Manual for Male Circumcision under Local Anaesthesia

Male circumcision under local anaesthesia
Version 3.1 (Dec09)
If the machine fails to respond when the surgeon activates the current
or there is no obvious and immediate visual evidence of coagulation,
the surgeon should immediately stop applying current and check all
connections. If current continues to flow, burns may occur where
resistance is greatest, most commonly where the grounding plate is in
contact with the body, or where the body is in contact with metal. In
rare circumstances the burn may occur elsewhere in the body.
Monopolar diathermy should not be used for infant circumcision
because the point of greatest electrical resistance may be at the base
of the penis with risk of coagulation and loss of the whole penis.
Further technical description of the current types is beyond the scope
of this manual but the circumcision surgeon should be aware that
many diathermy machines have different settings for coagulation or
cutting currents. Only the former should be used for haemostasis.
Diathermy technique: When using diathermy, the surgeon should
apply the forceps as precisely as possible. The best results will be
obtained if the blood vessel is grasped between the diathermy prongs
with minimal other tissue, and the current activated for the shortest
time required to ensure haemostasis. If too much tissue is grasped,
diathermy will not stop the bleeding because the heat is too diffuse.
Prolonged diathermy causing large black burns should be avoided as
these may increase the risk of infection, post operative pain or scar
tissue formation. Particular care must be taken near the frenulum
because there is a risk of burning through to the urethra which is near
to the surface and creating a fistula. Diathermy should also be used
with caution close to the skin and mucosal edges as transmitted heat
may cause burns. Diathermy can be used to stop bleeding from small
blood vessels, but it is safer to apply an artery forceps and tie or
under-run larger vessels 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.
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,
Surgical procedures for adults and adolescents Chapter 5-5