Mohs Surgery

brownbook · Jan 12, 2014

Hi, I am not directly involved in this procedure but in my limited exposure it is not too difficult.

The critical part is collecting and correctly labeling the sample. The Dr. will be (has to be) the one to say to you something like, "it is from the right side of the nose, inner margin, at 9:00 o'clock" or whatever terminology he uses. You must repeat back to him word for word what he said and I repeat correctly label the specimen. I don't even know how they are processed for histotech. You or a "runner" takes it to the pathologists. (At least in my limited exposure? I suppose the Dr. could be the one to look at it?) The pathologist reports back if the margins are clear or not.

If you don't get a better response than mine. And remember I an not directly involved in these, ask the question in the Operating Room section under Allnurses specialties.

littlekaneRN · Jan 19, 2014

Hello! I work as an RN in an office that does mohs. i am responsible for setting up the sterile tray, rooming the pt, ensuring consents signed and review their hx. When the surgeon evaluated and marks the site, I will numb with local anesthetic and clean the skin with whatever that physician prefers. During surgery, I blot blood. After, bandage them and review wound care. Depending on the surgeon, I may take the specimen to the lab. I was trained to do the processing of tissue at one time but another nurse functions only as a mohs tech.

Please let me know if I can answer any questions.

nursediesel · Jan 19, 2014

Thank you so much for the info. From what I understand, some procedures can be quite deep and extensive. Do you feel that each case is different and that keeps it fresh, or is it more of a "you've seen one, you've seen 'em all"? In my area, it seems that there is somewhat of a higher turnover in derm clinics and I don't know if it burnout, salary, or people continuing their education, etc...

littlekaneRN · Jan 20, 2014

I will say we have had a higher turn over in the past, not so much in the last year. I feel many nurses are looking for that "dream job" in a hospital. I feel lucky to work somewhere that's off all major holidays and weekends. I also feel that I am paid very fair as compared to hospital floor nurses. Mohs cases to me are generally similar, but I also work in a practice where there are 2 suregons both work one day a week doing mohs, so we may only have 10 cases a week. They also do not do mohs on very complex areas often, like the ear or peri ocular. Some can go deep. When they get very deep or wide we will coordinate closure with plastics. I really like working with mohs cases, personally. I know nurses who have started with us concerned that they would be stuck in derm if they started there but it hasn't been true. They sometimes move on to OR or plastics.

kendraj · Jan 22, 2014

Hello! I also work as an RN in an outpatient ambulatory surgical center that specializes in Mohs. At our practice we have 1 Mohs surgeon, 3 RNs (including myself) and a MA to assist with surgery. In the morning before the MD comes in, we set up the rooms for the patients (setting up the sterile tray with instruments), draw up the anesthetic, and make sure the rooms are stocked with necessary supplies (cautery tips, gloves, gauze, etc). Once we get a patient, we review the patient chart, confirm the location of the skin cancer on the referring MD's pathology report, and document it on the sheet. We room the patient, ask questions verifying medical history/allergies, etc. and presence of skin cancer, explain the procedure, sign the consent, answer any patient questions take vital signs, and then confirm the location of the skin cancer with the patient using a mirror. After the spot is confirmed, we take a picture of it for our records, and cleanse the area with Iodine or Hibiclens (depending on the location/allergies). This is when we bring in the MD to talk to the patient, who will either numb the area or have us numb, and then take it out. He will then take the specimen to the lab where it is processed by a histotech (takes 1-2 hours for BCC, SCC and 3-4 for MM, MIS). This is when we cauterize, clean the area, bandage the wound, and send the patient to the waiting room. At the practice where I work right now we have 10-12 surgeries a day 4 days a week (the other day is a skin check/excision day), meaning I can see surgery on pretty much any part of the body at any time of the day (ears, noses, scalp are very common, but we also get a lot of trunk/shoulder/legs, etc - I've literally seen everything). We typically only send out closures to plastics when it's something as delicate as the eyelid, otherwise most of the closures are performed by our MD. Once the patient is clear (i.e. free of skin cancer), we bring the patient into a room, tell them the news, take another picture and get a measurement of the site, and then bring in the MD who decides the best way to close the area depending on what will look best for the patient anatomically and cosmetically (which could be a flap, graft, or letting it heal by second intention). He then marks what he will do and we numb, clean the area with Iodine or Hibiclens, and set up a sterile tray for the surgery. When assisting with the closures, we blot, cauterize, cut sutures, and use hooks to open up the wound for better visualization of a vessel if the MD is cauterizing. Once the closure is finished, we then clean the patient, take another picture and measurement, and bandage the area while giving the patient instructions. At the end of the day we do all of the charting for the surgeries, as well as another other visits we may have such as postops, skin checks, or consults. I find the practice I work at to be a very fast paced environment - there's always something to do and a lot that I've seen in my short time of working there. One extensive surgery that I was able to assist with was a paramedian forehead flap if you'd like to look it up to get kind of an idea of the types of surgery that can be done. Hope that helps!

nursediesel · Jan 22, 2014

Thank you. That really helps. I will also be cross trained as a histo, so I will see the process from beginning to end. We have a plastic surgeon in our department as well, so I assume he may close the more complex or delicate areas.