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## Meet the editors

Ahmad Zaghal, MD, MSc (Clin Ed), FACS, FEBPS, graduated from the general surgery residency program at the American University of Beirut Medical Center (AUBMC), Lebanon, in 2012. He then completed a two-year fellowship in pediatric surgery at the University of Iowa Hospitals and Clinics, USA, and a further year of fellowship in the same specialism at Chelsea and Westminster Hospital, UK. He has been a pediat-

ric surgeon and assistant professor of surgery at AUBMC since 2017. Dr. Zaghal is board certified by the European Board of Pediatric Surgery. His special interests are minimally invasive and neonatal surgery, and medical education. He is a fellow of the Higher Education Academy. Dr. Zaghal has published several articles in peer-reviewed journals and authored several chapters in general and pediatric surgery books.

Dr. Ali El Safadi graduated from the School of Medicine, Lebanese American University (LAU), in 2020, and is currently completing his residency training in the Department of Obstetrics and Gynecology at the American University of Beirut Medical Center. Dr. El Safadi is interested in basic and clinical research, with a particular focus on innovation, technology, and medical education. He has authored several

articles in peer-reviewed journals and presented his work at national and international conferences.

### Contents


## Preface

The practice of circumcising males for prophylactic reasons dates back over 6,000 years to ancient Egypt, as well as to cultures, such as in Sub-Saharan Africa, where it was performed on boys as a rite of passage into adulthood.

Today, opinions on circumcision remain divided, with some people opposing it and others investing in programs to circumcise men in regions with high rates of HIV infection. The different circumcision techniques described in the literature include both traditional and innovative methods.

This book helps healthcare providers to familiarize themselves with the different techniques for male circumcision, in order to provide optimal care and the best surgical outcomes for those seeking the procedure.

> **Ahmad Zaghal, MD, MSc (Clin Ed), FACS, FEBPS** Department of General Surgery, American University of Beirut Medical Center, Beirut, Lebanon

> > **Ali El Safadi, MD** Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon

**1**

Section 1

Introduction

Section 1 Introduction

#### **Chapter 1**

## Introductory Chapter: Novelty Meets Tradition

*Ahmad Zaghal and Ali El Safadi*

#### **1. Introduction**

Male circumcision has been practiced for centuries by different cultures; nowadays, it is considered one of the most commonly performed surgical procedures worldwide. The oldest picture depicting circumcision dates back to 2300 BC in ancient Egypt; it was considered a symbol of pledge between God and Abraham [1].

Apart from cultural and religious perspectives, circumcision is performed for medical reasons including preventing sexually transmitted diseases, recurrent urinary tract infections, phimosis, and balanoposthitis [2]. In 2007, the World Health Organization (WHO) recommended the practice of youth and adult circumcision as an effective method to prevent the transmission of Human Immunodeficiency virus (HIV) in high endemic areas [3].

There are different circumcision techniques described in the literature. The WHO manual on male circumcision recommends mainly three adult and four pediatric techniques for circumcision. The sleeve resection, surgical dorsal slit, and forcepsguided are advised for adults, whereas the Plastibell method, Mogen and Gomco clamps, and the dorsal slit technique are advised for the pediatric population [4].

#### **2. Novel techniques for male circumcision**

Currently, circumcision is performed using different techniques depending on instruments availability and surgeons' expertise. Most commonly utilized circumcision methods include Gomco clamp, Mogen clamp, Plastibell, dorsal slit, and bone cutter. Ring circumcision devices such as Plastibell, Shang Ring, and other plastic rings are popular and are the preferred instruments for circumcision due to their ease of usage, they allow a less traumatic technique with a low complication rate and better cosmetic outcomes [5].

Advances in the medical field have brought into light new methods to perform male circumcision. These techniques permit more desirable clinical outcomes in terms of less morbidity for the patient, less to no pain, shorter procedural time, and better cosmetic outcomes.

Laser circumcision (LC) has recently received attention as one of the innovative techniques of circumcision. A high-intensity light beam is used to cut and seal the foreskin. There are various types of LC namely using heat, carbon dioxide, or neodymium as energy output. Neodymium: yttrium-aluminum-garnet (Nd-YAG) lasers permit accurate cutting while achieving hemostasis and minimal tissue damage [6].

Carbon dioxide laser beam is used in focused mode to resect a demarcated circumferential incision through the skin reaching the subcutaneous mucosa. Because of its thermocoagulation effect, hemostasis is reached by cauterizing the small blood vessels with surrounding tissue [7].

Heat energy Metzenbaum scissors can be used as an alternative to conventional clamps in which circumcision is performed using bipolar scissors to remove the foreskin and underlying mucosa and proceed with the frenulotomy, and then closure of the wound is achieved using synthetic sutures depending on the size and age of the patient [8].

#### **3. Comparable overview of various techniques used in circumcision**

After circumcision, the penis is inspected for possible lacerations, bleeding, inflammation, hematoma, and edema. There are various factors that dictate potential acute complications including anatomical variances, patient's age, and surgical technique used.

Studies exploring complication rates of circumcision are sparse, but available statistics denote the overall complication rate of this procedure between 0.2 and 5% [9].

Traditional techniques such as dorsal slits and forceps-guided methods require more surgical expertise and procedural time than other traditional methods like Mogen and Gomco clamps, and Plastibell, which require shorter surgical time. Furthermore, they are easy to learn and perform. Less cosmetic satisfaction was noted using the dorsal slit method because of lack of symmetrical foreskin cutting [10].

Comparing the Mogen clamp and Plastibell method, studies have shown more risk of nonstandard amputation of the glans penis with the Mogen clamp, whereas Plastibell displacement can cause glans necrosis. However, higher risk of lacerations and bleeding was seen with Gomco clamp usage [11, 12].

