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1. Introduction
The problem of the network security is taken up since eighties (Denning et al., 1987) and is developed up today (Beltilch et al., 2004, Bera, 2010, Dasgupta, 1999, Basile, 2007, Wilson, 1999). A major problem of automatic intrusion detection is that, it is difficult to make a difference between normal and abnormal user behaviour. Intrusion detection system should not only recognise the previously known patterns of attacks, but also react in case of appearance of the new events that violate the network security policy. The distributed nature of the task of the network security monitoring requires applying of the distributed tools for network security maintaining. The most important postulate addressed to the intrusion detection systems is that, such systems should automatically react in case of detecting the security policy breach to prevent the attack execution or to reduce the potential loss in the network systems. Intrusion detection systems should be equipped with the components responsible for the permanent observation of the states of monitored nodes and components that integrate the results of these observations and diagnose the security level of the system (Kolaczek et al., 2005, Nguyen et al., 2006).
A comprehensive survey of anomaly detection systems is presented in (Patcha & Park, 2007) and a comparison of different approaches to intrusion detection systems is given in (Bejtlich, 2004). One of the first agent systems for network security monitoring has been proposed in works (Balasubramaniyet et al., 1998, Spafford & Zamboni, 2000). In work (Kolaczek et al., 2005) a framework of an original proposal of the intrusion detection system based on the multi-agent approach was presented. In particular, the architecture of such a system and the task of agents were specified. Proposed ideas were further developed and in work (Nguyen et al., 2006) the problem of anomalies detection on the basis of the nodes traffic analysis was discussed. The proposal of the method for Denial of Service Attack detection was given in (Prusiewicz, 2008a).
In this work we propose a novel framework of a multi-agent system for anomaly detection. The originality of our solution consists of applying the social network approach to Man in the Middle Attack (MITM) detection in a network system. Our proposal is based on the social networks discovery and their characteristics measurement to detect anomalies in network traffic. We assume that network communication between nodes constitutes social network of users and their applications, so the appropriate methods of social network formal analysis can be applied. The other important assumption is that values of these social network parameters for a given node and their distribution for all nodes tend to be constant under normal conditions (Golbeck, 2005, Jamali, 2006, Park, 2007).
We measure the values of the parameters that describe the social network consisted of the nodes and then verify whether the communication patterns between the members of the social network have been violated. The organization of the remaining part of this chapter is as follows. In Section 2 the social networks and the properties of social network are introduced. Then in section 3 the architecture of the multi-agent monitoring system is given. In section 4 the problem of anomaly detection in a social network is taken up. In particular the general schema of anomaly detection procedure is given, the case study of man-in-the-middle attack is carried and the method for this type of attack detection is proposed.
2. Social networks
The basic idea about social networks is very simple. It could be understood as a social structure made of actors which can be represented as network nodes (which are generally individuals or organizations) that are tied by one or more specific types of interdependency, such as values, visions, idea, financial exchange, friends, kinship, dislike, conflict, trade, web links, etc. The resulting structures are often very complex (Butts, 2008, Jamali, 2006, Golbeck, 2005). Social relationships in terms of nodes and ties among them could be used in various types of analysis. A number of academic researches have shown that dependences form social fields play a critical role also in many other fields and could be used in determining the way problems could be solved.
Fig. 1.
The example of social network structure (Batchelor, 2010)
Better understanding of social networks requires a complete and rigorous description of a pattern of social relationships as a necessary starting point for analysis. The most convenient situation is when we have complete knowledge about all of the relationships between each pair of actors in the population. To manage all pieces of information related to social network the mathematical and graphical techniques have been used. This formal apparatus allows us to represent the description of networks compactly and systematically. In this context, social network analysts use two kinds of tools from mathematics to represent information about patterns of ties among social actors: graphs and matrices.
Network analysis uses one kind of graphic display that consists of nodes to represent community members and edges to represent ties or relations. There are two general types of situation when there are a single type of relations among the community members and more than one kind of relation. The first one can be represented by the simplex graph while in the second case we use multiplex graphs. Additionally, each social tie or relation represented by graph may be directed or undirected (tie that represents cooccurrence, co-presence, or a bonded-tie between the pair of community members). Another important feature related to the social networks and their graph representation is the strength of ties among community members. In a graph it may be one of the following types: nominal or binary (represents presence or absence of a tie); signed (represents a negative tie, a positive tie, or no tie); ordinal (represents whether the tie is the strongest, next strongest, etc.); or valued (measured on an interval or ratio level).
Other basic social network proprieties that can be formally described and so can constitute a good background for analysis of community dynamics and which can be applied to detect various types of security breaches are as follows (Scott, 2000):
The Connections between nodes
The number of immediate connections may be critical in explaining how community members view the world, and how the world views them, so it could be also important factor while modelling trust relations within community. The number and kinds of ties are a basis for similarity or dissimilarity to other community members the direction of connections may be helpful to describe the role of the community member in the society, it can be “a source” of ties, “a sink”, or both.
Fig. 2.
A network with large number of connection between nodes (a) and small number of connections (b)
The size of a network
The size of a network is indexed simply by counting the number of nodes, critical element for the structure of social relations because of the limited resources and capacities that each community member has for building and maintaining ties. The size of a network also influences trust relations while in bigger group it is easier to preserve anonymity and it is more difficult to evaluate trust values.
The density of a social network
The density of a social network is defined as the number of existing connections divided by the number of maximum possible connections. The number of logically possible relationships grows exponentially as the number of actors increases linearly. In communities with greater value of density parameter it should be easier to maintain relations between nodes as we get more information about the other community members.
Fig. 3.
High density social network (Morrison, 2008)
The degree of a network node
It tells us how many connections a community member has. Where out-degree is the sum of the connections from the community member to others and in-degree is the sum of the connections to the particular community member from others. Out-degree and in-degree are also referred as fan-out and fan-in parameters. This type of parameter has been proved to be invariant for a long time periods and different scales (subnet sizes) or traffic types (protocols) of data flows in communication networks (Allmanz, 2005). Experiments showed that both Fan-in and Fan-out for a given node and their distribution for all nodes tend to be constant under normal conditions. While network is affected by some type of attack the structure of communication is often heavily affected and the distribution changes. There is also a detectible dependence between type of the attack and communication pattern disturbance (Kohler, 2002). At the other hand, community members that receive information from many sources may also be more powerful community members. However, these nodes could also suffer from “information overload” or “noise and interference” due to contradictory messages from different sources. Impact for the social relations between nodes is similar to that described in a case of density, dependently from in/out-degree when an individual has more or less information about its neighbourhood.
The reachability of community members
A community member is “reachable” by another if there exists any set of connections by which we can find link from the source to the target entity, regardless of how many others fall between them. If some community members in a network cannot reach others, there is the potential of a division of the network. For example, disconnected community members could have more problems to evaluate trust value.
Fig. 4.
The examples of networks with different node degree parameter values (a) Perfect graph of n nodes with avg. node degree n-1. (b) Star graph of n+1 nodes with avg. node degree (2n)/(n+1)
The transivity of network nodes connections
The transitivity principle holds that, if A is tied to B, and B is tied to C, then A should be tied to C. The triadic relationships (where there are ties among the actors) should tend toward transitivity as an equilibrium condition. One of the most important type of social relation as trust is not strictly transitive and so this propriety not necessarily influences trust evaluation process.
