Circumcision Techniques

Circumcision is a day surgery procedure that removes the foreskin, the fold of skin covering the head of the penis. It is traditionally performed on newborns; it can also be done in adults. In this post, we will be exploring the different techniques we offer and the factors to consider when making your decision.

Medical Indication for Circumcision

Circumcision is medically indicated for patients with the following medical conditions:

• Phimosis: This occurs when the foreskin is too tight and cannot be retracted (pulled back) over the glans. This can cause pain, difficulty urinating, infections, and sexual dysfunction.
• Paraphimosis: A medical emergency where the foreskin gets retracted but cannot be pulled back over the glans, causing swelling and potential tissue damage. It requires immediate medical attention.
• Balanitis: This is an inflammation of the glans penis. While treatable with medication, recurrent balanitis might be a reason to consider circumcision.
• Recurrent Foreskin Infections: Some males experience repeated infections under the foreskin. Circumcision can help prevent these.

Beyond Medical Reasons

Circumcision can also be considered for religious or cosmetic reasons.

Surgical Techniques

The specific technique used for circumcision depends on several factors, including the patient’s age, medical condition, and surgeon’s experience. The different surgical techniques include:

• Gomco Clamp technique
• Mogen Clamp technique
• Plastibell Device
• Sleeve circumcision technique
• Dorsal slit circumcision technique
• Laser circumcision
• Shang ring circumcision
• Stapler circumcision

Neonatal/Infant Circumcision

The Gomco clamp technique, Mogen clamp technique, and Plastibell device are common techniques for neonatal circumcision.

Let us discuss the different techniques.

Gomco Clamp Technique

This is a time-tested method method for circumcision in neonates (infants under 3 months old). It utilizes a specialized clamp to achieve a bloodless procedure and it consist of three components: a metal plate with a hole at one end, a round metal bell, and a screw device.

A brief elaboration of the procedure:

• Preparation: The foreskin is gently retracted to expose the glans.
• Gomco clamp placement: An appropriate-sized bell is positioned over the glans, followed by the foreskin being stretched over the bell and secured. The clamp itself is then positioned and tightened, effectively minimizing blood flow.
• Circumcision: With blood flow controlled, the excess foreskin is precisely removed.
• Completion: The clamp remains in place for five minutes to ensure proper clotting before removal.

Gomco clamp circumcision is a safe and near-bloodless procedure. Studies have shown that it has a low complication rate (around 0.2%) when performed on newborns. While highly effective for newborns, the Gomco clamp may not be the ideal choice for older children or adults due to potential limitations in controlling blood flow from larger blood vessels.

Mogen Clamp Technique

The Mogen clamp technique, originally developed for ritual circumcisions, has become a popular choice for its minimally invasive approach. It constitutes a simple hinged metal plate that is curved on one side. The clamp is divided by a tiny 3mm slit which allows the passage of the foreskin but helps prevent glans entrapment and injury.

The below provides a brief description of the Mogen Clamp technique:

• Preparation: Adhesions between the foreskin and glans are carefully separated.
• Mogen clamp Placement: The Mogen clamp is meticulously positioned to ensure a cosmetically pleasing outcome.
• Circumcision: The clamp applies controlled pressure, allowing the foreskin to be trimmed in a precise manner with minimal discomfort.
• Completion: Following a brief period to ensure clotting, the clamp is removed and the glans is carefully freed.

Studies have shown that the Mogen clamp was associated with the least discomfort and shortest application time when compared to other neonatal circumcision techniques such as the Gomco clamp and Plastibell technique. It is a safe and quick technique with good cosmetic results.

Plastibell Device

The Plastibell device is a popular technique as it offers a convenient and effective approach to newborn circumcision. Its popularity stems from its ease of use, minimal complications, and suitability for local anesthesia. The technique involves the use of a suture that is tied around the foreskin, over the grooved plastic ring also called the Plastibell.

