Lipoma Excision with Split Thickness Skin Graft

Procedure Overview

This procedure involves the surgical excision of a lipoma located on the back, followed by coverage using a split thickness skin graft (STSG) harvested from the thigh or buttock region. The scrub nurse must be prepared with appropriate instruments, grafting materials, and positioning equipment.

Relevant Anatomy

Knowledge of subcutaneous tissue planes and vascular supply to the back and donor site is crucial. Graft take depends on bed vascularity and careful handling of the graft tissue.

1. Instruments and Equipment Checklist

Minor Surgical Tray

• Scalpel blades (No. 10, 15)
• Metzenbaum scissors
• Adson forceps (toothed and non-toothed)
• Needle holders
• Mayo scissors
• Skin hooks
• Small retractors (e.g., Senn, Ragnell)
• Electrocautery device (monopolar)

Grafting Instruments

• Dermatome or Humby knife
• Graft mesher (optional)
• Graft carrier and skin stapler
• Saline bowl for graft preservation
• Non-adherent dressing (e.g., Mepitel or Jelonet)

Sutures and Dressings

• 3-0 Nylon or Prolene for skin
• Absorbable sutures for deeper layers (e.g., 3-0 Vicryl)
• Skin staples (if used for graft fixation)
• Foam dressing or pressure bolster for graft

Fluids and Medications

• Antibiotics: Cefazolin IV pre-op per protocol
• Normal saline: For irrigation and wound washout
• Hydrogen peroxide: Clean surgical wound, loosen clotted blood and debris
• Local anaesthetic: Ropivacaine, Bupivacaine or lignocaine with adrenaline (surgeon preference)

2. Preoperative Preparation

1. Ensure full instrument and sponge count
2. Prep both the back (surgical site) and donor site (usually thigh or buttock)
3. Mark the lesion and confirm margins with the surgeon

Patient Positioning

• Position: Prone position with chest rolls or lateral position depending on surgeon’s access preference
• Padding: Under knees, elbows, and head
• Donor site: Ensure easy access to lateral thigh or buttock region

Skin Preparation and Draping

• Prep both surgical and donor sites with alcoholic chlorhexidine or iodine scrub
• Use separate trolleys if contamination is a concern
• Apply fenestrated drapes to isolate both fields

3. Intraoperative Stages

1. Incision: Skin incision over lipoma with scalpel
2. Dissection: Blunt and sharp dissection to fully mobilize and excise lipoma
3. Haemostasis: Achieved with diathermy
4. Graft Harvest: Harvest split thickness graft using dermatome or Humby knife
5. Graft Meshing (if needed): Optional to allow expansion
6. Graft Placement: Apply graft to defect, suture or staple in place
7. Dressings: Non-adherent layer over graft, then foam or pressure dressing

4. Postoperative Tasks

• Final instrument and swab count
• Assist in applying pressure dressings to both donor and graft sites
• Ensure graft is immobilized appropriately
• Transfer patient with care to recovery
• Dispose of used instruments properly and send specimens (if required) to pathology
• Document all relevant operative details