More Information

For further in-depth information and results about male circumcision based on medical research, see circinfo.net.

Main Circumcision Methods

Circumcision on newborns is usually performed either before they leave the hospital or in out-patient clinics a few days after birth. It should be noted that from the age of a few months, the procedure becomes more complicated and also more expensive.

  At the time the circumcision is to be performed, the infant is taken to the operating room where sterile conditions exist. Utilizing a Y-shaped plastic frame (called a "circumstraint"), the infant is first restrained to inhibit movement during the operation. The skin of the perineum and thighs are prepared with 10% povidone-iodine solution (Betadine) and the area is draped with sterile towels.

  The operation itself is normally performed using one of three possible methods methods [2]: the Gomco clamp (the most commonly used method), the Plastibell or the Mogen clamp.





Gomco Clamp

The Gomco clamp [1] consists of a metal bell and a clamp with a plate and yoke. After a dorsal slit is made, and the foreskin is seperated from the glans. The bell portion of the clamp is then placed over the glans and the foreskin is pulled over the bell through the plate and yoke of the clamp. The clamp is then screwed tightly onto the bell so that it holds the foreskin in place. The Gomco clamp compresses the foreskin between the metal clamp and bell, allowing it to be cut and removed with minimal bleeding. After the foreskin is excised (usually with a scalpel), the clamp and bell are removed. A vaseline gauze dressing is then applied.

Plastibell

As in the case of the Gomco device, a dorsal slit is made first and the foreskin is separated from the glans. The Plastibell [4],[5], consists of grooved rings of various sizes with handles. The proper size ring corresponding to the size of the glans is then selected and placed over the glans. The foreskin is pulled over the edge of the ring so that the edge is at the coronal sulcus. A silk surgical ligature is then tied in a groove around the ring. The foreskin is excised and the ring with the suture left in place until avascular necrosis causes it to fall off. The remnant of the plastibell usually falls off in three to seven days.

Mogen clamp

When the Mogen clamp [6] [7] is used, the first step consists of attaching a hemostat to the dorsal foreskin to indicate the portion to be removed. The prepuce is then pulled forward so that the foreskin stretches and the glans retracts slightly. The clamp is then slided across the redundant foreskin which excises the foreskin (the beveled under edge of the clamp protects the glans from injury). The skin is then retracted to free any remaining adhesions. Finally a a Vaseline gauze dressing is applied.


Other Devices

Throughout Eastern and Southern Africa, the WHO recommends voluntary medical male circumcision (VMMC) to reduce heterosexual HIV acquisition. Evidence has informed policy and the implementation of VMMC programmes in these countries. VMMC has been incorporated into the HIV prevention portfolio and more than 9 million VMMCs have been performed.

Conventional surgical procedures consist of forceps-guided, dorsal slit or sleeve resection techniques (e.g. the Gomco clamp or Platibell devices discussed above). Devices are also becoming available that might help to accelerate the scale-up of adult VMMC. The ideal device should make VMMC easier, safer, faster, sutureless, inexpensive, less painful, require less infrastructure, be more acceptable to patients and should not require follow-up visits. Elastic collar compression devices cause vascular obstruction and necrosis of foreskin tissue and do not require sutures or injectable anaesthesia. Collar clamp devices compress the proximal part of the foreskin to reach haemostasis; the distal foreskin is removed, but the device remains and therefore no sutures are required. Newer techniques and designs, such as tissue adhesives and a circular cutter with stapled anastomosis, are improvements, but none of these methods have achieved all desirable characteristics. For further information see here.

Some of the devices currently in use include:


PrePex Device

The PrePex Device was developed to achieve rapid scale-up of voluntary medical male circumcision (VMMC) in resource limited settings, prevalent in Sub-Saharan Africa. PrePex is the first known device to facilitate non-surgical adult MC that can claim all of the following: No injected anesthesia. No surgery. No sutures. No sterile settings. For further information please see the website, for current research articles, see [8] [9] here.


