sleeve resection method
TRANSCRIPT
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Sleeve Resection Method
Chapter 5: Surgical Procedures for Adults and Adolescents 1
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Sleeve Resection Method
Chapter 5: Surgical Procedures for Adults and Adolescents 2
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
Chapter 5: Surgical Procedures for Adults and Adolescents 3
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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
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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.
Chapter 5: Surgical Procedures for Adults and Adolescents 5
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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.
Chapter 5: Surgical Procedures for Adults and Adolescents 6
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Sleeve Resection Method: Step 5b
Chapter 5: Surgical Procedures for Adults and Adolescents 7
Make the innerincision
Outer and innerincisioncompleted
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Sleeve Resection Method: Step 6Cut the skin between the proximal and distalincisions with scissors.
Chapter 5: Surgical Procedures for Adults and Adolescents 8
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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.
Chapter 5: Surgical Procedures for Adults and Adolescents 9
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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.
Chapter 5: Surgical Procedures for Adults and Adolescents 10
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Stopping the Bleeding
Chapter 5: Surgical Procedures for Adults and Adolescents 11
Vessels may be occluded by ligation (A), orby transfixion sutures (B)
A
B
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Chapter 5: Surgical Procedures for Adults and Adolescents 12
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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Chapter 5: Surgical Procedures for Adults and Adolescents 13
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
Chapter 5: Surgical Procedures for Adults and Adolescents 14
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
Chapter 5: Surgical Procedures for Adults and Adolescents 15
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.)
Chapter 5: Surgical Procedures for Adults and Adolescents 16
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).
Chapter 5: Surgical Procedures for Adults and Adolescents 18
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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.
Chapter 5: Surgical Procedures for Adults and Adolescents 19
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Dressing: Application of Sofratulle
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Dressing: Application of Gauzeand Strapping
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Chapter 5: Surgical Procedures for Adults and Adolescents 22
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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.
Chapter 5: Surgical Procedures for Adults and Adolescents 23