Clinical circumcision methods:

1. freehand of excision and stitched
forcep guided method
sleeve resection method
dorsal slit method

2. device method:
Gomco clamp
Mogen Clamp

Forcep guided method

This method quite straight forward, but may removed too much of shaftskin or leaving too much of mucosal skin.

Tight skin dilated, any adhesion removed. 2 artery forceps are used to grasped the foreskin at 3 and 9 o’clock position. The foreskin is stretched. Taking care not to catched the glans penis, a straight long forcep is applied across the foreskin. 

Using a scalpel, incision made through the skin distal to the straight forcep. When the forcep is released, the cut skin retracted back with raw bleeding area inside. 

Bleeding controlled by catching with forceps and ligated with sutures. The edges approximated with absorbable sutures.

Sleeve resection method

This method can be performed on retractable foreskin. If the foreskin is tight, it need to be dilated with forceps or dilator instrument. Any adhesion thus removed.

A first circumscribe marking is made around the external skin at shaft of penis, about 0.5-1cm behind the corona glans. Another marking is made over the inner mucosa skin about 0.5 – 1cm behind the edge of corona glans. 

A ‘v’ shaped marked is made at ventral surface for both the external layer and internal one. The external skin is incised deep to subcutaneous tissue around the mark. Another incision made through the inner mucosa layer. 

Thus a ‘sleeve’ like skin can be excised leaving raw area between the edges from external and internal layers. The edges then approximate after ligating the bleeding blood vessels.

Dorsal slit method

The most common method for relieving phimosis and paraphimosis. Required at least 2 hemostat and a fine scissor.

Before dorsal slit is made, nature and condition of foreskin and glans penis should be determined well. A circumferential mark is made around the foreskin at about 75% distance from meatus to the corona glans. 

The foreskin then was pulled and clamped dorsally by 2 hemostat for a short period. This can prevent active bleeding from dorsal slit incision. An incision is made between the hemostat and cut through the foreskin until the marking area. 

The incision is continued by cutting around the marking. Make sure not to cut the inner mucosa layer too much, otherwise there would not be any enough mucosa skin to approximate with the proximal part of the wound edge. 

Any active bleeding is secured by artery forceps and ligated. The frenulum is reapproximated first, as it can be a site of problematic bleeding. 

The cut edges of the foreskin are closed with multiple simple interrupted stitches using 4-0 or 5-0 absorbable sutures. Excess bleeding is controlled with direct pressure and electrocautery. A sterile dressing of petroleum gauze can then be applied over the sutures.