The distance between the network nodes
An aspect of how individuals are embedded in networks, two actors are adjacent when the distance between them is one. How many community members are at various distances from each other can be important for understanding the differences among community members in the constraints and opportunities they have as a result of their network location. Community members located more far apart from each other in the community have more problems with establishing new relations than the members, which are close.
The geodesic distance between the network nodes
The geodesic distance is defined as the number of relations in the shortest possible walk from one community member to another. Many algorithms in network analysis assume that community members will use the geodesic path when communicating with each other.
The diameter of a network
The diameter of a network is the largest geodesic distance in the connected network which tells us how “big” the community is, in one sense quantity in that it can be used to set an upper bound on the lengths of connections that we study.
The cohesion of a social network
The degree to which nodes are connected directly to each other by communication links. Count the total connections between actors more strong connection between community members should determine grater trust values.
Centrality, Power, Betweenness
Centrality, closeness, betweenness describe the locations of individuals in terms of how close they are to the “center” of the action in a network – though there are a few different definition of what it means to be at the canter. The more important community member is, the more important its opinions should be.
Fig. 5.
Example of betweenness centrality. Red colour indicates the lowest betweenness centrality value and blue the highest (Bailin, 2009)
Fig. 6.
Cliques example. Network with two cliques – first one is composed of nodes: A,G,H,J,K,M, the second: D,E,F,L
The eigenvector of the geodesic distances
An effort to find the most central community members in terms of the “global” or “overall” structure of the network, and to pay less attention to patterns that are more “local”
The cliques in the network
A subset of community members who are more closely tied to each other. A clique typically is a subset of community in which every node is connected to every other node of the group and which is not part of any other clique. Idea of cliques within a network is a powerful tool for understanding social structure and the embeddedness of individuals. Cliques reflect the groups of community members with strong relationship. So, sudden change in communication pattern within such a group may be related to security breaches.
The clustering coefficient
The probability that two nearest neighbours of a given node are also neighbours of each other. The value of clustering coefficient provides a quantitative measure for cliques in communication graph.
Fig. 7.
Example of clustering coefficients (cc) for different networks. a) cc=1, b) cc=0.3, c) cc=0
3. The architecture of the multi-agent monitoring system
It is assumed that there are two layers in the architecture of the multi-agent monitoring system: monitoring layer and control layer (Fig. 8). Monitoring layer consists of the nodes that are monitored by the monitoring agents. While control layer consists of the security control agents that are responsible for collecting data from monitoring agents and determining general characteristics of the network traffic in the monitored region. These characteristics describe communication patterns in the monitored region. We assume that communicating nodes constitutes the social network. Each security control agent is responsible for controlling one region (social network).
Fig. 8.
Two-layers multi-agent monitoring system architecture
The patterns of discovered social networks are temporally collated by security control agents with communication patterns stored in security control agents private databases in order to verify if any security policy breach has been occurred.
Before the internal organization of the monitoring and security control agents will be given, let us denote: V as the set of the nodes, V = {v1, v2,…, vk,…, vK}, K ∈ N, MA (MA = {MA1, MA2,…, MAk,…MAK}) as the set of the monitoring agents, SA (SA = {SA1, SA2,…, SAg,…SAG}), G ∈ N as the set of security control agents, SN (SA = {SNg : SNg : ⊆ V}) as the set of the social networks (monitoring regions) and P = {P1,.P2,…,Pz} as the set of the observed parameters describing the nodes from V.
3.1 Monitoring agent’s internal organization
Each monitoring agent MAk ∈ MA observes the states of one node from V in their monitoring regions (social networks) from SN with the reference to the values of the parameters from the set P. The results of the observations are captured in their private set of observations.
Definition 1. A single observation of agent MAk is stored as a tuple [Prusiewicz, 2008a]:
OkPjxtn∈DBkE1
where: Pj ∈ P, tn ∈ T and T is the universe of the timestamps and DBk denotes the database of the agent MAk.
Such observation refers to the situation that at the timestamp tn the agent MAk has observed in the node vk the value of the parameter Pj equals x.
3.2 Security control agents internal organization
Security control agents control the monitoring regions. The size of the monitoring regions may change by adding or removing nodes as a consequence of the social networks evolutions. Security control agent SAg, SAg ∈ SA is built from three modules: Data Storage Module, Social Network Module and Security Control Module. Security control agent SAg collects data from databases of the monitoring agents and builds communication matrix in Data Storage Module [Prusiewicz, 2008b].
Definition 2. The communication matrix CMg is defined as:
CMg=amnGxGE2
where amn is the set of time stamps of communication acts between nodes vm and vn. The node vm is a sender and vn - receiver.
Table 1.
En example of communication matrix: the node v2 communicated with the node v12 at the timestamps: t2, t5, t9, t23, t28, t34
On the basis of data from communication matrix CMg the values of the parameters describing the social network SNg, SNg ∈ SN are determined in Social Network Module. Additionally in Social Network Module the patterns of communication between nodes are determined that a are the basis for the social networks discovery. In Security Control Module the procedures for anomalies detections are implemented. In this case the procedure for Man-In-The Middle attack is implemented.
3.3 Determining of the social network characteristics
Social network characteristics are determined on the basis of the data from communication matrix CMg by the Social Network Module. In this module two data structure are used in order to control the security of the monitoring region: Social Network Patterns and Temporal Communication Patterns defined as follows:
Definition 3. A Social Network Patterns is defined as:
SNPtbteg=fin,vitbtefout,vitbteclvitbtecvitbteE3
where:
fin,vitbte is the number of nodes that originate data exchange with node vi during observation period [tb, te]
fout,vitbte is the number of nodes to which vi initiates conversations during observation period [tb, te]
clvitbte is the clustering coefficient defined according to the following equation:
clvitbte=2EG1vitbtedegvitbtedegvitbte−1E4
where:
fin,vitbte is the number of nodes that originate data exchange with node vi during observation period [tb, te]
degcvitbte – denotes degree of node vi during observation period [tb, te]
Glvvitbte – is the set of nodes which are connected with vi via single link (its immediate neighbors) during observation period [tb, te]
EGlvvitbte – is the number of edges among nodes in 1–neighbourhood of node vi during observation period [tb, te]
cvitbte is the centrality of the node, it describes the temporal location of the node vi during observation period [tb, te] in terms of how close it is to the “canter” of the action in a network.
There are four measures of centrality that are widely used in network analysis: degree centrality, betweenness, closeness, and eigenvector centrality. The proposed method uses Eigenvector centrality measure which assigns relative scores to all nodes in the network based on the principle that connections to high-scoring nodes contribute more to the score of the node in question than equal connections to low-scoring nodes. For examle Google\'s PageRank is a variant of the Eigenvector centrality measure (Page, 1998). For the node vi the centrality score is proportional to the sum of the scores of all nodes which are connected to it within observation period [tb, te]:
cvitbte=1λ∑j∈Mtbteivjtbte=1λ∑j=1NAi,jtbtevjtbteE5
where:
Mtbte (i) is the set of nodes that are connected to the node vi during observation period [tb, te],
N is the total number of nodes,
Ai,jtbte is the adjacency matrix of the network during observation period [tb, te],
λ is a constant.
