Crush - Electrocautery - Electrosurgery - Laser - Sutures - Wound Glue
What is the need for “Wound Closure”?
Support of the wound is needed until such time as the natural healing process gives the scar sufficient strength to resist any tension placed on it, otherwise it will tear. In the case of circumcision wounds, that tension can arise in two ways - tension created by a tight style of circumcision and/or tension arising as a result of erection (sexual arousal). Various techniques of wound closure have been developed so as to give the required physical support to a healing scar; here we consider only those methods relevant to circumcision.
In neonates, the strong crushing action of a device such as a Gomco or Mogen clamp is sufficient to seal the wound even though the clamp is removed a matter of minutes after the cut is made. The same is not true of older children and adults; if crush is to be used to close their wound then it must be sustained over a longer period of time. Hence the string of a Plastibell device and the sustained clamping action of fit-&-wear devices such as the Tara KLamp.
Circumcision using an electrocauter is eminently suitable for pre-pubescent circumcisions provided that the required style is not “fully low”. The wound seal created by the cauterisation will, for most small boys, be sufficient to ensure wound closure, meaning that no suturing is required.
Electrosurgery can be used to close a circumcision wound of a boy circumcised in any style. This can be (and is) done even when the cut itself has been performed using conventional means. Instead of being sutured, the wound is “spot welded”. Either monopolar or bipolar equipment can in theory be used; equipment availability tends to mean that monopolar is used in practice. The layers of tissue to be fused are held together in a wand somewhat similar to tweezers. The high frequency current is then applied momentarily, welding the layers together. The resulting fusion of tissue will be sufficient to ensure adequate closure pre-puberty, but not in adults. Therefore, as with electrocautery, this technique is primarily applicable to infant and boyhood circumcisions.
Like electrocautery, circumcision of a child patient using a laser scalpel will normally seal a wound sufficiently well for no further wound closure measures to be needed. A CIRCLIST member with experience of laser scalpel circumcision reports that wound glue suffices in adults, rendering sutures unnecessary.
Non-absorbable sutures must be proactively removed once wound healing has progressed to the point where their physical support of the circumcision scar is no longer needed. Such sutures are thin, hassle-free, unlikely to become infected and unlikely to leave marks unless the patient is prone to hypertrophic scarring.
Absorbable (self-dissolving) sutures
These are made of material that is degraded by the body’s naturally-occuring enzymes. Phagocytes carried by the bloodstream attack and destroy the suture material. Absorbable sutures are not intended to be used on the surface of the skin, only in a subcuticular or completely buried pattern. In the context of circumcision they should not be exteriorized unless they are to be proactively removed in their entirety - which somewhat defeats the purpose of using them in the first place! Failure of the dissolving action arises because, at the point where the stitch passes through the dry outer layer of skin, blood cannot reach the stitch to dissolve it.
Sutures and the problem of ‘stitch tunnels’
A particular problem with sutures used to close a circumcision wound is the formation of unsightly stitch tunnels. These are like tiny piercings that never go away. They can form around any suture material, but are more likely if absorbable material has been used externally. What happens is that the natural healing process forms a tunnel around the stitch. Thus the sutures should be removed as soon as the wound is strong enough to be self-supporting.
Sutures should be removed typically on the 7th or 8th day after circumcision; this is a simple process that can be carried out by a teenage or adult patient or the parent of a younger boy. A return to clinic or hospital should not normally be necessary unless the patient or parent is averse to carrying out this minor procedure. Self-removal has the advantage of being less ticklish; this is true of the removal of sutures from any scar - not just a circumcision scar.
Materials from which suture thread is made
can be made from synthetic material (such as nylon or polypropylene, both of which are inert), silk (an animal protein) or cotton (a plant material). Non-dissolving sutures are usually coloured blue or black to make them more visible against the blood red of a wound. They normally have a smooth surface that allows them to be withdrawn easily.
can be made of:
Either type of suture - absorbable or non-absorbable - can be either monofilament or braided:
- Catgut (obsolete technology): A natural fibre made from the submucosa of the bovine intestine. It excites considerable inflammatory reaction and tends to potenciate infections. It loses strength rapidly and is of little use in modern surgery. Plain catgut dissolves more quickly than the type treated with chromium salts. Mentioned here for historic interest only.
- Vicryl /Dexon (Polyglactin): Dissolves more slowly than catgut but causes less of a reaction on implantation. Normally used only below the surface of the skin, it can also be used in areas where suture removal might jeopardize the repair such as with small children who might not cooperate with suture removal.
