Loading...
Because weeks or months can elapse from biopsy to the Mohs procedure, healing may obscure the biopsy site. Information may be lost during transition from one physician to another. These authors present a detailed protocol for overcoming these problems and preventing wrong-site Mohs surgery.
This elaborate series of steps includes:
Using wristbands to identify patients
Having patients identify the site in a mirror, with family member/caregiver input
Having the surgeon mark the site after verification
Digitally photographing the marked site
Performing a documented presurgery time-out.
When patients and escorts are unsure of the site:
The surgeon contacts the biopsying dermatologist.
Loupe examination and skin abrasion are performed to identify the site.
If uncertainty remains, another biopsy is obtained and assessed with frozen-section analysis. If this biopsy does not show tumor, the surgeon follows the patient every 3 months for 2 years for evidence of tumor at the site.
During a 6-year period, the authors used their protocol in 7983 cases and did not detect any wrong-site surgery; surgery was deferred in 18 patients whose original biopsy site could not be identified. All deferred cases were followed for 2 years, with no tumors subsequently identified near the original site.
Starling J III and Coldiron BM. Outcome of 6 years of protocol use for preventing wrong site office surgery. J Am Acad Dermatol 2011 Jul 20; [e-pub ahead of print]. (http://dx.doi.org/10.1016/j.jaad.2011.05.011).
Comment
As the authors note, wrong-site surgery, one of the most commonly reported medical errors, is devastating. Mohs surgeons must be particularly careful, because the epidermis can heal rapidly postbiopsy, and elderly patients, who are the most likely to have skin cancers, often have obscuring scars, keratoses, and telangiectasia. Dermatologists increasingly provide preoperative photographs with the lesion marked, alongside biopsy reports. Protocols like this are appropriate in cases where the site is uncertain; protocol details are less important than consistent application of common-sense steps.
In my practice, we perform many of these steps, with the biopsying physician marking the lesion and three additional Mohs team members concurring on the marked site when the patient cannot see the tumor. Any persistent ambiguity prompts frozen-section biopsy. For nonmelanoma skin cancer, we are fortunate to have this minimally invasive test. Surgical dermatologists may also encourage referring doctors to photograph biopsy sites; even if they forget prebiopsy photography, a picture immediately postprocedure showing the wound site can be helpful. Reasonable, quick, low-cost precautions can virtually eliminate the risk for wrong-site Mohs surgery.