17-38% (vs 1-2% with complete excision)
• Histological surprise (unexpected malignancy on histology): approximately 1-2% of excised lesions
• Joint injection: symptom relief in 60-80% lasting 4-12 weeks; repeated injections may accelerate cartilage loss
• Abscess drainage: cure rate >90% with adequate drainage; recurrence 10-15% (higher with MRSA)

Local Anaesthetic Maximum Doses

ABCDE Criteria for Melanoma