Guided Freehand- Methods Freehand- Infant and Young Boy Techniques- Other Guided Methods- Alternative Methods:
Guided Freehand Methods
1.Shield and Knife (Scalpel): This is the method traditional used for a Jewish ‘bris’. The foreskin is pulled out in front of the glans, and a metal shield with a slot in it is slid over the foreskin immediately in front of the glans. The scalpel is run across the face of the shield to remove the foreskin. The glans is protected by the shield and the frenulum is not touched.
In a Bris the inner foreskin is then slit back to behind the glans and cut off. In a non-ritual circumcision by this method the inner foreskin may be similarly removed, or may be left intact and just folded back. No stitches are used, the wound simply being bandaged up.
The tightness of the finished result depends on the operator’s skill and whether or not the inner skin is also removed. Since the cut is always in front of the glans a relatively loose result is normal. The minimum amount of inner foreskin left is equal to the length of the glans. This method is usually only used on babies and very young children. For older children or adults the Forceps Guided method would be used.
2. Forceps Guided: This is a close relative of the Shield and Knife method for older children and adults. The foreskin is pulled out in front of the glans and a pair of stout locking forceps is clamped across it, parallel to the corona of the glans and immediately in front of the glans. The scalpel is run across the face of the forceps furthest from the glans to remove the foreskin. The glans is protected by the forceps. This method does not cut the frenulum but it can be removed before or after the circumcision if desired.
The tightness and relative amounts of inner and outer foreskin remaining depend on adjustments made before the forceps are fully closed. The minimum amount of inner skin remaining equals the length of the glans. The cut edges of inner and outer foreskin are then normally brought together and held by stitches.
3. Sleeve Resection: The foreskin is slid back along the shaft and a freehand cut is made around the shaft as far back as the scar line is to be placed. The foreskin is returned to cover the glans and another cut is made around the shaft at the same position along its length as the first. A longitudinal cut is made between the two circumferential ones and the strip of skin removed. The edges are pulled together and sutured. The glans and frenulum are not protected. The frenulum can be included in the main cutting or can be cut separately if desired. Results depend very much on the skill of the surgeon, but can be as tight or loose as desired with the scar line anywhere that is wanted.
4. Plastibell®: A plastic bell with a groove at the back of it is slipped between the glans and the foreskin (an initial dorsal slit may be needed to allow the bell to be placed). The foreskin is pulled slightly forward and suture material is looped around in the groove and a surgical knot tied tightly. The thread cuts off the blood supply to the foreskin which withers and drops off in 7 to 10 days, taking the Plastibell with it.
It is usual, but not essential, to remove the excess foreskin after the knot is tied – this is mainly cosmetic so that the boy already looks circumcised when returned to his parents. It also reduces the volume of dead foreskin which will drop off and thus reduces possible parental anxiety. The glans and frenulum are protected by the bell. The frenulum will never be cut when using the Plastibell. Very little blood is lost since the knotted thread seals off the blood vessels before the excess skin is cut off.
Tightness is moderate to slack. Because the bell remains on the penis for a week or so, the foreskin must not be pulled so tightly over it that it is caused to dig into the glans or obstruct the urethra. The groove is always forward of the corona of the glans and hence some inner foreskin must necessarily be retained. Only small size Plastibells are generally marketed and hence the method is only suitable for pre- pubescent boys (the makers say up to about 12 years of age only). No particular surgical skill is required beyond being able to tie a surgical knot. The Plastibell is thus very suitable for use by midwives and medical auxiliaries where doctors are not available.
Whilst we acknowledge the following alternative methods, they are not used in the Circumcision Centre.
5. Tara Klamp: This is a Malaysian invention which works in a very similar fashion to the Plastibell except that instead of having to tie suture material around a groove in the bell, plastic arms lock into place to force two surfaces into tight contact; with the foreskin trapped between them.
The device is much more bulky than a Plastibell and remains on the penis for 7 to 10 days until it is removed or falls off with the dead foreskin. The foreskin may be cut off just above the clamping ring but is more often left completely uncut (unless a dorsal slit is required to gain access for the bell part). The glans and frenulum are protected and the frenulum is never cut. The result is moderate to slack as with the Plastibell.
6. SmartKlamp: This works in the same general way as the Tara KLamp by trapping the foreskin between an outer ring and an inner tube, and thus cutting off the blood supply to the foreskin. Whereas the Tara Klamp is an ‘all-in- one’ design, with the locking arms at the top, the SmartKlamp consists of separate inner tube and outer clamping/locking part with the locking arms at the side. Once the clamp is in place the excess foreskin is removed using the inside of the baseplate as a guide. The glans and frenulum are protected. The result is normally moderate to slack.
7. Zhenxi Rings: grooved sleeve is passed over the glans to sit just behind the corona. The foreskin is replaced over this sleeve. A hinged plastic clamping ring is fitted over the sleeve, the position of the foreskin is adjusted and the nut tightened to hold the foreskin in place. An elastic cord is then wound tightly around the penis, compressing the foreskin into the groove of the sleeve below it. This cuts off the blood supply and the foreskin forward of it dies and falls off. The glans and frenulum are protected so the frenulum remains intact. The result is expected to be moderately tight, depending on the adjustment before clamping.
8. Gomco Clamp: A metal bell is placed over the glans and the foreskin replaced over it (a dorsal slit might be required to allow access for the bell). A metal plate, with a machined under surface in which the rim of the bell sits, is placed over the bell. The foreskin thus lies between the plate and the bell. A tensioning bar is hooked under a T-shaped piece on the top of the bell and screwed down tight to the baseplate; this traps the foreskin in position. A scalpel is run around the upper surface of the plate to remove the foreskin.
The whole device comes away with the severed foreskin. The cut edges are then normally sutured together. Tightness depends on the total amount of skin pulled through between the bell and baseplate before the clamp is finally tightened; while positioning depends on the relative amounts of inner and outer skin being pulled through. The back of the bell is usually very close to the glans rim and hence most of the inner foreskin can be removed if desired. The glans and frenulum are protected. The frenulum can be removed before or after the circumcision if required.
9. Laser: There have been reports of the use of laser surgery for circumcision. Literature references are very hard to find, but with increased use of lasers in other surgery it is quite possibly standard in some quarters. Laser circumcision was first reported as having been used in Israel to circumcise haemophiliac boys who could not otherwise have been circumcised.
The laser seals the blood vessels as it cuts and thus there is virtually no bleeding and minimal trauma to the penis, no sutures being required. The glans and frenulum are not protected. Tightness and scar placement are both unknown quantities and will depend very much on the skill of the operator.
10. Other Methods: There are a variety of other patented clamps and shields, all of which are related in some way to the traditional Shield and Knife method, the Plastibell method or the Gomco Clamp method. There are also numerous methods of freehand working which are variations on either the Forceps Guided or the Sleeve Resection method.