Biomedical Engineering – From Theory to Applications

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326 Biomedical Engineering – From Theory to Applications Conventional surgery under general anaesthetic normally uses the sleeve-resection technique, described in a series of diagrams with technical details by Elder (2007). This method takes longer and for this reason many surgeons will insist on using a general anaesthetic. By its nature sleeve resection removes mainly shaft skin, not foreskin, so having potential implications for HIV infection. An alternative is the Dissection Method. These two methods are often confused. Illustrated by Mousa (Mousa, 2007), the Dissection Method separates inner and outer foreskin in a manner similar to a very loose "tug and chop" circumcision, but then proceeds to excise most of the inner and all of the outer foreskin along with some shaft skin. The amount of shaft skin removed depends on the tightness required; inner foreskin is left only as necessary to provide an anchorage for sutures reconnecting the shaft skin to the sulcus. Interestingly, genital surgery in women often involves a course of topical estrogen in advance in order to increase thickening, cornification and keratinization of the vaginal epithelium (Short, 2006). This helps surgical outcome and has led to the suggestion that similar pre-treatment be carried out prior to circumcision in men. Pain from conventional surgery can last for up to a week or longer afterwards, during which time absence from work may be required. Some men, however, report no pain, just minor discomfort from the stitches. A large RCT found that at the 3-day post-circumcision follow-up, 48% reported no pain, 52% very mild pain, and none moderate or severe pain (Bailey et al., 2007). By 8 days, 89% had no pain and 11% mild pain. Vasectomy in men circumcised previously as adults (and who can thus attest to the difference) is said to be much more painful. 8.2 Instruments developed over earlier years The following devices were in common use for male circumcision prior to the start of the HIV epidemic. The patent information quoted relates to the country of residence of the inventor(s). In many instances other patents exist, especially in the USA, the European Union and, since its formation in 1967, the records of the World Intellectual Property Organisation (WIPO). 8.2.1 Traditional Jewish shield Inventor: Unknown Primary patent: None: historic Patent priority date: Not applicable Patient age range: Full-term neonate to adult Category: Tug-&-Chop shield Fig. 4. The traditional Jewish shield.
Male Circumcision: An Appraisal of Current Instrumentation Procedure: The foreskin is pulled forward and the shield slipped over it. The excess prepuce is then excised by running a scalpel or similar knife across the distal face of the device. 8.2.2 Gomco Clamp Inventor: Goldstein, A.A. Primary patent: United States Design Patent USD119180 (no Utility Patent has been traced) Patent priority date: 16 Mar 1939 Patient age range: Full-term neonate to adult Category: Bell clamp / scalpel guide Fig. 5. The Gomco Clamp showing components, in a range of sizes, that are assembled during the procedure described in the text. Procedure: First of all, a dorsal slit is made in the foreskin and the foreskin is separated from the glans. The bell of the Gomco clamp is then placed over the glans, and the foreskin is pulled over the bell. The base of the Gomco clamp is placed over the bell, and the Gomco clamp's arm is fitted. After the surgeon confirms correct fitting and placement (and the amount of foreskin to be excised), the nut on the Gomco clamp is tightened, causing the clamping of nerves and blood flow to the foreskin. The Gomco clamp is left in place for about 5 minutes to allow clotting of blood to occur, then the foreskin is dissected off using a scalpel. The Gomco's base and bell are then removed, and the penis is bandaged. It is a fairly bloodless circumcision technique. The circumcision is relatively quick compared to the Plastibell. It was the most popular method for circumcisions between 1950 and 1980 and is still common today, especially in the USA. A training video of a neonatal Gomco circumcision using dorsal penile nerve block and a sucrose pacifier, conducted by Dr Richard Green, Stanford University School of Medicine, is available at http://newborns.stanford.edu/Gomco.html Dr Sam Kunin, an experienced urological surgeon in Los Angeles, has developed a clever, and very effective, method in which local anaesthetic is injected into the distal foreskin (Kunin, 2007b). Doing so separates the inner and outer foreskin therefore allowing the inner layer to be pulled against the bell of the Gomco clamp, and results in a maximum amount of inner layer being removed (http://www.samkuninmd.com). He points out that the inner lining is the area most prone to adhesions, irritations, yeast and bacterial infections, particularly in diabetics. Gomco clamps exist in sizes from neonatal to adult. Suturing is required post-infancy. 327
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BIOMEDICAL ENGINEERING - FROM THEOR
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VI Contents Chapter 9 Targeted Magn
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120 6. Conclusion Biomedical Engine
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150 5. Conclusions Biomedical Engin
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162 1 st phase : half year 4 2 nd p
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172 12. Maturing projects’ story
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180 16. Acknowledgments Biomedical
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190 R* M M M M MR*M O O O O M O R*
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196 Fig. 9. Chemical structure of 5
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198 Relative Intensity (AU) Biomedi
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204 2. Preparation of IO nanopartic
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