How I Do It: Wound Approximation With Cyanoacrylate Tissue Glue In Circumcision In Paediatric Cases
Key words: tissue glue, change of dressing, removal of stitches, less pain
Introduction:
Circumcision is one of the most common minor procedures in daily surgical practice, worldwide. Absorbable suture materials have been used traditionally for wound approximation in circumcision. The disadvantage of these sutures is that they cause pain on dressing change post- operatively and sutures remain for weeks if not removed. These retained sutures might favour infection and inflammation. Tissue glue application for wound approximation as an alternative to suturing in circumcision especially in children is an option.1 We would like to share our experience how to apply tissue glue and take the advantage of avoiding unnecessary removal of stitches, better healing and cosmetic outcome.
Technique:
There are three common surgical techniques for circumcision used by surgeons around the world. These are 1. dorsal slit (especially for inflamed prepuce skin as emergency procedure), 2.Shield and clamp (special device required) and 3. Excision (conventional and commonly used method). Here we use excision method. I would like to mention the technique for young children ( infant – up to age 10 years ), operation is performed under General Anaesthesia .After the area is cleansed with 4% povidone iodine , narrow preputial opening is dilated with small curved artery forceps.Then prepuce is retracted proximal to the glan penis. Smegma are cleansed gently with wet gauze. Blunt and gentle adhesiolysis between glan and mucosal surface of prepuce is done with betadine gauze .Reduce the foreskin then pull the prepuce forward with 2 straight artery forceps to mark the imaginary excision line which is just at the tip of urethral orifice .The proposed excision line is clamped with straight artery forceps which is parallel to the corona plane. Then the prepucial skin is excised distal to the artery forceps with knife.Then release the forceps and retract the penile skin proximally. Visible dorsal veins and frenulum vessels are clamped and secured hemostasis with bipolar diathermy.
The cut edges of inner and outer prepuce are trimmed with curved tissue scissors. Inner prepucial skin edge is kept about 2-3 mm and outer prepuce skin edge is cut 2-3 mm proximal to the level of corona groove without tension. After meticulous hemostasis with bipolar diathermy, edges of cut prepuce skin are maintained with fine dissecting forceps loosely or held by stay sutures .Then Topocryl tissue glue is placed to the gap between the two edges of skin. The liquid glue filled wound glue is maintained by the operator’s fingers and forceps steadily about 15 seconds to get the gap dried up. Inadvertent contamination of glue to the glan is to be avoided. Tissue glue to be sealed at least 4 points circumferentially. After meticulous wound approximation and hemostasis is secured, TEO (Tetracycline Eye Ointment) and outer tulles dressing is applied over the wound and glan penis. Gauze dressing is not essential for all patients.
Figure 1. Cyanoacrylate tissue glue (Topocryl tube )
Figure 2. Cyanoacrylate tissue glue sealing at the edges of prepuce skin.
Figure 3. Cyanoacrylate tissue glue sealing at the edges of prepuce skin.
Figure 4. Circumcision wound after sealing with tissue glue.
Figure 5. Completion of procedure
Discussion
Cyanoacrylates were introduced in 1949. Ten years later, these agents were being used as tissue adhesives.2 Butlycyanoacrylates have been used successfully for topical skin closure in Canada and Europe since early 1980s with no adverse reports. There have been no reports of toxicity or carcinogenicity when these adhesives were used topically. In 2002, the Food and Drug Administration approved butylcyanoacrylates for external use and started to be used in the USA with great interest.
Recently, bacteriostatic and hemostatic effects of cyanoacrylates have been reported. These effects may also be having advantages of tissue glue. There was no tissue reaction to cyanoacrylate.
Previously, all of our circumcision cases were performed with absorbable sutures. Most of the children react aggressively in the post operative follow up clinic because of painful dressing. So it is very inconvenient for removal of stitches if needed to be done.
Use of tissue glue in circumcision is convenient, shorter procedure time and less postoperative pain, no need for removal of stitches after operation and superior cosmetic results thereafter.3
References
- wound approximation with tissue glue in circumcision by KU OZKAN – 2005 – Cited by 19 – Related articles International Journal of Urology … First published: 10 June 2005 … The results of wound approximation in circumcision with cyanoacrylate tissue glue and …
- Efferman RA, Synder JW. Antibacterial effect of cyanoacrylate glue. Arch. Ophthalmo.1983; 101: 958-60.
- Abdullahi Abdulwahab-Ahmed and Ismaila A. Mungadi Technique of male circumcision J Surg Tech Case Rep. 2013 Jan-Jun; 5(1): 1–7. doi: 10.4103/2006-8808.118588
