MALE CIRCUMCISION:

DORSAL SLIT METHOD

Prepared by Ken
Romblon

OUTLINE

Objectives
Introduction
Benefits and risks
Absolute and relative contraindications to
circumcision
General surgical procedures
Step-by-step procedures: dorsal-slit circumcision
OR Tech
Prescription writing: antibiotics and pain reliever

OBJECTIVES

To know the benefits and risks of circumcision

To know when circumcision is unsuitable
To learn the surgical procedures for safe
circumcision
To apply the theoretical knowledge into practice

INTRODUCTION

Circumcision is the surgical removal of the

foreskin, the fold of skin that covers the head of
the penis
May also be performed for medical reasons to
treat problems involving the foreskin
Superficial wound healing after circumcision in
adults generally takes 57 days
About 46 weeks are needed for the wound to
heal fully

BENEFITS AND RISKS

Benefits

Risks

It is easier to keep the penis clean

Pain; Bleeding; &Haematoma

There is a reduced risk of urinary

Infection at the site of the

tract infections in childhood

circumcision

Circumcision prevents

Increased sensitivity of the glans

inflammation of the glans (balanitis)

and the foreskin (posthitis)

penis for the first few months after

the procedure

Circumcision prevents the potential Irritation of the glans

development of scar tissue on the
foreskin, which may lead to phimosis Meatitis - inflammation of the
(inability to retract the foreskin) and opening of the urethra
paraphimosis (swelling of the
Injury to the penis
retracted foreskin resulting in

Benefits
There is a reduced risk of some

Risks
Adverse reaction to the anaesthetic

sexually transmitted infections

used during the circumcision
(STIs), especially ulcerative diseases,
such as chancroid and
Syphilis
There is a reduced risk of becoming
infected with human
immunodeficiency virus (HIV)
There is a reduced risk of penile
cancer
There is a reduced risk of cancer of
the cervix in female sexpartners

ABSOLUTE AND RELATIVE

CONTRAINDICATIONS
Absolute Contraindications
Anatomical abnormality
Hypospadias - urethral
meatus is on the underside of the
penis
Epispadias uerthral meatus is on
the upper side of the penis

Relative Contraindications
Tight foreskin as a result of scar tissue
(phimosis)
Scar tissue at the frenulum may result
to poor wound healing
Penile warts can cause a lot of

Chronic Paraphimosis - the foreskin is

permanently retracted; may indicate a
long-standing problem
Genital ulcer disease

bleeding
Balanitis Xerotica Obliterans - a plaque
of scar tissue that extends onto the
surface of the glans and involves the
urethral meatus and the foreskin

Urethral discharge
Scrotal swelling
Bleeding disorders i.e. Hemophilia

GENERAL PROCEDURES

1.

Skin preparation with povidone iodine

a)

Prepare the skin with povidone iodine antiseptic

solution, starting with the glans and the shaft of
the penis, and moving out to the periphery

b)

Retract the foreskin in order to clean the glans.

c)

The prepared area should include the penis, the

scrotum, the adjacent areas of the thighs and the
lower part of the abdomen.

2. Anesthesia
a) Maximum dose of local anaesthetic
Examples of maximum safe volume of plain lidocaine (3 mg per
kg body weight).
Patient
0.5%
1% lidocaine 2% lidocaine
lidocaine
(10 mg per
(20 mg per
(5 mg per ml)
ml)
ml)
3 kg infant
1.8 ml
0.9 ml
Not
(e.g. 8 days old )
applicable
15 kg boy (e.g.
age 4 years)

9 ml

4.5 ml

2.25 ml

40 kg boy
70 kg man

24 ml
Not
applicable

12 ml
21 ml

6 ml
10.5 ml

b) Safe injection of local anaesthetic

Locate the subpubic space using palpation. It is usually located at

the base of the penis.

Using a fine 23-gauge needle, inject approximately 0.1 ml of

lidocaine subcutaneously; advance the needle into subdermal
space without withdrawing and inject 2-3 ml of lidocaine. This will
block the dorsal penile nerves.

After injection at the 90 degrees position, slowly pull the needle

without completely withdrawing it and position the needle 45
degrees to one side first and finally to the other.

After

injection, massage the base of the penis for 1020 seconds to

increase the diffusion of the lidocaine into the surrounding
tissues

Note:
Before injecting any anaesthetic, the surgeon should gently aspirate to make sure that no
blood enters the syringe. This is to ensure that anaesthetic is not injected into a blood
vessel. This safety precaution should be repeated each time the needle is moved, before any
additional anaesthetic is injected.

3. Suturing
a) Simple interrupted - the simplest type of stitch
and results in good apposition.
b) The point of the needle should pass through the
skin at 90 degrees to the skin surface and exit at
the same angle
Note:
The nearer to the skin edge the needle goes in, the better the skin
edge apposition but the higher the risk of the stitch cutting out.
If the stitches are placed at a greater distance from the wound edge,
there is a risk of inversion (burying) of the skin edges and poor
healing.

4. Instrument tying
More economical
than of hand tying as
It uses less suture
material

5. Dressing
a)
b)

c)

d)

Check that there is no bleeding

Once the bleeding stopped, place a piece of sterile
gauze around the wound. Secure in position with
adhesive tape.
Do not apply the dressing too tightly, as it could
restrict the blood supply and cause necrosis of the
glans.
The dressing should be left in position no longer
than 48 hours.

STEP-BY-STEP PROCEDURE: DORSAL SLIT CIRCUMCISION

STEP 1: Prepare skin, drape and administer

anaesthesia

STEP 2: Retract the foreskin and remove any

adhesions

STEP 3: Grasp the foreskin

with artery forceps
at the 3 oclock and
9 oclock positions.
Take care to apply
the artery forceps so
that there is equal
tension on the inner and
outer aspects of the
foreskin

STEP 4: Mark the intended line of the incision using

straight mosquito at the 12 oclock position.
The depression marks made will be the
intended line of incision.
STEP 5: Removed the straight mosquito at the 12
oclock position, the mark that was created will
be the line of incision. Use dissection scissors to
make a cut (the dorsal slit) up to but not beyond
the
previously marked incision line.

STEP 6: Stop any bleeding and suture.

STEP 7: Clean the area using NSS
STEP 8: Dressing of the wound

REFERENCE

Manual for Male Circumcision Under Local

Anesthesia, WHO

OR TECH

Includes:

Px profile
History of:

Immunization
Allergies
UTI
Hepatitis

Summary

of the surgical procedures done

Should be signed by licensed surgeon

OR TECH SAMPLE

SURGICAL PROCEDURES (INORDER)

Patient supine
Asepsis, antisepsis, and drapes
Local infiltration of anesthesia using Lidocaine (2%)
Dorsal slit done
Approximation of wound using Chromic 3-0
Hemostasis done
Dressing done
Patient tolerated the procedure well

PRESCRIPTION
Rx

Amoxicillin capsule 250 mg

Dispense no. 15
Label: Take 1 capsule every 8 hours round the
clock for 5 days

Mefenamic acid capsule 250 mg

Dispense no. 12
Label: Take 1 capsule every 6 hours for 3 days