The procedure is performed in the following manner:

• Preparation: The foreskin is retracted and carefully cleansed. Adhesions between the foreskin and glans are gently separated to prep for circumcision.
• Plastibell Placement: A dorsal slit is then performed at the 12 o’clock position and an appropriate-sized Plastibell is meticulously placed for optimal results.
• Circumcision: A suture is securely placed around the base of the Plastibell to minimize blood flow. The excess foreskin is then removed.
• Naturel detachment: The Plastibell falls off naturally within a few days, eliminating the need for further intervention.

The Plastibell method offers a simple and convenient approach, often requiring only local anesthesia. There is minimal discomfort, with a low risk of complications. The Plastibell naturally detaches, promoting a smooth healing process.

Adult Circumcision

There are a multitude of different circumcision techniques for adult circumcision. They include conventional surgical techniques such as the sleeve technique and the dorsal slit technique. Lasers have also been employed for laser circumcision, and increasingly medical devices such as the Shang Ring and surgical staplers are employed to perform circumcision. We elaborate on the different techniques in this post.

Conventional Surgical Techniques

Sleeve Technique

The sleeve incision technique is a well-established method for adult circumcisions and older children. It offers precise control over the amount of foreskin to be removed, and a favorable aesthetic outcome.

Here is a simplified breakdown of the process:

• Marking and Planning: The surgeon carefully plans and marks the incision line on the outer foreskin to ensure that the correct amount of foreskin is removed.
• Precise Incision: Two incisions are made. The first on the outer foreskin followed by a second incision on the inner layer.
• Tissue Removal: The excess foreskin is meticulously removed as a single piece.
• Bleeding Control: Bleeding points are identified and addressed with electrocautery.
• Closure: The remaining foreskin edges are stitched together for optimal healing.

Dorsal Slit Technique

The dorsal slit technique is a specialized approach used for patients with phimosis, a condition where the foreskin tightly covers the glans and cannot be retracted. This method is similar to the sleeve incision technique except that a vertical slit is first performed at the 12 o’clock position.

Here is a simplified breakdown of the process:

• Marking and planning: Surgical marking is performed on the outer foreskin to ensure an adequate amount of foreskin is to be removed for a good cosmetic outcome.
• Dorsal slit: Two hemostat clamps are placed over the foreskin vertically at the 12 o’clock position to reduce bleeding. The foreskin is then incised between the 2 perpendicular clamps to expose the urethral meatus.
• Circumferential incision: Incisions are made on the outer foreskin and inner layer to complete the circumcision.
• Bleeding control: Meticulous hemostasis is performed on all bleeding points.
• Closure: The remaining foreskin edges are stitched together for optimal healing.

Pros and Cons of Conventional Circumcision Techniques

Conventional surgical techniques, like the sleeve and dorsal slit methods, offer a high degree of control and customization for adult circumcision. Here’s a look at the key considerations:

Advantages

• Precise control: The surgeon can meticulously mark the incision line, ensuring that the desired amount of foreskin is removed, leading to the desired cosmetic outcome.
• Favorable aesthetic outcome: The technique results in a symmetrical and fine incision line giving a more aesthetically pleasing appearance. Furthermore, conventional surgical techniques allow for tailoring the procedure to your preferences.

The disadvantages of conventional techniques include:

• General anesthesia: While local anesthesia can be used in some cases, most patients opt for general anesthesia due to the nature of the procedure.
• Longer operative time: This technique would typically take 30-45 minutes, translating to more discomfort and anxiety for patients who did not receive general anesthesia.
• Increased discomfort: Studies have shown that patients who underwent conventional surgical circumcision had more pain immediately after and a few days following the procedure
• Higher rates of complications: Bleeding is a common complication associated with adult circumcision, and this is generally higher in conventional surgical circumcision.

Laser Circumcision

Laser circumcision, while similar in principle to traditional surgical circumcision, utilizes a CO2 laser to trim the foreskin instead of a scalpel or scissors. This technology offers several advantages, however, there are certain disadvantages which we will discuss in the paragraph below.

Advantages:

• Reduced bleeding: The laser’s ability to cauterize tissue as it cuts minimizes blood loss.
• Shorter operative time: Laser circumcisions are often completed more quickly than traditional methods.
• Improved cosmetic outcomes: Laser circumcision may result in better aesthetic results due to the precise cutting and sealing of the laser.
• Less postoperative pain: Studies have shown that laser circumcision can lead to significantly less postoperative pain compared to traditional methods. Patients reported lower pain scores both one day and seven days after the procedure.

