Manual for Male Circumcision under Local Anaesthesia

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Male circumcision under local anaesthesia Version 3.1 (Dec09) diluted as recommended by the manufacturer. Other parts of the clinic, such as the waiting and recovery areas, should be cleaned regularly with water and detergent. The lighting in the procedure room should be arranged so that the penis is well lit, and the surgeon can see what he is doing. Ideally, the clinic should be equipped with an operating theatre minor procedures lamp, but these are expensive. Adequate illumination can be provided by fluorescent lighting over the operating table. Emergency medications and equipment for managing anaphylactic reactions 1 should be available in or near the procedure room. These should be kept in a clearly labelled box, and the contents should be checked periodically (at least every 6 months) to ensure that they are complete and that none of the medications are approaching or beyond their expiry date. The box should be kept in a cool place, away from direct sunlight. In addition, it is important to have available, in or near the procedure room, alternative antiseptic surgical cleaning solution, such as chlorhexidine, for patients allergic to povidone iodine, and spare sutures and needles. The following equipment and instruments are required for standard adult male circumcision: 2 • instrument tray wrapped with sterile drape • dissecting forceps (finely toothed) • artery forceps (2 straight, 2 curved) • curved Metzenbaum’s scissors • stitch scissors • Mayo’s needle holder • sponge-holding forceps • scalpel knife handle and blades • “O” drape (80 cm x 80 cm, with ~5 cm hole) • gallipot for antiseptic solution (e.g. povidone iodine) • povidone iodine (50 ml of 10% solution) • plain gauze swabs (10 × 10 cm; 10 for the procedure, 5 for dressing) • petroleum-jelly-impregnated gauze (5 × 5 cm or 5 × 10 cm) (tulle gras) and sticking plaster • 15 ml of 1% plain lidocaine (without epinephrine) anaesthetic solution • syringe, 10 ml (if single-use syringes and needles are unavailable, use equipment suitable for steam sterilization) • injection needles (18- or 21-gauge) 1 2 Emergency medications and equipment: Essential: pocket mask with one-way valve, atropine (0.6 mg/ml ampoules), epinephrine (1 in 1000 solution (1 mg in 1 ml) ampoules). Desirable: diazepam suppositories for rectal administration (10 mg in 2.5 ml), oxygen supply with mask and reservoir bag, saline for intravenous administration and giving set. Additional information on surgical equipment is available in the WHO Essential Emergency Equipment List (www.who.int/surgery/imeesc) Facilities and supplies and preparation for surgery Chapter 4-2
Male circumcision under local anaesthesia Version 3.1 (Dec09) • suture material (chromic gut or vicryl 3-0 and 4-0) with 3/8 circle reverse-cutting needle • gentian violet (no more than 5 ml) or sterile marker pen • gloves, masks, caps and aprons • condoms and information materials for client. A specimen list of the disposable materials required for one adult circumcision is given in Appendix 4.2. Equipment should be disinfected and cleaned as described in Chapter 8. A detailed discussion of kits and bundles of supplies (consumables, reusable and disposable instrument sets) for efficient delivery of circumcision programmes is included in the WHO document Considerations for implementing models for optimizing the volume and efficiency of male circumcision services. 3 This discusses various combinations of consumables and supplies required according to circumcision method and approaches to implementing a high throughput circumcision service. MAINTENANCE AND REVIEW OF EQUIPMENT Surgical instruments wear out with use and with repeated disinfection and sterilization. Each clinic should therefore carry out a periodic review of all surgical instruments. Failure to maintain instruments in good working condition can cause operative difficulties and complications. A haemostatic artery forceps with bent blades, for instance, will not properly occlude a bleeding vessel, while blunt dissection scissors can result in a ragged wound. Checklist for haemostatic artery forceps • Do the points meet accurately • Is the grip on the points worn • Does the ratchet lock securely or is it worn Checklist for surgical dissection scissors • Is the cutting edge of the blade sharp • Do the blades meet securely • Is the screw loose Checklist for needle holders • Do the points meet accurately • Is the grip on the points worn Checklist for dissection forceps (tweezers) 3 World Health Organization. Considerations for implementing models for optimizing the volume and efficiency of male circumcision services (field testing edition). Geneva, World Health Organization, 2010 (available at www.malecircumcision.org). Facilities and supplies and preparation for surgery Chapter 4-3
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Manual for Male Circumcision under Local Anaesthesia

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