- Vicryl Rapide: A similar substance to Vicryl, but absorbed in a shorter period (5 days).
- Monocryl: The least reactive substance of this group and therefore the one that should leave least scarring. Unfortunately this is not a very soft material; it may be slightly irritating while the stitches are in place.
Monofilament sutures cause less reaction than do braided sutures but require more ties to ensure an adequate maintenance of the knot compared to braided suture.
Braided sutures usually incite a greater inflammatory response but require fewer ties to maintain the knot’s integrity. Examples include silk, cotton and Mersilene.
The physical strength of any given suture material is designated by a standardised numbering system that takes into account both breaking strain and diameter. The degree of wound support achieved depends on this mechanical strength, on the number of stitches inserted and upon the adequacy of the anchoring of each one.
Because each suture becomes, from the point of view of the immune system, a “foreign body” and is also an additional wound, it is wise to use only what is necessary and no more. Excessive suturing is to be discouraged.
Patterns of suturing - the "T-shape" anchor:
In situations where a strong pull is likely to be applied to a stitch, it is important to anchor the stitch well so that it does not tear the tissue into which it has been inserted. This is normally achieved using a T-shaped stitch as illustrated in the following photographs. If an erection causes severe pulling, the "T" stretches into a "Y" shape. This compresses the tissue into which the energy is dissipated, doing so far more effectively than would be the case if the tension was applied directly to a single point of attachment. This makes a tear much less likely. The technique is particularly applicable to tight circumcisions, removal of shaft skin having left the erectile tissue with less opportunity for expansion than was the case previously. The pre-pubescent patient in the left-hand image below received 4 such sutures. The adult on the right received 16, on account of the greater tension that any erection of his would place on the healing scar.
|SUTURING TECHNIQUE FOR TIGHT CIRCUMCISIONS.
|© 2007 Professor Gamal Mousa
Pre-pubescent boy being circumcised Low and Tight (glans:shaft ratio 67:33 or 2:1). Only 4 anchor sutures were deemed necessary to constrain any erections occuring during healing.
|© 2009 CIRCLIST Archives
Circlist Member circumcised High and Tight as an adult. Close inspection of the scar line reveals the former position of 16 anchor sutures used to constrain erections during healing.
CIRCLIST Member experiences of suturing:
When I had my circumcision, my doctor recommended to bathe my penis in warm camomile tea for 15-20 minutes several times a day until all stitches have dissolved and fallen off. I did so (using a toothbrush glass, by the way), and there are no stitch marks or even tunnels left. - Martin
Mine was done with soluble sutures, with no adverse effects. But the fact remains that non-dissolving ones are less likely to leave a mark, and less likely to get infected. I recently had a minor operation on my arm which was sutured with non-soluble ones and they were quite hassle-free and left no mark at all. (Actually my wife took them out - it doesn’t need a doctor to do it!)
In cosmetically sensitive areas such as faces non-dissolving sutures are always used. Why does the medical profession think that the penis is not cosmetically important? - Anonymous
Most of us circumcised as adults report having had dissolving (absorbable) stitches, which are obviously more convenient than ones which have to be removed. If my experience is any guide, removable ones may be less inclined to leave stitch marks. They are much finer and they can be removed as soon as they are no longer required (a week or thereabouts) whereas dissolving stitches may persist for considerably longer. My ‘second circumcision’ (properly called a revision) was performed by a plastic surgeon. It was a botch job, unsatisfactory enough to necessitate yet another revision; the result of mistakes on the part of several people. First, my GP for referring me to a plastic surgeon to do something right out his specialist field of competence. Second, me for not knowing better; I simple-mindedly thought that if anyone could do a neat cosmetic job, it would be a plastic surgeon. Third, and most culpable, the surgeon himself, for agreeing to perform a procedure he knew nothing about. But, getting back to the subject of stitches, he used silk stitches and - I have to admit - did a great job with them, leaving no stitch marks at all. - Anonymous
The stitch marks will never go away completely. The big problem with disolving stitches are skin tunnels, which are like piercings. They never go away either. My first circ left both tunnels and stitch marks. On my second circ and third partial circ, I had the stitches removed after a week and no mark or tunnel was left. The dotor told me just to let them dissolve, but I insisted that he remove them. The results were great. - Sam
The doctor did not cut my frenulum, so no sutures were required in that area.. There were 13 soluble sutures around my shaft, the last of which I removed on the10th day after the operation (May 19th 1978 to be precise!). Instinctively I knew they would cause scarring if left in too long, and I did get one small tunnel which has gone now.
