CIRCUMCISION MADE EASY

DORSAL SLIT METHOD OF CIRCUMCISION

The dorsal slit method requires more surgical skill than the forcepsguided
method. It is helpful to have an assistant present during the
procedure, although it can be done without one. There is a risk that
more skin is cut away from one side than the other, giving an
asymmetric result. Nevertheless, the technique is widely used by
general and urological surgeons throughout the world. It is the
technique illustrated in the WHO manual, Surgical care at the district
hospital.1

Step 1. Prepare skin, drape and administer anaesthesia, as described
above.

Step 2. Retract the foreskin and remove any adhesions, as described
above.

Step 3. Mark the intended line of the incision, as described above.

Step 4 (optional). Some surgeons prefer to mark the line of incision
by making a very shallow incision using a scalpel. This is useful on a
deeply pigmented man on whom it is difficult to see the line of the
marking pen or dabs of gentian violet. Before making the shallow
incision, check carefully that the incision line is level with the corona
and that even amounts of skin are marked for removal from each side
of the penis. The incision should be made just through the skin; it is
very important not to cut too deeply and divide blood vessels (Fig.
5.27).

One disadvantage of marking the line of incision with a scalpel is that
there may be an increased risk of accidental injury to the surgical staff.
In addition, a relatively inexperienced surgeon may cut too deeply.
However, these risks must be balanced against the risk of a poor result
of the circumcision operation if the marking is difficult to see and too
much or uneven amounts of skin are removed.


Step 5. 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.



Step 6. Place two artery forceps on the foreskin in the 11 o’clock and 1
o’clock positions (Fig. 5.29). 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.



Step 7. Between the two artery forceps, in the 12 o’clock position, use
dissection scissors to make a cut (the dorsal slit) up to the previously
marked incision line (Fig. 5.30).




Step 8. Using dissection scissors, cut the foreskin free, following the
previously marked circumcision line (Fig. 5.31).




Step 9. Any skin tags on the inner edge of the foreskin can be
trimmed to leave approximately 5 mm of skin proximal to the corona
(Fig. 5.32). Care must be taken to trim only the skin and not to cut
deeper tissue.



Step 10. Stop any bleeding and suture, as described in steps 7–10 of
the forceps-guided method.

Step 11. Check for bleeding. If there is none, apply a dressing (see
“Dressing” at the end of this chapter).