Pediatric sutureless circumcision

The technique used to perform sutureless circumcision is a modification of the standard sleeve technique with the use of a bipolar diathermy and the application of 2-octyl cyanoacrylate (2-OCA) to approximate the tissue edges. It results in faster operative times, with a significant cost savings, while maintaining comparable complication rates to the standard suture technique. This is a viable, less expensive surgical option for patients whose circumcisions are not covered by Medicaid in the US. For further information about the method see here, and regarding the cost effectiveness, see here.


Unicirc Device

The Unicirc device is a plastic and metal single-use-only disposable instrument designed in South Africa.

In a recent study it was shown that by using topical anaesthesia, excising the foreskin after applying the the Unicirc instrument for 5 minutes and sealing the wound with cyanoacrylate tissue adhesive in adults is rapid, easy to learn, heals rapidly by primary intention with excellent cosmetic results, and is potentially cheaper and safer than other methods. The use of this new method can facilitate the scale-up of mass circumcision programs.


AccuCirc Device

Another device which has been used in Africa is the AccuCirc device. It was designed to protect infants from injury, it consists of two innovative components: the Foreskin Probe/Shielding Ring and the Single-Action Clamp. These two components work together to deliver the delicate hemostatic crush and precision cut of the foreskin in a single actuation, improving the safety, consistency and convenience of the circumcision procedure. The Foreskin Probe/Shielding Ring ensures that the glans is protected and the foreskin is properly aligned, while the Single-Action Clamp ensures adequate hemostatis and the precise delivery of the protected, circular blade. The AccuCirc uses the Foreskin Probe/Shielding Ring and the Single-Action Clamp to complete the circumcision procedure. No dorsal slit, freehand scalpels, scissors, reusable clamps or safety pins are required. The AccuCirc comes in a single, self-contained kit and is completely disposable.

Here is a link to an educational video made for the Botswana Ministry of Health demonstrating how the AccuCirc early infant male circumcision device works.


Links to Websites with Further Information

The Encyclopedia of Surgery
Information about the circumcision procedure from the The Encyclopedia of Surgery site.


References

1. Urologic Surgery, ed. J.E. Fowler, Jr. Published by Little, Brown and Company.
Operative Obstetrics, 3rd Edition, R.G. Douglas and W.B. Stromm.

2. J.R. Holman, E.L. Lewis and R.L. Ringler, Neonatal circumcision techniques, Am Fam Physician 1995; 52:511-16.

3. For more information on the Gomco Clamp, see: D. Peleg and A. Steiner, The Gomco circumcision: common problems and solutions, Am Fam Physician 1998.

4. For more information on the Plastibell, see:
A.Y. al-Samarrai et al, A review of a Plastibell device in neonatal circumcision in 2000 cases, Surg Gynecol Obstet 1988; 167(4):341-3.

5. Pillai RG, Al Naieb Z, Plastibell circumcision supported by a calcium-alginate fibre dressing to reduce bleeding, Arab J Urol. 2015 Sep;13(3):179-81. doi: 10.1016/j.aju.2015.04.001. Epub 2015 May 19. For the online abstract, see here.

6. For more information on the Mogen Clamp, see: http://www.euroband.com/mogen.htm.

7. R. Reynolds, Use of the Mogen clamp for neonatal circumcision, Am Fam Physician 1996; 54:177-82.

8. Lebina L, Taruberekera N, Milovanovic M. et al., Piloting PrePex for Adult and Adolescent Male Circumcision in South Africa - Pain Is an Issue, PLoS One. 2015 Sep 25;10(9):e0138755. doi: 10.1371/journal.pone.0138755.
Link to the onsite abstract.

9. Ndagijimana A, Mugenzi P, Thomson DR et al., PrePex Male Circumcision: Follow-Up and Outcomes during the First Two Years of Implementation at the Rwanda Military Hospital, PLoS One. 2015 Sep 23;10(9):e0138287. doi: 10.1371/journal.pone.0138287. eCollection 2015.
Link to the onsite abstract.