If I have a regret it is that my scar is a thin white line, just a boundary between the two skin colours. I always wanted a nice brown ring, which I realize now is usually caused by the Gomco or TaraKLamps. I was circumcised freehand. - Anonymous
I had skin tunnels which lasted several years after I was circumcised (at age 20) even though I had non-dissolving stitches for the sutures. I finally treated it myself - I boiled a blade to sterilise it, swabbed my scar area with savlon, and for each tunnel, I inserted a needle down through the tunnel, and ran the blade down along shaft of the needle, quite safely removing the skin on top. It all healed nicely with the tunnels disappearing completely, though the stitch marks are quite visible. This alone, seems like a good argument to support routine infant circumcision. Have you ever seen a guy who was circumcised at birth that has skin tunnels? - Paul
Regarding self dissolving stitches; my surgeon who did my original circ put dissolving stitches in and told me to soak bandages off in a warm bath with some Savlon** in it. He said to take a daily bath and soak for a good 15 minutes, this caused the self dissolving stitches to keep soft and come out fairly quickly and leave no holes as some of you seem to have had. Perhaps you might like to try this and see if it helps.
**Savlon is a British personal disinfectant so you can use any brand common in your own country. Its use is basically to prevent the circumcision site getting infected. - Brian (UK)
The concept of Wound Glue has been around for a long time. It is applied in layers, with or without reinforcing embedded in it - depending upon the location of the scar and the direction of any tension liable to be placed on it. Potentially replacing suturing even in adults, it too has attracted correspondence from Circlist members:
Personal experience from the early 1960s
I first encountered wound glue in January 1962, when I had the second part of a two-stage orchidopexy in Great Ormond Street Hospital. The operation involved re-opening a scar from previous surgery done one year before; the first time around conventional non-soluble sutures had been used. The wound glue did the job, after a fashion, but the scar became hypotrophic afterwards whereas other scars I had, both surgical and accidental, did not. Coincidence? A consequence of the chemical content of early surgical glues? I don’t know.
Chris (age 12 at the time) - London, UK
The Wall Street Journal of December 28, 1998, page B1
Quote from an article entitled “Surgical Glue Removes Much Pain and Time From Closing Wounds”:
Dermabond... is sterile and doesn’t contain the basic chemicals found in some common fast-drying glues, which, if applied to an open wound, could irritate or lead to infection. It takes about 50 seconds to set - just enough time for a doctor to manipulate the skin edges so they fit together well. The surgical glue goes on bluish purple and is applied in at least three thin layers. After about two and a half minutes, it is said to be as strong as week-old sutures. It sloughs off in five to 10 days, meaning patients don’t have to return to the doctor to have stitches removed. The glue is applied from a small plastic tube that looks similar to the ones used for fast-drying household products such as Krazy Glue.
Although Dermabond isn’t sold directly to consumers, a Johnson & Johnson unit licensed to market it is believed to be considering an advertising campaign urging people to ask doctors for adhesive instead of stitches. But he warned: the glue isn’t always an option. It can’t be used on elbows and knees - where children often get cuts and scrapes - because the excessive motion would probably cause it to peel too soon. For similar reasons, it isn’t a good choice for hands and feet and it can’t be used in the mouth, groin or other moist areas.
Hal - USA
Int J Urol. 2005 Apr;12(4):374-7. Wound Approximation with Tissue Glue in Circumcision.
Ozkan KU, Gonen M, Sahinkanat T, Resim S, Celik M. Department of Pediatric Surgery, University Medical Faculty, Kahramanmaras, Turkey.
To assess the feasibility of using tissue glue in the approximation of circumcision wounds in children. Patients and methods: A prospective randomized trial was carried out on 30 boys (age, 1-10 years) admitted to the Kahramanamaras Sutcuimam University Medical Faculty, Turkey. The results of wound approximation in circumcision with cyanoacrylate tissue glue and suturing with interrupted 5/0 plain catgut were compared. The operations were carried out by the same surgeon using an identical technique. The wounds were assessed 1 day, 3 days, 1 week and 1 month postoperatively.Results:
There was no difference between the two groups in the rates of wound inflammation, infection, bleeding and dehiscence, although cosmetic appearance was better in the tissue glue group
. The operation time was also shorter in this group.Conclusion:
Using tissue glue for wound approximation in circumcision is a feasible alternative.
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