Definition 4. A Temporal Communication Patterns is the set of social network characteristics that has been determined at the time intervals, defined as:
where each element of the set TCPg has the same structure as Social Network Patterns. The difference is that the values of SNPtb,teg are the patterns that describe the monitored social network SNg (SNg ⊆ V). They are discovered on the basis of the historical network traffic data analysis. Social Network Patterns are used to discover any security policy breaches in a network system. While the values from Temporal Communication Patterns describe the current communication characteristics of monitored region. The last element of the TCPg is a current characteristics of communication patterns of a social network SNg.
Having the values of the parameters from Social Network Patterns and current social network characteristics the procedure for anomaly detection might be applied.
On the fig. 9 the process of anomaly detection carried out by the security control agent is illustrated. First the observations from the monitoring agents embodied in the nodes v6, v7, v8, v9 are captured by the Data Storage Module and used to determine communication matrix CM2. Data from CM2 are sent to Social Network module, responsible for determining the patterns of communications in an observed network. The social network patterns SNPt5t352 have been determined for the nodes: v6, v7, v8, v9 and the time interval [t5, t35] to control the security. The current communication patterns TCP2 are compared with SNPt5t352 to control the security of SN2.
Fig. 9.
The process of determining of the social network characteristics and anomaly detection
4. Man-in-the-middle attack detection
The man-in-the-middle attack (often abbreviated MITM) is a form of active eavesdropping in which the attacker makes independent connections with the victims and relays messages between them, making them believe that they are talking directly to each other over a private connection when in fact the entire conversation is controlled by the attacker. To perform the effective attack, the attacker must be able to intercept all messages going between the two victims and inject new ones, which is straightforward in many circumstances (Fields, 1995).
This type of attack can be as analyzed as a general problem resulting from the presence of intermediate parties acting as proxy for clients on either side (Asokan, 2002, Shim, 2003, Welch, 2003). The problems related to the MITM attacks are also related to trust relation among geographically distributed subjects. If communicating with each other subjects are trustworthy and competent the risk of the MITM attack is low. If communicating parts do not know each other or has no trust relation, the risk of the attack increases. By acting as proxy and appearing as the trusted client to each side, the intermediate attacker can carry out much mischief, including various attacks against the confidentiality or integrity of the data passing through it. So, one of the most urgent question is how one can detect MITM attacks.
It is important to notice, that MITM attack is a general security problem not only related to cryptographic applications. An example of such non-cryptographic man-in-the-middle attack was caused by one version of a Belkin wireless network router in 2003 (Leyden, 2003). This router periodically would take over an HTTP connection being routed through it: it would fail to pass the traffic on to destination, but instead itself respond as the intended server. The reply it sent, in place of the requested web page, was an advertisement for another Belkin product. This \'feature\' was removed from later versions of the router\'s firmware (Scott, 2000).
Another example of such type of man-in-the-middle attack could be the “Turing porn farm”. This schema of the attack potentially could be used by spammers to defeat CAPTCHAs (Petmail). The general idea is that the spammer sets up a pornographic web site where access requires that the user solves the CAPTCHAs in question. However, this attack is merely theoretical because there is no evidence of building Turing porn farm by the time being (Atwood, 2006). There are available several ready to use tools which implement the MITM idea and which can be used for communication interception in various environments, e.g. dsniff – a tool for SSH and SSL MITM attacks, Ettercap - a tool for LAN based MITM attacks, AirJack - a tool that demonstrates 802.11 based MITM attacks, and many others.
4.1 Evaluation of MITM event probability value
We assume tracking four communication patterns: Fan-in (from here on denoted as fin,viΔtfor node vi during the observation period Δt), Fan-out fout,viΔt, clustering coefficient clviΔt and centrality cviΔt.
According to the assumption presented by (Allmanz, 2005) that these types of parameter has been proved to be invariant for a long time periods and different subnet sizes or traffic types of data flows, the risk of the MITM incident will be estimated as the abnormal change of the characteristic parameters values for a given social network member.
Let us assume that the collected history record consists of a number of observations of Fan-in values from some starting point up to current time t. So we have fin,viΔt1,fin,viΔt2,fin,viΔt3,…,fin,viΔtk. Now, consider the Fan-in as a random variable Fin,vi. Thus, fin,viΔt1fin,viΔt2fin,viΔt3…fin,viΔtk is a sample of size k of Fin,vi. We also assume all of the fin,viΔt to be independent. It is commonly known that the mean value and the variance of Fin,vi can be estimated by using the following formulae:
F¯in,vi=1m∑j=ikfin,viΔtjE7
Sin,vi=1k−1∑j=1kfin,viΔtj−F¯in,vi2E8
F¯in,vi and Sin,vi are thus the estimations (based on the data being at our disposal) of mean value and the variance of Fin,vi. Obviously the bigger our sample is, the better they approximate EFin,vi (expected value of random variable) Fin,vi and VarFin,vi (variance of random variable Fin,vi) respectively. From this point we assume that the observations ‘number is big enough to state that EFin,vi and VarFin,viare known.
Let also EFout,vi and VarFout,vi for the Fan-out, as well as EclviΔt and VarclviΔt for clustering coefficient and centrality EcviΔt,VarcviΔt be defined in the same way.
In our approach, we will detect the possible MITM events by evaluation of some weighted value related to mean value and variance of fan-in, fan-out, clustering coefficient and centrality. At this stage of research we assume that we will analyze all four parameters independently. This means that it is enough to assume MITM incident if only one of the parameters exceeds threshold value.
From the Chebyshev\'s inequality we can estimate the upper bound of the probability that F¯−x is greater than kS. Where F¯ and S are mean value and the variance of X, while X denotes the random variable related to x (in this case one of the followingfin,vi,Δtfout,vi,ΔtcviΔt,clviΔt).
According to this estimation the probability expectation Eϖvivalue of the MITM event for a given parameter will be evaluated using the following formula:
Eϖvi=1−1αk2E9
Where α is a coefficient, which value should be set during a process of tuning-up the detection system to the real network conditions. Parameter k is defined as follows:
k=1ifF¯−xS<1F¯−xSifF¯−xS≥1E10
4.2 The procedure of the Man-in-the-middle attack detection
Our approach of MITM attack detection has been dedicated especially to effectively detect automated attacks of this type. For example this method should be convenient for detection HoneyBot-based attacks as it has been described in their work by researchers from Institut EURECOM in France (Lauinger, 2010), who are working on automation of social engineering attacks on social networks.
French researchers have developed an automated social engineering tool that uses a man-in-the middle attack and strikes up online conversations with potential victims. In the work (Lauinger, 2010) the proof-of-concept HoneyBot has been presented that poses convincingly as a real human in Internet Relay Chats (IRC) and instant messaging sessions. It lets an attacker collect personal and other valuable information from victims via these chats, or tempt them into clicking on malicious links. The researchers had proved the feasibility and effectiveness of their MITM attack variant. During the tests they were able to get users to click onto malicious links sent via their chat messages 76 percent of the time.
We propose the following idea of algorithm for MITM detection using social network patterns.
Input: D – set of data that can be used to derive and observe patterns of the social network (e.g. e-mail logs, chat rooms records, network traffic, etc.)
