there is often a relatively tight prepuce and also physiological adhesions 2013 (apps.who.int/iris/bitstream/10665/93178/1/9789241506267_eng.pdf,

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9-19.1. INTRODUCTION By the time the client is in the procedure room, several important services and preoperative actions will have already been undertaken. The client has been found eligible for circumcision at the clinic or facility level and an appropriate method has been selected (as applicable). The clientŠor his parent(s)/guardian(s)Šhas provided consent/assent (see Box 9.1). In addition, the necessary equipment and supplies have been prepared for the circumcision procedure. There are several different methods for conventional or device-based surgical circumcision. The most appropriate method for a particular client depends on many factors: Ł capacity of the clinic or facility to provide the method, that is, the skill level of the provider who will be doing the procedure and the availability of supplies and equipment required; Ł medical eligibility of the client for the method, based on a focused history and physical examination, including a detailed examination of the penis and assessment of penile development; and Ł client™s preferred method (depending on medical eligibility), as feasible. This chapter describes three widely used conventional or device-based surgical circumcision methods for adolescent boys and men: forceps-guided, dorsal slit and sleeve resection. These surgical techniques were also described in the 2009 edition of this Manual for male circumcision under local anaesthesia and HIV prevention services for adolescent boys and men (Manual) . At that time, these techniques were chosen on the basis of extensive experience worldwide and their use in three randomized controlled trials of male circumcision in Kenya, South Africa and Uganda. In this edition of the Manual , the three techniques have been slightly modified because of the experience of more than 10 million adult and adolescent male circumcisions performed in East and Southern Africa. Male circumcision device methods recommended by the World Health Organization (see Box 9.2) are also efficacious, safe and acceptable methods of male circumcision among healthy men in the context of HIV prevention (1) . Devices are also prequalified through the World Health Organization for quality assurance. This Manual provides only limited information on devices. Providers who perform male circumcision using device-based surgical circumcision methods should know which methods are recommended and receive manufacturer-accredited training for the proper use of a particular device method. Thereafter, they should also consult the manufacturer™s most recent instructions for use of the device because device-based methods are relatively new and manufacturer™s instructions for use frequently change to keep up to date with user experience. Box 9.1. Reminder on consent/assent Even after all preparations are complete, a client may withdraw consent/assent at any time . While the provider can try to reassure any client who expresses doubt about the procedure, ultimately, whether the client is an adult or adolescent, the provider should respect the client™s decision. This chapter provides information on the following: Ł preparations for the circumcision procedure Ł local anaesthesia for male circumcision Ł step-by-step process for three conventional methods of surgical circumcision for adolescent boys and men: forceps-guided, dorsal slit and sleeve resection Ł variations in technique necessary when there is phimosis or scarring of the frenulum Ł devices used for male circumcision

