Circumcision surgical procedure

In the 21st century, most circumcisions in boys and men are performed using one of three open surgical methods. The forceps-guided method, the [[dorsal slit]] method, and the sleeve resection method are well described by the World Health Organization in their Manual for Male Circumcision under [[Local anesthesia|Local Anaesthesia]].{{cite web |title=Manual for male circumcision under local anaesthesia |publisher=World Health Organization |date=December 2009 |location= Geneva|url=https://www.who.int/hiv/pub/malecircumcision/local_anaesthesia/en/index.html|archive-url=https://web.archive.org/web/20090328041930/http://www.who.int/hiv/pub/malecircumcision/local_anaesthesia/en/index.html|archive-date=March 28, 2009}} The Gomco clamp and Mogen clamp are sometimes used after the newborn period, in conjunction with either [[surgical suture]]s or [[cyanoacrylate]] tissue adhesive to prevent post-operative bleeding.{{cite journal | vauthors = Lane V, Vajda P, Subramaniam R | title = Paediatric sutureless circumcision: a systematic literature review | journal = Pediatric Surgery International | volume = 26 | issue = 2 | pages = 141–4 | date = February 2010 | pmid = 19707772 | doi = 10.1007/s00383-009-2475-y | s2cid = 27495715 }}

In the 21st century, most circumcisions in boys and men are performed using one of three open surgical methods. The forceps-guided method, the [[dorsal slit]] method, and the sleeve resection method are well described by the World Health Organization in their Manual for Male Circumcision under [[Local anesthesia|Local Anaesthesia]].{{cite web |title=Manual for male circumcision under local anaesthesia |publisher=World Health Organization |date=December 2009 |location= Geneva|url=https://www.who.int/hiv/pub/malecircumcision/local_anaesthesia/en/index.html|archive-url=https://web.archive.org/web/20090328041930/http://www.who.int/hiv/pub/malecircumcision/local_anaesthesia/en/index.html|archive-date=March 28, 2009}} The Gomco clamp and Mogen clamp are sometimes used after the newborn period, in conjunction with either [[surgical suture]]s or [[cyanoacrylate]] tissue adhesive to prevent post-operative bleeding.{{cite journal | vauthors = Lane V, Vajda P, Subramaniam R | title = Paediatric sutureless circumcision: a systematic literature review | journal = Pediatric Surgery International | volume = 26 | issue = 2 | pages = 141–4 | date = February 2010 | pmid = 19707772 | doi = 10.1007/s00383-009-2475-y | s2cid = 27495715 }}

Circumcision surgical instruments should be distinguished from circumcision devices. Circumcision instruments are used at the time of surgery, and the circumcision is complete at the end of the procedure. The Gomco clamp, the Mogen clamp, and Unicirc are surgical instruments.{{cite report|url=http://www.malecircumcision.org/programs/documents/MC_device_evaluation_framework_Feb11.pdf|title=Framework for Clinical Evaluation of Devices for Adult Male Circumcision|publisher=WHO|date=2007|access-date=2017-04-18|archive-url=https://web.archive.org/web/20111114232740/http://www.malecircumcision.org/programs/documents/MC_device_evaluation_framework_Feb11.pdf|archive-date=2011-11-14}} Circumcision devices remain on the penis for 4 to 7 days and either spontaneously detach or are removed surgically at a subsequent visit.{{cite journal | vauthors = Ridzon R, Reed JB, Sgaier SK, Hankins C | title = VMMC Devices-Introducing a New Innovation to a Public Health Intervention | journal = Journal of Acquired Immune Deficiency Syndromes | volume = 72 | pages = S1-4 | date = June 2016 | issue = Suppl 1 | pmid = 27331583 | pmc = 4936419 | doi = 10.1097/QAI.0000000000000967 }} Plastibell, Shang Ring, and other plastic rings are all circumcision devices, also known as "[[in situ]]" devices. Circumcision via instrument results in healing by [[primary intention]] and healing via devices is by [[secondary intention]], so healing is delayed. All circumcision procedures should involve adequate injectable or [[topical anesthetic|topical anesthesia]].

