Chapter 24: Surgical Complications and Their Management

INTRODUCTION

Complications, defined as any adverse and unexpected events, are inevitable in surgery. The recent increase in the number of outpatient surgical procedures has led to a critical appraisal of its safety. Yet several studies have demonstrated the overwhelming safety of dermatologic surgery.^1,2 In a 10 year prospective study of office-based surgeries in Florida, where there is mandatory reporting of surgical complications, there were 309 reported adverse incidents, out of which dermatologists accounted for just 1.3% of all complications (no deaths).³ The first comprehensive prospective study documenting the relative incidence of postoperative complications in dermatologic surgery, specifically Mohs surgery, found the overall incidence to be 1.6%.⁴ In a recent multicenter prospective study of 20,821 Mohs procedures, there were 149 adverse events (0.72%), including four serious events (0.02%), and no deaths reported.⁵ The most common adverse events were infections (61.1%), dehiscence and partial or full necrosis (20.1%), and bleeding and hematoma (15.4%). This chapter will review some common complications associated with dermatologic surgery and provide strategies for the prevention, assessment, and management of these complications.

PREOPERATIVE ASSESSMENT

Preoperative assessment, particularly of pre-existing medical conditions and medications, can help the surgeon identify patients at higher risk for intra- and postoperative complications such as bleeding, infection, and poor wound healing. A preoperative evaluation, discussed thoroughly in other parts of this text, includes guidelines on identifying the correct surgical site, reviewing pertinent medical history, prior surgeries including any problems with wound healing, medications (including anticoagulants), allergies, social history (including the use of tobacco and alcohol), and anticipating the postoperative care of the wound in the patient’s particular social supportive setting.

Identifying the Correct Surgical Site

Identifying and confirming the correct surgical site prior to surgery is axiomatic. In a survey that included 300 Mohs surgeons, wrong-site surgery was the most frequent cause of medical lawsuits.⁶ A photograph of the prebiopsy site is crucial for avoiding wrong-site surgery, as evidenced in a study by McGinness and Goldstein, in which all surgical sites were identified correctly with a preoperative biopsy-site photograph. Without the photograph, 16% of patients and 5.9% of physicians incorrectly identified the site, and in 4.4% of cases, both the patient and physician incorrectly identified the site despite having access to the pathology report listing the anatomic site.⁷ Once the surgical site has been identified with a prebiopsy picture, the physician should have the patient mark the site to confirm the area with a pen and mirror.

Pacemakers

It was previously thought that the use of electrosurgical devices in dermatologic surgery could cause pacemaker and implantable cardiac defibrillator (ICD) malfunction; however, it is now known that patients with these devices have a low overall risk of cardiac complications in dermatologic surgery,⁸ and that the types of interference reported have not led to any significant morbidity ...