Circumcision عامر التواتي

Circumcision

Amer Eltwati  Irhuma *Saied Abdel Jawad,* *

Introduction:

Male circumcision is practiced over wide area of the world by some one – sixth of its population. Little is known of the origin of circumcision, despite the very considerable lit        on the subject. Circumcision has been practiced in west Africa for over 5000 years. The earliest Egyptian mummies (2300 B.C.) were circumcised. Circumcision in ancient Egypt was under taken for premarital ceremonial initiation.  Among the American Indians, circumcision was mainly adopted as an alternative to human sacrifice. Circumcision was introduced into Roman Europe with Christianity. In the Jewish community circumcision remains religious ritual and is usually performed on the child’s eighth day of life by a  Mohel. Religious circumcision is also practiced by Muslims. In western society, circumcision is usually performed for medical reasons, the commonest of which is phimosis.

Indications:

- Religion reasons : in Muslims and Jewish

- Medical reasons: include phimosis, paraphimosis, balanitis, and preputial neoplasms, with the recent increase in the number of urinary tract anomalies detected with in utero ultrasonography, circumcision should be advice in order to decrease the risk of ascending urinary tract infections once the urinary tract anomalies has been identified.

Contraindications:

Circumcision is contraindication in boy with hypospodias, chrodee without hypospedia circumcision should also be deferred in children with significant penoscrotal tethering, buried penis with large fat fed, or small penis, occasionally, as in the megameatus intact prepuce ano    (Mip variant fo hypospodieas), there is a normal prepuce, despite on underlying penil abnormality. Therefore it is mandatory the prepuce be retracted prior to circumcision in all cases, to expose the glans and meatus before foreskin removal.

· Surgical technique:

· General considerations:

Circumcision, particularly in infants and children, is not a trivi  procedure than can be performed within a few minutes by an inexperienced surgeon to the contrary, circumcision should be performed by an experienced individual who can evaluate the patient preoperatively and identify contraindications to the procedure, manage possible complications and evaluate the patient postoperatively.

Anesthesia:

Avoid cutting through the skin edges:

· Sleeve resection technique:

Although several technique of circumcision or available, the sleeve resection technique allows uniformly good cosmosis with direct visualization of the glans throughout the procedure. The fore skin is retracted and adhesions between the prepuse and the glans are broken manually. The visceral prepuce should be retracted until the deep purple coronal sulcus is visualized completely. With the prepuce in its usual position and with out applying any tension, the coronal junction is outlined with a marking pencil and is incised circumferentially with care taken to follow the “V” of the frenulum on the ventral surface. A circular circumferential incision is then made just proximal to the coronal sulcus on the mucosal surface of the prepuce. The sleeve of skin between the two incision is then excised in the avascular plane between dartos and Buck’s fascia. Hemostasis is meticulously  carried out using ligature. The skin edges are reapproximated with care using 410 or 510 chronic in an interrupted fasion. A compressive dressing of sterile vaselinated gauze is applied which is secured with tapes.

Dorsal slit technique:

The prepuce is retracted and the glandular adhesions are divided. The skin is marked at the coronal margin as described previously for solve technique. One hemostat is applied on the frenulum and two hemostats are applied on either side of the glans with a straight hemostat in between the dorsal clamps, crushing the skin to reduce bleeding. Then cut with scissors this crushed line arriving until 3mm of the gland. A curved incision is made to the fenulum, leaving the ventral part long enough so it would not retract. The skin layer is retracted and bleeding points are secured and ligated with 4/0 catgut ties. The cut edges in th immediate vicinity of the frenulum are drawn together by U shaped from the corona, the 2 cut edges are approximated accurately with 4/0 interrupted

*) Department of  Surgery, Faculty of Medicine, Sebha University.

catgut stiches. Lastly circular vaselinated gauze is used for dressing which is secured with tapes patient is discharged on the same day. Valium 5mg (diazepam) before sleeping is prescribed for 3 days, especially for young adults and children to reduce morning erection. If there is adhesion on the glans, topical antibiotic is applied.

· Complications:

Careful neonatal circumcision is associated with a very low complication rate. In two large series. This rate was 0,2% with most problems being minor. Complications include excessive skin removal, postoperative bleeding, penile adhesions, buries penis secondary to inadequate skin removal, metal stenosis, urethrocutaneous fistula secondary to removal of excess ventral skin, necrosis of the glans or penil amputation.

· Management of complications:

In most cases, excessive skin removal can be managed conservatively with local antimicrobial ointment and healing by secondary intention with good cosmosis. Most post operative bleeding ceases with manual pressure, which should not be excessive. Occasionally, suture ligaiton or a compressive dressing may be required. Urethrocutaneous fistulae can be avoided by careful preoperative evaluation to detect minimal hypospadias or chordee without hyposadias in which there is deficient corpus spongiosum. Concealed penis due to a scarred preputeal ring after circumcision usually results from inadequate skin removal and /or the presence of a large prepubic fat pad.

 

Traditional South Libyan custom for a child prepared for Circumcision

References:

1. Zareh GK., Amir, NA: Circumcision in 734 male adult, Arab J. urol., 2003; vol I. No.3:43-45.

2. Wiswell TE, Geschke DW. Risks from circumcision during the first month of life compared with those from uncircumcised boys. Pediatrics 1989; 83:1011

3. Jay BL, Stephen AK. Circumcision. Glenn’s urologic surgery, fifth edition 1998; vol.2, 897.