Circumcision surgical instruments should be distinguished from circumcision devices. Circumcision instruments are used at the time of surgery, and the circumcision is complete at the end of the procedure. The Gomco clamp, the Mogen clamp, and Unicirc are surgical instruments.{{cite report|url=http://www.malecircumcision.org/programs/documents/MC_device_evaluation_framework_Feb11.pdf|title=Framework for Clinical Evaluation of Devices for Adult Male Circumcision|publisher=WHO|date=2007|access-date=2017-04-18|archive-url=https://web.archive.org/web/20111114232740/http://www.malecircumcision.org/programs/documents/MC_device_evaluation_framework_Feb11.pdf|archive-date=2011-11-14}} Circumcision devices remain on the penis for 4 to 7 days and either spontaneously detach or are removed surgically at a subsequent visit.{{cite journal | vauthors = Ridzon R, Reed JB, Sgaier SK, Hankins C | title = VMMC Devices-Introducing a New Innovation to a Public Health Intervention | journal = Journal of Acquired Immune Deficiency Syndromes | volume = 72 | pages = S1-4 | date = June 2016 | issue = Suppl 1 | pmid = 27331583 | pmc = 4936419 | doi = 10.1097/QAI.0000000000000967 }} Plastibell, [[ShangRing]], and other plastic rings are all circumcision devices, also known as "[[in situ]]" devices. Circumcision via instrument results in healing by [[primary intention]] and healing via devices is by [[secondary intention]], so healing is delayed. All circumcision procedures should involve adequate injectable or [[topical anesthetic|topical anesthesia]].

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Because the Gomco clamp is made of three major parts, there is a chance that pieces could be incorrectly assembled from differently sized units or those produced by different manufacturers. Using mismatched parts results in a device that might not sufficiently crush the foreskin, potentially resulting in bleeding.

Because the Gomco clamp is made of three major parts, there is a chance that pieces could be incorrectly assembled from differently sized units or those produced by different manufacturers. Using mismatched parts results in a device that might not sufficiently crush the foreskin, potentially resulting in bleeding.

====History====

====History====

The idea of using a tourniquet approach to infant circumcision is attributed to Cecil J. Ross, who patented steel circumcision rings in 1939. Subsequently, Kariher patented a plastic ring with a removable handle in 1955. The Plastibell comes in a sterile package with a single ligature.

The idea of using a tourniquet approach to infant circumcision is attributed to Cecil J. Ross, who patented steel circumcision rings in 1939. Subsequently, Kariher patented a plastic ring with a removable handle in 1955. The Plastibell comes in a sterile package with a single ligature.

===Shang ring===

===ShangRing===

The Shang Ring is a disposable plastic "in situ" device for male circumcision. It has been studied in China and Africa, and has been approved by WHO for circumcision in males over 13 years of age to prevent HIV. The Shang Ring consists of two concentric medical grade plastic rings: an inner ring with a silicone band and an outer, hinged ring that acts as a ligature. The appropriate size is determined through use of a measuring strip. The inner ring is placed underneath the foreskin. The outer (hinged) ring is placed on the outside of the foreskin and locks against the inner ring when snapped together. The distal foreskin is then excised. The Shang Ring is removed after one week when the outer ring locking mechanism is opened using a special tool. A pair of scissors designed for this purpose is then used to remove the inner ring.

The ShangRing is a disposable plastic "in situ" device for male circumcision. It has been studied in China and Africa, and has been approved by WHO for circumcision in males over 13 years of age to prevent HIV. The ShangRing consists of two concentric medical grade plastic rings: an inner ring with a silicone band and an outer, hinged ring that acts as a ligature. The appropriate size is determined through use of a measuring strip. The inner ring is placed underneath the foreskin. The outer (hinged) ring is placed on the outside of the foreskin and locks against the inner ring when snapped together. The distal foreskin is then excised. The ShangRing is removed after one week when the outer ring locking mechanism is opened using a special tool. A pair of scissors designed for this purpose is then used to remove the inner ring.

