A Novel Technique for Circumcision - Alshekh Technique: A Case Series

Male Circumcision (MC) is defined as partial or complete surgical removal of the foreskin (prepuce) of the penis. The word ‘circumcision’ comes from the Latin circumcidere (meaning ‘to cut around’) [1]. It is considered very wide popular procedure which is done for many porpoises. Surgeons usually perform this procedure under local anesthesia for babies and use many techniques as they prefer and available. the United States Centers for Disease Control and Prevention (CDC) released draft policy recommendations in December 2014 affirming Male Circumcision (MC) as an important public health measure MC confers immediate and lifelong protection against numerous medical conditions For example, MC protects against a number of STIs including HIV, and it partially protects against oncogenic types of Human Papillomavirus (HPV) that together with phimosis, balanitis, and smegma are major risk factors for penile cancer [2]. The most common indications for Circumcision are religious beliefs, Phimosis, and Urinary tract infection. Circumcision has many complications including bleeding, infection, Suture sinus tracts, Phimosis and concealed penis, Meatitis, Meatal stenosis, Chordee, Necrosis of the glans, amputation and failure [3,4]. Early infant MC confers immediate and lifelong benefits by protecting against urinary tract infections having potential adverse long-term renal effects, phimosis that causes difficult and painful erections and “ballooning” during urination, inflammatory skin conditions, inferior penile hygiene, candidiasis, various sexually transmissible infections in both sexes, genital ulcers, and penile, prostate and cervical cancer [5]. Alshekh technique for circumcision is safe and cost effective for every surgeon to do at his clinic. This work has been reported in line with the PROCESS criteria [6].

Alshekh technique has performed for 1000 babies at Zakia city in Syria therie ages are between one week to 3 months. It is done under local anesthesia, after sterilization with povidone 4%, about 1.5ml of lidocaine 1% is injected around the base of the penis, then wait about a minute and then catch the penis with left hand and retract foreskin by pulling it downward this makes the hiatus clear. After that a tip of closed Kelly pens is introduced gently under direct vision then open it to widen the hiatus and when the glans is seen the surgeon proceed with a blunt dissection in right hand using gauze until the glans is totally free of skin. After that the skin is returned forward to its natural position. A blue mark is made at the level of posterior border of glans to determine the amount of skin to be removed .after that the surgeon catch the skin at the hiatus by a tip of pens and push the glans backward using tips of greater and index finger of the other hand while applying a straight pens at the blue mark and this seals and protects the glans below. Then cut and remove the skin above the straight pens using KAWE (electrical instrument that is used for electrical purposes) and by this way no bleeding will occur. Finally, the pens is removed and glans will be projected freely. After that put povidone powder and rap the wound by clean gauze. at last give paracetamol drops to control pain and no antibiotics are needed.

The three commonly used devices for neonatal circumcision are the Gomco clamp, Plastibell device, and Mogen clamp, or devices based on the principles of these three techniques. In randomly assigned trials, no one device is clearly superior [7]. 

Alshekh technique by using KAWE which is an electrical instrument used for electrical purposes is found to be safe and cost effective and has no side effects like bleeding and little pain compared with stitching. This devise provides heat at its tip that cuts and cauterizes, its price is about 10 $(consider very cheap compared with formal devices which cost about 200$ and any surgeon can have it at his clinic. 

There are four principles common to all forms of circumcision, and it is the compliance with these principles that allows for circumcision without complications. These principles are asepsis, adequate but not excessive excision of outer and inner preputial layers, hemostasis, and cosmesis.all of them are achieved by AL Shekh method. 

The most common complications of male circumcision are bleeding and local infection [8], followed by unsatisfactory cosmetic results (too little or too much skin removed) and surgical trauma or injury. 

By AL Shekh technique Minor hemorrhage occurs in 10 cases (1%) and was controlled by direct pressure. two cases (0.2%) require suturing for hemostasis. Bleeding most commonly results from disruption of the frenular vessels in response to excessive force on the frenulum. The risk of severe bleeding is higher if there is an underlying coagulopathy. There appears to be no difference in the risk of bleeding based on the technique chosen to perform the circumcision. 

Wound infection infrequently occurs after circumcision. It is usually mild and manifested by local inflammatory changes, which typically resolve with local topical triple antibiotic ointment [9]. 

For AL Shekh technique and by monitoring all cases were healed completely within two weeks and only 10 cases (1%) were infected and managed successfully with local antibiotics. no other complications occurred. 

In general, the rate of procedure-related complications during and after circumcision in the neonate is approximately 2 to 6 per 1000 for traditional methods and this was near to complications rate of AL Shekh method. Surgical complications include the following: urethral injuries, glans injury, removal of excessive skin, Inadequate skin removal ,epidermal inclusion cyst ,abnormal scarring, resulting in adhesions, cicatrix, or penile curvature and anesthetic complications [10], some of which may require reoperation. None of them were occurred by AL Shekh technique. Babies are followed for 6 months and there were no problems. 

AL Shekh technique is superior to other methods in many ways: first it’s easy to learn and its learning curve is only one operation because it is so easy for surgeons, second: it is cost effective and the devise that is used (KAWE) is very cheap and every surgeon can obtain it especially at low economic countries. Thirdly, this technique has little if any complications especially little if any pain since no devise stay in the place for many days like the other methods and that was noted on babies who were very Comfortable after AL Shekh procedure and fed perfectly during healing time. Fourth, the time required for the procedure is too short and it is about five minutes only .see table below [11] (Table 1). 

Table 1: Alshekh technique. 

Alshekh technique is considered very safe and effective as there is no bleeding compared with traditional methods that cut and suture. In addition, sutures may cause urethral fistula if taken through, and this never occurs by AL SHEKH method.

AL SHEKH method for circumcision is very safe and effective and we advise to be used worldwide as it is easy and can be done under local anesthesia at clinics.