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Marking skin for surgery

Definition

Skin marking is carried out to unambiguously identify the intended site of surgical incision. Any markings should be arrows; should be drawn with an indelible, latex‐free marker pen; and should extend to, or near to, the exact incision site (Figure 16.12).
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Figure 16.12  Example of skin marked for surgery.

Related theory

The surgeon may need to mark an area of the body for surgery (e.g. a limb to be operated on) or the position of an organ (e.g. a specific kidney in a patient undergoing a nephrectomy). Marking the surgical site is essential for the planning of any surgical procedure and for the prevention of wrong‐site surgery (Table 16.7) (Bathla et al. [27]). The incidence of wrong‐site surgery is low but any error can be devastating and in some cases fatal.
Table 16.7  Pre‐operative marking recommendation
How should marking be carried out?
  • Use an indelible marker pen.
  • Mark an arrow that extends to, or near to, the incision site.
  • This mark must remain visible after the application of skin preparation and after the application of theatre drapes.
Where should be marked?
  • Any surgical operations involving one side (laterality) of the body should be marked at, or near, the intended incision.
  • For digits on the hand or foot, the mark should extend to the specific digit.
Who should be involved in the pre‐operative marking?
  • Marking must be carried out by the operating surgeon or by a nominated deputy who will be present in the operating theatre at the time of the patient's procedure.
  • Pre‐operative marking of the intended site should involve the patient and/or their family members or significant others wherever possible.
When should marking be carried out?
  • The marking of the surgical site should be carried out on the ward or in the day care area prior to the patient's transfer to the operating theatre.
  • The marking should take place before pre‐medication.
Verification of the mark
The surgical site mark should subsequently be checked against the patient's documentation, such as consent form or X‐ray. This check should confirm the mark is (a) correctly located and (b) still legible. This check should occur at each transfer of the patient's care and end with a final verification prior to commencement of surgery. Confirmation of the site marking happens at the following pre‐operative stages:
  • when ward staff are preparing the patient for the operating room
  • when ward staff hand over the patient to the anaesthetic practitioner
  • during the ‘Sign In’ stage of the WHO Surgical Safety Checklist (see ‘Intraoperative care: anaesthesia’ below) by the anaesthetist and anaesthetic practitioner (before any needle‐to‐skin in the anaesthetic room)
  • during the ‘Time Out’ stage of the WHO Surgical Safety Checklist, when the patient is on the operating table before the surgical procedure begins (carried out by the operating surgeon with the presence of all team members).
All team members should be involved in checking the mark.
Source: Adapted from Bathla et al. ([27]), NPSA ([154]).
The marking should be undertaken by the surgeon performing the operation or a competent deputy (i.e. an individual capable of performing the procedure themselves) who will be present at the surgery, to ensure the correct site is marked; the site should be checked against the patient's consent form (Schäfli‐Thurnherr et al. [183]). The mark should be an arrow, drawn with an indelible, latex‐free marker pen, and should extend to, or near to, the exact incision site. The majority of surgical site marking pens contain gentian violet ink, which has antifungal properties (Maley and Arbiser [116], Wise et al. [232]). Other types of marker pen include permanent ink markers, which despite their lack of antifungal properties have not been found to affect the sterility of the surgical field (Zhao et al. [239]). Marking must be undertaken before pre‐medication or anaesthesia so that patients can be involved in ensuring the mark is in the correct place. It needs to remain visible after the application of antiseptic (aqueous or alcohol‐based) skin preparation (e.g. povidone‐iodine or chlorhexidine) and after the application of theatre drapes (Mears et al. [121]). The surgical site mark should not be easily removed with skin preparation but should not be so permanent as to last weeks or months after the surgical procedure.
Following surgery, once the wound has healed, residual traces of the marker pen can be gently removed using warm, soapy water. It is important not to rub too hard to prevent irritating the skin or sinking the ink deeper into skin tissues, making it harder to extract. This process may need to be repeated over a series of days.
There are circumstances where marking may not be appropriate:
  • emergency surgery
  • surgery on teeth or mucous membranes
  • bilateral procedures such as tonsillectomy or squint surgery
  • situations where laterality of surgery will be confirmed during the procedure (NPSA [154]).
If a patient refuses pre‐operative skin marking, local policy should be followed and documentation should clearly state that the patient refused marking, particularly on the WHO Surgical Safety Checklist (see ‘Intraoperative care: anaesthesia’ below).
There are some situations in which a specialist nurse may mark the skin. For example, stoma therapists mark the position on the patient's skin that is the optimum place for the stoma to be placed (see Chapter c06: Elimination).
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