====Advantages====

====Advantages====

The Shang Ring is marketed as simple, disposable, easy to use, and provides sutureless circumcision that may be an acceptable alternative to conventional surgical techniques.{{cite journal | vauthors = Cao D, Liu L, Hu Y, Wang J, Yuan J, Dong Q, Wei Q | title = A systematic review and meta-analysis of circumcision with Shang Ring vs conventional circumcision | journal = Urology | volume = 85 | issue = 4 | pages = 799–804 | date = April 2015 | pmid = 25711156 | doi = 10.1016/j.urology.2014.12.007 }}

The ShangRing is marketed as simple, disposable, easy to use, and provides sutureless circumcision that may be an acceptable alternative to conventional surgical techniques.{{cite journal | vauthors = Cao D, Liu L, Hu Y, Wang J, Yuan J, Dong Q, Wei Q | title = A systematic review and meta-analysis of circumcision with Shang Ring vs conventional circumcision | journal = Urology | volume = 85 | issue = 4 | pages = 799–804 | date = April 2015 | pmid = 25711156 | doi = 10.1016/j.urology.2014.12.007 }}

====Complications====

====Complications====

As with other "in situ" devices, complications may occur up to several days following the placement procedure and must be dealt with promptly to prevent serious sequelae. Shang Ring should only be used where surgical care is rapidly available. In a review by WHO personnel, 0.4% men required rapid intervention with surgical circumcision as the excision had occurred but the foreskin slipped from the device and required suturing. No serious adverse events occurred; 1% experienced moderate adverse events from a total of 1983 successful device placements. All adverse events were managed with minor interventions and resolved without long-term sequelae. Rates were similar to those observed with conventional surgical circumcision.{{cite journal | vauthors = Samuelson J, Baggaley R, Hirnschall G | title = Innovative device methods for adult medical male circumcision for HIV prevention: lessons from research | journal = Journal of Acquired Immune Deficiency Syndromes | volume = 64 | issue = 2 | pages = 127–9 | date = October 2013 | pmid = 23892240 | doi = 10.1097/QAI.0b013e3182a61dd3 | doi-access = free }}

As with other "in situ" devices, complications may occur up to several days following the placement procedure and must be dealt with promptly to prevent serious sequelae. ShangRing should only be used where surgical care is rapidly available. In a review by WHO personnel, 0.4% men required rapid intervention with surgical circumcision as the excision had occurred but the foreskin slipped from the device and required suturing. No serious adverse events occurred; 1% experienced moderate adverse events from a total of 1983 successful device placements. All adverse events were managed with minor interventions and resolved without long-term sequelae. Rates were similar to those observed with conventional surgical circumcision.{{cite journal | vauthors = Samuelson J, Baggaley R, Hirnschall G | title = Innovative device methods for adult medical male circumcision for HIV prevention: lessons from research | journal = Journal of Acquired Immune Deficiency Syndromes | volume = 64 | issue = 2 | pages = 127–9 | date = October 2013 | pmid = 23892240 | doi = 10.1097/QAI.0b013e3182a61dd3 | doi-access = free }}

In settings where skilled surgeons are mostly located in urban centers, referral of clients who require surgical management of device-related complications within the recommended time frame of 6–12 hours may not be possible. Healing is by secondary intention and is therefore delayed compared to techniques which allow for healing by primary intention. There is a risk of HIV transmission if men engage in unprotected sex before the wound is healed. Thus, Shang Ring circumcision requires a longer period of post-circumcision [[sexual abstinence]] than surgical or instrumental methods.

In settings where skilled surgeons are mostly located in urban centers, referral of clients who require surgical management of device-related complications within the recommended time frame of 6–12 hours may not be possible. Healing is by secondary intention and is therefore delayed compared to techniques which allow for healing by primary intention. There is a risk of HIV transmission if men engage in unprotected sex before the wound is healed. Thus, ShangRing circumcision requires a longer period of post-circumcision [[sexual abstinence]] than surgical or instrumental methods.