The most common acute complication with the use of Plastibell is bleeding with a rate ranging between 2.5 and 4%. Paraphimosis is another complication of Plastibell technique attributed to the dislodgement of the plastic ring [13, 14].

The use of bipolar scissors for foreskin cutting in circumcision is comparatively new. Marsh et al. reported the first case of bipolar usage in 1995 [15]. Common acute complications of this procedure include bleeding, edema, erythema, hematoma, and pain [8].

Carbon dioxide laser-directed circumcision has been shown to provide adequate incision and hemostatic properties under the effect of small vessel cauterization. In addition, better cosmetic outcomes were noted with the use of laser and less postoperative pain compared to the conventional scalpel method [7].

#### **4. Future perspectives**

Male circumcision can be safely performed at any age, but most of the procedures are done during infancy. That said, most of the procedures are done at an early age to maximize circumcision benefits and reduce possible adverse events [16]. Various techniques are used to perform male circumcision. When performed properly, surgical complications rate is low. Minor complications are noted between 0.5 and 1% when performed in infancy [17].

#### *Introductory Chapter: Novelty Meets Tradition DOI: http://dx.doi.org/10.5772/intechopen.109370*

Current studies are directed at describing a technique that can achieve the best surgical and cosmetic outcomes for the patient and attempt to prevent transmission of HIV [18]. Traditional and novel techniques for circumcision are detailed in the literature in terms of proper usage, pros and cons of each technique, and efficacy of innovative methods compared to traditional ones. Few new techniques of circumcision are described in the literature, however, there is not enough data to compare their efficacy and safety profiles with the traditional methods, and hence they are not yet fully supported.

It is key for the healthcare providers to acquaint themselves with available procedures for male circumcision that can potentially deliver the optimal care and best surgical outcomes for boys and men seeking circumcision.

### **Author details**

Ahmad Zaghal\* and Ali El Safadi Department of Surgery, American University of Beirut Medical Center, Lebanon

\*Address all correspondence to: az22@aub.edu.lb

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Meijer B, Butzelaar RM. Circumcisie in historisch perspectief [Circumcision from a historical perspective]. Ned Tijdschr Geneeskd. 2000;**144**(52):2504-2508

[2] Anwer AW, Samad L, Iftikhar S, Baig-Ansari N. Reported male circumcision practices in a muslimmajority setting. BioMed Research International. 2017;**2017**:4957348

[3] WHO. Preventing HIV through Safe Voluntary Medical Male Circumcision for Adolescent Boys and Men in Generalized HIV Epidemics. Geneva, Switzerland: World Health Organization; 2020

[4] Hargreave T. Male circumcision: Towards a World Health Organisation normative practice in resource limited settings. Asian Journal of Andrology. 2010;**12**(5):628-638

[5] WHO/UNAIDS. Male Circumcision: Global Trends and Determinants of Prevalence, Safety, and Acceptability. Geneva, Switzerland: World Health Organization; 2008

[6] Xu Y, Li F, Li Z, et al. A prospective, randomized controlled trial of circumcision in adult males using the CO2 laser: Modified technique compared with the conventional dorsal-slit technique. Photomed Laser Surgery. 2013;**31**:422-427

[7] Ronchi P, Manno S, Dell'Atti L. Technology meets tradition: CO2 laser circumcision versus conventional surgical technique. Research and Reports in Urology. 2020;**12**:255

[8] Méndez-Gallart R, et al. Bipolar scissors circumcision is a safe, fast, and bloodless procedure in

children. Journal of Pediatric Surgery. 2009;**44**(10):2048-2053

[9] Kaplan GW. Complications of circumcision. Urology Clinical North America. 1983;**10**:543-546

[10] Lei JH, Liu LR, Wei Q, et al. Circumcision with "no-flip Shang Ring" and "Dorsal Slit" methods for adult males: A single-centered, prospective, clinical study. Asian Journal of Andrology. 2016;**18**(5):798-802

[11] Plank RM, Ndubuka NO, Wirth KE, et al. A randomized trial of Mogen clamp versus Plastibell for neonatal male circumcision in Bostwana. Journal of Acquired Immune Deficiency Syndrome. 2013;**62**(5):e131-e137

[12] Chan PS, Penna FJ, Holmes AV. Gomco versus Mogen? No effect on circumcision revision rates. Hospial Pediatric. 2018;**8**(10):611-614

[13] Bastos JM, Netto G, de Araújo J, Jr NMF, Passos BR, Lopes HE, et al. A prospective evaluation of Plastibell® circumcision in older children. International Brazil Journal of Urology. 2013;**39**(4):558-564

[14] Al-Ghazo MA, Banihani KE. Circumcision revision in male children. International Brazil Journal of Urology. 2006;**32**(4):454-458

[15] Marsh SK, Archer TJ. Bipolar diathermy haemostasis during circumcision. Journal of British Surgery. 1995;**82**(4):533

[16] Blank S, Brady M, Buerk E, Carlo W, Diekema D, Freedman A, et al. American academy of pediatrics, task force on circumcision: Male circumcision. Pediatrics. 2012;**130**:e756-e785

*Introductory Chapter: Novelty Meets Tradition DOI: http://dx.doi.org/10.5772/intechopen.109370*

[17] Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: A systematic review. BMC Urology. 2010;**10**:2

[18] Mutabazi V, Kaplan SA, Rwamasirabo E, Bitega JP, Ngeruka ML, Savio D, et al. HIV prevention: Male circumcision comparison between a nonsurgical device to a surgical technique in resource-limited settings: A prospective, randomized, nonmasked trial. Journal of Acquired Immune Deficiency Syndrome. 2012;**61**:49-55

Section 2
