Surgical Steps in Circumcision

Contraindications (Check Before Proceeding)

• Hypospadias
• Penile curvature (chordee)
• Buried or webbed penis
• Dorsal hood deformity
• Known coagulopathy
• Any condition requiring the intact foreskin for future repair

Anesthesia

Note: Epinephrine must NOT be used in penile blocks (end artery risk).

Technique 1: Sleeve (Double-Incision) Method

Standard technique for adults and older children

Step 1 - Retract and Inspect

• Retract the foreskin fully.
• If fibrotic/non-retractile, perform a dorsal slit first.
• Use a blunt-tipped curved hemostat and iodine-soaked gauze to lyse adhesions between foreskin and glans and remove smegma.
• Examine the glans and meatus carefully - this is the time to identify anomalies (megameatus, hypospadias with intact foreskin) before any incision.

Step 2 - Divide the Frenulum

• Pass a fine curved clamp underneath the frenulum to create a potential space.
• Clamp for 10 seconds to crush and achieve hemostasis.
• Divide the crushed tissue sharply or with electrocautery on cut setting.
• Stay well clear of the ventral glans to avoid injury.

Step 3 - Mark the Outer Incision

• Replace the foreskin.
• Using a fine marking pen, trace the outer incision line at the level of the coronal sulcus.

Step 4 - Mark the Inner Incision

• Retract the prepuce again.
• Mark the inner incision approximately 0.5-1 cm from the edge of the glans, following the curve of the glans.
• A common error is drifting too close to the glans - avoid this.

Step 5 - Make Both Incisions

• Incise along both marked lines using a #15 blade.
• Either incision can be made first.
• Use a fresh blade; stretch skin taut with dry gauze.
• Check hemostasis after each incision.
• On the ventral surface, be careful not to incise too deeply to avoid urethral injury.

Step 6 - Create the Skin Strip (Sleeve)

• A collar of skin is now isolated between the two incisions.
• Divide this collar longitudinally to convert it into a long strip of skin.
• This can be done sharply with knife/scissors or carefully with electrocautery.

Step 7 - Free the Skin from Dartos

• Elevate the skin edges and free them from the underlying dartos fascia using sharp dissection with scissors or electrocautery.
• Achieve thorough hemostasis using electrocautery or 5-0 or 6-0 absorbable suture ligatures.

Step 8 - Skin Closure

• Sew the shaft skin edges to the new preputial collar using fine absorbable sutures:
  • 6-0 for infants/children
  • 5-0 for older children/adults
• Place the first suture at 12 o'clock (dorsally) and second at 6 o'clock (ventrally) to prevent penile skin torsion.
• Leave tails long and apply mosquito clamps to help position the penis.
• In older boys, additional stay sutures at 3 o'clock and 9 o'clock may be placed.
• Incorporate some subcutaneous tissue in suture bites to align skin edges properly.

Technique 2: Dorsal Slit + Circumferential Excision

Bailey & Love's technique (commonly used in the UK)

1. Under anaesthesia, hold the prepuce in artery forceps and put it on gentle stretch.
2. Make a circumferential incision in the penile skin at the level of the corona using a knife.
3. Slit the prepuce dorsally in the midline to within 1 cm of the corona - this converts the foreskin into two flaps (the alternative is to slit first, then make the circumferential cut).
4. Separate the undersurface of the prepuce from the glans.
5. Mark the inner incision with a pen, leaving approximately 0.5 cm of inner preputial skin.
6. Make the second circumferential incision through this marked line.
7. Complete excision by cutting remaining connective tissue.
8. Secure vessels with bipolar diathermy or absorbable sutures.
9. Approximate cut skin edges with interrupted absorbable sutures, ensuring the frenular vessels are ligated.

In lichen sclerosus (LS/BXO), adhesion between foreskin and glans may be particularly dense. Always send excised foreskin for histology in suspected LS cases.

Technique 3: Device Methods (Neonates)

Postoperative Care & Dressings

• Petroleum jelly gauze or antimicrobial ointment (e.g., bacitracin) dressing applied.
• Warm baths to prevent eschar formation if skin degloving occurs.
• Topical antibiotic ointment routinely applied to prevent wound infection.

Complications (0.2-5% overall)

• Hinman's Atlas of Urologic Surgery, Chapter 120 - Sleeve Technique
• Bailey and Love's Short Practice of Surgery, 28th Edition, Chapter 85
• Campbell-Walsh-Wein Urology, Chapter 44 - Pediatric Circumcision