Prepuce transillumination: A safety tool in forceps guided circumcision

Maged Rihan, MD, MRCS

General surgery department, Faculty of medicine- Cairo university- Egypt 

Correspondence to: Maged Rihan, MD, MRCS. E-mail: magedrihan@hotmail.com

Abstract

Background: Injury or even amputation of the glans or the penile shaft occurs rarely, but is a tragic circumcision related complication. Forceps guided technique is liable to this complication due to inability to visualize the glans before doing the incision. This study was designed; aiming to solve this problem by doing transillumination for the prepuce before doing the incision, thus exploring whether it contains any tissue between its layers and accordingly visualizing what is being done rather than performing the procedure blindly. Methods: Forceps guided circumcision was done for 432 males from August 2018 to July 2019. The mean age of them was 15.57 (1- 348) days. Transillumination through the pulled prepuce was done, illustrating the prepuce and verifying that no glanular or penile tissue is involved in the forceps lock before doing the incision. Results: The mean follow-up period was 12.45 (2-35) days. Twenty-one patients had postoperative bleeding; six patients had a hematoma. Fourteen of 21 patients were managed by a tight bandage; the remaining seven patients needed surgical exploration. None of the patients had glanular or penile injury. Conclusion: Transillumination of the prepuce as a modification for forceps guided circumcision is a protective safety step before cutting the prepuce in order to eliminate the incidence of glanular or penile injuries.

 

Keywords: Circumcision, Prepuce, Transillumination, Forceps, Complication 

Ann Afr Surg. 2020; **(*):*** DOI:http://dx.doi.org/10.4314/aas.v***.*

Conflicts of Interest: None

Funding: None

© 2020 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.

 

Introduction

Circumcision means total or partial surgical excision of the prepuce. Commonly, it is performed for neonates but can be done at any age (1, 2). All over the world, about 25-33% of males are circumcised (3).
The rate of circumcision is 70% in US and 6% in Britain. Circumcision for religious reasons is practiced by the Jews, Muslims, Black Africans and other racial groups. In Western communities, circumcision is commonly done for medical indications as phimosis, paraphimosis, balanitis and localized condylomata acuminata or carcinoma (4-6). There are many surgical techniques for circumcision which can be classified into one of three groups: shield and clamp (like: Plastibell, Gomco or forceps Guided), dorsal slit, and excision (5, 6). 
Complications of circumcision include: bleeding, phimosis, concealed penis, infection, urinary retention, infection, necrosis of the glans or the shaft, urethrocutaneous fistulas or iatrogenic hypospadias and epispadias (7). Injury or even amputation of the glans or the penile shaft occurs rarely, but is a tragic complication. Forceps guided technique (like using bone cutting forceps) is liable to this complication due to inability to directly visualize the glans before doing the incision (3, 8, 9).
Considering those mentioned complications and problems (especially glans or shaft injuries), this study was designed; aiming to improve the outcome and solve those problems which may occur by using the blind forceps guided technique. This can be done by transilluminating the prepuce before doing the incision, thus delineating and exploring whether it contains any tissue between its layers and accordingly visualizing what is being done rather than performing the procedure blindly. The aim of this study is to recommend the introduction of prepuce transillumination step before incision as a protective step aiming to eliminate the incidence of glanular or penile injuries.

Methods

Study design and population
This prospective cohort study was conducted at Aljedaani Hospital (private hospital in Jeddah- Kingdom of Saudi Arabia). The research and ethics review committee at the hospital gave approval to this study. Circumcision was done for 432 males from August 2018 to July 2019. Sampling of cases was done randomly. The mean age of them was 15.57 (1- 348) days. 

Perioperative care
Physical examination, complete blood count and prothrombin time tests were done prior to the procedure. Cases with hypospadias or epispadias were excluded. Informed consent was obtained from the parents. 
Twenty cases were done under general anesthesia (more than 6 months age) and the remaining cases were done by local anesthesia. All cases done by local anesthesia were discharged half an hour after procedure. Cases done under general anesthesia were discharged after six hours. All cases were seen in the outpatient clinic in the second and fifth days postoperatively. Daily Ibuprofen 7mg/kg was prescribed postoperatively. The dressing was removed by the surgeon in the second day of the procedure. Local application of a cream containing 0.2% nitrofurazone three times daily for the wound was recommended. All complications were reported. 

