What are the operative steps for a circumcision procedure?

Circumcision Operative Steps

Preoperative Preparation

The procedure should be performed only by trained and competent practitioners using sterile techniques and effective pain management. 1

Patient Selection and Timing

• Ensure the infant's condition is stable and healthy before proceeding with elective circumcision 1
• Verify informed consent has been obtained, with discussion of potential complications including infection, bleeding, poor cosmetic results, and changes in sensation 2

Anesthesia Administration

Dorsal penile nerve root block is the most effective anesthetic technique for circumcision, reliably eliminating procedural pain. 3

• Administer dorsal penile nerve block (DPNB) with lidocaine injection at the penile root, which has demonstrated superior pain control compared to distal branch blocks or subpubic techniques 3
• Consider adding a circumferential penile block for enhanced anesthesia in adult procedures 2
• For neonates, combine pharmacological anesthesia with nonpharmacological interventions (pacifier, comfortable restraint positioning) as adjuncts, though these alone are insufficient 4, 1
• Topical anesthetics like EMLA cream are less effective than injectable anesthesia and should not be used as the sole analgesic 4

Important caveat: Nonpharmacologic techniques alone (positioning, sucrose pacifiers) are insufficient to prevent procedural pain and should only serve as adjuncts 1

Surgical Technique Selection

Device-Based vs. Standard Surgical Techniques

Circumcision devices probably reduce operative time by approximately 17 minutes compared to standard surgical techniques (from ~24 minutes to ~7 minutes), representing a clinically meaningful time saving. 5

• The Mogen clamp has been shown to result in shorter procedure time and less pain compared to the Gomco clamp 4
• Device-based circumcisions may slightly increase moderate adverse events (8 more per 1000 participants) compared to standard techniques, though serious adverse events are rare with either approach 5
• Patients may slightly prefer circumcision devices over standard surgical techniques 5

Standard Surgical Approaches

Two primary techniques are commonly employed:

Dorsal Slit Technique

• Especially useful in patients with phimosis 2
• Allows direct visualization and management of tight, non-retractile foreskin

Sleeve Technique

• May provide better control of bleeding in patients with large subcutaneous veins 2
• Offers improved hemostasis in vascular cases

Operative Steps for Standard Surgical Technique

Step 1: Preparation and Marking

• Identify anatomical landmarks including the coronal sulcus, frenulum, and extent of foreskin to be removed
• Mark the planned incision lines ensuring adequate tissue removal while preserving sufficient shaft skin

Step 2: Dorsal Slit (if using this technique)

• Create a dorsal slit in the prepuce to allow retraction and visualization
• Extend the incision to the level of the coronal sulcus

Step 3: Circumferential Incision

• Make a circumferential incision at the level of the coronal sulcus on the outer prepuce
• Create a second circumferential incision on the inner mucosal surface
• Ensure surgical margins of 5-10 mm, which are as safe as 2-cm margins and provide adequate tumor control when performed for oncologic indications 6

Step 4: Excision and Hemostasis

• Remove the foreskin between the two incision lines
• Achieve meticulous hemostasis through electrocautery or ligation of bleeding vessels
• The sleeve technique specifically aids in controlling venous bleeding 2

Step 5: Closure

• Approximate the skin edges with absorbable sutures in an interrupted or running fashion
• Ensure the frenulum is preserved and properly secured

Step 6: Dressing Application

• Apply petroleum-based ointment to prevent adhesion to dressing
• Place a light, non-constrictive dressing

Special Considerations for Oncologic Cases

When circumcision is performed for penile cancer, it should always precede radiotherapy to prevent radiation-related complications. 6

• Perform intraoperative frozen sectioning to achieve negative surgical margins when treating malignancy 6
• Send all excised tissue for histopathological examination to confirm diagnosis and exclude penile intraepithelial neoplasia or squamous cell carcinoma 7, 8
• Apply topical steroids postoperatively if inflammatory changes or lichen sclerosus is present to prevent Koebnerization and recurrence 9

Postoperative Management

Immediate Care

• Provide postoperative analgesia with acetaminophen 4
• Instruct parents or patients in proper penile care regardless of circumcision status 1

Follow-Up Protocol

• Assess for bleeding, infection, wound healing, and urinary function in early postoperative period 8
• For circumcisions performed for lichen sclerosus, schedule follow-up at 3 months to evaluate for residual disease on the glans and coronal sulcus 8
• Review histopathology results to confirm diagnosis and guide long-term management 8

Critical pitfall to avoid: When circumcision is performed for suspected lichen sclerosus, failure to send tissue for pathological examination can result in missed diagnoses of premalignant or malignant conditions 7, 8