Output: R∈{Y,N} – information about the social network state according to risk of MITM incidents
BEGIN
Take the data set D and derive the social network structure (e.g. using one of the approach presented in section 3.1)
For each node find the current value of the monitored social network patterns (fan-in, fan-out, centrality, clustering)
Analyze the history of network patterns changes. As we treat the network patterns values as the realization of the random variable, mean value and variance will be calculated for each pattern.
For each node compare the latest change of the patterns values to the assumed threshold value.
If the result of the step 4 is that the observed parameter value exceeded the threshold, the value of the result variable is set to Y – the high risk of the MITM incident, otherwise it is set to N – small risk of MITM incident.
Return to step 2.
END
Remarks:
due to the social network dynamics, we may consider some periodic more thorough updates of the network structure; it could be represented in the above algorithm by adding a time related condition in step 6 and then by return to step 1 instead of returning to step 2
it is possible to consider situation when we are interested only in monitoring for one particular or some specific subset of all nodes (bank client, chat room participant, etc.), then we may investigate some additional information about its activity and use some data fusion methods to improve the accurateness of the final decision (e.g. we may concurrently track the node’s activity within several different social network and so build more comprehensive profile of the network identity).
we should consider if some “suspicious” behaviour in the context of the only one observed parameter is enough to assume MITM incident or we would prefer to wait for more premises or else we will combine the values of all parameters and only after using data fusion methods set up the final decision.
Output: The risk of the MITM incidents in the nodes of SNg
BEGIN
For each node vi ∈ SNg determine the probability expectation values: EωFin,vi,EωFout,vi,EωClvi,EωCvi according to the formula 9.
If EωFin,vi>Fin,vi‐maxorEωFout,vi>Fout,vi‐maxorEωClvi>Clvi−maxorEωCvi>Cvi‐max then the risk of MITM incident in the node Vi:Rvi≔YelseRvi≔N
END
5. Conclusion
Generally the aim of the network security systems is to protect computational and communication resources from any security policy breaches. Such systems should be equipped with the meachnisms for permanent monitoring the values of the parameters describing their states in order to diangose and protect of their resources. The most important postulate addressed to the intrusion detection systems is that, such systems should automatically react in case of detecting the security policy breaches to prevent the attack executions or to reduce the potential loss in the network systems. Although the problem of the network security has been studied for decades and several methods and approaches have been proposed there is still open problem how to differentiate normal and abnormal states of the network system. In this work we proposed the social network approach to evaluate the security state of the network. The values of the chosen coefficients that characterise the users behaviour are used to discover security breaches occurrence. The idea of our proposal is as follows. First the user behaviours are monitored and the social networks are discovered. Then having the pattern values of social networks characteristics we are able to compare them with the current observations and detect any aberrances.
We proposed two-layers multi-agent system for security monitoring and the algorithm for MITM attack detection.
Acknowledgments
The research presented in this work has been partially supported by the European Union within the European Regional Development Fund program no. POIG.01.03.01-00-008/08
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Introduction",level:"1"},{id:"sec_2",title:"2. Social networks",level:"1"},{id:"sec_3",title:"3. The architecture of the multi-agent monitoring system",level:"1"},{id:"sec_3_2",title:"3.1 Monitoring agent’s internal organization",level:"2"},{id:"sec_4_2",title:"3.2 Security control agents internal organization",level:"2"},{id:"sec_5_2",title:"3.3 Determining of the social network characteristics",level:"2"},{id:"sec_7",title:"4. Man-in-the-middle attack detection",level:"1"},{id:"sec_7_2",title:"4.1 Evaluation of MITM event probability value",level:"2"},{id:"sec_8_2",title:"4.2 The procedure of the Man-in-the-middle attack detection",level:"2"},{id:"sec_10",title:"5. Conclusion",level:"1"},{id:"sec_11",title:"Acknowledgments",level:"1"}],chapterReferences:[{id:"B1",body:'Allmanz M. et.al. (2005). A First Look at Modern Enterprise Traffic, In Proc. 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1. Introduction
This chapter will try and help general practitioners master minor surgical procedures.
General practitioners require these procedures for diagnostic or therapeutical reasons, in the outpatient setting as well in the emergency (excision of skin lesions or wound suturing for example). For that reason, the training of the general doctors in minor surgery is an additional tool for good medical practice and acquiring skills in minor surgical procedures has become a critical part of medical training.
Minor surgical procedures do not involve very sophisticated devices. However, some basic requirements in terms of infrastructure and equipment must be met [1, 2].
It is recommended that each facility has a specific room for these procedures. This room (Figure 1) must include:
Figure 1.
Well-equipped room of minor surgery.
Surgical room: a well-ventilated room, with a suitable temperature, it is imperative that is clean, but it does not require sterile isolation. The surgical room should be cleaned properly at the end of the surgical session, particularly after contaminated procedures (e.g. abscesses).
Operating table: It should be easily accessible from all sides, Height-adjustable and articulated tables. It is essential that allows the doctor to work in comfort, both standing and sitting.
Doctor’s stool: A height-adjustable stool on wheels.
Side table: it is used to place the surgical instruments and material used during the surgery.
Lamp: It is necessary to have a directional light source, and it must provide adequate lighting with, at least, 45,000 lux of illuminance. It is advisable to have another auxiliary lamp with a magnifying glass.
Showcase and containers: For storing consumables and surgical instruments. There should also be properly marked containers for bio contaminated material, and a disposal system in accordance with current health legislation.
Resuscitation equipment: Including material for vascular access, airway intubation, saline, drugs for resuscitation (e.g. epinephrine, atropine, bicarbonate) and a defibrillator.
2. Sterilization system
2.1 Physician’s preparation for minor surgery
Performing minor surgical procedures carries some risk of transmission of infectious diseases (such as HCV and HIV), both from patient to doctor and vice versa. To minimize this risk, all physicians performing invasive procedures should adopt and apply universal precautions, which include:
Surgical attire: surgical shirts and trousers (“scrubs”) or gowns and sterile gloves. Surgical masks and eye goggles is considered highly desirable but not essential. Disposable gowns are very useful.
Hand washing: Hygienic scrubbing is suitable for minor surgery and involves using a normal soap solution (no brush) and washing thoroughly all skin folds for at least 20 seconds. Time span from scrubbing to glove placement should never exceed 10 minutes.
Sterile glove placement: Outer surface of the glove should be sterile, therefore they cannot be touched with the hands, only with the other glove; nonetheless, the inner or powdered part of the glove can be touched.
3. Surgical instruments (handling) and suture material
3.1 Surgical instruments for minor surgery
The quality, condition and type of instruments used in any procedure can affect its outcome. Choosing the right instruments for each surgical intervention is, therefore, an important issue [1].
Scalpel: A number 3 handle with leaves number 15 for dissection and 11 for incisions and withdrawal of points. The scalpel blade is installed on the handle in a unique position, matching the blade guide with the handle guide. The scalpel is handled with the dominant hand like a pencil (Figure 2), allowing small and precise incisions. To increase precision, hand should be partially supported on the working surface. Skin should be tightened perpendicularly to the direction of the incision using the contralateral hand, cutting the skin perpendicularly. In hairy areas (eyebrows or scalp), to avoid damaging the follicles, the incision should be parallel to the hairshafts.
Figure 2.
Correct way of managing of the scalpel.
Scissors: The scissors allows us both the cutting dissection of the tissues and the blunt dissection.
