MCChapter5_3

8/4/2019 MCChapter5_3

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Forceps Guided Method

Chapter 5: Surgical Procedures for Adults and Adolescents 57


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Forceps Guided Method Advantages:

Can be learned bysurgeons/surgical

assistants who arerelatively new to surgery

Ideal for use in a clinic withlimited resources

Can be done without asurgical assistant

Disadvantages:

Leaves 0.51.0 cmof mucosal skin

proximal to corona Cosmetic effect

may be lesssatisfactory



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Forceps Guided Method:

Steps 12Step 1: Skin preparation, draping and anaesthesia

(as previously described)

Step 2: Retraction of foreskin and separation ofany adhesions



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Marking Incision Line: Step 3a


This step is common to all the methods of circumcision.With the foreskin in a natural resting position, indicatethe intended line of the incision with a marker pen. The

line should correspond with the corona, just under thehead of the penis.


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Marking Incision Line: Step 3b Some uncircumcised men

have a very lax foreskin,which is partially retracted inthe resting position.

In such cases, it is better toapply artery forceps at the 3and 9 oclock positions, toapply a little tension to theforeskin before marking thecircumcision line.

It is important not to pullthe foreskin too hardbefore marking the line, asthis will result in too muchskin being removed.



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Forceps Guided Method: Step 4Grasp the foreskin atthe 3 and 9 oclock

positions with twoartery forceps, on thenatural apex of theforeskin in such a wayas to put equal tensionon the inside andoutside surfaces of theforeskin.



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Forceps Guided Method: Step 5


Put sufficient tension on the foreskin to pull the previously made markto just below the glans. Taking care not to catch the glans, apply along straight forceps across the foreskin just proximal to the mark.Once the forceps is in position, feel the glans to check that it has not

been accidentally caught in the forceps.


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Using a scalpel, cut away the foreskin flush with the outeraspect of the forceps. The forceps protects the glans frominjury, but nevertheless particular care is needed at this

stage.


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Grasp and trim any skin tags on the inner edge of the foreskin toleave approximately 5 mm of skin proximal to the corona. Care mustbe taken to trim only the skin and not to cut deeper tissue.



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Stopping the Bleeding


Vessels may be occluded by ligation(A), or by transfixion sutures (B)

A

B


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Stopping the bleeding: Cut blood vessels should be locatedaccurately and tied or transfixed.

1. Using forceps (tweezers),the blood vessel islocated.

2. The blood vessel is then held withthe forceps and gently pulled up sothat an artery forceps can be applied.

3. The artery forceps is thenapplied, taking the minimumamount of extra tissue.


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Blood vessels should be accurately clipped with artery forceps, taking care to avoid takingtoo big a chunk of tissue. If it is difficult to see the source of bleeding, apply pressure with aswab and wait for 23 minutes and usually the bleeding vessel can then be occludedaccurately.


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Forceps Guided Method:

Step 9

Suturing Plan


a b c

Horizontal mattress suture at the frenulum (6 oclock). Vertical mattress

sutures at 9, 12 and 3 oclock and simple sutures between these.


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Suturing the Circumcision


Place a horizontal mattress suture at the frenulum.Whenplacing the horizontal mattress suture at 6 oclock position,take care to align the midline skin raphe with the line of thefrenulum (see below). A common error is to misalign the

midline and raphe, which results in misalignment of the wholecircumcision closure.


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Suturing the Circumcision (cont.)


Place a vertical mattress suture at the 12 oclock position.The suture should be placed so that there is an equal amountof skin on each side of the penis between the 12 and 6 oclockpositions. Place two further vertical mattress stitches in the

3 oclock and 9 oclock positions.


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Suturing the Circumcision (cont.)

After placement of thesutures at 6,12, 3 and

9 oclock, place two ormore simple sutures inthe gaps between.



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Forceps Guided Method

Final outcome:


Note residual mucosal portion of the foreskin


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Suturing the Circumcision:

Step 10Once the procedure is finished, check forbleeding and apply a dressing (described later).



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Sleeve Resection Method



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Sleeve Resection Method


Provides best cosmetic results More room for surgical error

The technique requires an assistant The sleeve resection method requires good

surgical skill Better suited to a hospital rather than a clinic

setting


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Sleeve Resection Method:

Steps 12Step 1: Skin preparation, draping and anaesthesia

Step 2: Retraction of foreskin and separation of

any adhesions



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Step 3

Marking the Outer LineMark the line of the outsidecut, just below the corona

Chapter 5: Surgical Procedures for Adults and Adolescents

Note V shape pointing towards frenulum

Mark the intended outer lineof the incision with a V- shape,pointed towards the frenulum,on the underside of the penis

The apex of the V shouldcorrespond with the midlineraphe

79


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Sleeve Resection Method: Step 4

Marking the Inner Mucosal LineRetract the foreskin and mark the inner (mucosal)incision line 12 mm proximal to the corona. At the frenulum,the incision line crosses horizontally as shown by the arrow.



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Using a scalpel, make incisions along the markedlines, taking care to cut through the skin to thesubcutaneous tissue but not deeper. During the incision,the assistant retracts the skin with a moist gauze swab.



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Sleeve Resection Method: Step 5b


Make the innerincision

Outer and innerincisioncompleted


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Cut the skin between the proximal and distalincisions with scissors.



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Sleeve Resection Method: Step 7Hold the sleeve of foreskin under tension with two arteryforceps and dissect the skin from the shaft of thepenis, using dissection scissors. Tie off any bleeding

vessels with under-running sutures.



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Steps 810Step 8: Haemostasis and suturing are the sameas described for the forceps guided method.

Step 9: Suturing the circumcision is the same asdescribed for the forceps guided method.

Step 10: Check for bleeding, and provided there isnone, apply a dressing as described later.



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Applying the Penile Dressing

Irrespective of the method of circumcision, astandard penile dressing technique is used:

Check that there is no bleeding. Once all bleeding has stopped, place a piece of

petroleum-jelly-impregnated gauze (tullegras)around the wound.

Apply a sterile, dry gauze over this, and secure itin position with adhesive tape.

Take care not to apply the dressing too tightly.



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Dressing: Application of Sofratulle



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Dressing: Application of Gauzeand Strapping



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Removing the Penile Dressing

The dressing should be left in position nolonger than 48 hours.

If the dressing has dried out, it should be gentlydabbed with antiseptic solution (aqueouscetrimide, Savlon) until it softens.

It can then be removed gently. It is important

not to disrupt the wound by pulling at adressing that has dried to the wound.



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Summary

Three common methods of MC have beenreviewed:

Description of the dorsal slit method of malecircumcision

Description of the forceps guided method of malecircumcision

Description of the sleeve method of malecircumcision



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Summary (cont.)

The recommended operative techniques havebeen described in detail.

Surgeons should become expert in thetechnique most suited to the circumstances oftheir practice.

It is not recommended to learn all of the

techniques. It is best to become a master ofone adult technique and, if appropriate, onepaediatric technique.



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Photo credits: Dipo Otolorin

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