Atlas of Procedures in Neonatology, 4th Edition

Miscellaneous Procedures

44

Circumcision

Mhairi G. MacDonald

  1. Indications

Newborn male circumcision, one of the oldest formally recorded surgical procedures, remains controversial (1,2 and 3). Many physicians and lay people consider circumcision routine, but complications, although relatively rare, can be severe. Therefore, despite the perceived simplicity of the procedure, meticulous attention to anatomic landmarks, wound care, and follow-up is necessary.

A large French study compared the cost-effectiveness of circumcision and topical steroids as treatments for phimosis. The study concluded that topical pharmacologic treatment is effective in approximately 85% of patients, avoids the disadvantages, trauma, and potential complications of circumcision, and could reduce costs by 75% (4).

  1. Contraindications
  2. Age <1 day (i.e., before complete physical adaptation to extrauterine life has occurred)
  3. Any current illness
  4. Prematurity (<37 weeks' gestation)
  5. Bleeding diathesis or family history of bleeding disorder
  6. Abnormality of urethra or penile shaft (foreskin may be essential for later reconstruction [e.g., hypospadias, chordee, very small penis])
  7. Local infection
  8. Lack of truly “informed” parental consent (see Chapter 1)
  9. Equipment
  10. Necessary for all methods

Sterile

  1. Gown and gloves
  2. Cup with antiseptic
  3. 4x4-in gauze pads
  4. Small, flexible, blunt probe
  5. Two straight mosquito hemostats
  6. Large, straight hemostat
  7. Tissue scissors

Nonsterile

  1. Materials for restraint
  2. Optional equipment
  3. Local anesthetic: 1% lidocaine hydrochloride without epinephrine in a tuberculin syringe with a 1.2-cm x 27-gauge needle

Circumcision of neonates has frequently been used as a model to study the response of the newborn to pain (see Chapter 5). However, until recently, neonatal circumcision has been performed without anesthesia. Since the initial report by Kirya and Werthmann in 1978 (5), there have been reports of several controlled studies that have concluded that the use of dorsal penile nerve block is both effective and safe (5,6,7,8,9,10,11, and 12).

The effectiveness of EMLA (eutectic mixture of local anesthetics; lidocaine and prilocaine, Astra Pharma) 5% cream has also been studied (13,14 and 15). Conclusions from meta-analysis of data from refs. (12,13 and 14) led to the conclusion that EMLA cannot be recommended over other analgesic techniques with proven efficacy, such as regional nerve block with lidocaine. However, current data provide sufficient evidence to recommend routine use of EMLA for neonatal circumcision pain in settings in which no analgesics are routinely administered (15).

  1. Sterile fine-tipped marking pen
  2. Sterile gauze impregnated with petroleum jelly (e.g., Vaseline)
  3. Additional equipment for use with Gomco clamp

All equipment is sterile.

  1. Gomco circumcision clamp (Gomco Surgical Manufacturing Corp., Buffalo, NY, USA) (16), size 1 to 2 cm for average newborn glans (size range 1 to 3.5 cm)

Be sure to use a size that is large enough to protect the glans (17).

  1. 11 scalpel blade and holder
  2. A small safety pin
  3. Additional equipment for use with Plastibell

All equipment is sterile.

  1. Plastibell plastic cone (Hollister, Libertyville, IL, USA); available in presterilized packs; size range based on size of glans penis: 1.1, 1.3, and 1.5 cm. A linen suture is included in the pack (Fig. 44.1).

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When selecting size, make sure that it is not so large that it allows proximal migration of the bell and excessive loss of penile skin nor so small that it could impair penile circulation.

  1. Scissors capable of cutting through plastic
 

FIG. 44.1. Plastibell with linen suture.

  1. Precautions
  2. Obtain fully informed consent (see Chapter 1).
  3. Explain expected course of circumcision to parents. When Plastibell is used, parents should be told to call their physician if ring has not fallen off within 10 days (18).
  4. Be aware of laws pertaining to ritual circumcision (e.g., Jewish brit milah) (1,19,20) and the complications of the practice of orally suctioning the blood after cutting the foreskin (oral metzitzah) (21).
  5. Never circumcise at time of delivery. Circumcise long enough before discharge to allow adequate wound observation.
  6. Do not use local anesthetic containing epinephrine.
  7. Specifically locate coronal sulcus and urethral meatus.
  8. Make sure that inner epithelium is completely separated from glans penis and that prepuce can be retracted to visualize entire circumference of coronal sulcus.
  9. Never use electrocautery.
  10. Do not use circumferential dressing.
  11. Recheck wound prior to discharging patient and 1 to 2 weeks after circumcision. Residual skin should retract completely, and entire coronal sulcus must be visible to avoid postcircumcision adhesions, the most common complication.
 

FIG. 44.2. Penis is stabilized at angle of 20 to 25 degrees from midline. The formation of a lidocaine ring is shown (see text).

  1. Technique

A complete description of formal surgical excision has been excluded from this edition because of the requirement to use sutures and the associated increased risk of bleeding compared with methods that involve crushing of tissue.

