Manual for Male Circumcision under Local Anaesthesia

Male circumcision under local anaesthesia
Version 3.1 (Dec09)
Safe injection of local anaesthetic
It is the surgeon’s responsibility to check the vial of anaesthetic, to
ensure that the correct agent at the correct concentration has been
selected, and to check the expiry date. It is important to verify that the
anaesthetic is clear and that there are no visible particles, which may
suggest that the vial is contaminated.
Once the needle is in place, but before injecting any anaesthetic, the
surgeon should gently aspirate to make sure that no blood enters the
syringe. This is to ensure that anaesthetic is not injected into a blood
vessel. This safety precaution should be repeated each time the
needle is moved, before any additional anaesthetic is injected.
Additional analgesia
Analgesics, such as paracetamol, may be given after the operation.
However, best practice is to give one paracetamol tablet (adult dose
500 mg) 1–2 hours before surgery, and one tablet for the patient to
take 6 hours later. This produces better postoperative analgesia than
postoperative tablets alone.
Ring block technique
Using a fine (23-gauge) needle, inject approximately 0.1 ml of
anaesthetic subcutaneously at the 11 o’clock position. Then, without
withdrawing the needle, advance it into the subdermal space, making
sure that the needle is freely mobile. At this point, inject 2–3 ml of
anaesthetic to block the dorsal penile nerves (Fig. 5.13). Then advance
the needle subcutaneously around the side of the penis and inject an
additional 1 ml of anaesthetic. Withdraw the needle and repeat the
procedure, starting at the 1 o’clock position so as to complete a ring of
anaesthetic. In some cases it may be necessary to make an additional
injection on the underside of the penis to fully complete the ring of
anaesthetic. After injection, massage the base of the penis for 10–20
seconds to increase the diffusion of the lidocaine into the surrounding
tissues. Once the anaesthetic has been injected, the surgeon should
wait for 3–5 minutes (timed by the clock). A common mistake is to start
the procedure before the anaesthetic has had time to work. Sensation
should be tested before starting the surgery. This can be done by
gently pinching the foreskin with an artery forceps. If there is any
residual sensation, the surgeon should wait for a further 2–3 minutes
and test again. If there is still sensation, more local anaesthetic should
be given. Sometimes, it helps to give additional local anaesthetic
separately to the frenulum area, but usually the ring block at the base
of the penis is sufficient.
Surgical procedures for adults and adolescents Chapter 5-13