|Year : 2004 | Volume
| Issue : 2 | Page : 126-129
A simple modification of the free hand technique of circumcision
GR Sharma, Anshu Sharma
Solapur Kidney Care and Research Centre Pvt. Ltd, Solapur, India
G R Sharma
Onkar Nilayam, 3/27 Samarth Nagar, North Sadar Bazar, Solapur-413 003
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective : To evaluate a modification of the free hand technique of circumcision for achieving better cosmetic results
Methods : The prepuce is first divided at the 12 o'clock and then at 6 o'clock. Two preputial flaps are thus obtained which are then divided from ventral, i. e., 6 o'clock to dorsal i.e. 12 o'clock aspect from below upwards. The mucosal collar is thus cut under vision and a good cosmetic result is obtained. Circumcision was done in 126 cases using this modification of the free hand technique.
Results : Good cosmetic result was obtained in all cases. No complications were seen
Conclusions: The modification described makes the free-hand technique of circumcision a simpler and safe operation that gives very good functional and cosmetic results.
Keywords: Circumcision, penis, phimosis.
|How to cite this article:|
Sharma G R, Sharma A. A simple modification of the free hand technique of circumcision. Indian J Urol 2004;20:126-9
| Introduction|| |
Circumcision is one of the commonest surgical procedures performed, with a sixth of the male population being circumcised world wide.  In a significant number of cases there are complications and dissatisfaction with the end result mainly on account of the cosmetic failure. , A good result is assured if the skin and mucosa are cut cleanly, sharply and an adequate collar of mucosa of about 6 mm in young boys and 12 mm in adults is kept all around the corona. 
A number of techniques of circumcision are described. Each has its own advantages and disadvantages. The described technique is a modification of the free-hand technique of circumcision.
| Patients and Methods|| |
Between April 1999 to February 2003, 126 circumcisions were done. The patients consisted of young boys as well as adults. The age distribution of the patients is given in the table. The indication for the procedure in all the cases was phimosis. All the circumcisions were done as day care cases and were performed under local anesthesia in adults and under caudal block with or without supplementation of general anesthesia in smaller boys.
In this technique the prepuce is held with mosquito forceps at 10 and 2 o'clock position. Minimal stretch is given so as to minimize excision of large amount of shaft skin. The adhesions between the glans and the prepuce are separated. A dorsal slit is then taken at the 12 o'clock [Figure - 1] extending to a point distal to the corona; which is about 6mm in small boys and is 10-12 mm in adults. The prepuce is then retracted and any adhesions or accumulation of smegma is cleared. The prepuce is then brought to its normal position and 2 mosquito forceps are applied at the 4 and 8 o'clock position. The prepuce is then divided at 6 o'clock position just lateral to the frenulum [Figure - 2]. The cut extends to a point just distal to the corona, similar to the one taken at 12 o'clock position. This results in the formation of the two flaps of the prepuce. They are then held at both their dorsal and ventral tips with hemostats. The skin along with mucosa is then divided from 6 o'clock to 12 o'clock from below upwards using sharp scissors [Figure - 3]. This is done on both the flaps. As two preputial flaps are formed, the mucosa is cut under vision and hence an adequate and uniform collar of mucosa is obtained around the corona. The bleeders are then coagulated with bipolar diathermy forceps. , Skin and the mucosa are approximated with 4-0 chromic catgut. We do not take a figure-of-8 stitch at the level of the frenulum. A single dose of broad-spectrum antibiotic was given intraoperatively in all the cases. Post operatively dressing was done which was removed on the third postoperative day.
| Results|| |
Very good cosmetic results were obtained in all the cases [Figure - 4]. No complication was seen in any of the cases. None of the cases had any reactionary bleed. No major complication like glans injury or urethral injury occurred in any of the cases. Healing was satisfactory in all the cases. Infection was not seen in any of the cases. Some pain on erection was complained by most of the adult patients in the immediate postoperative period. None of the adult patients complained of any difficulty in intercourse later on.
| Discussion|| |
The aim of circumcision is to excise enough shaft skin and inner preputial epithelium so that the glans is sufficiently uncovered to prevent or to treat phimosis and render the development of paraphimosis impossible.  A number of different techniques are followed to do circumcision like the sleeve technique, Free hand technique, Bone cutters, Oblique hemostat, Plastibell, Gomco clamp etc. 
A common cause of dissatisfaction after circumcision is the cosmetic failure occurring on account of inadequate and/or improper excision of skin and mucosa.  A cause of complaint, at times, is the loss of coronal differentiation between the glans and the shaft, which is caused by excising all of the mucosal skin right up to the corona.  An avoidable complication of circumcision is excision of too much of shaft skin, which leads to a buried penis or excessive hair bearing skin on the shaft. ,,
Of the commonly followed techniques for circumcision, the Sleeve technique is considered to give the best results cosmetically; as it involves all incisions under direct vision. , But this technique is considered tedious and difficult by some, especially in smaller boys. , The Bone Cutter and Hemostat methods are simple, quick and relatively bloodless; but have a major risk of injury to the glans.  In the free hand technique the prepuce is first divided at 12 0' clock position and then circumcision is done by dividing it from dorsal towards the ventral aspect by using scissors. This technique requires more surgical expertise and it is more difficult to leave a regular strip of mucosa uniformly around the corona, as the inner surface of prepuce is not divided under vision.  Also routinely a figure of eight stitch is taken by many at the level of frenulum, which causes bunching of skin at that level giving a poor cosmetic appearance.
In the technique described by us the initial cuts are at 12 and 6 o'clock positions resulting in the formation of two flaps, which are then divided, from 6 o'clock upwards under vision. Thus the chance of having irregular, inadequate or improper cutting of skin and mucosa are minimized. The end result is an adequate and uniform collar of mucosa all around the corona. This modification of the free hand technique is simple, easy to perfoun and gives a very good cosmetic result. Also it can be performed with equal ease in smaller boys as well as adults.
| Conclusions|| |
The described modification of the free-hand technique of circumcision is simple and easy to perform in smaller boys as well as adults, and gives a very satisfactory cosmetic result.
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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
[Table - 1]