Biopsy / excision of eyelid lesion

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• incomplete excision and need for further surgery once the report comes
• recurrence of the lesion
• notching of the lid margin
• lid malposition (ectropion, entropion, retraction)
• wound opening up
• watering if the tear drainage is involved near the inner corner
• exposure, dry eye and corneal irritation
• visible scar and change in lid shape

Pre-operative details for this operation

1. Lesion descriptionlid (upper/lower), side, position (medial/central/lateral third), size in mm, margin involved or not, lashes lost, ulcer, pearly edge, pigment
2. Clinical diagnosisBenign (papilloma, naevus, xanthelasma, cyst)Suspected basal cell carcinomaSuspected squamous cell carcinomaSuspected sebaceous gland carcinoma (recurrent chalazion-like nodule)Suspected melanoma
3. Lids everted, fornices checked for spreadYes, fornices freeConjunctival involvement seen
4. Lacrimal syringing (lesions near the medial canthus)PatentNot patentNot applicable
5. Preauricular and submandibular nodes
6. ImagingNot needed (mobile lesion)CT / MRI done (fixed lesion or suspected orbital or bone spread)
7. Anticoagulant / antiplatelet historydrug, stopped or continued
8. Pre-op photograph takenYesNo
9. Horizontal lid laxitydecides whether a wedge can be closed directly

Anaesthesia and position

1. AnaesthesiaLocal: topical drops + infiltrationLocal with monitored sedationGeneral (child or large lesion)drug, strength, adrenaline
2. PositionSupine
3. Globe protectionLid guard / corneal protectorNone

Operative findings

1. Size and extent of lesion at surgerymm; skin only or through the tarsus; conjunctival surface involved or not
2. Clinical margin takenmm of normal tissue around the lesion
3. Size of defectwidth in mm, and roughly what fraction of the lid length
4. Canaliculus and canthal tendonsNot involvedInvolved (details)

Procedure (steps)

1. Painting and drapingantiseptic used; eye protected
2. Type of biopsyExcision biopsy, full-thickness pentagonal wedgeExcision biopsy, skin and orbicularis only (lesion away from margin)Incisional biopsy (large lesion, diagnosis only)
3. Excision margins markedmarking pen; margin in mm; for a wedge the tarsal cuts are perpendicular to the lid margin
4. Lid margin heldtraction suture or lid clamp; lid guard behind the lid
5. Lesion excisedblade size or scissors; full-thickness pentagon or skin ellipse
6. Margin controlFrozen sectionMohs micrographicRoutine paraffin HPE onlynumber of stages, result of each
7. Specimen orientedmap drawn; margins marked with dye as agreed with the pathologist
8. HaemostasisPressureBipolar cautery
9. Extra length neededNot neededLateral canthotomy and cantholysisLocal flap (name)
10. Lid margin aligned6-0 silk at grey line, left long for traction; suture at posterior and anterior lash lines
11. Tarsus closednumber of partial-thickness 6-0 polyglactin sutures on a spatulated needle (2 in lower lid, 3 in upper lid)

Closure, drains and dressing

1. Margin suture endsfolded away from the cornea and tied under the anterior lash-line suture
2. Skinsuture type and size; dog-ear handled (Burow's triangle)
3. Ointment and padAntibiotic ointment + padOintment only

Specimens and implants

1. Specimen for HPEcontainer, formalin, labelled with side, lid and orientation; clinical diagnosis on the requisition
2. Frozen section specimensnumber of pieces and their labels

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Padremove next morning (or when the surgeon says)
2. Topical antibiotic ointmentto the eye and wound: drug, frequency, duration
3. Analgesiaoral drug, dose, frequency
4. Watch forbleeding, pain, reduced vision, wound gaping
5. Anticoagulant restartwhen
6. Suture removaldate planned by the operating surgeon; skin and margin sutures
7. HPE follow-update to review the report; plan further excision if margin is involved

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery