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Snip Chat: Circumcisions
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Lisa and Amy review some tips and tricks for circumcision.
- The medical evidence for doing circumcision centers on the decreased risk of UTI in the first year of life; reduction of risk for phimosis and balanitis and decreased risk of STIs in the future.
- However, the AAP has not found the evidence strong enough to routinely recommend circumcision for every newborn male. The AAP does support the practice, however, of offering it to every family and states it should be a procedure covered by insurance.
- Circumcisions in the newborn period are faster, less expensive, have shorter recoveries, and have cosmetically better results than when done on older children.
- Gomco clamp:
- The foreskin is pulled up over a metal bell to help determine how much skin to remove; the glans of the penis is protected
- This is usually the preferred method pediatricians use.
- Is a similar shape, but part of the bell is broken off and the plastic ring stays attached to the baby; the foreskin turns black and falls off.
- Mogen Clamp:
- Looks like a little guillotine in which the foreskin is pulled through and cut off. This is often used by mohels (Jewish ritual circumcisers) and OB/GYNs.
- Clinical criteria and contraindications for circumcision:
- The glans must be big enough for the 1.1 Gomco
- The foreskin must be complete
- Babies with epispadias or obvious hypospadias should not be circumcised as surgical revision might be needed.
- If the raphe is turned more than 90 degrees around the shaft of the penis (torsion), then circumcision should not be performed.
- If the torsion is less than 90 degrees, it is OK to complete the circumcision.
- A webbed penis (the connection between the scrotum and the base of the shaft), a shawl scrotum (in which the penis comes from the middle of the scrotum), a buried penis (can be difficult to tell sometimes with a fat pad), and/or if the cut is going to go through any scrotal skin, the penis should not be circumcised.
- If a family wants a circumcision, but the baby has a medical contraindication, it may be helpful to use the phrase “we are preserving length” as opposed to “abnormal anatomy.”
- Risks include:
- Highest risk in the first 1-2 hours after the procedure
- Very small risk of infection
- Damage to the neighboring areas (again, very unlikely but always good to mention to families)
- Procedure (for Gomco type of circumcision):
- Circumcision is a sterile procedure and therefore, sterile gloves, drapes, and instruments are needed.
- Anesthesia options:
- Dorsal penile nerve block: here is a video from Stanford showing how to perform the dorsal penile nerve block and Plastibell circumcision
- EMLA (only anesthetizes the very top layer of skin)
- Ring block
- Lysis of adhesion
- Freeing up the foreskin from the shaft of the penis as all babies are born with some degree of phimosis
- Dorsal slit
- This is how much skin you are going to take off (2/3rds to 3/4ths of the length)
- It is OK to stop here if there are any anatomic abnormalities that would contradict completing the procedure
- Assembling the clamp (if using Gomco clamp, see the link to video above if using Plastibell)
- Disassembling the clamp
- Bleeding: there may be bleeding in the first few minutes, or with the first diaper check - hold pressure for a few minutes, and this will usually stop the bleeding
- If the bleeding does not stop, the next step is to use pro-coagulant gauze, and sometimes two layers are needed
- This gauze will dissolve on its own
- If needed, a small 6-0 fast-absorbing suture can be used to stop bleeding
- After the circumcision, place vaseline and then a big piece of gauze to cover the penis.