A 14 cm long curved blunt May scissors (cutting scissors) and an 11.5 cm curved blunt Metzenbaum scissors (dissecting scissors) should be available.
Scissors are handled by inserting the distal phalange of the thumb and fourth finger into the rings, then supporting the second finger on the branches of the scissors. Usually scissors are inserted with the tip closed and are then opened, separating the tissues in the anatomical layers, except for sharp dissection they are inserted with the tip open, then cutting the tissue.
Needle-holder: needle-holders are meant to hold curved needles while stitching. The needle is held 2/3 of the way back from its point. A small or medium (12–15 cm). Long needle holders are not recommended.
Like other instruments with rings, the needle support is handled equally. To facilitate the passage of the needle through the tissues, the needle holder should describe a prono-supination movement, and for a proper edge eversion of the wound the angle of entry of the needle should be 90°. The non-dominant hand holds the skin with a retractor or dissecting forceps, opposing the pressure of the needle.
Dissecting forceps: Use of a 12 cm-long Adson forceps with teeth to handle the skin, plus a toothless Adson forceps for suture removal or two standard forceps, one with and one without teeth. It is important not to manipulate the skin using non-toothed forceps.
They used with the non dominant hand, between the first, second and third fingers.
They allow the surgeon to expose the tissues to manipulate them.
Homeostats: homeostats are used to pull tissue, for homeostasis and, in some cases, for blunt dissection in absence of small scissors. Usually with 12 cm curved non-toothed Mosquito forceps.
For most minor surgical interventions, a basic set of surgical instruments is enough (Figure 3). But some surgical procedures require the use of special instruments or equipment, such as:
Figure 3.
Basic set of instruments of minor surgery: Scalpel (handle of the number 3 for scalpel number 15), scissors of May, Adson forceps with teeth, needle-holders and mosquito forceps.
Biopsy punch: it is an instrument consisting of a handle and a cylindrical cutting edge (trephine) for obtaining tissue biopsies. It allows the surgeon to obtain full- thickness samples of the skin.
The most useful in minor surgery is the 4 mm punch but they are manufactured in different diameters. They are handled with the dominant hand, performing rotational movements of the instrument to cut the skin and obtain the sample [3].
Curette: it allows scraping of lesions on the skin Surface with a simple surgical technique that involves “scraping” or enucleating different types of superficial, hyperkeratotic or raised partial-thickness skin lesions.
Cryosurgical equipment: these are devices that spray a cryogen, which is usually liquid nitrogen that uses extremely cold temperatures to treat benign and malignant skin lesions (solar lentigines, common warts, myxoid cysts, actinic keratosis, etc.).
It is available, cost-effective, and rapid treatment that rarely requires anesthesia [4].
Electrocautery: it applies an electric current with ability to coagulate and cut through different tissues. There are different terminals depending on the type of procedure that is to be performed [5].
3.2 Suture materials
Different types of suture materials are available: threads, staples, adhesive sutures and tissue adhesives.
Depending on the material used for the suture, the operation time will be modified and will require anesthesia or not.
Conventional sutures require the use of anesthesia, operating time is increased, and tissue is traumatized, but provide a secure wound closure and minimal wound- dehiscence rate compared to other types of closure [6].
3.2.1 Sutures
They are classified according to their origin (natural, such as silk, or synthetic polymers that produce less tissue reaction), their configuration (monofilament or multifilament), and their size (the thickness of the suture is measured using a zero-scale [USP system] (Figure 4). The most commonly used in minor surgery range from 2/0 to 4/0 or 5/0.
Figure 4.
Information on suture: (1) caliber of the thread (system USP and metric), (2) trade name of the suture, (3) composition and physical structure of the thread, (4) length of the thread, (5) color of the thread, (6) model of needle (every manufacturer uses different references), (7) I draw from the needle to scale 1:1, (8) circumference of the needle (expressed in parts of circle), (9) section of the needle, (10) length of the needle, (11) expiry date, (12) indexes of the manufacturer, (13) indicator of sterile packing.
The size and type of suture will be selected depending on the anatomical site, the type of wound and on the patient’s features.
3.2.1.1 Features of main sutures
Nonabsorbable sutures: They are not degraded by the body and they are used for skin wounds in which stitches that are to be removed or for internal structures that must maintain a constant tension (like tendons and ligaments), Polypropylene and Nylon, causes minimal tissue reaction.
Silk: Suitable for skin suture and for removable sutures in general, it is easy to handle and tie.
Nylon: Indicated for precise skin sutures and internal structures that must maintain constant tension.
Polypropylene: Indicated in continuous intradermal skin closure. It is a very soft suture with high package memory and, therefore, it requires more knots for secure tying, and it is more expensive than Nylon.
Absorbable sutures: A suture is considered absorbable if, when placed under the skin surface, it loses most of its tensile strength in 60 days. It has low tissue reactivity, high tensile strength. They are use in dermal suturing, subcutaneous tissue, deep suturing and ligatures of small vessels. The most commonly used, are the synthetic sutures (polyglactin 910 [Vicryl], polyglycolic acid [Dexon]…).
3.2.1.2 Stitch removal
The period of time (in days) recommended for the extraction of points, together with an indication of the type of suture is described in Table 1.
Anatomical region
Skin suturing
Subcutaneous suturing (Vicryl® or Dexon®)
Stitch removal
Adults
children
Scalp
Staples 2/0 silk
3/0
7–9
6–8
Eyelids
6/0 monofilament or silk
—
3–5
3–5
Ears
4/0–5/0 monofilament or silk
—
4–5
3–5
Face, neck, nose, forehead
4/0 monofilament or silk
4/0
4–6
3–5
Lips
4/0 monofilament or silk
4/0
4–6
4–5
Trunk/abdomen
3/0–4/0 monofilament
3/0
7–12
7–9
Back
12–14
14
Lower extremity
3/0 monofilament
3/0
8–12
7–10
Penis
4/0 monofilament
3/0
7–10
6–8
Foot and pulp of fingers
10–12
8–10
Upper limb/hand
8–10
7–9
Mouth and tongue
3/0 Vicryl®
—
—
—
Table 1.
Indications of types of sutures and time for stitch removal.
3.2.2 Suturing needles
Needle selection depends on the type of tissue to be sutured, its accessibility and suture thickness.
Needles are classified as triangular, spatulate or conical, according to their section. Triangular needles are considered the first choice in minor surgery, as they have sharp edges that allow suturing through highly-resistant tissues such as subcutaneous tissue, skin or fascia.
Curved needles are used with the needle holder, that is designed to hold needles atraumatically and safely. Short needle holders are preferred in minor surgery; however, they should be selected in accordance with the size of the needle and the surgical area.
3.2.3 Staples
Staples are applied by disposable staplers and they are available in different widths (R: normal staples, W: Wide staples). Staplers are preloaded with a variable number of staples. It has certain advantages such as the speed with which the suture is performed, low resistance and no tissue reaction.
They are applied with the dominant hand, while the non dominant hand everts the skin edges using dissecting forceps with teeth. Staple removal is performed using a staple extractor.
Indications: In linear wounds on the scalp, trunk and limbs, and for temporary closure of wounds in patients to be transferred or with other serious injuries.
Contraindications: Wounds on face and hands and regions that are going to be studied through CT or MRI.
