Sleeve Resection Method

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Sleeve Resection Method

Chapter 5: Surgical Procedures for Adults and Adolescents 1


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Sleeve Resection Method


Provides best cosmetic results More room for surgical error

The technique requires an assistant The sleeve resection method requires good

surgical skill Better suited to a hospital rather than a clinic

setting


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Sleeve Resection Method:

Steps 12Step 1: Skin preparation, draping and anaesthesia

Step 2: Retraction of foreskin and separation of

any adhesions



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Sleeve Resection Method:

Step 3

Marking the Outer LineMark the line of the outsidecut, just below the corona

Chapter 5: Surgical Procedures for Adults and Adolescents

Note V shape pointing towards frenulum

Mark the intended outer lineof the incision with a V- shape,pointed towards the frenulum,on the underside of the penis

The apex of the V shouldcorrespond with the midlineraphe

4


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Sleeve Resection Method: Step 4

Marking the Inner Mucosal LineRetract the foreskin and mark the inner (mucosal)incision line 12 mm proximal to the corona. At the frenulum,the incision line crosses horizontally as shown by the arrow.



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Sleeve Resection Method: Step 5Using a scalpel, make incisions along the markedlines, taking care to cut through the skin to thesubcutaneous tissue but not deeper. During the incision,the assistant retracts the skin with a moist gauze swab.



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Sleeve Resection Method: Step 5b


Make the innerincision

Outer and innerincisioncompleted


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Sleeve Resection Method: Step 6Cut the skin between the proximal and distalincisions with scissors.



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Sleeve Resection Method: Step 7Hold the sleeve of foreskin under tension with two arteryforceps and dissect the skin from the shaft of thepenis, using dissection scissors. Tie off any bleeding

vessels with under-running sutures.



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Sleeve Resection Method: Step 8

Stopping the bleeding:

Pull back the skin to expose the raw area.

Identify bleeding vessels and clip with arteryforceps as accurately as possible.

Tie each vessel or under-run with catgut and tieoff. Take care not to place haemostatic stitches too

deeply. When dealing with bleeding in the frenular area,

care must be taken not to injure the urethra.



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Stopping the Bleeding


Vessels may be occluded by ligation (A), orby transfixion sutures (B)

A

B


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Stopping the bleeding: Cut blood vessels should be locatedaccurately and tied or transfixed.

1. Using forceps (tweezers),the blood vessel islocated.

2. The blood vessel is then held withthe forceps and gently pulled up sothat an artery forceps can be applied.

3. The artery forceps is thenapplied, taking the minimumamount of extra tissue.


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Blood vessels should be accurately clipped with artery forceps, taking care to avoid takingtoo big a chunk of tissue. If it is difficult to see the source of bleeding, apply pressure with aswab and wait for 23 minutes and usually the bleeding vessel can then be occludedaccurately.


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Sleeve Resection Method :

Step 9

Suturing Plan


a b c

Horizontal mattress suture at the frenulum (6 oclock). Vertical mattress

sutures at 9, 12 and 3 oclock and simple sutures between these.


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Suturing the Circumcision


Place a horizontal mattress suture at the frenulum. Whenplacing the horizontal mattress suture at 6 oclock position,take care to align the midline skin raphe with the line of thefrenulum (see below). A common error is to misalign the

midline and raphe, which results in misalignment of the wholecircumcision closure.


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Suturing the Circumcision (cont.)


Place a vertical mattress suture at the 12 oclock position.The suture should be placed so that there is an equal amountof skin on each side of the penis between the 12 and 6 oclockpositions. Place two further vertical mattress stitches in the

3 oclock and 9 oclock positions.


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Suturing the Circumcision (cont.)

After placement of thesutures at 6,12, 3 and

9 oclock, place two ormore simple sutures inthe gaps between.



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Suturing the Circumcision:

Step 10Once the procedure is finished, check forbleeding and apply a dressing (described later).



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Applying the Penile Dressing

A standard penile dressing technique is used:

Check that there is no bleeding.

Once all bleeding has stopped, place a piece ofpetroleum-jelly-impregnated gauze (tulle gras)around the wound.

Apply a sterile, dry gauze over this, and secure it

in position with adhesive tape. Take care not to apply the dressing too tightly.



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Dressing: Application of Sofratulle



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Dressing: Application of Gauzeand Strapping



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Removing the Penile Dressing

The dressing should be left in position nolonger than 48 hours.

If the dressing has dried out, it should be gentlydabbed with antiseptic solution (aqueouscetrimide, Savlon) until it softens.

It can then be removed gently. It is important

not to disrupt the wound by pulling at adressing that has dried to the wound.


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Sleeve Resection Method