here - Paediatric Circumcision

Current Techniques for Circumcision
Anies Mahomed MBBCh, FCS (SA), FRCS(Glasg., Ed.), FRCS(Paediatric Surgery)
Ram Nataraja BSc MBBS MRCSEd
Department of Paediatric Surgery, Royal Alexandra Children’s Hospital
Eastern Road, Brighton, BN2 5BE, United Kingdom.
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Introduction:
Circumcision is one of the oldest procedures described. The earliest Egyptian mummies (2300BC), the
indigenous people of the Australian and American continents were all found to be circumcised. There are
also references to this procedure in all of the major religious texts including the Bible and the Koran.
The majority of circumcisions, especially within Judaism, are performed in the community whilst the male is
still a neonate. Over 60% of neonates are circumcised in the United States 1. However circumcision is still one
of the most common operations that a paediatric surgeon and urologist will encounter in their practice 2.
There are many techniques that have been described to perform the removal of the foreskin either by the
operative technique or with the use of devices. In this chapter we will focus on the most commonly applied
surgical techniques; the sleeve dissection technique, a modified guillotine technique employing a glans
guard, and the most commonly used device; the Plastibell TM (Hollister Incorporated, Illinois, USA).
There has been much debate over the possible indications for circumcision over the past few decades, which
extends beyond the scope of this chapter. The only true indications for circumcision however remain a
pathological phimosis secondary to balanitis xerotica obliterans or the presence of squamous cell carcinoma
of the penis. The only true contraindications include the presence of either a hypospadias or an epispadias,
as the foreskin may be needed for the formation of the neourethra.
There is a suggested approximate 3.5% complication rate with the open technique; the commonest
complications being infection (1.3%) and bleeding (0.8%) 3,4. There is a similar complication rate of 2-3%
reported with the PlastibellTM technique5, and only 1.8% with the glans guard technique 6. Other
complications include; pain, haematoma, glandular injury, increased sensitivity and irritation of the glans,
urethral meatitis, urinary retension, urethrocutaneous fistulae, and anaesthetic complications.
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Sleeve resection technique:
This technique is well established in the paediatric urological community. It requires the procedure to be
conducted in the operation theatre under general anaesthetic and it is standard practice to have a surgical
assistant present. It provides an excellent cosmetic result although there is a slightly increased risk of
iatrogenic injury which includes glandular injury and urethra-cutaneous fistula formation 7-9. Though well
documented, these injuries are seen extremely rarely in specialised centres performing this technique. This
procedure requires more time to perform compared to techniques involving devices and is performed with
the surgeon and assistant standing either side of the operating table.
Step 1:
Once prepucial adhesiolysis is achieved and smegma removed with a betadine soaked swab the frenulum is
divided with diathermy.
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Step 2:
The skin of shaft is marked circumferentially at the level of the corona.
Step 3:
The foreskin is then retracted and the mucosa cuff marked approximately 3 to 4 mm inferior to the corona.
Step 4:
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The skin is then incised as per the markings starting with the shaft and proceeding to the mucosal cuff. Care
should be taken to incise only superficially to avoid damage to the deeper tissue, particularly on the ventral
aspect.
Step 7:
The foreskin between the incisions is then resected utilising sharp or diathermy dissection and the
underlying tissue is examined with meticulous haemostasis.
Step 9:
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The shaft skin and the mucosal cuff are aligned and approximated with absorbable sutures +/- a horizontal
mattress suture at the frenulum. Two haemostats are used at the 6 and 12 o’clock positions to stabilise the
penile shaft while the remaining sutures are placed to complete closure.
Step10:
The completed circumcision
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PlastibellTM technique:
The PlastibellTM technique was first described in the United States by Kariher and Smith in 1956. Since it was
described it gained popularity with the paediatric surgical community for performing safe neonatal
circumcisions 10-12. As with the sleeve resection technique there are potential rare complications that include
excessive skin loss, urethrocutaneous fistulae, and partial necrosis of the glans 12-14. These are primarily
thought to be due to the incorrect size of Plastibell TM being applied13. Commoner complications include;
PlastibellTM retention, slippage and inadequate circumcision 12. The PlastibellTM technique is reserved for
younger patients and can be safely utilised in up to 2 year olds. Use in older patients risks higher
complications. Depending on the age of the patient it may be performed under local or a general
anaesthetic.
Step 1:
A standard ring block with 0.5% lignocaine in a dose of 1mg/kg is applied to the penile base. Once
satisfactory anaesthetic is achieved the foreskin is comprehensively freed from the underlying glans and
calibrated with an appropriately sized Plastibell TM device.
Step 2:
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After the foreskin is returned to the normal anatomical position, it is grasped between 2 haemostatic clips to
either side of the dorsal midline. The foreskin between the two clips is then crushes and divided to a depth
of 1cm. The two layers at the apex of the incision are approximated with a 6 cm length of 4/0 silk and held
on a haemostat.
Step 3:
A pre-moistened PlastibellTM is then introduced through the widened foreskin to encase the glans. The
correct orientation is with the handle at 90 o to the frenulum to avoid damage to this structure during
separation of the handle. An appropriate amount of foreskin is then drawn over the Plastibell TM with a
bimanual manoeuvre of forward traction on foreskin via the haemostatic clips and simultaneous gentle
downwards pressure on the Plastibell TM. Two sequential silk 0 sutures are then placed on the groove of the
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PlastibellTM device with care to avoid knot overlap. The authors have found this to be superior to the use of
the string ligature which comes packaged with the device 12.
Step 4:
Correct suture placement is confirmed prior to division of the foreskin approximately 2mm distal to the ring.