3.2.4 Adhesive sutures
It consists of adhesive tapes made of porous paper and capable of approximating the edges of a wound or incision. They are available in various widths and lengths, and it can be cut.
Indications: linear and superficial wounds with little tension. The regions where they are used most are: the face, chest, non-articular surfaces of the limbs and fingertips. They are also a good choice for elderly patients and to wound-reinforcement after stitch removal.
Any wound closed with adhesive suture should not be wet for the first few days, due to the risk of tape detachment.
Contraindications: irregular wounds, on the scalp and hairy areas, skin folds and joint surfaces.
Application and removal of adhesive sutures: For a good application the wound should be free of blood or secretions and dry. The suture tape is applied to the wound using dissecting forceps without teeth or fingers, first on one edge of the wound and then the other and along the wound.
Time for adhesive suture removal parallels time for conventional suture.
3.2.5 Tissue adhesives (glues)
These products (cyanoacrylates) act as an adhesive, producing an epidermal plane closure, so they bind the most superficial epithelial layer (stratum corneum) and hold together the wound edges for 7–14 days. After this time, adhesive and stratum corneum are shed along.
Adhesive can be used in deeper wounds or with great tension, associated at sutures in the subcutaneous plane.
It have advantages when compared with sutures: More rapid repair time, less painful procedure, better acceptance by patients, no need for suture removal or follow-up, good cosmetically results. Finally they are safer than sutures because needlesticks are avoided [1, 7].
3.2.5.1 Application technique
After cleanliness and hemostasis of the wound, tissue adhesive will be applied:
Using fingers or dissecting forceps to approximate the wound edges, apply the adhesive on the outer surface of the skin. Then Keep the edges in contact for 30–60 seconds. The process can be repeated 3 times.
The wound does not require dressings but should be kept dry 5 days. The glue will disappear after 7–10 days.
3.2.5.2 Warnings for correct use
If adhesive contact the eyes, use of a generous amounts of ophthalmic antibiotic ointment should be placed within the eye and on the eyelid to break down the adhesive and reopening of eyelids with a gentle manual traction. If adhesive reach the cornea, it should be assessed for corneal abrasion.
4. Surgical procedures and techniques of anesthesia in minor surgery
4.1 Basic surgical maneuvers
The practice of any surgical procedure, however minimal, is not without risks. The possibility of complications during and after surgery must always be kept in mind. The results of surgical treatment are not always predictable, and depend on many factors, involving not only the physician’s skills, but also the patient.
4.1.1 Surgical incision and dissection
There are two ways to dissect tissue: with a blunt dissection, separating the tissue, using Metzenbaum scissors or mosquito forceps, or cutting dissection, with a scalpel or scissors.
4.1.1.1 Incisions shape in minor surgery
Incisions must parallel the minimal tension lines, which match skin relaxation lines and facial expression. Thus, they result in an acceptable scar, both functionally and cosmetically. There are diagrams of the relaxed skin tension lines, for correct incision planning before surgery.
The incision can be marked prior to skin antiseptic preparation or a previously sterilized marking pen can be used in the surgical field after skin preparation and draping.
For excisional biopsies, it is necessary to leave an adequate margin (1–2 mm) of healthy skin both around the lesion and in depth, depending on each lesion.
4.1.1.2 Types of incisions for minor surgery
Incision: Used for drainage of abscesses or surgical exposure of deeper tissues (e.g., epidermal cysts, lipomas, lymph node biopsies). Depending of surgery or the anatomic area, Incisions can be angled, curved or straight.
Elliptical excision: Its should be oriented along the lines of minimal tension.
Usually the length of the ellipse should be 3 times its width and the ends form a 30° angle. Its used to remove skin lesions with a margin of healthy skin in depth and around lesion, and include all skin layers plus some subcutaneous fat (Figure 5). This technique allows diagnosis, treatment and facilitates closure producing good cosmetic results.
Figure 5.
Characteristics of the elliptical excision.
It is the ideal technique to remove the majority of skin lesions [8, 9, 10].
The procedure involves the following steps:
Design of the incision
Preparation of the surgical field
Local anesthetic injection.
Superficial skin incision along the marked ellipse, going through the entire dermis to prevent jagged edges.
Using the nondominant hand the deep wedge-shaped incision is made (always under direct vision), until fat is reached and the lesion is, thus, removed en bloc.
Hemostasis of the surgical area.
Wound closure by layers
Cleaning the surgical area and dressing placement
After 48 hours the wound can be washed gently
Tangential excision: it is the technique of choice to remove very superficial lesions using scalpel or scissors, eliminating only the most superficial layers of the skin and for which diagnosis is certain. The defect created is allowed to heal by secondary intention. Tangential excision also called “skin shave”.
No surgical procedure is complete until the pathology report has been received and the patient informed of the results and prognosis.
4.1.2 Hemostasis
Most episodes of bleeding in minor surgery can be controlled with pressure with a gauze or a surgical towel. It is recommended to apply a compressive bandage on the wound in the immediate postoperative period to reduce hematoma or seroma.
4.1.2.1 Types of hemostasis
Tourniquet: Its allows the exploration of the wound and reduces the surgical time. Its use is limited to distal areas (the fingers nail surgery, etc.) and should not exceed 15 minutes.
The hemostats: The surgeon holds bleeding vessel with the tip of a hemostat without teeth and controls the bleeding. To avoid damaging important structures (for example, tendons or nerves) it is necessary to identify the bleeding vessel.
The ligatures: they are threads that tied around a blood vessel, occlude their light and prevent bleeding. After that, vessel should be fixed with a hemostat. The ligature should pass under the clamp and several knots must be tied.
In the hemostasis by electrocoagulation, the Bovie is used in coagulation mode.
4.1.3 Suture techniques
4.1.3.1 Interrupted sutures
This is the most appropriate for minor surgery, as it helps to distribute stress, and promotes the drainage of the wound. The number of sutures needed varies according to the length, shape and location of the laceration. In general, the sutures are placed away from each other so that no space appears on the edges of the wound.
Simple stitch (percutaneous): It is used alone or in combination with buried stitches in deeper wounds and it is considered the technique of choice.
Simple stitch with buried knot: Used to reduce tension within the wound and approximate the deep planes, before skin suturing. Absorbable material is used, the knot leaving in the depth of the wound, and is cut flush.
Mattress stitch or “U” stitch: It is useful in areas of loose skin (e.g., elbow, back of the hand), where the wound edges tend to invaginate. In addition this suture provides good obliteration of dead space, avoiding the need for buried sutures in shallow wounds.
Horizontal mattress stitch: provides a good eversion of wound edges, especially in areas where the dermis is thick or with high tension [6]
Half-buried horizontal mattress stitch: is used to suture wound angles or surgical edges of uneven thickness.
4.1.3.2 Running sutures
They are contraindicated if an infection is suspected and in very contaminated wounds.
Simple running suture: is a sequence of points with an initial knot and a final knot. It takes a short time to do it, but it makes it difficult to adjust the tension of the skin. It is rarely used in minor surgery.
Continuous intradermal suture (subcuticular): this type of suture allows the wound to be sutured without breaking the skin, avoids the “cross-hatching” and provides an optimal esthetic result. Non-absorbable monofilament suture material or absorbable material can be used. Intradermal sutures are used in wounds where it will be necessary to maintain the suture for more than 15 days. In minor surgery its usefulness is limited.
