Don't circumcise a child, unless his parents have very strong religous reasons for wanting it, or because there is some surgical indication for doing so. Remind them that the normal adhesions between the glans and the foreskin disappear as a child grows older. In areas where the incidence of carcinoma of the penis is high, circumcision can be considered good preventive medicine, but improving standards of hygiene would be better. A further argument against circumcision is that the prepuce is useful raw material for plastic surgery.

Aim to leave a 2 or 3 mm fringe of the inner layer of his prepuce. One of the purposes of the foreskin is to provide enough skin to allow the penis to erect, so when you do circumcise him, be careful not to take off too much skin, or his pubic hair will later be drawn up the root of his erected penis. On the other hand don't leave too much, or he runs the risk of recurrent phimosis. The method is the same in adults and children, except that an adult foreskin needs more dissection, and is more likely to need a dorsal slit.

A STORY FROM MULAGO HOSPITAL. Horrible shrieks used to be heard from the theatre whenever circumcisions were being done. A caring surgeon put Fig. 23-34 on the wall whereupon they stopped completely, to the gratitude of the staff[md]and the patients! Ten years later this event was still remembered. Fig. 23-35 CIRCUMCISION. A, free up the patient's prepuce. B, retract his foreskin and clean his glans. C, make a dorsal slit. D, cut the outer skin only with a scalpel. E, cut the inner layer with scissors leaving a 2 mm fringe at the corona. F, stitch the fringe of prepuce to the skin of the shaft. This will control most of the bleeding. G, control frenal bleeding with this special stitch.

CIRCUMCISION INDICATIONS FOR INFANTS. (1) Phimosis. (2) Extreme desire by the parents. Dissuade them if you can.

INDICATIONS FOR ADULTS. (1) Phimosis; recent balanitis, such as that due to diabetes. (2) The relief of paraphimosis following the dorsal slit operation. (3) A suspected malignant lesion confined to a small area of the foreskin.

ANAESTHESIA. Admit an older child or adult, and starve him. (1) If he is [lt]15 give him ketamine. (2) If he is [mt]15 use local anaesthesia, as in Fig. 23-34. You will have to cut the inner and outer skin of his prepuce, so you will have to infiltrate them both. A, and B, with the prepuce forward, infiltrate a ring of anaesthetic solution without adrenalin at site of section. C, pull back the prepuce. To do this you may have to infiltrate a little more solution and make a dorsal slit in it. D, infiltrate another ring of solution at the site of section just behind his glans. E, pull his prepuce forwards and do the circumcision. Or, (3) do a ring block round the base of his penis with 7[nd]10 ml of 0.75% bupivacaine or 2% lignocaine. Or, (4) give him a general anaesthetic.

METHOD. Paint and drape him for surgery. If adhesions or a tight phimosis prevent you pulling his prepuce back, paint up and drape as best you can. Use a probe to free up the prepuce from adhesions to the glans (A, in Fig. 23-35). Retract his foreskin if you can (B), clean up thoroughly and then pull it forwards again. With his penis in its normal relaxed position, feel for the bulge of the corona of his glans. Use scissors to cut a dorsal slit in his prepuce up to the level of the bulge in his corona (C).

CAUTION ! Make sure that the point of the scissors is not in his meatus.

Now cut the outer skin only round his corona (D). Cut the inner layer with scissors, leaving a 2 mm fringe at his corona (E). Use 2/0 or 3/0 plain catgut to control bleeding, by stitching the fringe of his prepuce to the skin of the shaft of his penis (F). Finally, control bleeding from his frenal vessels with a special encircling stitch (G). Dress the wound with vaseline gauze. No dressing is needed after 24 hours. The sutures will fall out on their own.

CAUTION ! (1) Don't cut his glans. (2) Don't use diathermy on the penis, it can cause gangrene of the whole organ. (3) Never use adrenalin in a local anaesthetic for the penis, this too can cause gangrene.

DIFFICULTIES [s7]WITH CIRCUMCISION If you CANNOT SEPARATE HIS PREPUCE AND HIS GLANS, because the cleft between them is obliterated, you may find yourself dissecting his glans from his thick adherent prepuce. If necesary, work slowly and carefully with a sharp scalpel. This will leave a raw area. Allow this to granulate on its own, and don't try to graft it with split skin.

If an adult has postoperative PRIAPISM, sedate him. Do this as a routine, if it is a problem in your area.

If he BLEEDS, insert one or two more interrupted sutures.