Manual for Male Circumcision under Local Anaesthesia

Male circumcision under local anaesthesia Version 2.5C (Jan08)
Chapter 5
Surgical procedures for adults and adolescents
SUMMARY
This chapter gives step-by-step instructions for performing a
circumcision on an adult or an adolescent. It covers tissue handling,
skin preparation, local anaesthesia, the circumcision itself, suturing,
and dressing the wound.
Three surgical techniques are described:
• the forceps-guided method;
• the dorsal slit method;
• the sleeve resection method.
SURGICAL SKILLS REQUIRED FOR SAFE CIRCUMCISION
Anatomy of the penis and choice of surgical technique
It is important to have a good understanding of penile anatomy before
undertaking male circumcision. This is described and illustrated in
detail in Chapter 4 and Appendix 4.3.
Three widely used surgical techniques for adult and adolescent
circumcision are described in detail in this chapter. They have been
selected on the basis of extensive experience worldwide, as well as the
results from three randomized controlled trials of circumcision in
Kenya, South Africa and Uganda. It is not recommended that a
nursing, clinical or medical officer learn all three surgical techniques – it
is best to become a master of one adult technique and, if appropriate,
one paediatric technique. This will produce the best results with the
least complications. Providers should become expert in the technique
most suited to the circumstances of their practice or the preferred
technique adopted nationally. All three recommended techniques are
fully illustrated and can be referred to in the context of a training
course. After the training the illustrations and step-by-step guide can be
used to reinforce what has been learnt and for retraining. Experienced
surgeons should be able to perform all three techniques with little
difficulty, and to train less experienced providers in any of the three
techniques described.
Tissue handling
The surgeon should handle tissue gently. Unnecessary crushing of
tissue causes more scarring, delays healing and increases the risk of
infection. Use dissecting forceps (tweezers) to hold the skin edge when
suturing the circumcision wound; do not use artery forceps. Place
haemostatic sutures accurately, taking care to avoid inserting the
needle too deep into the surrounding tissue.
Surgical procedures for adults and adolescents Chapter 5-1
Male circumcision under local anaesthesia Version 2.5C (Jan08)
Haemostasis 1
Minimizing blood loss is part of good surgical technique and safe
medical practice. It is very important, particularly for men who are
anaemic. (Ideally, these men should not be circumcised in the clinic,
but should be referred to a hospital.) Another important reason to
minimize blood loss is to reduce contamination of instruments,
operating theatre drapes and gowns, to lower the risk of transmitting
blood-borne diseases, such as HIV and hepatitis B, to theatre staff.
The following techniques can be used to reduce blood loss.
Compression. After the incision has been made, and at any time
during the procedure, oozing of blood from cut surfaces can be
controlled by applying pressure over a gauze swab for a few minutes.
Usually, this will stop the bleeding.
Temporary occlusion of blood vessels. Control individual bleeding
vessels by applying an artery forceps (Fig 5.1), taking care not to
grasp too big a chunk of tissue.
Fig 5.1 Artery forceps applied to occlude a blood vessel
An alternative technique is to pick up the vessel using forceps
(tweezers) and then apply an artery forceps (Fig 5.2).
1 Adapted from Surgical care at the district hospital (1).
Surgical procedures for adults and adolescents Chapter 5-2