Surgical technique
After skin preparation with betadine and draping, local anesthesia was performed using penile dorsal nerve block by injecting the local anesthetic agent without adrenaline at a dose of 1 ml + 0.1 ml/kg body weight around the main trunk of the dorsal nerve of the penis and its ventral branch just below the symphysis pubis and deeper to the fascia on both sides of the penile suspensory ligament. The prepuce is freed from the glans by lysis of adhesions, the glans was inspected and the frenulum is cut by the bipolar cautery. The edges of the prepuce are pulled out in front of the glans by a pair of small artery forceps at 12 and 6 o’clock positions. The bone cutting forceps is applied across the prepuce parallel to the corona without forcible tightening and immediately in front of the glans to provide glans protection, hemostasis and a platform for adequate prepuce removal flush to it later on. Transillumination through the pulled prepuce is done using a simple light source like otoscope or a light torch held by the assistant from the back side of the prepuce after turning the room light down without direct contact to the prepuce (Figure 1).
The light is transmitted through the prepuce illuminating and backlighting it, this allows the surgeon to illustrate the prepuce to verify that no glanular or penile tissue is involved in the lock of the forceps in case of improper forceps placement which will appear as a dark area in the shining prepuce (Figure 2). 
In addition, transillumination will localize the course of blood vessels in the prepuce as a proactive step to facilitate bleeding control later on. After making sure that no any other tissue is involved within the prepuce, forcible tightening of the forceps is done and the scalpel is used to excise it. Hemostasis (if needed) was carried out by bipolar electrocautery. 4/0 vicryl rapid absorbable sutures were used for bleeding control and for wound closure in some cases.

Click to view figure 1

Click to view figure 2

Results

A total of 432 males were included. The mean age of them was 15.57 (1- 348) days. The mean follow-up period was 12.45 (2-35) days. Twenty-one patients had postoperative bleeding; six patients had a hematoma. Fourteen of 21 patients were managed by a tight bandage; the remaining seven patients needed surgical exploration for successful control of a retracted active bleeding vessel by bipolar cautery. None of the patients had glanular or penile injury.

Discussion

Circumcision related glanular or penile injuries has been recorded repeatedly with varying levels of severity starting from skin or meatal injury to partial or total glanular or penile amputation. In one large series in the pediatric population; 64 boys with penile trauma were hospitalized over 20 years and 43 (67%) were caused by circumcision (10). Glans partial removal has been recorded with the use of clamp techniques when the operator accidentally catches the glans in the clamp (11). Circumcision by bone cutting forceps is a settled and time-tested technique of circumcision in many developing countries (12). 
In a study conducted by Javed et al comparing bone cutter and open method of circumcision concluded that both methods proved to be safe and effective techniques with reproducible results but they emphasized that trauma to glans is more common with bone cutter circumcision especially in the hands of an inexperienced operator. (13).
In this study (as stated in the results), there was no recorded cases of penile or glandular injuries, this may be related to that all the cases were done by only one experienced surgeon which may be considered as a bias in the study. But I assume that even with less experienced hands if this transillumination technique is used, it will eliminate any incidence of this type of trauma.   
 The aim of this study is to recommend the introduction of prepuce transillumination step before prepuce incision as a simple and fast modification on the classical circumcision forceps guided technique to avoid any probability of penile or glandular injury.

 

Conclusion
Circumcision is a minor operation which should be done in hospitals by trained surgeons using standard techniques as Plastibell, Gomco or by open method. The use of bone cutting forceps guided circumcision is a settled, time tested and widely used technique in many developing countries. Trauma to the penis including glans amputation is more frequently seen with the use of this method. Therefore, the search for cheap and fast tools to add more safety and protection is an important requirement for this technique in these countries. From this point, this study recommends the use of the transillumination step before cutting the prepuce as a modification for all forceps guided circumcisions in order to eliminate the incidence of this type of trauma.
 

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declarations of interest

None

References

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