Disposable circumcision suture device: A potential bedside tool for circumcision – A series of 18 cases

INTRODUCTION

Male circumcision (MC) is a surgical procedure that holds the distinction of being one of the oldest known surgeries in human history.¹ In addition to promoting hygiene, this procedure plays a crucial role in protecting against various infections, including human papillomavirus, genital herpes, human immunodeficiency virus (HIV), and penile cancers.²

There are three frequently used surgical techniques for MC: The dorsal slit, the forceps-guided method, and the sleeve resection technique.³ The most common complications associated with these methods include peri/post-operative pain, bleeding, and infection.⁴

Recently, a circular stapler device is introduced to perform circumcisions.⁵ The disposable circumcision suture device (DCSD) is available in nine different models, each designed to accommodate various penile girths, including 10, 12, 14, 16, 18, 22, 26, 30, 32, and 34.⁶ In this report, we present our experience with the DCSD method of MC, which was performed on 18 patients with different genitalia related diseases. We thoroughly analyzed the perioperative and post-operative outcomes as well as complications associated with this method.

It is worth mentioning that the existing literature lacks similar studies specifically focusing on the dermatological applications of circumcision and the potential benefits that it can offer in our clinical management.

Material and methods

The study involved a retrospective analysis of MC cases which were performed in a private clinic in urban Gujarat between 2020 and 2023. All patients underwent routine blood investigations and written informed consent was obtained before the start of the procedure.

Procedure

• Appropriate device size selected based on penile circumference using a stencil

• Penis and surrounding area cleaned with betadine and spirit

• Local anesthesia (2% lidocaine) infiltrated for ring block at penis base

• Adjusting knob opened, inner ring removed

• Foreskin stretched, inner bell inserted over glans

• Dorsal slit given in phimosis/paraphimosis cases for easy passage

• Plastic cable tie used to tie prepuce over inner bell shaft [Figure 1a]

• Prepuce length assessed and adjusted; redundant length cut off

• Outer bell placed over inner bell, adjusting knob tightened

• The safety bolt was removed and trigger handle pressed for 1 min [Figure 1b]

• Adjusting knob opened, outer bell removed, followed by inner bell [Figure 1c]

• Ring secured at incision line for hemostasis [Figure 1d]

• The dressing was applied with mupirocin ointment and self-adhesive tapes.

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Figure 1:

(a) Clamping of foreskin after creating a dorsal slit (b) An outer bell is inserted and the trigger is pushed to perform cutting of excess foreskin, (c) Excess foreskin removed, (d) Post-circumcision appearance of penis, and (e) Appearance of penis two months post procedure.

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Patients were prescribed oral antibiotics for 5 days, along with analgesics and topical antibacterial agents. Dressings were recommended every alternate day for a week. Subsequently, follow-up visits were scheduled every 2 weeks for 2 months.

CASE SERIES

The cases comprised 18 male patients aged between 20 and 60 years, with an average age of 40.44 years. Among the 18 patients, three had diabetes, and one had hypertension. The procedures were performed for various conditions, including phimosis (2), paraphimosis (5), lichen sclerosus atrophicus (3), condyloma acuminata (2), and recurrent candidal balanitis (6). The most common conditions observed were paraphimosis and recurrent candida balanitis. The time taken to perform the procedure was 15–20 min.

Complications observed in the study included edema in two patients. However, there were no instances of instrument malfunction, infection, hematoma, or scarring/adhesions observed in the patients. Bleeding was almost nil throughout the procedure and post-procedure. Wound healing time was documented to be 7–10 days post-procedure during when there was self-dislodgement of staplers.

DISCUSSION

Circumcision is the removal of foreskin and is frequently performed for various medical indications. Recently, the procedure has gained more importance due to its protection against HIV infection by reducing HIV receptors over the foreskin.⁷

In our analysis, we observed that the total time required to complete the DCSD technique was shorter compared to other conventional methods. This is particularly important for dermatologists who have a busy daily practice, as it helps save valuable time. In addition, the DCSD method resulted in minimal blood loss during and after the procedure. Patients who underwent the DCSD method experienced less pain post-procedure. This finding is supported by two meta-analysis studies performed by Fan, et al., and Huo, et al.^8,9 One of the key advantages of the DCSD method was its notably shorter healing time. Since the device comes in a pre-sterilized disposable kit, the occurrence of post-operative infections and other complications is less frequent. The study observed that the only complication present was edema. However, it was resolved within 2 weeks following the procedure.

Conventional methods of circumcision have numerous disadvantages. The extended period required to acquire the skills to perform procedure poses a challenge in resource limited environments. The occurrence of complications like wound dehiscence, which is often observed with other methods, is less frequent with DCSD. However, it is essential to assess these factors through well-designed larger trials. Due to the absence of suturing, the DCSD does not result in a nodular appearance at the incision lines in the post-operative phase. The procedure results in a smooth incision line on healing [Figure 1e].

In addition to its efficacy in treating dermatological genital diseases, DCSD [Figure 2] also plays a role in the prevention of various sexually transmitted infections and recurrent infections associated with coexisting medical conditions. The primary drawback of DCSD lies in its high cost which limits its utilization in resource-limited areas.

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Figure 2:

Circumcision stapler device designed for single use.

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The lack of available literature on the application of circumcision procedures in the field of dermatology has motivated this study, as we seek to explore the significant role that it can play in the daily practice of dermatologists.

CONCLUSION

The benefits of disposable circular staplers, including reduced operative time, improved wound healing, and lower complication rates, make them a preferred choice in circumcision procedures. However, further research is needed to validate these findings and explore the long-term outcomes associated with disposable circular staplers. As technology continues to advance, it is crucial to embrace innovative approaches that enhance the safety, efficiency, and patient satisfaction in surgical interventions like circumcision.