EMILIO AGUINALDO COLLEGE

School of Dental Medicine

GENERAL ANATOMY I (REGIONAL ANATOMY)

CASE CONFERENCE FOR FINAL PERIOD

Circumcision

Submitted by:

Medina, Katrina Mae E.

Doctor of Dental Medicine Class 2022

Submitted to:

Dr. Beda Jay Igasan

Professor, General Anatomy I

Date Submitted:

December 11,2018
 CHAPTER ONE

BACKGROUND OF THE CASE

I. Short introduction of the case

Circumcision is a surgical procedure of removal of the foreskin (prepuce), which covers the tip of

the penis. The procedure is usually performed for religious and traditional reasons, often 2 days

or first two weeks on newborn boy or at the beginning of stage of adolescence as a rite passage

on the adulthood. The procedure is also performed for medical reasons to treat problems in

which it involves the foreskin. During the procedure, a general anesthesia will be injected on the

base of penis then the foreskin. surgical clamp will be attached to the penis, then the foreskin

will be retracted or pushed from the head of the penis and trimmed it off. Then the surgeon

would sew down the edges using small stitches.

II. Patient’s profile and Chief Complaint

Patient K.A., a 12-year-old male, Roman catholic, Filipino, grade 6 student at St. Francis

school in general trias, residing at Dasmariñas city, Cavite went to wellcare clinic and laboratory

general trias for a surgical procedure known as prepucectomy.

III. History of present illness

1 hr prior to the procedure, patient K.A. consulted for circumcision.

IV. Past medical history

Patient had no any past surgery or any procedures before the circumcision.

V. Family history

Patient’s mother and father are both healthy.

VI. Personal and social history

 Patient K.A. is a non-smoker, and a non-alcoholic person. His hobbies include playing volleyball,

and playing online games. He is also a varsity in a volleyball team at the school.

VII. Physical Examination

Height =5 ft and 8 in (172 cm) weight= 59 kg (130.073 lbs) BMI= 19.78 kg/m2

Patient K.A.’s BMI was noted as normal.

General: Patient is awake, conscious, and oriented.

Vital Signs: BP = 110/80 mmHg, CR = 75 bpm, RR = 15 bpm, Temperature = 36.9°C

Pain Scale: Patient K.A noted a 1/10 pain in the scale, 10 being severely painful and 1 being

a pain that is bearable.

HEENT: Head is normocephalic. Tympanic membranes and auditory canals are all clear.

No nasal discharge. No infections were seen on the Oral cavity and pharynx.

Lung: normal breath sound was heard during auscultation.

Heart: regular rhythm, no murmurs heard upon auscultation

Abdomen: Soft abdomen, non-tender, normal bowel sounds, absence of any masses or

hernias.

Pelvic: No presence of abnormalities in the pelvic region

Rectal: absence of hemorrhoids, soft to normal stool

Extremities: no clubbing, no signs of edema, no cyanosis, no any deformities can be seen. No

any genital problems were seen during genital examination.

 CHAPTER TWO

DIAGNOSIS

I. Short discussion about Circumcision

The circumcision I not just done for medical, cultural, religioned purposes but it also had health

benefits. The benefit includes; easier hygiene for cleaning the penis, decreases the risk of

urinary tract infections, reduces the sexually transmitted disease, prevention of penile problems

e.g. phimosis, inability to retract the foreskin and paraphimosis, inability to return the foreskin

to its original location), balanitis, inflammation of glans, and balanoposthitis, inflammation of

glans and foreskin of penis, protection against penile cancer. if circumcision is not done properly

there are possible risk that can be affect the penis which includes; pain, bleeding and infection

at the site of circumcision, irritation of glans, increased risk of meatitis (inflammation of opening

of the penis), injury to the penis. Circumcision doesn’t affect fertility and it doesn’t enhance or

retract sexual pleasure for men or their partners.

II. Treatment

After the procedure, a wrap around dressing is applied to the penis. on the second day, he

should remove the bandage then apply bacitracin ointment around the sutures, several times

each day. Also avoid tight clothing (it can put pressure on the penis leading to pain). Exudate

and wounds are expected since it’s a normal part of healing process. A tissue would be applied

with gentle pressure to stop the oozing. A medication for pain reliever (e.g. Tylenol) would be

intake if it is prescribed by the doctor.