4.1.3.3 Knot-tying
When a multifilament yarn is knotted (for example, Silk), three loops are usually sufficient (first a double loop plus two simple loops). When knotting a monofilament yarn (e.g., Nylon, polypropylene), an additional loop must be added to increase knot security. The knots should be placed on one side of the wound, rather than placed on top of the incision. This will allow a better visualization of the wound and will interfere less with the healing and facilitate the removal of points.
4.2 Local anesthesia in minor surgery
Local anesthetics block the transmission of nerve impulses and they causing, the absence of sensation in a specific part of the body, also other local senses may be affected.
Local anesthetics can be classified into two groups: esters and amides (lidocaine, mepivacaine, bupivacaine, prilocaine, etidocaine and ropivacaine). For their remarkable safety and efficacy we will only use amides. The association of vasoconstrictors allows better visualization of the surgical field. The most widely used is adrenaline and the maximum dose must not exceed 250 micrograms in adults or 10 micrograms/kg in children [11].
4.2.1 Available presentations
The concentration of the anesthetic is expressed in %. We must know that a concentration of 1% means that 100 ml of the solution contain 1 g of anesthetic. Therefore a 2 ml ampoule of 2% mepivacaine, its contain 40 mg (Table 2).
4.2.2 Use of vasoconstrictors
Due to the risk of necrosis and other alteration like delayed healing, adrenaline should not be used in acral areas (e.g., toes), or in traumatized and devitalized skin.
4.2.3 Basic techniques of local anesthesia
4.2.3.1 Topical anesthesia
It is use in an intact skin and for lacerations and mucosae, especially in children. And their characteristics are shown in the Table 2.
1–3 ml applied directly on wound for 15–30 minutes
Onset 20–30 minutes after application.
Can be effective in children for face and scalp lacerations and less effective in limbs
No important adverse effects reported
For mucosae and acral areas
EMLA® lidocaine 25 mg/ml plus prilocaine 25 mg/ml,
1–2 g of cream should be applied for each 10 cm2 of intact skin and occluded. Maximum dose is 10 g
Onset 60–120 minutes after application. Duration of effect is 30–120 minutes. Not useful on palms of hands and soles of feet
Admitted for procedures on intact skin: scraping and shaving, cryosurgery, electrosurgery, laser hair removal, pre-anesthesia for infiltration
Local mild irritation, contact dermatitis. There have been reports of Methemoglobinemia in children aged <6 months
For wounds or deep tissues
Table 2.
Topical anesthetics used in minor surgical procedures and their characteristics.
4.2.3.2 Infiltration anesthesia
Angular infiltration: From the point of entry, the anesthetic is infiltrated in three or more different directions, like a fan (Figure 6).
Perilesional infiltration: Starting from each point of entry the anesthetic is infiltrated in a single direction. The different points of entry will be forming a polyhedral figure.
Linear infiltration: If the lesion to be operated on is a skin laceration, the anesthetic should be directly infiltrated into the wound edges in a linear fashion. If the wound is bruised and has irregular edges, it is preferable to use a perilesional technique from the uninjured area, and follow along the margins of the wound to avoid introducing microbial contamination.
Figure 6.
Anesthetic angular infiltration: it infiltrates following three or more different directions, like a fan.
4.2.3.3 Loco-regional block
The needle is inserted at the base of the proximal phalanx in a dorsal and lateral location, in the collateral palmar digital nerve, and then local anesthetic is injected (maximum 4 ml). The needle is removed and after aspiration proceeds to infiltrate again the subcutaneous plane.
The surgeon must wait 10–15 minutes to obtain a complete effect of the blockage.
5. Preoperative considerations
5.1 Diagnostic criteria for the most common lesions in minor surgery
It is important that general practitioners have an extensive knowledge of the lesions most frequently treated by minor surgery [12].
The following paragraphs contain an overview of the most important diagnostic consideration in lesions usually treated with minor surgery.
5.1.1 Seborrheic keratoses
These lesions are easily treated with curettage, electrosurgery or cryosurgery. In case of doubt, an incisional biopsy should be sent for histopathological analysis.
5.1.2 Epidermal cysts
They are also known as epithelial cysts, epidermoid cysts, or improperly, “sebaceous cysts.” The cyst wall consists of normal stratified squamous epithelium derived from the follicular infundibulum. Queratin is the main component inside the cyst. Their treatment is surgical removal for cosmetic reasons or due to recurrent infections.
5.1.3 Warts
They are a form of benign epithelial hyperplasia induced by the human papillomavirus (HPV). Clinical presentations of cutaneous HPV infection include:
Verruca Vulgaris or plantar wart: you can use liquid nitrogen or salicylic acid.
5.1.4 Molluscum
It is presents as pearly white papules of 1–5 mm (sometimes even bigger) with central dimpling. They may appear isolated or in groups in the neck, trunk, anogenital area or eyelids. Their first choice treatment is cryosurgery, curettage.
5.1.5 Lipoma
Lipomas are slow-growing benign tumors of mature adipose tissue. They appear as soft, elastic, smooth or multilobulated tumors of variable size, with ill-defined borders, and not adherent to deep planes. The diagnosis is usually made clinically. But ultrasound can be helpful to distinguish a lipoma from an epidermoid cyst or a ganglion cyst [13]. They are generally asymptomatic and they are treated by surgical removal [2].
5.1.6 Fibroma pendulum, skin tags
They are not malignant and their treatment is justified for cosmetic reasons.
5.1.7 Melanocytic nevi
They are acquired lesions in the form of macules or papules or small nodules (<1 cm) and are constituted by groups of melanocytes located in the epidermis, dermis or both areas and rarely in the subcutaneous tissue. Sun exposure contributes to the induction of these lesions.
5.1.8 Actinic keratosis
It is located in sun-exposed areas such as bald scalp, the face, shoulders, ears, neck and the back of the hands. It is caused by damage from exposure to ultraviolet radiation. Actinic keratoses are more prevalent in males of middle-aged.
Actinic keratosis is considered a precancer. 13–25% it could develop into a squamous cell carcinoma.
If lesions are scarce and localized, they may be treated with liquid nitrogen.
5.1.9 Basal cell carcinoma
It is the most common skin malignancy. Approximately 70% of basal cell carcinoma occurs on the face, and 15% presents on the trunk [14]. Exposure to ultraviolet (UV) radiation in sunlight, especially during childhood, is the most important factors that contribute to the development of Basal cell carcinoma.
5.1.10 Squamous cell carcinoma
This is a malignant tumor that usually appears on a previous premalignant lesion and requires a multidisciplinary therapeutical approach involving dermatologists, surgeons, radiotherapists, and chemotherapists [14].
5.1.11 Melanoma
Of all skin malignancies, melanoma has the worst prognosis, Five-year survival rates for people with melanoma depend on the stage of the disease at the time of diagnosis.
5.2 Body areas of risk in minor surgery
High-risk areas for minor surgery include the facial and cervical regions, axillary and supraclavicular regions, wrists, hands and fingers, the groin, the popliteal fossa and the feet.
We must consider those regions with a greater tendency to develop pathological scars (e.g., shoulder, sternal and interscapular region). Also the skin of black patients and children are especially prone.
