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Lau W, Teo CPC. Circumcision wound dressing with octylcyanoacrylate tissue adhesive. J Wound Care 2023; 32:116-120. [PMID: 36735528 DOI: 10.12968/jowc.2023.32.2.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Circumcision wounds are commonly dressed with paraffin gauze dressings. Octylcyanoacrylate tissue adhesive (Dermabond; Ethicon, US) is increasingly being used for wound closure, as well as wound dressing. This study compared the outcomes of tissue adhesive dressing versus paraffin gauze dressing for circumcision wounds. METHOD Adult male patients undergoing circumcision were randomised into two groups: tissue adhesive dressing (study group) or paraffin gauze dressing (control group). They were followed up at two weeks and at two months after surgery. The primary objective of this study was to determine the difference in patient-reported dressing satisfaction at two week follow-up. Our secondary outcomes included operation time, postoperative pain, postoperative complications, patient-reported cosmetic satisfaction, surgeon-reported cosmetic satisfaction, and surgeon-reported objective measure of cosmetic outcome using a validated scale. RESULTS A cohort of 40 patients was randomised into two equal groups, study and control. Tissue adhesive dressing was associated with a significantly better patient-reported dressing satisfaction, with a mean Likert scale score of 4.53±0.51 for the study group versus 3.20±1.24 for the control group (p<0.001). It was also associated with a significantly better patient-reported cosmetic satisfaction of 4.58±0.51 versus 4.00±1.12 (p<0.05), respectively. There was no difference in operation time, postoperative pain, postoperative complications or surgeon-reported cosmetic outcomes. CONCLUSION Tissue adhesive dressing is an acceptable alternative to paraffin gauze dressing for circumcision wounds. This option should be offered to all patients undergoing circumcision.
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Affiliation(s)
- Weida Lau
- Khoo Teck Puat Hospital, Urology, 90 Yishun Central, 768828, SG, Singapore
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Sutureless circumcision using monopolar diathermy and 2-octyl cyanoacrylate is safe and effective in a cohort of 634 post-neonatal prepubescent boys. J Pediatr Urol 2022; 18:790-795. [PMID: 35466011 DOI: 10.1016/j.jpurol.2022.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Circumcision is the most commonly performed surgical procedure in the world, with one-third of males circumcised globally. Post-neonatal, prepubescent sutured circumcision demonstrates complication rates ranging from 1.7% to 9.1%. We have previously reported that 2-octyl cyanoacrylate (2-OCA, Dermabond, Ethicon) primary circumcision (PC) and circumcision revision (CR) in prepubescent children demonstrated superior cosmesis, shorter operating room (OR) times and cost savings. OBJECTIVE The aim of our study is to evaluate complication and reoperation rates with a scalpel-free and suture-less technique for primary circumcision (PC) and circumcision revision (CR) using 2-OCA. METHODS Following IRB approval, we conducted a retrospective review of all boys at our institution who underwent PC or CR using 2-OCA and monopolar diathermy between January 2014 and January 2021. All procedures were performed by a single surgeon. The technique is outlined in the figure below. No aligning sutures or instruments were used in this process. Patients that required sutures or compressive dressings based on age or associated anomalies were excluded from analysis. We obtained all returns to our system within 30 days of the procedure and returns to the OR during the study period using the REDCap database. RESULTS Of 1107 procedures performed during the study period, 634 procedures (479 PC and 155 CR) met inclusion criteria. Median age was 12 months (range 3 months-10.4 years) with minimum follow up of 1 year. There were 3 patients (0.47%) that returned to system within 30 days for surgical site bleeding, and one patient (0.15%) required surgical intervention within 30 days. Nine patients required reoperation after 30 days, five (0.8%) for iatrogenic phimosis, 3 (0.5%) for redundant prepuce and 1 for keloid formation. We observed an overall complication rate of 1.3% (6/634) and reoperation rate of 1.6% (10/634). DISCUSSION Since FDA approval in 1998, 2-OCA has been widely adopted as a replacement for sutures in tension-free wounds. However, it has yet to gain widespread use for circumcision given concerns for wound dehiscence and surgical site bleeding. This study demonstrates that a scalpel-free and suture-less technique demonstrates complication and reoperation rates are lower than reported circumcision using scalpel and sutures. Limitations include retrospective design, single surgeon experience, and REDCAP database only identifying patients with complications that required a return to system. CONCLUSION Our technique for suture-less circumcision using 2-OCA offers superior cosmesis, shorter OR times, cost savings, and a lower complication rate (1.3%) compared to sutured circumcision (>1.7%) reported in post-neonatal prepubescent boys.
