Principal Methods of Circumcision

Guided Freehand Methods – Children and Adults

1. 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.

2. 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. Morgen clamp is used for the traditional circumcision

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.

Freehand Method – Adults

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.

Styles (Modes) of Adult Circumcision

1. High and low “cut” circumcision: This concept is determined by the scar line from the groove (sulcus) of the head of penis (corona of the glans) and also depends upon how much inner skin is removed. High “cut” means extra outer skin along with shaft of penile skin is cut and leaving long inner skin. Low “cut” means to cut more inner skin so that scar line is very close to the groove of head of the penis. Some men think completely opposite to this concept. They may think “cut” or scar line is taken in relation of base of penis. These high or low styles are not possible in all men. To put a scar line at the middle of shaft or close to the base of the penis is not recommended as it leaves a too long inner skin which can swell up due to lymphatic drainage (lymphoedema) and also with time, the inner skin stretches up to become a loose fold of skin which gives unsatisfactory results in the long term. This also involves cutting off too much penile skin from the shaft.

2. Tight versus loose circumcision: This may depend upon many factors for example: how much total foreskin is removed, the mobility of penile shaft skin and the attachment of the skin at the base of the penis (the base is the part nearest the abdomen). Tightness of skin around the penis is sometimes not possible, no matter how much foreskin is removed during the circumcision. This may be due to a loose attachment of skin at the shaft of the penis. Tight circumcisions should not be confused with the quality of erection which depends upon many factors. Erection is not related to circumcision. A loose circumcision may be referred to as a partial circumcision. A tight circumcision is not possible in those who have a considerable difference in size between fully flaccid and fully erect penis. They may have painful erections during sexual activity if a tight circumcision is performed.

Circumplast and Plastibell – Babies and Younger Boys

This is the preferred choice of procedure for infants and younger children.

The key feature of the Plastibell & Circumplast method is the use of the “plastic ring”. This method causes the foreskin to fall off naturally by blocking blood supply, in a similar fashion to how an umbilical cord falls off. This contrasts with surgical methods where a cut is made to remove the foreskin.

The procedure is carried out under local anaesthetic using sterile single use instruments and takes around 15 minutes to perform.

There are 2 types of plastic ring that we use. The Plastibell or the Circumplast. The Circumplast is the latest ring to be used and it has lower risks involved with proximal migration of the device due to the cylindrical design. However, in some children the Plastibell may still be the better suited option.

Once the local anaesthetic has taken effect, a small cut is made in the foreskin and the plastic device placed under the foreskin (over the head of the penis) and tied in place. The excess foreskin is the cut away.

In some very rare cases there maybe a clinical reason that the ring method has to be converted to the forceps guided method (see paragraph 1 above), if this is the case the reasons will be discussed before proceeding.

Methods We Do Not Use

Whilst we acknowledge the following alternative methods, they are not used in the Circumcision Centre.

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 bulkier 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.

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.

Zhenxi Rings or Shangring: 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.

Other Guided Methods

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.