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Transcript of MCChapter5_3
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Forceps Guided Method
Chapter 5: Surgical Procedures for Adults and Adolescents 57
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Forceps Guided Method Advantages:
Can be learned bysurgeons/surgical
assistants who arerelatively new to surgery
Ideal for use in a clinic withlimited resources
Can be done without asurgical assistant
Disadvantages:
Leaves 0.51.0 cmof mucosal skin
proximal to corona Cosmetic effect
may be lesssatisfactory
Chapter 5: Surgical Procedures for Adults and Adolescents 58
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Forceps Guided Method:
Steps 12Step 1: Skin preparation, draping and anaesthesia
(as previously described)
Step 2: Retraction of foreskin and separation ofany adhesions
Chapter 5: Surgical Procedures for Adults and Adolescents 59
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Marking Incision Line: Step 3a
Chapter 5: Surgical Procedures for Adults and Adolescents 60
This step is common to all the methods of circumcision.With the foreskin in a natural resting position, indicatethe intended line of the incision with a marker pen. The
line should correspond with the corona, just under thehead of the penis.
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Marking Incision Line: Step 3b Some uncircumcised men
have a very lax foreskin,which is partially retracted inthe resting position.
In such cases, it is better toapply artery forceps at the 3and 9 oclock positions, toapply a little tension to theforeskin before marking thecircumcision line.
It is important not to pullthe foreskin too hardbefore marking the line, asthis will result in too muchskin being removed.
Chapter 5: Surgical Procedures for Adults and Adolescents 61
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Forceps Guided Method: Step 4Grasp the foreskin atthe 3 and 9 oclock
positions with twoartery forceps, on thenatural apex of theforeskin in such a wayas to put equal tensionon the inside andoutside surfaces of theforeskin.
Chapter 5: Surgical Procedures for Adults and Adolescents 62
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Forceps Guided Method: Step 5
Chapter 5: Surgical Procedures for Adults and Adolescents 63
Put sufficient tension on the foreskin to pull the previously made markto just below the glans. Taking care not to catch the glans, apply along straight forceps across the foreskin just proximal to the mark.Once the forceps is in position, feel the glans to check that it has not
been accidentally caught in the forceps.
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Forceps Guided Method: Step 6
Chapter 5: Surgical Procedures for Adults and Adolescents 64
Using a scalpel, cut away the foreskin flush with the outeraspect of the forceps. The forceps protects the glans frominjury, but nevertheless particular care is needed at this
stage.
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Forceps Guided Method: Step 7
Grasp and trim any skin tags on the inner edge of the foreskin toleave approximately 5 mm of skin proximal to the corona. Care mustbe taken to trim only the skin and not to cut deeper tissue.
Chapter 5: Surgical Procedures for Adults and Adolescents 65
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Stopping the Bleeding
Chapter 5: Surgical Procedures for Adults and Adolescents 67
Vessels may be occluded by ligation(A), or by transfixion sutures (B)
A
B
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Chapter 5: Surgical Procedures for Adults and Adolescents 68
Stopping the bleeding: Cut blood vessels should be locatedaccurately and tied or transfixed.
1. Using forceps (tweezers),the blood vessel islocated.
2. The blood vessel is then held withthe forceps and gently pulled up sothat an artery forceps can be applied.
3. The artery forceps is thenapplied, taking the minimumamount of extra tissue.
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Chapter 5: Surgical Procedures for Adults and Adolescents 69
Blood vessels should be accurately clipped with artery forceps, taking care to avoid takingtoo big a chunk of tissue. If it is difficult to see the source of bleeding, apply pressure with aswab and wait for 23 minutes and usually the bleeding vessel can then be occludedaccurately.
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Forceps Guided Method:
Step 9
Suturing Plan
Chapter 5: Surgical Procedures for Adults and Adolescents 70
a b c
Horizontal mattress suture at the frenulum (6 oclock). Vertical mattress
sutures at 9, 12 and 3 oclock and simple sutures between these.
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Suturing the Circumcision
Chapter 5: Surgical Procedures for Adults and Adolescents 71
Place a horizontal mattress suture at the frenulum.Whenplacing the horizontal mattress suture at 6 oclock position,take care to align the midline skin raphe with the line of thefrenulum (see below). A common error is to misalign the
midline and raphe, which results in misalignment of the wholecircumcision closure.
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Suturing the Circumcision (cont.)
Chapter 5: Surgical Procedures for Adults and Adolescents 72
Place a vertical mattress suture at the 12 oclock position.The suture should be placed so that there is an equal amountof skin on each side of the penis between the 12 and 6 oclockpositions. Place two further vertical mattress stitches in the
3 oclock and 9 oclock positions.
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Suturing the Circumcision (cont.)
After placement of thesutures at 6,12, 3 and
9 oclock, place two ormore simple sutures inthe gaps between.