III. Procedure

 Equipments

(standard equipments for surgical procedure):

1. Instrument tray
 2. Dissecting forceps

3. Artery forceps

4. Curved Metzenbaum’s scissors

5. Stitch scissors

6. Mayo’s needle holder

7. Sponge-holding forceps

8. Scalpel knife handle and blades

9. “O” drape (80 x 80 cm, with -5 cm hole)

10. Gallipot for antiseptic solution (e.g. povidone iodine)

11. Povidone iodine (50 ml of 10% aqueous solution)

12. Plain gauze swabs (10 x 10 cm; 10 for procedure and 5 for dressing)

13. Petroleum-jelly-impregnated gauze (5 x 5 cm or 5 x 10 cm) and sticking plaster or

paper tape.

14. 15 ml of 1% lidocaine (without epinephrine) anaesthetic solution.

15. 10 ml or 20 ml syringe

16. Injection needles (-18 or -21 gauge)

17. Suture material (chromic gut or vicryl 3-0 and 4-0) with 3/8 circle reverse-cutting

needle

18. Gentian violet (no more than 5ml) or sterile marker pen

19. Gloves, masks, caps, and aprons

 Procedure:

Before procedure the patient undergoes in these steps:

1. The patient would be given a counselling to give him an idea about the procedure. (the

risks and the benefits of circumcision).

 2. An HIV testing would be done on the patient. This is recommended on any medical

institutions to take precautions of avoiding infections (passing infection from one

patient to another).

3. A medical staff would take medical history on the patient to know if he would be

suitable for the procedure or not. (e.g.- his current health, medications he is taking,

history of any disorders, etc.)

4. A physical examination and genital examination will be done to check if there’s any

anatomical problems on the penis and this helps to know if the procedure would be

suitable for the patient.

5. The patient would be given an informed written consent to be fill up before the

circumcision is performed. If the patient is a child or adolescent or a newborn (a legal

guardian would be the one who would put the information of the patient).

6. The schedule of procedure would be given to the patient

Preparation of the patient:

1. Preoperative washing by the patient. On the day of the surgery the patient should

wash his genital area and penis using water and mild soap, retracting the foreskin

and washing under it. This ensures the genital area is clean before the procedure.

2. If the pubic hair is long, it should be clipped before the patient enters the operating

room. Shaving is not necessary.

3. The patient should empty his bladder before entering the operating room.

Preparation of the surgical team:

Before they enter the operating room, all members of the surgical team should:

1. Remove all jewelry and ensure nails are trimmed or filed.

2. Remove any artificial nails or nail, polish.

3. Wash hands and arms up to the elbow with a non-medicated soap.

4. Pat and dry the hands and arms using clean towel.

5. Put on the surgical gloves, wear your surgical crown, facemasks, and protective eyewear.

In the circumcision of an adult or adolescent there are three types of surgical techniques that can be

used for the procedure. The three techniques wouldn’t be required to be learned all by the nurse,

medical or clinical officer, since it is the best to only master one technique in which it would give

them the best results with just a least of complications on the procedure. The healthcare provider

should become an expert in the technique of they preferred.

Surgical methods

I. Forceps-guided method

it is a simple step-by-step procedure which is suitable for a clinic setting. This can be learnt

by surgeons and surgical assistants who are new to surgery. This can be also done without

an assistant. This technique was used in south Africa and Kenyan trials of circumcision and

HIV infection.

Step-by-step procedure

1. Use povidone iodine antiseptic solution starting with the glans and the shaft of the

penis, and moving out to the periphery during skin preparation. While Holding the penis

with a swab, retract the foreskin in order to clean the glans. the applying of the solution

on skin should include the penis, the scrotum, the adjacent areas of the thighs and the

lower part of the abdomen (suprapubic area), so it would avoid the risk to the surgeon

when touching the unprepared skin during the procedure. An alternative solution such
 as chlorhexidine gluconate can be used for a patient with an allergy on povidone iodine.

The solution should remain wet on the skin for at least 2 minutes.

2. A sterile drape with a hole would be placed on the penis by covering the entire knee-to-

chest area for providing an adequate large sterile field. The drape provides sterile

operative field and prevention of wound contamination. The HCP should scrub and put

gown and gloves before covering the patient with sterile drape.