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9-29.2. SAFE SURGERY 9.2.1. Key safety principles for male circumcision services Providers doing male circumcision procedures should keep the following in mind: Ł Male circumcision is an elective procedure performed on a healthy adolescent boy or man for partial protection from HIV. Ł Male circumcision presents a different situation from performing a medically necessary procedure on someone who is ill, when the risk of possible adverse events is balanced against harm caused by the illness (or resulting from not doing the procedure). Ł Client safety is a top priority in the context of male circumcision as part of a comprehensive HIV prevention strategy. To ensure that client safety is a top priority, the provider doing the male circumcision, and the provider™s managers or supervisors, should apply the following principles: Ł Competence in basic surgical skills is key. The most important component of safe surgery is having proper training in basic surgical skills (see Chapter 8) and in one or more of the specific methods described in Chapter 9. Ł Necessary supplies, equipment and other resources are available and ready for use. These include materials needed for providing safe, appropriate and routine services, and managing any adverse events. Ł Allowing enough time is critical. Overly hurried surgery is associated with an increase in adverse events. Most surgical methods require about 20Œ30 minutes per procedure. Allowing adequate time for safe surgery can be a problem when there is pressure to undertake a large number of procedures, but the provider doing the procedure must always put the client™s safety first. This is particularly important if there are difficulties in stopping bleeding during a procedure. Ł Proper sterile technique and infection prevention save lives. Anyone who touches the client during the procedure or comes into contact with any of the supplies, equipment, materials or waste from the screening or examination should be trained and skilled in performing standard infection prevention practices, as well as those practices specific to male circumcision. These specific practices are in the procedures regarding actions to take before, during and after the male circumcision (see Chapters 8Œ10). They are also presented in more detail and in a broader context in Chapter 5. Ł Providers should know the limits of their expertise. The provider doing the circumcision procedure should know his or her limits. Everyone on the team should work to create an environment where those doing the circumcision are supported and encouraged to seek advice or backup at any time. If something goes wrong, the provider doing the procedure should let others know about it and receive encouragement to get another trained provider to helpŠand not try to hide the problem. Problems are much easier to manage in a supportive environment, where asking for help is encouraged and where there is backup. Adverse events are often made worse by panicked attempts to overcome problems without help. Box 9.2. Devices prequalified by the World Health Organization For current information about male circumcision device recommendations and those prequalified by the World Health Organization, visit these webpages: http://www.who.int/hiv/topics/malecircumcision/en/ http://www.who.int/diagnostics_laboratory/evaluations/PQMCdevices_list/en/

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9-3Ł It is safer to have a trained assistant. Having a trained assistant helps to keep the surgery safe for the client, reduces the chance of the sterile area becoming contaminated and reduces stress if there is any difficulty with the procedure. Ł Use the World Health Organization™s safe surgery checklist to improve client safety. Using the World Health Organization™s safe surgery checklist has improved the safety of surgery throughout the world. A version of this checklist was adapted for male circumcision and is in Chapter 7. The use of the checklist is particularly important in any clinic or facility shared by male circumcision services and other services, such as family planning or general surgery, where other types of surgery are done, and, particularly, where other types of surgery are done in the same procedure room as the one used for male circumcision. Adverse events, while rare, can negatively influence the uptake of male circumcision services in the community, particularly if these incidents are not appropriately managed. 9.2.2. Circumcision-specific skills The provider who is doing the procedure should be trained and skilled in basic surgical skills (see Chapter 8) and in skills specific to the method of male circumcision that he or she will be performing. These are highlighted below and presented in more detail in this chapter. The basic surgical skills are the following: Ł Prepare the skin and drape the client before the procedure (see Section 9.3). Ł Give injectable local anaesthesia using subcutaneous ring block or dorsal nerve block, or both (see Section 9.4). Ł Retract the foreskin and manage adhesions (see Section 9.5.1). Ł Mark the line for circumcision (see Section 9.5.2). Ł Realign tissue and skin after the procedure (see Section 9.5.3). Ł Avoid damaging the urethra by having proper understanding of the anatomy of the frenulum and knowing the relationship between the frenulum and the underlying urethra (see Section 9.6.1). Ł Perform the forceps-guided method of circumcision (see Section 9.6.1). Ł Perform the dorsal slit method of circumcision (see Section 9.6.2). Ł Perform the sleeve resection method of circumcision (see Section 9.6.3). Ł Dress the wound (see Section 9.7). Ł Ensure that there is good recordkeeping and reporting (see Section 9.8). 9.3. SKIN PREPARATION AND DRAPING 9.3.1. Skin preparation Before the client™s skin is prepared, his genital area should be washed with soap and clean water to remove all visible dirt and debris. If he has not done so at home, this should be done at the clinic or facility. Cleaning is an essential step, as antiseptics will not be effective without thorough cleaning. Cleaning may be done with clean exam gloves. Prepare the skin with povidone iodine aqueous solution, starting with the glans and the shaft of the penis, and then moving out to the periphery (see Fig. 9.1). If the client has a history of allergy to iodine, use an alternative solution, such as chlorhexidine gluconate. Cleaning should be gentle. Holding the penis with a gauze swab, retract the foreskin to clean the glans. If there are adhesions, then give the client anaesthesia at this time; go back and clean the glans and coronal sulcus after the anaesthesia has worked (that is, after it has taken effect). The areas prepared with antiseptic include the penis, scrotum, adjacent areas of the thighs and lower part of the abdomen (suprapubic area), so there is no risk that the provider doing the procedure will touch unprepared skin. Repeat the

