Manual for Male Circumcision under Local Anaesthesia

Male circumcision under local anaesthesia
Version 3.1 (Dec09)
SURGICAL METHODS
Three widely used methods of circumcision are described below. All
three methods produce a good long-term result, but require different
levels of skill. The sleeve method produces an excellent result, but
requires the highest level of surgical skill. The forceps-guided method
produces a less tidy result initially, but has the advantage that it is a
simple technique suitable for a clinic setting. In clinical trials it has
been shown to produce consistently good results with low complication
rates. It cannot be used for men with phimosis, since the foreskin
cannot be fully retracted. The dorsal slit method is probably the most
widely used method worldwide.
At present, devices similar to those used for paediatric circumcision
(see Chapter 6) are either not available or not suitable for adult
circumcision. Evidence is needed from clinical trials before such
devices can be recommended.
Forceps-guided method of circumcision
This is a simple step-by-step procedure, which can be learnt by
surgeons and surgical assistants who are relatively new to surgery. It
can be used in clinics with limited resources, and it can be done
without an assistant. A disadvantage of the procedure is that it leaves
between 0.5 and 1.0 cm of mucosal skin proximal to the corona. The
forceps-guided technique was used in the South African and Kenyan
trials of circumcision and HIV infection. The version described here
was standardized by the Kenyan study team.
Step 1. Prepare skin, drape and administer anaesthesia, as described
above.
Step 2. Retract the foreskin and separate any adhesions, as described
above.
Step 3. Mark the intended line of the incision, as described above.
Step 4. Grasp the foreskin at the 3 o’clock and 9 o’clock positions with
two artery forceps. Place these forceps on the natural apex of the
foreskin, in such a way as to put equal tension on the inside and
outside surfaces of the foreskin. If this is not done correctly, there is a
risk of leaving too much mucosal skin or of removing too much shaft
skin.
Step 5. Put sufficient tension on the foreskin to pull the previously
made mark to just beyond the glans. Taking care not to catch the
glans, apply a long straight forceps across the foreskin, just proximal to
the mark, with the long axis of the forceps going from the 6 o’clock to
the 12 o’clock position (taking the frenulum as the 6 o’clock position).
Surgical procedures for adults and adolescents Chapter 5-17