Operating on an adult

FREEHAND
Operations on older boys and adults are typically done freehand, without mechanical aids. A popular technique involves first slitting the foreskin from the opening down to the corona of the gland, then cutting around from there. One published procedurei lays down rules to ensure a predictable result. First the foreskin is cut down from the tip to the ridge of the gland on top. Then a second, shorter cut is made down the lower side of the foreskin to the point where the fraenulum joins the gland. A straight line is marked, on each side, between the ends of the two cuts, and the outer skin is cut along this line. Then the inner skin is trimmed to leave a short collar which is sutured to the cut edge of the outer skin. This technique will always give a moderate circumcision, with not much inner skin remaining. Freehand circumcision along these lines is also sometimes done on infants. SLEEVE RESECTION

Diagram of the sleeve resection technique from Lucas, 1984ii A method popular among specialist urologistsiii involves removing only the surface layer of skin, carefully avoiding cutting any blood vessels and the loose connective tissue layers beneath the surface. Lines are marked on the skin (1 & 2) and the surface skin is removed between them (3). The edges are brought together and stitched (4), with the remaining blood vessels looping around beneath the surface, where they seem to cause no problem. Since no blood vessels have been cut, bleeding is minimal - no dressing is needed, and healing is rapid. The end result can be anything from a complete to a partial circumcision, depending on the way the initial marks were made, but the measurements shown in Lucas diagram, reproduced here, would leave quite a lot of loose skin.

Jones D.R. and B.K Gray. 1989. A measured circumcision. Journal of the Royal College of Surgeons of Edinburgh 34, 283 Circumcision is a common operation and a number of techniques have been described. The aim is to cut the foreskin at the correct length and angle so that it can be sutured to a neat rim of mucosa at the base of the gland without tension or excess skin. ii Lucas, M.G. 1984. A method of circumcision. British Journal of Urology 56, 551-553 A case is made for a method of circumcision which is little known in the United Kingdom. [...] The aim is, with the foreskin retracted, to remove a strip of skin from its underlying loose connective tissue. [...] It takes rather longer to perform than a conventional circumcision but the extra time is justified by improved cosmetic and functional results. iii Taguchi, Yosh, 1988. Private Parts - a health guide for men. McDonald Optima, 159pp From page 25: When I was in training I remember a senior urologist telling me that, if called upon, any doctor could perform a circumcision. As specialists in the field, he suggested, we should be prepared to offer more. The procedure he recommended removes skin, but nothing more. An analogy can be made to a down-filled jacket. We can shorten the sleeve by slicing off the end, as in the bell-clamp method, or we can cut the outer material and the lining and push the filling up the sleeve. By leaving behind the tissue between the outer and inner skin, we leave behind the vessels and nerves. There is less discomfort, less chance of bleeding, and an earlier return to normal function. One doctor, on whom I carried out such a circumcision, told me he was sexually functional in two weeks.