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9-4procedure so that the skin area is prepped two more times (three total). The cleaned penis should not be placed on skin that is not prepared (for example, abdomen or thigh). After the third wash, the wet antiseptic solution should remain on the skin for at least two minutes and allowed to dry. Fig. 9.1. Preprocedure skin preparation with povidone iodine aa Photograph © R. Bailey, Kisumu Project 9.3.2. Draping Draping provides a sterile operative field and helps prevent wound contamination. Before covering the client with sterile drapes, the provider doing the procedure (and any trained assistant) should carry out hand preparation, put on a sterile apron and put on sterile gloves. Only the operative area and the area where the anaesthesia will be administered should be left uncovered. A single drape with a hole for the penis (O-drape) (see Fig. 9.2) is better than four drapes secured with towel clips. The drape should cover the entire knee-to-chest area to provide an adequately large sterile field. The drape edges that hang below the procedure table are not sterile.

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9-6with bupivacaine as 2 mg/kg of lidocaine/lignocaine and 0.5 mg/kg of bupivacaine (2) . Tables 9.1Œ9.4 give examples of starting volumes and maximum volumes, and these tables are helpful guides to ensure that the maximum dose is not exceeded. It is good clinical practice to initially administer a starting dose and move to the maximum dose only if needed. Table 9.1. Maximum doses of lidocaine/lignocaine (1%) local anaesthetic agent(s) SAFE LOCAL ANAESTHETIC DOSINGŠSTARTING a AND MAXIMUM b VOLUMES 1% LIDOCAINE/LIGNOCAINE Weight in kg Starting volume Maximum safe volume 20Œ29 kg c4 mL Additional 2 mL to TOTAL of 6 mL 30Œ39 kg 6 mL Additional 3 mL to TOTAL of 9 mL 40Œ50 kg 8 mL Additional 4 mL to TOTAL of 12 mL More than 50 kg 10 mL Additional 5 mL to TOTAL of 15 mL a Starting dose of lidocaine/lignocaine is 2 mg/kg. b Maximum safe dose of lidocaine/lignocaine is 3 mg/kg. c For those weighing less than 30 kg, use 5 mL syringe so that volumes can be measured accurately. Starting volume is usually adequate; increase to maximum volume (dose) only if it is required for pain control up to the maximum . WARNING: Lidocaine/lignocaine with adrenaline (lidocaine/lignocaine with epinephrine) or bupivacaine with adrenaline (bupivacaine with epinephrine) should never be used for male circumcision surgery because of the risk of ischaemia (vessel constriction) of the whole penis, particularly if the penis is small. Also, the use of lidocaine/lignocaine with adrenaline (lidocaine/lignocaine with epinephrine) or bupivacaine with adrenaline (bupivacaine with epinephrine) may delay the onset of bleeding from blood vessels that require ligation or diathermy. Source: (2)