3. For administration of anaesthesia, there are two types; general and local. Local

anesthesia is preferred since it is less risky and less expensive. There are two types of

techniques for local penile anaesthesia used during circumcision procedure; penile

nerve block and the ring block technique. The ring block technique is used for the adult

or adolescent during circumcision while the penile nerve block is used for the infant. For

patient K.A., the ring block technique was used since he’s at the adolescent stage.

In this technique, a 23 fine gauge needle, inject approximately 0.1 ml of anaesthesia

solution subcutaneously at the 11 o’ clock position. Then without withdrawing the

 needle, advance it to the subdermal space of the penis, then inject 2-3 ml of anaesthesia

Then advance the needle subcutaneously around the side of the penis

And inject an additional 1 ml of anesthetic solution. After that withdraw the needle and

repeat the procedure, starting at 1 o’ clock position so as to complete a ring of

anaesthetic. After the injection, massage the base of the penis for 10-20 seconds for

increasing the diffusion of lidocaine surrounding tissue.

4. The foreskin should be retracted. If the opening of the foreskin is tight, dilate the

aperture of the foreskin with a pair of artery forceps. Once it has been retracted,

separate any adhesions by gentle traction using a gentle probe (artery forceps).

5. With the foreskin returned to a natural resting position, the surgeon would indicate the

intended line of the incision with a marker pen or gentian violet. The line should

correspond with the corona, under the head of the penis.

6. Grasp the foreskin at the 3 o’clock and 9 o’clock positions with two artery forceps. Place

these forceps on the natural apex of the foreskin, in such a way as to put equal tension

on the inside and outside surfaces of the foreskin. If this is not done correctly, there is a

risk of leaving too much mucosal skin or of removing too much shaft skin.
7. Put sufficient tension on the foreskin to pull the previously made mark to just beyond

the glans. Taking care not to catch the glans, apply long straight forceps across the

foreskin, just proximal to the mark, with the long axis of the forceps going from the 6

o’clock to the 12 o’clock position (taking the frenulum as the 6 o’clock position). Once

the forceps are in position, feel the glans to check that it has not been accidentally

caught in the forceps.

8. Using a scalpel, cut away the foreskin flush with the outer aspect of the forceps. The

forceps protect the glans from injury, but nevertheless, particular care is needed at this

stage.

9. Pull back the skin to expose the raw area. Clip any bleeding vessels with artery forceps.

Take care to catch the blood vessels as accurately as possible and with minimal adjacent

tissue. Tie each vessel or under-run with a suture and tie off. Take care not to place

haemostatic stitches too deeply. When dealing with bleeding in the frenular area or on

the underside of the penis, care must be taken not to injure the urethra.

10. Place a horizontal mattress suture at the frenulum. Make two sutures, aligned beside

one another. Align the first stitch across the wound; begin the second on the side that

the first ends. Then tie the knot on the side of the original entry point. A horizontal

mattress suture is placed in the 6 o’clock position (frenulum).

When placing the frenulum suture, take care to align the midline skin raphe with the

line of the frenulum. A common error is to misalign the frenulum and the midline skin

raphe, which results in misalignment of the whole circumcision closure.

11. Place a vertical mattress suture opposite the frenulum, in the 12 o’clock position. A

suture should be placed so that there is an equal amount of skin on each side of the
 penis between the 12 and 6 o’clock positions. The technique of vertical mattress suture

is place two further vertical mattress stitches in the 3 o’clock and 9 o’clock positions.

12. After placement of the sutures at the 6, 12, 3 and 9 o’clock positions, place two or more

simple sutures in the gaps between them.

13. Once the procedure is finished, check for bleeding. If there is none, apply a dressing
On the affected area to stop the bleeding. Once the bleeding stopped, place a piece of

petroleum jelly impregnated gauze around the wound.

II. Dorsal slit method

This method requires more surgical skill than the forceps-guided method. An assistant can

be helpful in this type of method. The technique is widely used by general and urogical

surgeons.

Step-by-step procedure

1. Use povidone iodine antiseptic solution and apply it starting with the glans and the shaft of the

penis, and moving out to the periphery during skin preparation. Hold the penis and retract the

foreskin and apply the solution on the penis, the scrotum, the adjacent areas of the thighs and

the lower part of the abdomen (suprapubic area).

