Circumcision

Circumcision

Potential benefits

Contraindications

Complications

Postoperative care

  1. Depending on patient age and habitus, may benefit from gently retracting shaft skin to prevent adhesions
  2. Usually dressing can be removed after 24hr, may benefit from applying bacitracin or vaseline to incision
  3. Usually avoid physical activity for 2-3 weeks, avoid sexual activity for 6 weeks

Adult OR technique

  1. Place patient supine, prep/drape (clean under foreskin), give cefazolin for skin flora
  2. Give dorsal penile and ring block
  3. Place glans traction stitch with 2-0 silk (place deep to avoid tearing)
  4. Mark distal and proximal incisions, ensure adequate length by tensioning skin at base
  5. Gently incise skin with #15 scalpel, make sure skin separates but do not go through underlying layers
  6. Place mosquito snaps x4 on dorsal skin, then create tunnel with metzenbaum scissors and incise skin to create flaps
  7. Completely excise skin off penis with electrocautery, taking care not to cauterize remaining penile skin or shaft, send skin for specimen if needed
  8. Obtain hemostasis with point cautery
  9. Reapproximate frenulum with U-stitch (can use chromic or monocryl)
  10. Place stitches at 6, then 3 and 9 o'clock
  11. Close remaining skin edges with either simple or horizontal mattress interrupted
  12. Apply bacitracin, telfa, and coban dressing

Gomco technique

  1. Place on circumcision board
  2. Inject ~5mL 1% lidocaine as dorsal penile block, sit for 5 minutes
  3. Dilate phimotic ring with hemostat
  4. Crush foreskin at 12 o'clock position then cut to expose glans
  5. Remove all smegma and adhesions to fully expose glans
  6. Place hemostat x2 on the corners of the cut foreskin and place bell within foreskin on top of glans
  7. Place outer device over foreskin, grasp corners with new hemostat to bring the foreskin up and through device
  8. Confirm adequate and even position of Gomco device prior to tightening
  9. Leave for 5 minutes after tightening, can cut off foreskin at any time
  10. After 5 minutes, remove device and gently push edges off bell to expose penis
  11. Apply bacitracin and dressing

Pediatric OR technique #1

  1. Supine positioning
  2. Take down adhesions with a snap and sponge, sterilize with betadyne
  3. Demarcate proximal border, make incision w/ #15 scalpel
  4. Demarcate distal border, make incision w/ #15 scalpel
  5. Use 4 snaps to grap foreskin at dorsal aspect
  6. Spread with tenotomy scissors, cut at dorsal aspect
  7. Remove foreskin with cautery, discard unless abnormal appearing
  8. Obtain hemostasis of any active or potential bleeding
  9. Place two 5-0 stitches at ventral portion
  10. Reapproximate frenulum if necessary with simple interrupted
  11. Suture subcutaneous at 12 o’clock with 6-0, then perform running subcuticular dorsal to ventral, perform on either side
  12. At ventral portion, put stitch through skin, then go back through skin again and tie to loop
  13. Place mastisol, telfa strip, and tegaderm with cut on ventral then dorsal portion
  14. Cover with bacitracin
  15. Send home with tylenol, ibuprofen, and bacitracin

Pediatric OR technique #2

  1. Supine positioning
  2. Take down adhesions, sterilize with betadyne
  3. Demarcate proximal border, make incision w/ #15 scalpel
  4. Demarcate distal border, make incision w/ #15 scalpel
  5. Use 4 snaps to grap foreskin at dorsal aspect
  6. Spread with tenotomy scissors, cut at dorsal aspect
  7. Remove foreskin with cautery, discard unless abnormal appearing
  8. Obtain hemostasis of any active or potential bleeding
  9. Place 12 6-0 chromic stitches simple interrupted
  10. Place mastisol, telfa strip, and tegaderm with cut on ventral then dorsal portion
  11. Send home with tylenol and ibuprofen

Pediatric OR technique #3

  1. Supine positioning
  2. Take down adhesions, no betadyne
  3. Place 5-0 prolene stitch in glans for positioning
  4. Demarcate borders, incise with electrocautery on cut (or coag)
  5. Use 4 snaps to grap foreskin at dorsal aspect, spread with tenotomy scissors, cut at dorsal aspect
  6. Can also just cut through foreskin and take down in parts
  7. Remove foreskin with cautery, discard unless abnormal appearing
  8. Obtain hemostasis of any active or potential bleeding
  9. Place 12 o’clock stitch and 6 o’clock stitch and hold on with snaps (5-0 fast gut)
  10. Place 8 stitches total with 5-0 fast gut
  11. Place dermabond
  12. Send home with tylenol and ibuprofen

Dorsal Slit at bedside

  1. Perform dorsal penile and ring block, prep/drape
  2. Crush preputial skin at 12 o'clock with straight hemostat then incise - take care not to insert hemostat into meatus!
  3. If necessary, retract skin and continue to crush/cut until glans of penis completely exposed
  4. Suture edges with 3-0 or 4-0 chromic as running or interrupted stitch to provide hemostasis

Phalloplasty (for buried penis)

  1. Prep/drape, perform dorsal penile and ring blocks
  2. Take down all adhesions and clean smegma to visualize entire penis, then place 4-0 ethibond traction stitch
  3. Demarcate the inner preputial incision by drawing a circumferential line, then incise with #15 scalpel
  4. Deglove the penis down to the base, exposing edges and using cautery or tenotomy to cut attachments
  5. Assess where skin will comfortably lie on the shaft, then cut the dorsal skin at 12 o'clock with tenotomy until a point where it will come together with the glans edge
  6. Place fixation sutures at 12, 5, and 7 o'clock to fix shaft skin to penile base, bury the knots, use 5-0 PDS (or similar suture)
  7. Wrap dorsal skin flaps around ventrally for coverage and excise the excess tissue
  8. Realign ventrally, recreate frenulum and raphe as needed to bring skin together without tension
  9. Bring circumcising incision together through desired technique (running/interrupted)
  10. Apply dermabond and dressing, remove traction stitch