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9-7Table 9.2. Maximum doses of lidocaine/lignocaine (1%) and bupivacaine (0.25%) local anaesthetic agents SAFE LOCAL ANAESTHETIC DOSINGŠSTARTING a AND MAXIMUM b VOLUMES MIXTURE OF 1% LIDOCAINE/LIGNOCAINE AND 0.25% BUPIVACAINE 1:1 MIXTURE (EQUAL VOLUMES OF EACH) Weight in kg Starting volume c (1:1 mixture) Maximum safe volume (1:1 mixture) 20Œ29 kg 3 mL of each (6 mL total) Additional 1 mL of each drug to TOTAL of 8 mL (maximum 4 mL of each) 30Œ39 kg 4 mL of each (8 mL total) Additional 2 mL of each drug to TOTAL of 12 mL (maximum 6 mL of each) 40Œ50 kg 5 mL of each (10 mL total) Additional 3 mL of each drug to TOTAL of 16 mL (maximum 8 mL of each) More than 50 kg 5 mL of each (10 mL total) Additional 5 mL of each drug to TOTAL of 20 mL (maximum 10 mL of each) a Starting dose of lidocaine/lignocaine is 1.5 mg/kg and bupivacaine is 0.3 mg/kg. b Maximum safe doses of lidocaine/lignocaine is 2.0 mg/kg and bupivacaine is 0.5 mg/kg. c Starting volume is usually adequate; increase to maximum volume (dose) only if required for pain control up to the maximum .To improve provider efficiency through minimizing numbers of syringes needed, starting doses have been kept at or below 10 mL and maximum doses at or below 20 mL. WARNING: Lidocaine/lignocaine with adrenaline (lidocaine/lignocaine with epinephrine) or bupivacaine with adrenaline (bupivacaine with epinephrine) should never be used for male circumcision surgery because of the risk of ischaemia (vessel constriction) of the whole penis, particularly if the penis is small. Also, the use of lidocaine/lignocaine with adrenaline (lidocaine/lignocaine with epinephrine) or bupivacaine with adrenaline (bupivacaine with epinephrine) may delay the onset of bleeding from blood vessels that require ligation or diathermy. Source: (2)

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9-8Table 9.3. Maximum doses of lidocaine/lignocaine (2%) local anaesthetic agent SAFE LOCAL ANAESTHETIC DOSINGŠSTARTING a AND MAXIMUM b VOLUMES 2% LIDOCAINE/LIGNOCAINE Weight in kg Starting volume Maximum safe volume 20Œ29 kg c2 mL Additional 1 mL to TOTAL of 3 mL 30Œ39 kg c3 mL Additional 1 mL to TOTAL of 4 mL 40Œ50 kg 4 mL Additional 2 mL to TOTAL of 6 mL More than 50 kg 5 mL Additional 2 mL to TOTAL of 7 mL a Starting dose of lidocaine/lignocaine is 2 mg/kg. b Maximum safe dose of lidocaine/lignocaine is 3 mg/kg. c Use 5 mL syringe so that volumes can be measured accurately. Starting volume is usually adequate; increase to maximum volume (dose) only if required for pain control up to the maximum .WARNING: Lidocaine/lignocaine with adrenaline (lidocaine/lignocaine with epinephrine) or bupivacaine with adrenaline (bupivacaine with epinephrine) should never be used for male circumcision surgery because of the risk of ischaemia (vessel constriction) of the whole penis, particularly if the penis is small. Also, the use of lidocaine/lignocaine with adrenaline (lidocaine/lignocaine with epinephrine) or bupivacaine with adrenaline (bupivacaine with epinephrine) may delay the onset of bleeding from blood vessels that require ligation or diathermy. Source: (2) Table 9.4. Maximum doses of lidocaine/lignocaine (2%) and bupivacaine (0.5%) local anaesthetic agents SAFE LOCAL ANAESTHETIC DOSINGŠSTARTING a AND MAXIMUM b VOLUMES MIXTURE OF 2% LIDOCAINE/LIGNOCAINE AND 0.5% BUPIVACAINE 1:1 MIXTURE (EQUAL VOLUMES OF EACH) Weight in kg Starting volume (1:1 mixture) Maximum safe volume (1:1 mixture) 20Œ29 kg c1 mL of each (2 mL total) Additional 1 mL of each drug to TOTAL of 4 mL (maximum 2 mL of each) 30Œ39 kg c2 mL of each (4 mL total) Additional 1 mL of each drug to TOTAL of 6 mL (maximum 3 mL of each) 40Œ50 kg 3 mL of each (6 mL total) Additional 1 mL of each drug to TOTAL of 8 mL (maximum 4 mL of each) More than 50 kg 4 mL of each (8 mL total) Additional 1 mL of each drug to TOTAL of 10 mL (maximum 5 mL of each) a Starting doses of lidocaine/lignocaine are: lidocaine/lignocaine 1.5 mg/kg / bupivacaine 0.3 mg/kg b Maximum safe doses of lidocaine/lignocaine is 2 mg/kg and bupivacaine is 0.5 mg/kg. c Use 5 mL or smaller syringe so that volumes can be measured accurately. Starting volume is usually adequate; increase up to maximum volume (dose) only if required for pain control up to the maximum .WARNING: Lidocaine/lignocaine with adrenaline (lidocaine/lignocaine with epinephrine) or bupivacaine with adrenaline (bupivacaine with epinephrine) should never be used for male circumcision surgery because of the risk of ischaemia (vessel constriction) of the whole penis, particularly if the penis is small. Also, the use of lidocaine/lignocaine with adrenaline (lidocaine/lignocaine with epinephrine) or bupivacaine with adrenaline (bupivacaine with epinephrine) may delay the onset of bleeding from blood vessels that require ligation or diathermy. Source: (2)