2. Place the drape on the penis by covering the entire knee-to-chest area.

3. Administer anaesthesia by injecting approximately 0.1 ml of anaesthesia solution

subcutaneously at the 11 o’ clock position. Then without withdrawing the needle, advance it to

the subdermal space of the penis, then inject 2-3 ml of anaesthesia Then advance the needle

subcutaneously around the side of the penis. After that withdraw the needle and repeat the

procedure, starting at 1 o’ clock position so as to complete a ring of anaesthetic. After the

injection, massage the base of the penis for 10-20 seconds and inject an additional 1 ml of

anesthetic solution.
4. Retract the foreskin by dilating the aperture of the foreskin with a pair of artery forceps. Once it

has been retracted, separate any adhesions by gentle traction using a gentle probe (artery

forceps).

5. indicate the intended line of the incision with a marker pen or gentian violet as the foreskin is at

the natural resting state. The line should correspond with the corona, under the head of the

penis.

6. Grasp the foreskin with artery forceps at the 3 o’clock and 9 o’clock positions. Take care to apply

the artery forceps so that there is equal tension on the inner and outer aspects of the foreskin.

7. Place two artery forceps on the foreskin in the 11 o’clock and 1 o’clock positions. Check that the

inside blades of the two artery forceps are lying between the glans and foreskin, and have not

been inadvertently passed up the urethral meatus.

8. Between the two artery forceps, in the 12 o’clock position, use dissection scissors to make a cut

(the dorsal slit) up to but not beyond the previously marked incision line.

9. Using dissection scissors, cut the foreskin free, following the previously marked circumcision

line.

10. Any skin tags on the inner edge of the foreskin can be trimmed to leave approximately 5 mm of

skin proximal to the corona. Care must be taken to trim only the skin and not to cut deeper

tissue.

11. Stop any bleeding, and proceed with suturing.

a. For stopping the bleeding, pull back the skin to expose the raw area, identify the

bleeding vessels and clip it with artery forceps carefully, then tie each vessel try not to

place haemostatic stitches too deeply.

b. For suturing:
 b.1 place a horizontal mattress suture at the frenulum by a 6 o’clock position then

carefully align the midline skin raphe with the line of frenulum.

b.2 Place a vertical mattress suture place at the 12 o’clock position for an even amount

of skin sutured between 6 and 12 o’clock positions. then the surgeon would place two

further vertical mattress stitches in the 3 and 9 o’ clock positions.

b.3 once the four mattress sutures are in place, place simple sutures accurately and

carefully at the wound edges.

12. Check again for bleeding and manage as needed. Once there is no bleeding, apply a dressing on

the wounded area. Then place a dry, sterile gauze swab over the one already placed and secure

both gauzes in position with adhesive tape. Strap the penis to the lower abdomen using

adhesive tape

III. Sleeve Resection method

It is also known as double circular incision. This method requires a good surgical skill and its

more suited to a hospital setting than the clinic. An assistance is needed on this method.

Step-by-step procedure

1. Use povidone iodine antiseptic solution and apply it starting with the glans and the shaft of

the penis, and moving out to the periphery during skin preparation. Hold the penis and

retract the foreskin and apply the solution on the penis, the scrotum, the adjacent areas of

the thighs and the lower part of the abdomen (suprapubic area).

2. Place the drape on the penis by covering the entire knee-to-chest area.

3. Administer anaesthesia by injecting approximately 0.1 ml of anaesthesia solution

subcutaneously at the 11 o’ clock position. Then without withdrawing the needle, advance it

to the subdermal space of the penis, then inject 2-3 ml of anaesthesia Then advance the

needle subcutaneously around the side of the penis. After that withdraw the needle and
 repeat the procedure, starting at 1 o’ clock position so as to complete a ring of anaesthetic.

After the injection, massage the base of the penis for 10-20 seconds and inject an additional

1 ml of anesthetic solution.

4. Mark the intended outer line of the incision, with a V shape, pointed towards the frenulum,

on the underside (ventral aspect) of the penis. The apex of the V should correspond with the

midline raphe.

5. Retract the foreskin and mark the inner (mucosal) incision line, 1–2 mm proximal to the

corona. At the frenulum, the incision line crosses horizontally. Any significant bleeding

vessels should be clipped with an artery forceps and tied or secured with an under-running

suture. Provided the cut has not been made too deeply, most bleeding will be from the skin

edge and can be stopped by simple pressure over a swab.