====History====

====History====

The Shang Ring was developed by Jianzhong Shang in 2003.{{cite book |title=Male circumcision for HIV prevention : WHO technical advisory group on innovations in male circumcision : evaluation of two adult devices, January 2013: meeting report |date=2013 |publisher=World Health Organization |isbn=978-92-4-150563-5 |hdl=10665/85269 }}{{pn|date=September 2022}} The Shang Ring has been approved by WHO, and is cleared by the U.S. FDA under the 510(k) mechanism with Plastibell as the predicate device.{{Cite report|title=510(k) -Summary for the Wuhu Snnda Medical Treatment Appliance Technology Co., Ltd. ShangRing|url=http://www.accessdata.fda.gov/cdrh_docs/pdf12/k121789.pdf|archive-url=https://web.archive.org/web/20170207115244/http://www.accessdata.fda.gov/cdrh_docs/pdf12/K121789.pdf|archive-date=February 7, 2017|date=2012}}

The ShangRing was developed by Jianzhong Shang in 2003.{{cite book |title=Male circumcision for HIV prevention : WHO technical advisory group on innovations in male circumcision : evaluation of two adult devices, January 2013: meeting report |date=2013 |publisher=World Health Organization |isbn=978-92-4-150563-5 |hdl=10665/85269 }}{{pn|date=September 2022}} The ShangRing has been approved by WHO, and is cleared by the U.S. FDA under the 510(k) mechanism with Plastibell as the predicate device.{{Cite report|title=510(k) -Summary for the Wuhu Snnda Medical Treatment Appliance Technology Co., Ltd. ShangRing|url=http://www.accessdata.fda.gov/cdrh_docs/pdf12/k121789.pdf|archive-url=https://web.archive.org/web/20170207115244/http://www.accessdata.fda.gov/cdrh_docs/pdf12/K121789.pdf|archive-date=February 7, 2017|date=2012}}

==Related devices==

==Related devices==

=== Circumstraint ===

=== Circumstraint ===

The Circumstraint, Named after a combination of circumcision and restraint, is a tool used to "immobilize newborns for circumcision."{{Cite web |title=Circumstraint Newborn Immobilizer |url=https://www.medline.com/product/Circumstraint-Newborn-Immobilizer-by-Olympic-Medical/Z05-PF11971 |access-date=19 June 2025 |website=medline.com}} The device consists of two parts, a plastic board that is shaped with a full-body depression that fits newborn children, and 4 straps to restrain the limbs. The shape of the device is specifically designed to present the genitals of the infant for surgery.{{Cite web |title=Olympic Circumstraint™ - Natus Medical - PDF Catalogs {{!}} Technical Documentation |url=https://pdf.medicalexpo.com/pdf/natus-medical/olympic-circumstraint/76900-216069.html |access-date=2025-06-19 |website=pdf.medicalexpo.com}} Originally made by Olympic in 1959, it is now made by Natus Medical.

The Circumstraint, named after a combination of circumcision and restraint, is a tool used to "immobilize newborns for circumcision."{{Cite web |title=Circumstraint Newborn Immobilizer |url=https://www.medline.com/product/Circumstraint-Newborn-Immobilizer-by-Olympic-Medical/Z05-PF11971 |access-date=19 June 2025 |website=medline.com}} The device consists of two parts, a plastic board that is shaped with a full-body depression that fits newborn children, and 4 straps to restrain the limbs. The shape of the device is specifically designed to present the genitals of the infant for surgery.{{Cite web |title=Olympic Circumstraint™ - Natus Medical - PDF Catalogs {{!}} Technical Documentation |url=https://pdf.medicalexpo.com/pdf/natus-medical/olympic-circumstraint/76900-216069.html |access-date=2025-06-19 |website=pdf.medicalexpo.com}} Originally made by Olympic in 1959, it is now made by Natus Medical.

== References ==

== References ==