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Minimally Invasive Anesthesia in Pediatric Circumcision: A Case Series. A A Pract 2021; 15:e01527. [PMID: 34606484 DOI: 10.1213/xaa.0000000000001527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Anesthetic management of pediatric circumcisions typically involves intravenous access and advanced airway management. We explored the use of a minimally invasive anesthetic protocol for pediatric circumcisions akin to the anesthetic management for bilateral myringotomy and tympanostomy. Five pediatric circumcisions were performed under mask ventilation without intravenous access and evaluated for intraoperative anesthesia times, patient outcomes, and complications. The mean (standard deviation) intraoperative anesthesia time was 41.4 (5.7) minutes, and 1 patient experienced a mild intraoperative complication with emesis at induction. Pediatric circumcisions can be efficiently and safely performed with minimally invasive anesthesia.
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Abstract
Introduction: Today is the era of “wireless” in technology and here comes era of “sutureless” in the field of surgery. Every surgeon wishes for better wound healing with better cosmesis without complications and early back to routine activities. All this is possible by use of adhesive for wound edges of circumcision is shown by us in this study. In addition, other aim was to study the efficacy, safety, functional outcome, and cosmesis of isoamyl cyanoacrylate when used as adhesive for wound edges of pediatric circumcisions. Materials and Methods: Group A comprised 162 pediatric patients who underwent sutureless circumcisions and Group B comprised a similar number, i.e., 162 pediatric patients who had undergone circumcision by conventional method using absorbable interrupted sutures. Comparative analysis of both the groups was done based on various parameters such as bleeding, infection, foreign body reaction, excessive swelling, and wound dehiscence. In addition, visual analog pain scoring was done after 6 h and after 12 h postoperative. Results: Complications were more commonly seen in sutured Group B versus sutureless circumcision-Group A. In addition, postoperative pain and need of analgesics were seen more commonly in sutured Group B patients. Wound healing and final cosmesis were far better in Group A patients. Conclusion: Our results show that isoamyl cyanoacrylate is comparatively safe, efficient, has better functional outcome and good cosmesis when used as adhesive for wound edges of pediatric circumcisions. Sutureless circumcision technique is better than conventional sutured circumcision.
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Affiliation(s)
- Amit Raut
- Department of Paediatric Surgery, Apollo Speciality Hospitals, Nashik, Maharashtra, India
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Martin A, Nataraja RM, Kimber C, Pacilli M. The Use of Tissue Glue for Circumcision in Children: Systematic Review and Meta-analysis. Urology 2018; 115:21-28. [DOI: 10.1016/j.urology.2018.01.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 01/09/2018] [Accepted: 01/18/2018] [Indexed: 01/08/2023]
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Gorgulu T, Olgun A, Torun M, Kargi E. A fast, easy circumcision procedure combining a CO2 laser and cyanoacrylate adhesive: a non-randomized comparative trial. Int Braz J Urol 2017; 42:113-7. [PMID: 27136476 PMCID: PMC4811235 DOI: 10.1590/s1677-5538.ibju.2015.0284] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 10/12/2015] [Indexed: 01/01/2023] Open
Abstract
Background Circumcision is performed as a routine operation in many countries, more commonly for religious and cultural reasons than for indicated conditions, such as phimosis and balanitis. There are many techniques available, and recently electrocautery and both Nd:YAG and CO2 lasers, instead of blades, have been used for skin and mucosal incisions. However, the infection risk in circumcisions performed using a CO2 laser was 10% higher. There are also reports of sutureless procedures using cyanoacrylate, but these have higher risks of hematoma and hemorrhage. We combined a CO2 laser and cyanoacrylate to shorten the operation time and to decrease bleeding complications. Materials and Methods : Circumcisions were performed under general anesthesia with CO2 laser and cyanoacrylate combination in 75 6–9-year-old boys between May 2013 and August 2014 only for religious reasons. As a control, we compared them retrospectively with 75 age-matched patients who were circumcised using the conventional guillotine method in our clinic. Results No hematomas, bleeding, or wound infections were observed. One wound dehiscence (1.33%) occurred during the early postoperative period and healed without any additional procedures. The median operating time was 7 (range 6–9) minutes. The conventional guillotine group comprised one hematoma (1.3%), two wound dehiscences (2.6%), and two hemorrhages (2.6%), and the median operating time was 22 (range 20–26) minutes. The difference in surgical time was significant (p<0.001), with no significant difference in the rate of complications between the two groups. Conclusion The combined CO2 laser and cyanoacrylate procedure not only decreased the operating time markedly, but also eliminated the disadvantages associated with each individual procedure alone.
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Affiliation(s)
- Tahsin Gorgulu
- Department of Plastic, Reconstructive and Aesthetic Surgery, Bulent Ecevit University Medical Faculty, Zonguldak, Turkey
| | - Abdulkerim Olgun
- Department of Plastic, Reconstructive and Aesthetic Surgery, Bulent Ecevit University Medical Faculty, Zonguldak, Turkey
| | - Merve Torun
- Department of Plastic, Reconstructive and Aesthetic Surgery, Bulent Ecevit University Medical Faculty, Zonguldak, Turkey
| | - Eksal Kargi
- Department of Plastic, Reconstructive and Aesthetic Surgery, Bulent Ecevit University Medical Faculty, Zonguldak, Turkey
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Sutureless Adult Voluntary Male Circumcision with Topical Anesthetic: A Randomized Field Trial of Unicirc, a Single-Use Surgical Instrument. PLoS One 2016; 11:e0157065. [PMID: 27299735 PMCID: PMC4907451 DOI: 10.1371/journal.pone.0157065] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 05/23/2016] [Indexed: 12/02/2022] Open
Abstract
Introduction The World Health Organization has solicited rapid and minimally invasive techniques to facilitate scale-up of voluntary medical male circumcision (VMMC). Study design Non-blinded randomized controlled field trial with 2:1 allocation ratio. Participants 75 adult male volunteers. Setting Outpatient primary care clinic. Intervention Open surgical circumcision under local anesthetic with suturing vs. Unicirc disposable instrument under topical anesthetic and wound sealing with cyanoacrylate tissue adhesive. Primary Outcome Intraoperative duration. Secondary Outcomes Intraoperative and postoperative pain; adverse events; time to healing; patient satisfaction; cosmetic result. Results The intraoperative time was less with the Unicirc technique (median 12 vs. 25 min, p < 0.001). Wound healing and cosmetic results were superior in the Unicirc group. Adverse events were similar in both groups. Conclusions VMMC with Unicirc under topical anesthetic and wound sealing with cyanoacrylate tissue adhesive is rapid, heals by primary intention with superior cosmetic results, and is potentially safer and more cost-effective than open surgical VMMC. Trial Registration Clinicaltrials.gov NCT02443792
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Van Haute C, Tailly T, Klockaerts K, Ringoir Y. Sutureless circumcision using 2-Octyl cyanoacrylate results in more rapid and less painful procedures with excellent cosmetic satisfaction. J Pediatr Urol 2015; 11:147.e1-5. [PMID: 25910797 DOI: 10.1016/j.jpurol.2015.02.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Accepted: 02/18/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Circumcision is the most common surgical procedure in male children in the world and is performed because of cultural, religious or medical reasons. Traditionally, interrupted sutures are used to close the wound, but 2-Octyl cyanoacrylate (2-OCA) tissue glue can be used as an alternative method to close the circumcision wound. OBJECTIVES To compare the use of 2-OCA with absorbable sutures in circumcision wound closure in prepubescent patients in terms of operative time, complication rate, postoperative pain and cosmetic results. STUDY DESIGN We retrospectively evaluated 662 circumcision procedures using sutures and 609 procedures using 2-OCA for wound closure in prepubescent boys. All circumcision procedures were performed by 2 surgeons in a single centre. Operative time was collected from the hospital surgical software system. 62% of the patients in the suture group and 59% of the patients in the 2-OCA group presented for a postoperative check-up 6 weeks after the circumcision. Data regarding postoperative pain, need for analgesia, cosmetic satisfaction and the ease of wound care were collected through questionnaires completed by 25% of the boy's parents in the suture group and 53% of the parents in the 2-OCA group. RESULTS Mean operative time was significantly shorter in the 2-OCA group (13 min) than in the suture group (17 min). Complications were comparable and mostly minor. Reintervention was only required in 3 cases. According to the parents, the degree of postoperative pain and the postoperative need for analgesics was significantly lower in the 2-OCA group. Wounds closed with 2-OCA were easier to care for. The cosmetic results after 1 day, after 1 week and after 1 month in the 2-OCA group were significantly superior than in the suture group, according to the parents' evaluation. DISCUSSION The use of 2-OCA in circumcision wound closure has been reported before. Previous studies with mainly limited patient numbers report less pain, shorter procedure times and a higher surgeon satisfaction in terms of cosmetic results. This study is the largest study comparing the use of 2-OCA and interrupted sutures in circumcision wound closure. The retrospective character of the study, the lack of a validated questionnaire tool for the cosmetic evaluation and the use of the parent's evaluation are the limitations of this study. CONCLUSION The use of 2-OCA in circumcision wound closure results in a shorter operative time, in less postoperative pain, in easy postoperative wound care and in excellent cosmesis when compared to interrupted absorbable sutures. 2-OCA is our current technique of choice in circumcision wound closure.
