Manual for Male Circumcision under Local Anaesthesia

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Male circumcision under local anaesthesia Version 2.5C (Jan08) A B Fig 5.2 Picking up a blood vessel with forceps (tweezers) (A) to facilitate accurate placing of the artery forceps (B) Tying and under-running. Either tie the vessel or under-run and tie it. The simplest procedure is to tie the vessel below the artery forceps (Fig. 5.3). The basic tie consists of two throws (Fig. 5.3A), but many surgeons make a third throw (Fig. 5.3B) to give the knot extra security. A B C Fig. 5.3 Simple tie. A: the knot with two throws. B: the knot with three throws. C: the finished knot pulled tight. It is important to ensure that the tie is securely placed and not liable to slip off, particularly in the first few days following the operation during a penile erection. If there is any doubt about the security of the tie, it is better to use the under-running technique (Fig. 5.4). Secure the bleeding vessel with an artery forceps. Pass the suture needle beneath the artery (not too deep!) and pull through, leaving enough suture material for the tie. Then pass the suture beneath the vessel a second time, pull gently to occlude it, and tie a knot, as above. Surgical procedures for adults and adolescents Chapter 5-3 Male circumcision under local anaesthesia Version 2.5C (Jan08) Surgical procedures for adults and adolescents Chapter 5-4 A Fig. 5.4 Under-running a bleeding vessel. A: the knot with two throws. B: the knot with three throws. Diathermy. Bleeding can be stopped by coagulation using a diathermy machine. This requires a secure electricity supply and may not be available in a clinic setting. The techniques described in this manual can all be undertaken safely without diathermy equipment. Surgeons undertaking male circumcision should be adept at stopping bleeding without diathermy. If diathermy is available, it should be bipolar. Monopolar diathermy should not be used for penile surgery because of the risk of extensive coagulation of the base of the penis, which can lead to the loss of the penis. When using diathermy, apply the forceps as precisely as possible. The best results will be obtained if the blood vessel is between the diathermy tongs with minimal other tissue. If too much tissue is grasped, diathermy will not stop the bleeding. Largearea diathermy and large black burns should be avoided. Large amounts of burnt tissue cause infection and scar formation. Bipolar diathermy can help reduce bleeding from small blood vessels, but bleeding from larger blood vessels should be stopped with an artery forceps first. The vessel can then be tied or under-run with a suture as described above. Suture material Suture size is a compromise between ensuring adequate tensile strength and keeping the amount of foreign material to a minimum. Larger suture sizes produce a more unsightly scar, and small lumps can persist when large-size sutures have been used to tie the blood vessels. The preferred suture size for adult male circumcision is 3/0 or 4/0 chromic gut or vicryl rapide. Vicryl rapide is more expensive than chromic gut. The suture may be mounted on a taper-cut, round-bodied or reverse-cutting needle, according to the surgeon’s preference. The taper-cut needle passes more easily through the skin, but easily tears the skin on the inner aspect at the corona. B .
Male circumcision under local anaesthesia Version 2.5C (Jan08) Suturing The following are the basic suturing techniques: Simple interrupted suture. This is the simplest type of stitch, and results in good apposition. The point of the needle should pass through the skin at 90 degrees to the skin surface and exit at the same angle (Fig. 5.5). The nearer to the skin edge the needle goes in, the better the skin edge apposition but the higher the risk of the stitch cutting out. If the stitches are placed at a greater distance from the wound edge, there is a risk of inversion (burying) of the skin edges and poor healing. For this reason, in male circumcision, a combination of simple and mattress sutures is recommended. A Fig. 5.5 Simple interrupted suture. A: suture in place holding the skin edges together. B: simple sutures closing the circumcision incision. Mattress sutures. Mattress sutures give a more precise apposition of the wound edges and reduce the risk of burying the skin edges. They are more complex than simple interrupted sutures, and therefore more time-consuming to put in. Vertical mattress suture The technique is illustrated in Fig. 5.6. 1. Start the first bite wide of the incision and pass to the same position on the other side of the wound. 2. Start the second bite on the side of the incision where the needle has just exited the skin. Pass the needle through the skin between the exit point and the wound edge, in line with the original entry point. From this point, take a small bite; the final exit point is in a similar position on the other side of the wound. 3. Tie the knot so that it does not lie over the incision line. This suture approximates the subcutaneous tissue and the skin edge. When suturing the circumcision wound, vertical mattress sutures are usually placed in the 12 o’clock, 3 o’clock and 9 o’clock positions (taking the frenulum as the 6 o’clock position). Surgical procedures for adults and adolescents Chapter 5-5 B Male circumcision under local anaesthesia Version 2.5C (Jan08) A Surgical procedures for adults and adolescents Chapter 5-6 B C D Amended drawing To come Fig. 5.6 Vertical mattress suture. A, B: the technique. C: vertical mattress suture holding the skin edges and subcutaneous tissues together. D: A vertical mattress suture in the 9 o’clock position. Horizontal mattress suture The technique is illustrated in Fig. 5.7. 1. Make two sutures, aligned beside one another. Align the first stitch across the wound; begin the second on the side that the first ends. 2. Tie the knot on the side of the original entry point. A horizontal mattress suture is placed in the 6 o’clock position (frenulum). A C B D
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Manual for Male Circumcision under Local Anaesthesia

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