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SUTURE-LESS CIRCUMCISION - WHAT MAKES IT SO SPECIAL?

Updated: Jun 16




The practice of male circumcision was believed to start back in ancient Egyptian time and it is one of the earliest procedures done on humans(Yuan et al., 2014). The procedure was done as a part of religious belief especially in Judaism and Islam as well as some sociocultural practice.


Currently, evidence-based medicine proved that the procedure is able to significantly decrease the transmission of STIs such as HIV, syphilis, HPV, and others. Apart from that, it was able to reduce the risk of penile cancer and generally improve penile hygiene. With the myriad benefit of circumcision, it is also advocated by WHO ( World Health Organization) especially in HIV-prevalence countries. The latest study found that the HIV transmission from women to men reduces approximately by 60% with circumcision


Conventional methods of circumcision are used worldwide, however, it is associated with high complication rates of bleeding, edema, and suboptimal cosmetic results. It is also consuming a longer time for the procedure. Newer technique in practice now is using devices such as Shang ring and stapler which has lower complication rates and shorter operating time compared to the conventional technique.


Methods of performing Circumcision


There are three techniques by which circumcision can be performed. The most commonly used and trusted technique is standard circumcision in which the foreskin is removed with the help of scissors and self-dissolving stitches. The stapler circumcision is another way of performing circumcision. In this technique, the foreskin is cut using a stapling device which also stitches the wound with the help of fine stainless steel staples. Nowadays LASER is also frequently used to perform circumcision in which laser energy is used to cut the foreskin and self-dissolving stitches are placed.

  • Standard Circumcision

  • Stapler Circumcision

  • Laser Circumcision

  • Other techniques: Plasti-bell Circumcision, Gomco Clamp Circumcision, Sham ring Circumcision

Advantages of Stapler Circumcision

  • Short operative time of just 5 minutes compared to 10-12 minutes of standard circumcision.

  • Minimal pain and tissue injury, and a low blood loss volume. Therefore, the stapler also has the potential to be used in high-volume settings by health care providers with minimal training and experience because of its simplicity and short operative and recovery times.

  • More uniform suture line as cutting is done by a surgical circular blade which is a part of the stapling device.

Disadvantages of Stapler Circumcision

  • The main disadvantage of the Stapler is that there may be a need to remove Residual staples after surgery. Ideally, the staples used for incisional closure need to fall off spontaneously, however, sometimes, they don’t fall off, as a result, the surgeon needs to remove them.

  • It is not a Standard Male Circumcision technique and we have more data on standard circumcision and its long term complications.

  • The stapler has a fixed diameter that cuts in a particular shape thus circumcision cannot be customised when using a stapler

  • It is a relatively costly procedure since it is a single-time usable Device and the cost of the device is added.

  • The stapler device is currently available in a limited range of sizes, thus, limiting its application in patients with Abnormal penis sizes and in children.


Stapler circumcision


Developed in China, the circular stapler is a new device used to perform circumcision. From studies, it is found that stapler circumcision requires a shorter operative time, causes minimal pain, and a low blood loss volume compared with another circumcision device, Shang Ring. The circumcision can be easily performed using local anesthesia on an outpatient basis.


The stapler device is a disposable device that includes two parts, an inner bell, and an outer bell. The inner bell is designed to protect the head of penis. For the outer bell, it has a circular blade to cut the foreskin and staples to close the wound which prevents bleeding.





The procedure


a) Informed consent will be taken, during this time the patient must be told about possible complication and post-operative care

b) The doctor will measure the penile glans to decide the most suitable size for stapler device required.

c) Local anesthesia will then be applied and when the numbing effect of the anesthetics has taken place, it is then cleaned with antiseptic solutions.

d) Inner bell is inserted and its position must cover the glans penis. (In severe phimosis, small slit may be needed to correct the inner bell position)

e) The inner bell is then screwed clockwise into the outer bell to sandwich the foreskin tightly.

f) Safety pin is then removed and the stapler is triggered. (Once the handles are triggered, the foreskin is cut and wound is close by staple concurrently)

g) Device is unscrewed and removed.

h) Wound is checked and pressed with gauze for 1-2 mins to stop any bleeding.

i) Penis is then bandaged using special compression bandages.






Post-operative care


Patients will undergo wound inspection within 2-3 days to examine for any possible complications such as bleeding or infection. Other possible complications include edema and wound dehiscence where the wound might fail to close. Hence, patients will be taught proper wound care in the comfort of their homes. In about 14 days after the procedure; the staples that are held together by a silicon cascade will detach. If it is not detached spontaneously, it may require removal by the doctor. All patients are advised to avoid sexual intercourse and masturbation for at least 4 weeks after circumcision for maximise healing.


Conclusion


The stapler circumcision is a simple and user-friendly device for performing circumcision. With shorter operative time, lower blood loss, and fewer postoperative complications than other techniques circumcision. The only disadvantage is the residual stapler might need to be removed post-surgery. However, with a high satisfaction rate and excellent cosmetic result, it is recommended mode of circumcision for male adults.