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Year : 2004  |  Volume : 20  |  Issue : 2  |  Page : 126-129

A simple modification of the free hand technique of circumcision

Solapur Kidney Care and Research Centre Pvt. Ltd, Solapur, India

Correspondence Address:
G R Sharma
Onkar Nilayam, 3/27 Samarth Nagar, North Sadar Bazar, Solapur-413 003
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Source of Support: None, Conflict of Interest: None

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Objective : To evaluate a modification of the free hand technique of circumcision for achieving better cosmetic results
Methods : The prepuce is first divided at the 12 o'clock and then at 6 o'clock. Two preputial flaps are thus ob­tained which are then divided from ventral, i. e., 6 o'clock to dorsal i.e. 12 o'clock aspect from below upwards. The mucosal collar is thus cut under vision and a good cos­metic result is obtained. Circumcision was done in 126 cases using this modification of the free hand technique.
Results : Good cosmetic result was obtained in all cases. No complications were seen
Conclusions: The modification described makes the free-hand technique of circumcision a simpler and safe operation that gives very good functional and cosmetic results.

Keywords: Circumcision, penis, phimosis.

How to cite this article:
Sharma G R, Sharma A. A simple modification of the free hand technique of circumcision. Indian J Urol 2004;20:126-9

How to cite this URL:
Sharma G R, Sharma A. A simple modification of the free hand technique of circumcision. Indian J Urol [serial online] 2004 [cited 2022 Jul 1];20:126-9. Available from:

   Introduction Top

Circumcision is one of the commonest surgical proce­dures performed, with a sixth of the male population be­ing circumcised world wide. [1] In a significant number of cases there are complications and dissatisfaction with the end result mainly on account of the cosmetic failure. [1],[2] A good result is assured if the skin and mucosa are cut cleanly, sharply and an adequate collar of mucosa of about 6 mm in young boys and 12 mm in adults is kept all around the corona. [3]

A number of techniques of circumcision are described. Each has its own advantages and disadvantages. The de­scribed technique is a modification of the free-hand tech­nique of circumcision.

   Patients and Methods Top

Between April 1999 to February 2003, 126 circumci­sions were done. The patients consisted of young boys as well as adults. The age distribution of the patients is given in the table. The indication for the procedure in all the cases was phimosis. All the circumcisions were done as day care cases and were performed under local anesthesia in adults and under caudal block with or without supple­mentation of general anesthesia in smaller boys.

In this technique the prepuce is held with mosquito for­ceps at 10 and 2 o'clock position. Minimal stretch is given so as to minimize excision of large amount of shaft skin. The adhesions between the glans and the prepuce are sepa­rated. A dorsal slit is then taken at the 12 o'clock [Figure - 1] extending to a point distal to the corona; which is about 6mm in small boys and is 10-12 mm in adults. The pre­puce is then retracted and any adhesions or accumulation of smegma is cleared. The prepuce is then brought to its normal position and 2 mosquito forceps are applied at the 4 and 8 o'clock position. The prepuce is then divided at 6 o'clock position just lateral to the frenulum [Figure - 2]. The cut extends to a point just distal to the corona, similar to the one taken at 12 o'clock position. This results in the formation of the two flaps of the prepuce. They are then held at both their dorsal and ventral tips with hemostats. The skin along with mucosa is then divided from 6 o'clock to 12 o'clock from below upwards using sharp scissors [Figure - 3]. This is done on both the flaps. As two preputial flaps are formed, the mucosa is cut under vision and hence an adequate and uniform collar of mucosa is obtained around the corona. The bleeders are then coagulated with bipolar diathermy forceps. [4],[5] Skin and the mucosa are ap­proximated with 4-0 chromic catgut. We do not take a figure-of-8 stitch at the level of the frenulum. A single dose of broad-spectrum antibiotic was given intraopera­tively in all the cases. Post operatively dressing was done which was removed on the third postoperative day.

   Results Top

Very good cosmetic results were obtained in all the cases [Figure - 4]. No complication was seen in any of the cases. None of the cases had any reactionary bleed. No major complication like glans injury or urethral injury occurred in any of the cases. Healing was satisfactory in all the cases. Infection was not seen in any of the cases. Some pain on erection was complained by most of the adult patients in the immediate postoperative period. None of the adult patients complained of any difficulty in intercourse later on.

