Circumcision (Male; Newborn and Infant)

Published on 30/05/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 5898 times

Chapter 237 Circumcision (Male; Newborn and Infant)

DESCRIPTION

Male circumcision is the removal of some or all of the foreskin of the phallus.

INDICATIONS

Parental or religious preference (not a medically indicated procedure). Circumcision of newborns should be performed only on healthy and stable infants.

CONTRAINDICATIONS

Age greater than 6 to 8 weeks (relative), age less than 12 hours, ambiguous genitalia, hypospadias, illness, less than 1 hour postprandial, possibility of blood dyscrasia, prematurity, undescended testicles (relative). A family history of intolerance or allergy to local anesthetics should prompt reconsideration.

REQUIRED EQUIPMENT

• Infant restraint board (“papoose” board)
• Sterile gloves
• Sterile drape (one with a small fenestration or multiple drapes)
• Skin preparation materials (e.g., povidone–iodine and 70% isopropyl alcohol)
• Sterile gauze pads (2″ × 2″ or 4″ × 4″)
• Three hemostats (small tips, two curved, one straight)
• Small scissors or scalpel (#10 or #11 blade)
• Flexible blunt probe
• Gomco clamp (1.1 to 1.45 cm) or Plastibell (1.3 to 1.6 cm) or Mogen clamp (for clamp methods)
• Sterile safety pin, clip, or skin staple (optional)
• Viscous lidocaine (2% to 5%) or 1% lidocaine without epinephrine, 1-cc syringe, 27-gauge needle for dorsal penile nerve or ring block. EMLA cream may also be used.
• Petrolatum (Vaseline) gauze
• Silver nitrate stick or Monsel solution
• Small suture (3-0 or 4-0 absorbable) and needle holder (available)

Electrosurgical devices should never be used in conjunction with any of the clamp-based procedures.

A bulb syringe should be kept near during circumcision as a protection against aspiration should the newborn regurgitate.

TECHNIQUE

All circumcision techniques begin with the undiapered newborn restrained on an infant restraint (papoose) board. The penis should be inspected to identify the meatus and its location on the glans. Once the anatomy has been confirmed to be normal, anesthesia by way of topical lidocaine or dorsal block may be administered.

Swaddling, sucrose by mouth, and acetaminophen administration may reduce the stress response but are not sufficient for the operative pain and cannot be recommended as the sole method of analgesia. EMLA cream, dorsal penile nerve block, and subcutaneous ring block are all reasonable options, although the subcutaneous ring block may provide the most effective analgesia.

Identifying the depth of the root of the penis using the index finger begins a dorsal penile block. The root is usually located 0.75 to 1 cm beneath the skin surface, with the size and consistency of a large blueberry. The skin of the penis and the surrounding areas should be disinfected by any suitable method and sterile drapes should be placed to provide a surgical field. Using aseptic technique, the physician places the penis on slight downward traction and inserts the needle at the 2 o’clock position near the base. The needle is passed in a posteromedial direction to a depth of 3 to 5 mm beneath the skin, about 5 to 7 mm distal to the penile root near the point at which the dorsal nerves branch. If it is correctly located outside of the corpus cavernosum, the tip of the needle should move freely. The syringe should be aspirated to prevent intravenous injection, and 0.2 to 0.4 mL of anesthetic should be injected. The procedure is repeated at the 10-o’clock position, although a single needle insertion point in the dorsal midline may also be used, if desired. Total anesthetic dose should remain less than 0.8 mL. Full anesthesia will be achieved in 2 to 4 minutes.

The specific technique used varies slightly with the type of instrument chosen, the final choice of which is generally based on the personal preference and experience of the provider.

Both the Plastibell and Gomco clamp techniques begin in the same way: A hemostat is used to grasp the edge of the foreskin dorsal to the 3- and 9-o’clock positions (dorsal as 12 o’clock). A hemostat or flexible probe is inserted just under the foreskin and swept laterally to bluntly lyse any adhesions. Care must be taken to avoid disrupting either the ventral attachment or the coronal reflection. The foreskin is tented away from the glans and a straight hemostat is inserted along the dorsal line and clamped to a depth of one third to one half of the way to the coronal reflection. This is left in place for approximately 1 minute before it is removed and the crushed tissue is incised using scissors. The glans must be avoided during both the clamping and incision process. The foreskin is next retracted, and any further adhesions are removed; if needed, the dorsal incision is extended by repeating the crush and cut process. The procedure is then completed based on the instrument preferred.

Plastibell

With the dissection of the foreskin free of the glans completed, the Plastibell string is placed as a loop near the base of the penis. The bell is placed under the foreskin, over the glans. This may be facilitated by upward traction on the edges of the foreskin grasped by hemostats and by downward pressure on the stem of the bell. When in a correct position, the bell should rest against the corona. The foreskin is pulled upward, ensuring even placement and positioning that leaves the groove in the bell well below the apex of the dorsal slit. The bell should move freely over the glans. While maintaining these relationships, the string is brought into position, resting in the groove of the bell. The string should be pulled firmly and all aspects should be rechecked before the string is tightened maximally. Tension on the string is maintained for at least 30 seconds and then a square knot is placed.

The foreskin is cut just above the level of the string, with care taken not to cut too close to the string or to damage the string itself. The string is trimmed, and the stem of the Plastibell is broken off at its junction with the bell. Hemostasis should be confirmed, and a dressing may be applied if desired. The bell may be expected to slough off in 5 to 8 days, or it may be removed by cutting the ligature after a minimum of 36 hours.