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Affiliation(s)
- C Van Haute
- AZ St Lucas, Department of Urology, Groenebriel 1, 9000 Ghent, Belgium.
| | - T Tailly
- AZ St Lucas, Department of Urology, Groenebriel 1, 9000 Ghent, Belgium.
| | - K Klockaerts
- AZ St Lucas, Department of Urology, Groenebriel 1, 9000 Ghent, Belgium.
| | - Y Ringoir
- AZ St Lucas, Department of Urology, Groenebriel 1, 9000 Ghent, Belgium.
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Fotso Kamdem A, Nerich V, Auber F, Jantchou P, Ecarnot F, Woronoff-Lemsi MC. Quality assessment of economic evaluation studies in pediatric surgery: a systematic review. J Pediatr Surg 2015; 50:659-87. [PMID: 25840083 DOI: 10.1016/j.jpedsurg.2015.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 12/27/2014] [Accepted: 01/14/2015] [Indexed: 01/20/2023]
Abstract
PURPOSE To assess economic evaluation studies (EES) in pediatric surgery and to identify potential factors associated with high-quality studies. METHODS A systematic review of the literature using PubMed and Cochrane databases was conducted to identify EES in pediatric surgery published between 1 June 1993 and 30 June 2013. Assessment criteria are derived from the Drummond checklist. A high quality study was defined as a Drummond score ≥7. Logistic regression analysis was used to determine factors associated with high quality studies. RESULTS 119 studies were included. 43.7% (n=52) of studies were full EES. Cost-effectiveness analysis was the most frequent (61.5%) type of full EES. Only 31.6% of studies had a Drummond score ≥7 and 73% of these were full EES. The factors associated with high quality were identification of costs (OR: 14.08; 95% CI: 3.38-100; p<0.001), estimation of utility value (OR: 8.13; 95% CI: 2.02-43.47; p=0.005) and study funding (OR: 3.50; 95% CI: 1.27-10.10; p=0.02). CONCLUSION This review shows that the number and the quality of EES are low despite the increasing number of studies published in recent years. In the current context of budget constraints, our results should encourage pediatric surgeons to focus more on EES.
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Affiliation(s)
- Arnaud Fotso Kamdem
- UMR-INSERM-1098, Department of Pediatric Surgery, Besançon University Hospital, 3 Boulevard Fleming, F-25000 Besancon, France.
| | - Virginie Nerich
- INSERM U645 EA-2284 IFR-133, Department of Pharmacy, Besançon University Hospital, 3 Boulevard Fleming, F-25000 Besancon, France.
| | - Frederic Auber
- UMR-INSERM-1098, Department of Pediatric Surgery, Besançon University Hospital, 3 Boulevard Fleming, F-25000 Besancon, France.
| | - Prévost Jantchou
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Sainte-Justine University Hospital, 3175, Chemin de la Côte Sainte-Catherine, H3T 1C5, Montréal, Quebec, Canada.
| | - Fiona Ecarnot
- EA3920, Department of Cardiology, Besançon University Hospital, 3 Boulevard Fleming, F-25000 Besançon, France.
| | - Marie-Christine Woronoff-Lemsi
- UMR-INSERM-1098, Department of Clinical Research and Innovation, Besançon University Hospital, 2 place Saint Jacques, F-25000 Besançon, France.