6. Cut the skin between the proximal and distal incisions with scissor.

7. Hold the sleeve of foreskin under tension with two artery forceps, and dissect the skin from

the shaft of the penis, using dissection scissors.

8. Stop any bleeding, and proceed with suturing.

a. For stopping the bleeding, pull back the skin to expose the raw area, identify the

bleeding vessels and clip it with artery forceps carefully, then tie each vessel try

not to place haemostatic stitches too deeply.

b. For suturing:

b.1. place a horizontal mattress suture at the frenulum by a 6 o’clock position then

carefully align the midline skin raphe with the line of frenulum.

b.2. Place a vertical mattress suture place at the 12 o’clock position for an even amount

of skin sutured between 6 and 12 o’clock positions. then the surgeon would place two

further vertical mattress stitches in the 3 and 9 o’ clock positions.

 b.3. once the four mattress sutures are in place, place simple sutures accurately and

carefully at the wound edges.

9. Check again for bleeding and manage as needed. Once there is no bleeding, apply a dressing

on the wounded area. Then place a dry, sterile gauze swab over the one already placed and

secure both gauzes in position with adhesive tape. Strap the penis to the lower abdomen

using adhesive tape

 CHAPTER THREE

GENERAL ANATOMY

I. Anatomic Discussion

The penis is an organ that has 2 functions; first, is for micturition which contains urethra, in

which it carries urine from bladder to the external urethral orifice, where the urine is expelled

from the body. Second, is for sexual intercourse in which during sexual stimulation, the penis

gets erected, become engorged with blood, following emission (mixing of components of semen

in the prostatic urethra) ejaculation will occur, wherein the semen moves out of the urethra

through the external urethral orifice, then lastly the penis undergoes remission (penis returns in

its flaccid state).

The penis has three main parts; Glans, body, and root. The glans is the most distal part of the

penis in which it covers the distal ends of corpora cavernosa. It is conical in shape and its formed

by expansion of corpus spongiosum. This contains an opening of the urethra which is called

external urethral meatus. The third main part is root, is the most proximal part of the penis. It

also a fixed part of the penis and its not visible part externally. It contains three masses of

erectile tissue; right and left crura of the penis, and the bulb of the penis.

The bulb of the penis is situated on the midline of the penile root, and transversed by the

urethra and is covered on its outer surface by the bulbospongiosus muscle. Each crus is

attached to the side of the pubic arch and covered on its outer surface by the ischiocavernosus
 muscle. the two crura anteriorly converges and come to lie side by side in the dorsal part of the

body of penis which forms the corpora cavernosa. The bulb is continued forward into the body

of the penis and forms the corpus spongiosum.

The third main part of the penis is called the body, it is the free part of penis. Which is located

between the root and glans of penis. The body of penis is composed of three cylinders of

erectile tissue enclosed with a tubular sheath of fascia (buck’s fascia); two dorsally placed

corpora cavernosa and a single corpus spongiosum applied to their ventral surface.

The other parts of the penis is the skin which contains two types; the foreskin and frenulum.the

foreskin (a.k.a prepuce) is a fold or skin that covers the glans penis. The frenulum is a median

fold of the skin in which it is connected between the glans and foreskin.

II. Anatomic Correlation

On uncircumcised penis the skin of the penis (foreskin or prepuce) is still visible and it covers the

penis. during an erection, the foreskin retracts and almost disappears which its won’t affect how
big the penis would look when its erected. When it is in its flaccid state, the foreskin can make

the penis look slightly bulkier. By hygiene it requires an extra attention so it should be cleaned

Because irregular cleaning under the foreskin, bacteria, dead cells, and oil can cause smegma to

build up which can make your penis smelly an even lead to glans and foreskin inflammation

(balanoposthitis) this can also make the foreskin difficult to pulling back (phimosis).

When the penis is circumcised, the foreskin consists of an inner layer of mucosa, and an outer

layer of skin. During the operation, both layers are removed. After the operation, the remnants

of the foreskin would stitch top the skin behind the head of penis uncovered. After few days the

stitches would fall out.

 CHAPTER FOUR

APPENDICES

I. References

II. List Of Tables and Figures