Disadvantages:

• Higher risk of wound dehiscence: There’s a slightly increased risk of the wound edges separating when compared to conventional circumcision.
• Need for sutures: The trimmed edges have to be stitched to reduce the risk of wound dehiscence.
• Individual variability: Healing times and outcomes can vary depending on factors such as the patient’s health and proper care.

Circumcision with Medical Devices

Medical devices are one of the innovations in circumcision techniques to reduce operative time and offer a sutureless procedure. The Shang Ring circumcision and the Stapler circumcision are devices commonly utilized for adult circumcision.

Shang Ring Circumcision

Shang Ring circumcision offers a modern, sutureless technique that has gained popularity due to its safety, effectiveness, and superior cosmetic outcomes. The procedure utilizes a specialized device, the Shang Ring, to perform the circumcision. Notably, the Shang Ring is one of only two circumcision devices to have achieved WHO Prequalification, and it holds medical device approval from the Health Authority of Singapore.

Advantages:

• Minimal anesthesia: The procedure typically requires only local anesthesia, using topical numbing cream and injections. This eliminates the need for general anesthesia, making the experience more comfortable for patients.
• Rapid procedure: Shang Ring circumcision is significantly faster than conventional techniques, taking approximately 10-15 minutes to complete, significantly reducing patient discomfort.
  • Sutureless healing: The Shang Ring device holds the trimmed edges together, eliminating the need for sutures. This not only speeds up healing but also results in a more aesthetically pleasing outcome with minimal bleeding.

Disadvantage:

Temporary device: The Shang Ring remains in place for 7-10 days following the procedure before being removed. This is a minor inconvenience, however, it is essential for proper healing and optimal results.

Stapler Circumcision

Stapler circumcision is a modern technique developed by Chinese physicians that offers several potential benefits. Popular stapler devices include the ZSR and CirCurer (LangHe) models, both produced in China. These devices allow the surgeon to cut and “stitch” the foreskin simultaneously, streamlining the circumcision process. Recently, the Health Authority of Singapore approved stapler circumcision as a medical device, positioning it as a potentially groundbreaking advancement in the field of circumcision.

Advantages:

• Minimal anesthesia: Stapler circumcision typically requires only local anesthesia, making it a more comfortable experience for patients.
• Rapid procedure: The simultaneous cutting and “stitching” capabilities of the stapler device significantly reduce the procedure time, often completing it in approximately 10 minutes. This is a substantial improvement compared to traditional methods.
• Sutureless technique: Stapler circumcision offers a sutureless approach, utilizing specialized staplers to join the trimmed edges of the foreskin. This eliminates the discomfort and potential complications associated with sutures, significantly reducing postoperative pain and healing time. The staplers typically fall off within 1-2 weeks, leaving a clean and aesthetically pleasing result.

Disadvantages:

While stapler circumcision shows promise, it’s important to note that as a relatively new technique, further research and studies are necessary to fully understand its long-term benefits and potential risks. Additionally, there’s a small risk of device failure or complications, as with any medical procedure.

Conclusion

This post has offered a comprehensive overview of various circumcision techniques, providing valuable insights into their advantages and potential drawbacks. To explore the best option for your individual needs, we invite you to schedule a consultation at Clifford Clinic, where we will discuss the most suitable circumcision technique for you. Our service page has detailed information about the recovery process and frequently asked questions, including MediSave/Insurance claims.

This post has provided a detailed list of the different techniques that circumcision can be performed. Do head down to the Clifford Clinic for a consultation so we can discuss the circumcision technique that is most suited for you. Our service page provides additional information regarding the recovery process and an FAQ for commonly asked questions such as MediSave/Insurance claims.

This post has offered a comprehensive overview of various circumcision techniques, providing valuable insights into their advantages and potential drawbacks. To explore the best option for your individual needs, we invite you to schedule a consultation at Clifford Clinic. Our dedicated team will discuss the most suitable circumcision technique and provide detailed information about the recovery process and frequently asked questions, including MediSave/Insurance claim procedures.