Clitoral Reconstructive Surgery After Female Genital Mutilation/Cutting: Anatomy, Technical Innovations and Updates of the Initial Technique.

INTRODUCTION: Female genital mutilation (FGM) includes all procedures that involve partial or total removal of the female external genitalia or any other injury of the female genitalia that is performed for nonmedical reasons. FGM is classified into 4 types. Surgical clitoral reconstruction was first described by Thabet and Thabet in Egypt and subsequently by Foldès in France. The technique was then modified by different authors. AIM: This article aims to provide a detailed description of clitoral surgical reconstruction and the modifications which have been made over time to improve the procedure while recalling current knowledge in the anatomy of the clitoris. METHODS: We performed a broad systematic search in PubMed/Medline and EMBASE bibliographic databases for studies that report the surgical technique of clitoral reconstruction. From the anatomical point of view, we examined available evidence (from 1950 until 2020) related to clitoral anatomy, the clitoral role in sexual functioning, female genital mutilation/cutting, and surgical implications for the clitoris. MAIN OUTCOMES: A review of the surgical techniques for clitoral reconstruction after female genital mutilation/cutting RESULTS: We described the current anatomical knowledge about the clitoris, and the procedures based on the surgical technique by Pierre Foldès, We included the technical modifications and contributions described in articles published subsequently. CONCLUSION: Surgical repair of the clitoris for FGM offers anatomical and functional results although they still have to be evaluated. However, it should not be the only therapeutic solution offered to women with FGM. Botter C, Sawan D, SidAhmed-Mezi M, et al. Clitoral Reconstructive Surgery After Female Genital Mutilation/Cutting: Anatomy, Technical Innovations and Updates of the Initial Technique. J Sex Med 2021;18:996-1008.

How to tie dangerous surgical knots: easily. Can we avoid this?

OBJECTIVE: Secure knots are essential in all areas of surgical, medical and veterinary practice. Our hypothesis was that technique of formation of each layer of a surgical knot was important to its security. DESIGN: Equal numbers of knots were tied, by each of three groups, using three techniques, for each of four suture materials; a standard flat reef knot (FRK), knots tied under tension (TK) and knots laid without appropriate hand crossing (NHCK). Each knot technique was performed reproducibly, and tested by distraction with increasing force, till each material broke or the knot separated completely. SETTING: Temporary knot tying laboratory. MATERIALS: The suture materials were, 2/0 polyglactin 910 (Vicryl), 3/0 polydioxanone, 4/0 poliglecaprone 25 (Monocryl) and 1 nylon (Ethilon). PARTICIPANTS: Three groups comprised, a senior surgeon, a resident surgeon and three medical students. OUTCOME MEASURES: Proportion of each knot type that slipped, degree of slippage and length of suture held in loop secured by each knot type. RESULTS: 20% of FRK tied with all suture materials slipped; all knots tied with the other two techniques, with all materials, slipped, TK (100%) and NHCK (100%). The quantitative degree of slip was significantly less for FRK (mean 6.3%-, 95% CI 2.2% to 10.4%) than for TK (mean 312%, 95% CI 280.0% to 344.0%) and NHCK (mean 113.0%, -95% CI 94.3% to 131.0%).The mean length of suture in loops held within (FRK mean 25.1 mm 95% CI 24.2 to 26.0 mm) was significantly greater than mean lengths held by the other techniques (TK mean 17.0 mm, 95% CI 16.3 to 17.7 mm), (NHCK mean 16.3 mm, 95% CI 15.9 to 16.7 mm). The latter two types of knot may have tightened more than anticipated, in comparison to FRK, with potential undue tissue tension. CONCLUSION: Meticulous technique of knot tying is essential for secure knots, appropriate tissue tension and the security of anastomoses and haemostasis effected.