Gomco Clamp

The Gomco clamp consists of a base plate, arm, bell, and thumbscrew. The bell of the Gomco clamp is placed under the foreskin and over the glans in the same manner as with the Plastibell. The bell and foreskin are then inserted through the opening in the baseplate of the clamp. This may be facilitated by reaching through the opening with a hemostat to help guide the foreskin. When the bell is passed through the baseplate, the foreskin must be brought completely through the opening and evenly drawn up on all sides. The entire length of the dorsal incision must be above the baseplate opening. The stem of the bell is placed into the top of the clamp, and the thumbscrew is gently tightened. The foreskin, bell, and shaft of the penis are again inspected before the final tightening is performed.

A scalpel is used to excise all of the tissue above the baseplate of the clamp. Care must be used to completely remove any tissue devitalized by the clamp. The Gomco clamp is loosened, and the bell is freed. The foreskin is freed from the bell by gentle traction using a gauze sponge. Hemostasis must be assured and may be assisted by pressure, the application of Monsel solution, or a fine suture. A petrolatum gauze dressing should be placed and the newborn should be diapered.

Mogen Clamp

When the Mogen clamp is used, the infant is restrained and inspected, and the skin is prepared as for the other two methods. Hemostats are used to pull the foreskin upward, and the tip of the penis is transilluminated to identify the glans. The Mogen clamp is applied with its curved side toward the glans. It is slid into place over the foreskin from dorsal to ventral in a horizontal plane, and the provider adjusts it so that the desired amount of skin is distal to the clamp. The clamp is angled so that more skin is removed from the dorsal side of the penis. The glans is again inspected and palpated to ensure it is clear of the clamp, and the clamp then is tightened. A scalpel is used to cut the foreskin flush with the surface of the clamp. The clamp is left in place for approximately 1 minute before it is removed. (If the Mogen clamp is left in place for more than a minute, the sides of the foreskin may become fused and difficult to separate.) The sides of the foreskin are separated by downward traction, inspected, and dressed. A gauze pad may be used to help separate the sides of the foreskin if necessary, although excess bleeding may be encountered if too much force is used. (A small ventral “dog ear” will often be present when the clamp is removed. This will partially necrose and heal without cosmetic defect.)

Silver nitrate should not be used for hemostasis because of the risk of permanent staining of the tissues.

COMPLICATIONS

The exact incidence of complications after circumcision is not known, but data indicate that the rate is low (0.2% to 0.6%), and the most common complications are local infection and bleeding. Rare complications include urinary fistulas, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias, impotence, and removal of too much tissue (sometimes causing secondary phimosis).

FOLLOW-UP

Following circumcision, the infant should be observed for at least 4 hours and should void before being released. The petrolatum gauze should be removed after 24 hours or if it becomes soiled. Petrolatum jelly should be applied at each diaper change until healing has occurred (about 7 to 10 days). At each diaper change the penile skin should be retracted to prevent adhesion formation.

CPT CODE(S)

54150 Circumcision, using clamp or other device with regional dorsal penile or ring block
54160 Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age or less)
00920 Anesthesia for procedure on male external genitalia; not otherwise specified

image

REFERENCES

Level II

Blass EM, Hoffmeyer LB. Sucrose as an analgesic for newborn infants. Pediatrics. 1991;87:215.

Marshall RE. Neonatal pain associated with caregiving procedures. Pediatr Clin North Am. 1989;36:885.

Strimling BS. Partial amputation of glans penis during Mogen clamp circumcision. Pediatr. 1996;97:906.

Level III

American Academy of Pediatrics, Committee on Fetus and Newborn, Committee on Drugs, Section on Anesthesiology, Section on Surgery, Canadian Paediatric Society. Prevention and management of pain and stress in the neonate. Fetus and Newborn Committee. Pediatrics. 2000;105:454. 461.

American College of Obstetricians and Gynecologists. Circumcision. ACOG Committee Opinion 260. Obstet Gynecol. 2001;98:707.

Baskin LS, Canning DA, Snyder HM, Duckett JW. Treating complications of circumcision. Pediat Emerg Care. 1996;12:62.

Benini F, Johnston CC, Faucher D, Aranda JV. Topical anesthesia during circumcision in newborn infants. JAMA. 1993;270:850.

Clair DL, Caldamone AA. Pediatric office procedures. Urol Clin North Am. 1988;15:715.

Kaweblum YA, Press S, Kogan L, et al. Circumcision using the Mogen clamp. Clin Pediatr. 1984;23:679.

Niku SD, Stock JA, Kaplan GW. Neonatal circumcision. Urol Clin North Am. 1995;22:57.

Reynolds RD. Use of the Mogen clamp for neonatal circumcision. Am Fam Physician. 1996;54:177.

Task Force on Circumcision, American Academy of Pediatrics. Circumcision policy statement. Pediatrics. 1999;103:686.

Warner E, Strashin E. Benefits and risks of circumcision. Can Med Assoc J. 1981;125:967. 992.

Wolkomir MS. Technique for freehand newborn circumcision. J Fam Pract. 1996;42:447.

Related posts:

Cervical Incompetence Bartholin’s Gland: Abscess/Infection Pre-Eclampsia and Eclampsia (Toxemia of Pregnancy) Sexually Transmitted Infections: Human Immunodeficiency Virus Breast: Galactocele Sheehan’s Syndrome