6. Good clinical practice in minor surgery
6.1 Preoperative
For most basic minor surgical procedures, no preoperative work-up is needed. Table 3 summarizes the precautions of minor surgery in primary care.
-Surgery in the lower extremities in patients with Diabetes Mellitus and peripheral vascular disease. -In patients with arrhythmia, severe hypertension, hyperthyroidism, pheochromocytoma or pregnancy, do not add vasoconstrictor to local anesthetic -Anatomic areas of risk -In patients with chronic use of corticosteroids. Protocol for minor surgery in anticoagulated patients - 3 Day Suspend Sintrom ® - 2 Day Suspend Sintrom ® and add subcutaneous LMWH - 1 Day Suspend Sintrom ® and add subcutaneous LMWH, single dose - 0 Day INR Control. If between 1 and 1.6 proceed to surgery. LMWH single subcutaneous dose. Patient will take the usual dose of Sintrom ® (the same as before the suspension). +1 Day LMWH single subcutaneous dose usual dose of Sintrom ® +2 Day usual dose of Sintrom ® +3 Day LMWH single subcutaneous dose. Usual dose of Sintrom ® +4 Day usual dose of Sintrom ® INR will be obtained on day +10 (seven days after surgery)
Table 3.
Precautions of minor surgery.
In patients with increased anxiety, 5–10 mg oral or sublingual diazepam, or 1–5 mg sublingual lorazepam can be administered 30 minutes before surgery.
Contraindications for minor surgery: Malignant skin lesion, allergy to local anesthetics, pregnancy (surgery should be deferred until the end of pregnancy, if malignancy is suspected, the patient should be referred to a specialist), an acute illness, doubt about patient’s motivations, patients with psychiatric disorders or uncooperative patients or refusal to sign the informed consent form is a contraindication for any minor surgery procedure or technique.
Direct oral anticoagulants [DOACs] (Dabigatran, Rivaroxaban, Apixaban, Edoxaban): If a moderate or high bleeding risk surgery, it can be omitted for approximately 2–3 days before a procedure, and resume 24 hours after surgery. However, cutaneous procedures (e.g., skin biopsy, tumor excision, bone marrow biopsy) generally considered to confer a low risk of bleeding [15].
6.2 Intraoperative complications
Vasovagal syncope is the most frequent complication and is more common in young men. Even some patients lose consciousness.
Treatment consists in administering oxygen and iv. fluids if needed and, in severe cases use atropine (0.5–1 mg sc or iv). Generally, most of patients recover spontaneously over a period of seconds to a few minutes.
6.3 Postoperative complications
Infection can occur in up to 1% of minor surgical patients, symptoms such as fever and/or chills are only rarely seen. Infections are treated by removing some of the stitches, plus daily cleaning and disinfection of the wound and allowing the wound to close by secondary intention. If necessary an oral antibiotic regimen may be initiated and inserted drain into the wound.
Hematoma-seroma: is paramount suturing the wound in layers with no gaps and, applying a compressive bandage to prevent their formation.
Wound dehiscence: After wound dehiscence, repairs will take place by secondary intention.
Hypertrophic scar and keloid scarring.
Conflict of interest
The authors declare no conflict of interest.
\n',keywords:"ambulatory surgical procedures, sutures, minor surgical procedures, electrocoagulation, anesthetics, local, lipoma, keratosis, actinic",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/68792.pdf",chapterXML:"https://mts.intechopen.com/source/xml/68792.xml",downloadPdfUrl:"/chapter/pdf-download/68792",previewPdfUrl:"/chapter/pdf-preview/68792",totalDownloads:236,totalViews:0,totalCrossrefCites:0,dateSubmitted:"April 15th 2019",dateReviewed:"July 25th 2019",datePrePublished:"August 31st 2019",datePublished:null,dateFinished:"August 27th 2019",readingETA:"0",abstract:"Minor surgical procedures are defined as a set of procedures in which short surgical techniques are applied on superficial tissues, usually with local anesthesia, and minimal complications, that usually do not require postoperative resuscitation and need minimal equipment, many of which are used on a daily basis, and can be easily and safely performed in a short amount of time during clinic visit. General practitioners should have an optimal infrastructure and medical furniture in a minor surgery operating room. It is important to manage the instruments and materials involved for basic and advanced surgery. Also, for a good clinical practice in minor surgery, it is necessary that general practitioners handle anesthesia techniques (local anesthetic infiltration and regional blocks) and have knowledge of the body areas of risk in minor surgery and the topographic anatomy of the skin for the right performance of surgical procedure. The patients should be informed about the procedure and its technical details before asking them to sign the informed consent form.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/68792",risUrl:"/chapter/ris/68792",signatures:"Jose Maria Arribas Blanco, Wafa Elgeadi Saleh, Belén Chavero Méndez and María Alvargonzalez Arrancudiaga",book:{id:"9139",title:"Topics in Primary Care Medicine",subtitle:null,fullTitle:"Topics in Primary Care Medicine",slug:"topics-in-primary-care-medicine",publishedDate:"January 14th 2021",bookSignature:"Thomas F. Heston",coverURL:"https://cdn.intechopen.com/books/images_new/9139.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"217926",title:"Dr.",name:"Thomas F.",middleName:null,surname:"Heston",slug:"thomas-f.-heston",fullName:"Thomas F. Heston"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. 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Sutures and suturing techniques in skin closure. Indian Journal of Dermatology, Venereology and Leprology. 2009;75(4):425-434'},{id:"B7",body:'Singer AJ, Quinn JV, Hollander JE. The cyanoacrylate topical skin adhesives. The American Journal of Emergency Medicine. 2008;26(4):490-496'},{id:"B8",body:'Hussain W, Mortimer NJ, Salmon PJ. Optimizing technique in elliptical excisional surgery: Some pearls for practice. The British Journal of Dermatology. 2009;161(3):697-698. Epub 2009 Jun 25'},{id:"B9",body:'Czarnowski C, Ponka D, Rughani R, Geoffrion P. Elliptical excision: Minor surgery video series. Canadian Family Physician. 2008;54(8):1144'},{id:"B10",body:'Wu T. Plastic surgery made easy—Simple techniques for closing skin defects and improving cosmetic results. Australian Family Physician. 2006;35(7):492-496'},{id:"B11",body:'Achar S, Kundu S. Principles of office anesthesia: Part I. Infiltrative anesthesia. American Family Physician. 2002;66(1):91-94'},{id:"B12",body:'Wolff K, Johnson RA. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. 6th ed. New York: El McGraw-Hill Companies, Inc; 2009'},{id:"B13",body:'Rahmani G, McCarthy P, Bergin D. The diagnostic accuracy of ultrasonography for soft tissue lipomas: A systematic review. Acta Radiologica Open. 2017;6:2058460117716704'},{id:"B14",body:'Wang YJ, Tang TY, Wang JY, et al. Genital basal cell carcinoma, a different pathogenesis from sun-exposed basal cell carcinoma? A case-control study of 30 cases. Journal of Cutaneous Pathology. 2018'},{id:"B15",body:'Beyer-Westendorf J, Gelbricht V, Förster K, et al. Peri-interventional management of novel oral anticoagulants in daily care: Results from the prospective Dresden NOAC registry. European Heart Journal. 2014;35:1888'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Jose Maria Arribas Blanco",address:"jarribasb@gmail.com",affiliation:'
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