Chapter 5: Surgical Procedures for Adults and Adolescents 73
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Forceps Guided Method
Final outcome:
Chapter 5: Surgical Procedures for Adults and Adolescents 74
Note residual mucosal portion of the foreskin
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Suturing the Circumcision:
Step 10Once the procedure is finished, check forbleeding and apply a dressing (described later).
Chapter 5: Surgical Procedures for Adults and Adolescents 75
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Sleeve Resection Method
Chapter 5: Surgical Procedures for Adults and Adolescents 76
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Sleeve Resection Method
Chapter 5: Surgical Procedures for Adults and Adolescents 77
Provides best cosmetic results More room for surgical error
The technique requires an assistant The sleeve resection method requires good
surgical skill Better suited to a hospital rather than a clinic
setting
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Sleeve Resection Method:
Steps 12Step 1: Skin preparation, draping and anaesthesia
Step 2: Retraction of foreskin and separation of
any adhesions
Chapter 5: Surgical Procedures for Adults and Adolescents 78
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Sleeve Resection Method:
Step 3
Marking the Outer LineMark the line of the outsidecut, just below the corona
Chapter 5: Surgical Procedures for Adults and Adolescents
Note V shape pointing towards frenulum
Mark the intended outer lineof the incision with a V- shape,pointed towards the frenulum,on the underside of the penis
The apex of the V shouldcorrespond with the midlineraphe
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Sleeve Resection Method: Step 4
Marking the Inner Mucosal LineRetract the foreskin and mark the inner (mucosal)incision line 12 mm proximal to the corona. At the frenulum,the incision line crosses horizontally as shown by the arrow.
Chapter 5: Surgical Procedures for Adults and Adolescents 80
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Sleeve Resection Method: Step 5
Using a scalpel, make incisions along the markedlines, taking care to cut through the skin to thesubcutaneous tissue but not deeper. During the incision,the assistant retracts the skin with a moist gauze swab.
Chapter 5: Surgical Procedures for Adults and Adolescents 81
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Sleeve Resection Method: Step 5b
Chapter 5: Surgical Procedures for Adults and Adolescents 82
Make the innerincision
Outer and innerincisioncompleted
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Sleeve Resection Method: Step 6
Cut the skin between the proximal and distalincisions with scissors.
Chapter 5: Surgical Procedures for Adults and Adolescents 83
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Sleeve Resection Method: Step 7Hold the sleeve of foreskin under tension with two arteryforceps and dissect the skin from the shaft of thepenis, using dissection scissors. Tie off any bleeding
vessels with under-running sutures.
Chapter 5: Surgical Procedures for Adults and Adolescents 84
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Sleeve Resection Method:
Steps 810Step 8: Haemostasis and suturing are the sameas described for the forceps guided method.
Step 9: Suturing the circumcision is the same asdescribed for the forceps guided method.
Step 10: Check for bleeding, and provided there isnone, apply a dressing as described later.
Chapter 5: Surgical Procedures for Adults and Adolescents 85
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Applying the Penile Dressing
Irrespective of the method of circumcision, astandard penile dressing technique is used:
Check that there is no bleeding. Once all bleeding has stopped, place a piece of
petroleum-jelly-impregnated gauze (tullegras)around the wound.
Apply a sterile, dry gauze over this, and secure itin position with adhesive tape.
Take care not to apply the dressing too tightly.
Chapter 5: Surgical Procedures for Adults and Adolescents 86
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Dressing: Application of Sofratulle
Chapter 5: Surgical Procedures for Adults and Adolescents 87
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Dressing: Application of Gauzeand Strapping
Chapter 5: Surgical Procedures for Adults and Adolescents 88
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Chapter 5: Surgical Procedures for Adults and Adolescents 89
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Removing the Penile Dressing
The dressing should be left in position nolonger than 48 hours.
If the dressing has dried out, it should be gentlydabbed with antiseptic solution (aqueouscetrimide, Savlon) until it softens.
It can then be removed gently. It is important
not to disrupt the wound by pulling at adressing that has dried to the wound.
Chapter 5: Surgical Procedures for Adults and Adolescents 90
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Summary
Three common methods of MC have beenreviewed:
Description of the dorsal slit method of malecircumcision
Description of the forceps guided method of malecircumcision
Description of the sleeve method of malecircumcision
Chapter 5: Surgical Procedures for Adults and Adolescents 91
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Summary (cont.)
The recommended operative techniques havebeen described in detail.
Surgeons should become expert in thetechnique most suited to the circumstances oftheir practice.
It is not recommended to learn all of the
techniques. It is best to become a master ofone adult technique and, if appropriate, onepaediatric technique.
Chapter 5: Surgical Procedures for Adults and Adolescents 92
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Chapter 5: Surgical Procedures for Adults and Adolescents 93
Photo credits: Dipo Otolorin