   Discussion Top

The aim of circumcision is to excise enough shaft skin and inner preputial epithelium so that the glans is suffi­ciently uncovered to prevent or to treat phimosis and render the development of paraphimosis impossible. [6] A number of different techniques are followed to do circumcision like the sleeve technique, Free hand technique, Bone cut­ters, Oblique hemostat, Plastibell, Gomco clamp etc. [7]

A common cause of dissatisfaction after circumcision is the cosmetic failure occurring on account of inadequate and/or improper excision of skin and mucosa. [6] A cause of complaint, at times, is the loss of coronal differentiation between the glans and the shaft, which is caused by excis­ing all of the mucosal skin right up to the corona. [7] An avoidable complication of circumcision is excision of too much of shaft skin, which leads to a buried penis or ex­cessive hair bearing skin on the shaft. [1],[8],[9]

Of the commonly followed techniques for circumcision, the Sleeve technique is considered to give the best results cosmetically; as it involves all incisions under direct vi­sion. [3],[7] But this technique is considered tedious and diffi­cult by some, especially in smaller boys. [10],[11] The Bone Cutter and Hemostat methods are simple, quick and rela­tively bloodless; but have a major risk of injury to the glans. [12] In the free hand technique the prepuce is first di­vided at 12 0' clock position and then circumcision is done by dividing it from dorsal towards the ventral aspect by using scissors. This technique requires more surgical ex­pertise and it is more difficult to leave a regular strip of mucosa uniformly around the corona, as the inner surface of prepuce is not divided under vision. [7] Also routinely a figure of eight stitch is taken by many at the level of frenu­lum, which causes bunching of skin at that level giving a poor cosmetic appearance.

In the technique described by us the initial cuts are at 12 and 6 o'clock positions resulting in the formation of two flaps, which are then divided, from 6 o'clock upwards under vision. Thus the chance of having irregular, inad­equate or improper cutting of skin and mucosa are mini­mized. The end result is an adequate and uniform collar of mucosa all around the corona. This modification of the free hand technique is simple, easy to perfoun and gives a very good cosmetic result. Also it can be performed with equal ease in smaller boys as well as adults.

   Conclusions Top

The described modification of the free-hand technique of circumcision is simple and easy to perform in smaller boys as well as adults, and gives a very satisfactory cos­metic result.

   References Top

1.Williams N, Kapila. Complications of circumcision. Br J Sing 1993: 80:1231-1236.  Back to cited text no. 1    
2.Niku SD, Stork JA, Kaplan GW. Neonatal Circumcision. Urol Clin North Am 1995; 22: 57-65.  Back to cited text no. 2    
3.Lucus MB. A method of circumcision. Br J Urol 1984; 56: 551-553   Back to cited text no. 3    
4.Marsh SK, Archer TJ. Bipolar Diathermy hemostasis during cir­cumcision. Br J Surg 1995; 82: 553.  Back to cited text no. 4    
5.Fearne C. Bloodless Circumcision. BJU Int 1999; 83: 717.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Gerharz EW. Haarmann C. The first cut is deepest? Medico legal aspects of male circumcision. BJU Int 2000:: 86: 332-338.  Back to cited text no. 6    
7.O' Sullivan DC, Heal MR, Powell CS. Circumcision; how do urolo­gists do it? Br J Urol 1996; 78: 265-270.  Back to cited text no. 7    
8.Kaplan GW. Complications of circumcision. Urol Clin North Am 1983; 10: 543-549.  Back to cited text no. 8  [PUBMED]  
9.Levitt SB. Smith RB, Ship AB. Iatrogenic microphallus secondary to circumcision. Urology 1976: 8: 472-474.  Back to cited text no. 9    
10.Jordan GH, Schlossberg SM, Devine CJ. Surgery of penis and urethra. In Walsh PC. Retik AB. Vaughan ED. Wein AJ (eds.). Campbell's Urology, 7 1 edition, Vol.111, Chapter 107. Philadelphia, WB.Saunders, 1998: 3316-3394.  Back to cited text no. 10    
11.Frank Hinman Jr. Circumcision. In Atlas of Urologic Surgery. Phila­delphia, W.B.Saunders, 1989: 77-81.  Back to cited text no. 11    
12.Gluckmann GR, Stoller ML, Jacobs MM, Kogan BA. Newborn penile glans amputation during circumcision and successful reat­tachment. J Urol 1995: 153: 778-779.  Back to cited text no. 12    


  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

  [Table - 1]


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