Dr. med. Dirk Manski

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Male Circumcision: Surgical Technique and Complications

Indications for Circumcision

Medical Indications for Circumcision

Religious and Non-Religious Traditions

Religious or non-religious traditions are the most common reason for circumcision in the postnatal period and childhood. The circumcision of the child at request of the parents is legally problematic. The child's right to physical integrity collides with the religious or traditional wishes of the parents.

Contraindications for circumcision

Contraindications to circumcision are coagulation disorders, acute and untreated balanitis, paraphimosis with necrosis or prominent edema, and untreated hypospadias with the need for surgical therapy.

Surgical Technique of Circumcision

Preoperative Preparations

Remove bothersome genital hair. Apply local anesthesia by a penile nerve block (see section above), alternatively spinal anesthesia or general anesthesia (in children). In patients with general anesthesia, an intraoperative penile nerve block reduces intra- and postoperative pain medication. Retract the prepuce if possible before skin disinfection.

Incision on the outer layer of the prepuce

Clamp and stretch of the outer prepuce. The skin incision is made along the coronal sulcus. Depending on the surgical technique, the incision is performed proximally (complete circumcision) or distally (incomplete or plastic circumcision) of the coronal sulcus. Careful hemostasis.

Incision of the inner prepuce:

Retract the prepuce. If this is impossible due to phimosis, incise the phimotic ring at 12 o'clock. The inner prepuce skin is incised in a circular manner along the coronal sulcus. The distance to the coronal sulcus is variable: if the space is ample, much of the inner leaf of the foreskin remains, and the frenulum can be left in place. Resect the frenulum if the distance is small (5 mm).

Resection of the prepuce

Resect the skin between both incisions. Careful hemostasis.

Wound closure:

Use 4-0 or 5-0 quickly absorbable suture material. Frenular sutures in the direction of the raphe should control the bleeding from the frenular artery. Subsequently, adapt the skin between the two incision lines, and use stay sutures for orientation at the 12 and 6 o'clock positions. Cover the wound with ointment dressing or gauze dressing with some compression.

Postoperative Care

Remove the gauze dressing the next day. Ointment dressing or loose protective wound dressings may be used for the following days. Advise regular showering and rinsing of wound secretions. After plastic (incomplete) circumcision, regular retraction of the penile shaft skin and cleaning of the coronal sulcus from wound secretions are necessary.

Complications of Circumcision

Alternative Techniques of Circumcision

Newborn Circumcision

Gomco clamp, Mogen clamp, or Plastibell clamp are standard techniques for neonatal circumcision. The devices simplify the procedure, which is possible with minimal anesthesia: application of topical EMLA, oral acetaminophen, and penile nerve block. The complication rate for newborn circumcision is 0.2–3%. Most complications are minor, but devastating complications like partial glans removal or ablative penile injury have occurred.






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  Deutsche Version: Technik der Zirkumzision