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Guillotine Technique with Glans Guard Assistance:
This technique is an adaptation of one that has been established in paediatric practice and involves the use
of a bone-cutting forceps15. With the original technique, after the mobilisation of the glans from the
preputial adhesions, the foreskin is lifted between two haemostats and the position of the glans palpated.
The bone-cutting forceps are then placed parallel to the coronal sulcus and the foreskin clamped above the
glands. A scalpel is then run against the bone-cutting forceps to complete the circumcision. With this
technique there are concerns however over the potential iatrogenic damage to the glans that can result 16.
For this reason the glans guard (Dixons Surgical Instruments, Wickford, UK) was introduced which greatly
decreases the likelihood of damage to this structure whilst giving an excellent result in a short procedure.
The use of the bone-cutting forceps creates a uniform suture line that some paediatric surgeons consider
superior to either of the previously described techniques. The technique is also quicker to perform and with
less blood loss.
Step 1:
After the glans has been released from its preputial adhesions the foreskin to be excised is marked and
elevated with two haemostats. The glans guard is placed onto the foreskin at the level marked. It’s
orientation is oblique and parallel to the corona. There are different aperture sizes to the glans guard (small,
medium and large) therefore the correct device for the patient is chosen.
Step 2:
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The bone-cutting forceps are then placed on the glans guard and foreskin crushed between the blades.
Step 3:
A scalpel is then run along the bone-cutting forceps to complete the foreskin division. If this step is
performed with one fluid movement a superior cosmetic result is obtained.
Step 4:
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The foreskin is then retracted and the mucosal cuff examined. It may be necessary at this point to trim the
cuff. The opposition of the skin and mucosa is then performed with absorbable sutures as previously
described with the other techniques.
Step 5:
A dressing can then be applied.
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Summary
In this chapter we have focused on the three popular techniques for circumcision. The Plastibell TM described
above is the most commonly utilised device although there are numerous other types available including the
GomcoTM (Allied Healthcare Products Inc, St Louis US) and the Tara TM clamp (Taramedic Corporation KL
Malaysia)17,18. The PlastibellTM is best utilised in the neonatal and infancy period. In this context it is
associated with a low complication rate and minimal anaesthetic risks whilst producing a good cosmetic
result12. The use of this device in older children is not advised as this can be associated with impaction rate of
26.9% compared to 2.3% in infants 19. With an older child there are psychological implications to the
placement of a device without a general anaesthetic. In these children therefore an operative intervention
such as either the sleeve dissection or guillotine method should be used. As discussed both techniques have
advantages and disadvantages but provide a good cosmetic result.
If the guillotine technique is used it is recommended that it should be performed with the glans guard as this
results in a decreased complication rate; 1.8% in a series of 224 patients 6. No injuries to the underlying glans
were seen although in some series this has been reported as high as 3.5% 20. The guillotine method can be
expeditiously performed and offers an excellent cosmetic result.
On the other hand the sleeve technique carries a low complication rate although associated with an
increased operative time3,4. It should be noted that these results are obtained from performing the
procedure in the controlled environment of a specialised centre and the complication rates following a
community circumcision are significant and may be as high as 35% 21.
In our experience when a suitable technique is applied adequate results are obtained in all age groups. The
circumcision process should never be underestimated and care should be taken to avoid potential
complications.
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References
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2. Drain PK, Halperin DT, Hughes JP, et al. Male circumcision, religion, and infectious diseases: an
ecologic analysis of 118 developing countries. BMC Infect Dis. 2006 Nov 30;6:172.
3. Krieger J et al. Adult male circumcision: Results of a standardized procedure in Kisumu District,
Kenya. BJU International 2005; 96:1109-1113.
4. Auvert B, Taljaard D, Lagarde E, et al. Randomised controlled intervention trial of male circumcision
for reducing HIV risk: The ANRS 1265 Trial. PLoS Medicine 2005:2(11):e298.
5. Manji KP. Circumcision of the young infant in a developing country using the plastibell. Ann trop
Paediatr 2000;20:101-104.
6. Mahomed A, Ogston K. Gomco circumcision correspondence. J Pediatr Surg. 2002 Apr;37(4):683.
7. Essid A, Hamzaoui M, Sahli S, Houissa T. Glans reimplantation after circumcision accident. Prog Urol.
2005 Sep;15(4):745-7.
8. Baskin LS, Canning DA, Snyder HM 3rd, Duckett JW Jr. Surgical repair of urethral circumcision
injuries. J Urol. 1997 Dec;158(6):2269-71
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Urol. 2007 Feb;3(1):32-35. Epub 2006 Jun 9.
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circumcision ring. J Pediatr Urol. 2009 Jun 29. [Epub ahead of print]
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Afr Med J. 2007 Mar;97(3):192-3.
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15. Machmouchi M, Alkhotani A. Is neonatal circumcision judicious? Eur J Pediatr Surg. 2007
Aug;17(4):266-9
16. El-Bahnasawy MS, El-Sherbiny MT. Paediatric penile trauma. BJU Int. 2002 Jul;90(1):92-6.
17. Wan J. GOMCO circumcision clamp: an enduring and unexpected success. Urology. 2002 May;
59(5):790-4.
18. Horowitz M, Gershbein AB. Gomco circumcision: When is it safe? J Pediatr Surg. 2001 Jul;36(7):
1047-9.
19. Samad A, Khanzada TW, Kumar B. Plastibell circumcision: A minor surgical procedure of major
importance. J Pediatr Urol. 2009 Jun 12. [Epub ahead of print]
20. Okeke LI, Asinobi AA, Ikuerowo OS. Epidemiology of complications of male circumcision in Ibadan,
Nigeria. BMC Urol. 2006 Aug 25;6:21.
21. Williams N, Kapila L. Complications of circumcision. Br J Surg. 1993 Oct;80(10):1231-6.
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