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Peng M, Meng Z, Yang ZH, Wang XH. The ultrasonic harmonic scalpel for circumcision: experimental evaluation using dogs. Asian J Androl 2012; 15:93-6. [PMID: 23042449 DOI: 10.1038/aja.2012.67] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Male circumcision is one of the most commonly performed operations worldwide, and many novel techniques have been developed for better postoperative outcomes. The purpose of this study was to explore the feasibility of applying the ultracision harmonic scalpel (UHS) for circumcision by using dogs. Sixteen adult male dogs were divided into two groups: the UHS group and the control group. The dogs were circumcised with either the UHS or a conventional scalpel. The UHS circumcision procedure and the effects were imaged 1 week after surgery. The two groups were compared with respect to the operative time and volume of blood loss. Postoperative complications, including oedema, infection, bleeding of the incision and wound dehiscence, were recorded for both groups. The mean operative time for the UHS group was only 5.1 min compared with the 35.5 min of the conventional group. The mean blood loss was less than 2 ml for the UHS group and 15 ml for the conventional group. There was only one case of mild oedema in the UHS group, but the postoperative complications in the conventional group included two cases of mild oedema, one infection of the incision and one case of bleeding of the incision. In conclusion, circumcision using UHS is a novel technique to treat patients with phimosis and excessive foreskin, and this method has a short operative time, less blood loss and fewer complications than the conventional scalpel method. This small animal study provides a basis for embarking on a larger-scale clinical trial of the UHS.
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Affiliation(s)
- Mou Peng
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
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Paediatric sutureless circumcision--an alternative to the standard technique. Pediatr Surg Int 2012; 28:305-8. [PMID: 22009213 DOI: 10.1007/s00383-011-3015-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2011] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Circumcision is one of the most commonly performed surgical procedures in male children. A range of surgical techniques exist for this commonly performed procedure. The aim of this study is to assess the safety, functional outcome and cosmetic appearance of a sutureless circumcision technique. METHODS Over a 9-year period, 502 consecutive primary sutureless circumcisions were performed by a single surgeon. All 502 cases were entered prospectively into a database including all relevant clinical details and a review was performed. The technique used to perform the sutureless circumcision is a modification of the standard sleeve technique with the use of a bipolar diathermy and the application of 2-octyl cyanoacrylate (2-OCA) to approximate the tissue edges. RESULTS All boys in this study were pre-pubescent and the ages ranged from 6 months to 12 years (mean age 3.5 years). All patients had this procedure performed as a day case and under general anaesthetic. Complications included: haemorrhage (2.2%), haematoma (1.4%), wound infection (4%), allergic reaction (0.2%) and wound dehiscence (0.8%). Only 9 (1.8%) parents or patients were dissatisfied with the cosmetic appearance. CONCLUSION The use of 2-OCA as a tissue adhesive for sutureless circumcisions is an alternative to the standard suture technique. The use of this tissue adhesive, 2-OCA, results in comparable complication rates to the standard circumcision technique and results in excellent post-operative cosmetic satisfaction.
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Tiwari P, Tiwari A, Kumar S, Patil R, Goel A, Sharma P, Kundu AK. Sutureless circumcision - An Indian experience. Indian J Urol 2012; 27:475-8. [PMID: 22279312 PMCID: PMC3263214 DOI: 10.4103/0970-1591.91435] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Context: Traditionally, circumcision wounds are closed by absorbable sutures. However, certain alternative methods are also being utilized to overcome the shortcomings of the conventionally used method for circumcision wound closuring. In the current study, the use of tissue glue ((iso amyl 2-cyanoacrylate) has been compared with traditional suturing for the approximation of circumcision wounds. In our study, both the methods were found to be comparable with significantly less time consumed in glue group. Aims: The purpose of the present study has been to compare directly cyanoacrylate as a better alternative to conventional suture material in terms of cosmetic result, time consumed and incidence of infection (comparative study). Materials and Methods: The results of all the patients seen in outpatient department for circumcision were included in this study. The study was conducted from Aug 2009 to May 2010. The tissue glue (iso amyl 2-cyanoacrylate) was compared to sutures as a method of wound approximation in circumcision. Results: Tissue glue group has been observed to have less wound inflammation, bleeding or hematoma rate and was cosmetically superior as compared to suture group; however, none of these findings could reach statistically significant level. The mean time taken for circumcision was 14.2 min (SD 2.42), when tissue glue was used for wound approximation. However, it was 24.4 min (SD 5.06) in case of the use of sutures. This difference was found as highly significant (P value < 0.001). However, regarding postoperative pain no significant reduction was observed when glue was used. Conclusions: This study showed that the use of tissue glue in comparison to sutures is having the following advantages: Cosmetically superior Less time consuming
All other parameters measured were nearly the same and statically insignificant.
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Affiliation(s)
- Punit Tiwari
- Department of Urology, SSKM Hospital, Institute of Post-Graduate Education and Research, Kolkata, WB, India
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Abstract
Using the Gomco circumcision clamp and sealing the wound with tissue adhesive results in a minimally invasive circumcision suitable for all age groups beyond the neonatal period. It is easy to perform and can be performed by generalists with local anaesthetic and standard instruments.
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