What do you do when a patient shows up in your surgical facility with something pierced besides her ears? If you're like 70 percent of the facility managers Outpatient Surgery Magazine surveyed, you ask the patient to remove her body jewelry before surgery (interestingly, none of the 90 OR managers who responded to our survey say they remove patients' piercings themselves).

One thing I've learned as a medical consultant for the Association of Professional Piercers is that people with body piercings often turn to peers or other medical sources instead of healthcare professionals when it comes to advice on their intimate piercings. It's believed that these patients are afraid of ridicule and worried that healthcare professionals who don't realize these piercings can close very quickly will automatically tell them to take it out. But as you'll see, for many common outpatient surgical procedures, your patients don't have to remove their body jewelry.

Primer on piercings
Starting at the top and working our way down:

• Airway. The anesthesia literature is divided on whether patients should remove oral jewelry before oral intubation. Several articles detail successful bag-mask ventilation, as well as placement of laryngeal mask airways and oral endotracheal tubes with tongue jewelry in place. Some feel that oral jewelry should be removed before you intubate, while others believe that as long as you're aware that the jewelry's there, you can safely perform oral intubation with the jewelry in place.

For nasal intubations, if the jewelry is on one side of the nose and you can't perform the intubation on the other side, the patient should remove the jewelry before intubation to avoid possible aspiration. Patients should routinely remove septal jewelry (the middle of the nose) before nasal intubations.

For those patients who wish to keep the hole open during surgical procedures, a professional piercer can place clear or flesh-colored non-metallic retainers. These minimize many of the concerns regarding metal tongue jewelry and intubation, but it's crucial that anesthesia is aware of their presence before entering the OR.

• Nasogastric tube placement. Much as with nasal intubation, if jewelry is on the right side, practitioners should place the nasal trumpet or NG tube on the left. Patients should remove septal jewelry before NG tube placement to prevent pressure injuries.
• Defibrillation and electrosurgery. The horror story is that when defibrillating a patient with nipple jewelry, the energy will "arc" across the jewelry and "everyone will be electrocuted." However, this is an urban legend - you can use conventional defibrillation techniques on patients with a variety of piercings without unduly risking staff.

Similar unfounded beliefs exist concerning the use of electrosurgery on patients with significant piercings. Though some authors recommend routine removal of all jewelry for operative procedures, if you practice safe electrosurgery and avoid direct contact between the cautery tip, the cord and the jewelry, there's little evidence to support the electrocution or burn concerns. Remember that quality body jewelry is made of either titanium or surgical LVM 316 stainless steel, the same metals used in orthopedic implants.

If you can tape down a wedding ring for surgery, you can probably tape down a piercing as well. According to the Emergency Care Research Institute, "the best practice is to remove jewelry if possible. However, if jewelry cannot be removed, it should be covered up and should not be positioned within the electric current. The risk of an electrosurgical injury due to jewelry is minimal, but precautions should still be taken to eliminate the risk completely."

• Urinary catheter placement. This is a bit tricky. For the most common male genital piercing (the Prince Albert), in which jewelry obviously is through the urethral meatus, or Apadravya (vertical head of the penis) piercings, you should remove the piercings before catheterization. However, with Ampallang (horizontal head of the penis) piercings, removal isn't always necessary. If you feel resistance long before reaching the prostate when attempting to place a catheter, the piercing is probably transurethral and you or your patient should remove it.

Why you do what you do
If you're considering removing a patient's body piercing, ask yourself these questions:

• Why are you removing the jewelry? If the piercing's not in the way of the operative site and it's not obviously infected, there's probably no reason to remove it for a surgical procedure.
• Is the patient willing to have the jewelry removed? If she's not, it's most likely due to concerns the hole will close up. This is a valid concern, especially with fresh piercings that haven't completely healed. There's no hard-and-fast rule as to how long holes stay open post-jewelry removal. The only way to make sure a piercing hole doesn't close is to keep something in it.
• Do you know how to remove the jewelry? If you don't properly remove a piercing, injury to the patient, especially bleeding and local tissue trauma, can occur. Removal is possible, but as with any procedure, is much easier with the correct tools. If you're going to attempt to remove piercings yourself, you'll need non-serrated hemostats, gauze and ring-opening pliers. If the patient is awake and able and willing to remove the jewelry, asking her to remove it can be the easiest removal technique. However, with some of the larger gauge or intricate jewelry, you should have a professional piercer assist.
• Is it possible to insert a retainer of some sort to maintain hole patency? The literature has described the use of epidural catheters, suture material or simply an IV catheter. The most important step in removing jewelry and maintaining hole patency is never to completely remove the jewelry and then try to place a retainer. In the outpatient surgical arena, using a sterile IV catheter to carefully push the jewelry out lets the IV catheter thread into the "tunnel." This technique is quick, easy to perform and doesn't interfere with imaging, laparoscopy and other similar procedures.

Get to know a piercer
Local professional piercers might be happy to provide education and in-services on common body jewelry and suggested removal techniques. You might also consider taking a field trip to a professional piercing shop. Learning removal techniques can be an invaluable experience.