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9-99.4.2. Safe injection of local anaesthetic agents The provider doing the procedure has the responsibility to personally check the vial of anaesthesia, ensure that the correct agent at the correct concentration has been selected and check the expiry date. It is important to verify that the anaesthesia is clearŠhas no visible particles in it (which may suggest that the vial is contaminated)Šand does not contain epinephrine (adrenaline). Always check the vial. Once the needle is in place in the base of the penis, the provider should aspirate the syringe to make sure that no blood has entered the syringe. If blood enters the syringe, do not inject the anaesthetic agent(s); move the needle to a new location and aspirate again. This ensures that the anaesthetic agent(s) is not injected into a blood vessel, corpora cavernosa or corpus spongiosum. Repeat aspiration each time the needle is moved and before any additional anaesthetic agent(s) is injected. Another method for injecting local anaesthetic is to fully insert the needle, aspirate to ensure that the needle is not in a blood vessel and then inject as the needle is withdrawn. With this method, it is important to inject only while the needle is being withdrawn. If the needle stops moving, then the injection must stop. Before resuming the injection, repeat aspiration to ensure that the needle is not in a blood vessel. 9.4.3. Additional analgesia Best practice is to give the client oral analgesia (for example, 500 mg tablet of paracetamol) 30 minutes before the procedure so that the oral agent is absorbed and effective as the anaesthesia wears off. Another dose of oral analgesia can be given for the client to take before he goes home. 9.4.4. Local anaesthetic techniques 9.4.4.1. Subcutaneous ring block technique The subcutaneous ring block technique involves administering local anaesthesia around the base of the shaft of the penis, thereby creating a subcutaneous ring of anaesthetic agent (see Fig. 9.3). This technique helps prevent any injury to the underlying penile tissue while achieving adequate control of pain on the skin of the shaft. Ł Using a fine-gauge needle (23Œ27 gauge), first inject approximately 0.1 mL of anaesthetic agent(s) subcutaneously at 12:00 o™clock. Ł Next, without withdrawing the needle, advance the needle into the subdermal space, making sure that the needle is freely mobile. At this point, aspirate the syringe and, if there is no blood, inject 2Œ3 mL of anaesthetic agent(s) to block the dorsal penile nerves. Ł Then, advance the needle subcutaneously around each side of the penis, aspirate the syringe and, if there is no blood, inject small additional amounts of anaesthetic agent(s) to complete a half-ring of anaesthesia around the dorsal half of the shaft (see Section 9.4.4.2). Ł To complete the block, make additional punctures at the 03:00 o™clock and 09:00 o™clock positions to continue the ring of anaesthesia around the ventral half of the shaft. If a puncture is made at the 06:00 o™clock position, there is a risk of urethral injury and injecting into a vessel. Once the anaesthesia has been injected, wait for a minimum of ˜ve minutes (timed by a clock) before beginning the male circumcision. A common mistake is to start the procedure before the anaesthesia has had time to work. Test sensation before starting the procedure by gently pinching the foreskin with an artery forceps. If there is any residual sensation, wait for an additional two to three minutes and test again. If there is still sensation, give more local anaesthesia, taking care not to exceed the maximum safe dose (see Tables 9.1Œ9.4).

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