Ritual circumcisions are most commonly performed using a Mogen clamp. The method involves no dorsal incision or sutures (22); however, because the glans is not visible at the time of excision of the prepuce, there is potential for damage to the glans and urethra.

  1. Immobilize infant in supine position.
  2. Put on cap and mask.
  3. Scrub as for major procedure.
  4. Put on gown and gloves.
  5. Prepare skin with antiseptic, and drape.
  6. Perform penile dorsal nerve block if desired.
  7. Be familiar with anatomy of dorsal nerves of penis (Fig. 44.2) (5).

Although only the two dorsal penile nerves are targeted by the injection of lidocaine, the ventral penile nerve is also blocked by infiltration through

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the subcutaneous tissue. Some have advocated additional anesthesia ventrally, blocking the perineal nerves (a branch of the pudendal nerve) (23).

  1. Identify dorsal nerve roots at 10 o'clock and 2 o'clock positions.
  2. Identify by palpation the symphysis pubis and corpora cavernosa at the penile base.
  3. Estimate depth of pubic bone from penile base to indicate necessary depth of injection (should not exceed 0.5 cm).

Although the ideal area for infiltration corresponds to the 2 and 10 o'clock positions, 1 cm distal to the penile base, if the base is buried in pubic fat, the injection must be done at the junction of pubic and pelvic skin.

  1. Stabilize organ, with gentle traction, at angle of 20 to 25 degrees from midline.
  2. Pierce skin over one of dorsal nerves at penile root, and advance carefully posteromedially (0.25 to 0.5 cm) (Fig. 44.2) into subcutaneous tissue to avoid lodging in the erectile tissue.

After entering skin, needle should not meet resistance and tip should remain freely movable. If the tip of the needle is not freely mobile, it is probably embedded in the corpora cavernosum beneath the dorsal nerve and should be withdrawn slightly.

  1. Aspirate to rule out intravascular position.
  2. Slowly infiltrate area with 0.2 to 0.4 mL of lidocaine (never infiltrate as needle is advanced or withdrawn).

Arnett et al. (24) have reported good results using 0.2 mL of lidocaine.

  1. Repeat procedure at other dorsolateral position.

After infiltration, a small lidocaine ring forms (Fig. 44.2). The swelling is minimal and does not interfere with the circumcision procedure.

  1. Wait 3 to 5 minutes for analgesia.

Analgesia is usually obtained after 3 minutes and typically disappears within 20 to 30 minutes. However, there is individual variation, and testing of the prepuce with a hemostat is suggested prior to dissection.

 

FIG. 44.3. Circumcision. A: Marking the position of the coronal sulcus. B: Dilating the preputial ring. C: Separating the prepuce from the glans penis. D: Grasping the prepuce with mosquito hemostats in preparation for the dorsal slit procedure. E:Dorsal slit.

  1. Locate coronal sulcus (Fig. 44.3A). Marking the position of the sulcus with ink on the skin of the penile shaft, prior to the procedure, is helpful in demarcating this vital landmark.
  2. Use mosquito hemostat to dilate preputial ring (Fig. 44.3B).
  3. Use blunt probe to separate inner epithelium of prepuce from glans penis (Fig. 44.3C).

Failure to do this completely may result in concealed penis (see G.3.c and G.13).

  1. Perform dorsal slit if desired.

This step is not mandatory as long as there is adequate separation of the glans from the prepuce.

  1. Grasp rim of prepuce on dorsal aspect with mosquito hemostats, approximately 2 to 4 mm apart (Fig. 44.3D).

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  1. Visualize urethra.
  2. Place lower blade of large, straight hemostat between prepuce and glans to within 3 to 4 mm of corona, making sure to avoid urethra.
  3. Close hemostat for 5 to 10 seconds to crush foreskin in dorsal midline.
  4. Use tissue scissors to cut prepuce along crush line (Fig. 44.3E).
  5. Check that prepuce is freed from entire surface of glans. Complete separation if necessary.
  6. Complete circumcision using method of choice.
  7. Use of circumcision clamp
  8. Check clamp to ensure that all parts are present, fit well, and are in good working order.
  9. Assemble clamp, ensuring that yolk (arm) articulates correctly with baseplate.
  10. Draw prepuce backward gently to expose entire glans penis.
  11. Break down all residual adhesions, and observe position of meatus. If meatus is abnormal, cease at this point.
  12. Sponge glans dry with gauze swabs.
  13. Select stud (bell) of adequate size (see C), and place over glans (Fig. 44.4A).
  14. Pull prepuce over stud.
  15. Approximate edge of dorsal slit. (A sterile safety pin may be used.)
  16. Observe amount of skin remaining under baseplate for accuracy.

Proper placement of prepuce over stud is essential. Pulling too taut may lead to removal of excessive penile skin. Insufficient

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tension may lead to incomplete circumcision.

 

FIG. 44.4. Circumcision with a Gomco clamp. A: Placing the stud over the glans. B: Placing the baseplate of the clamp over the stud until the stud engages with the baseplate (inset). C: Gomco clamp in position for circumcision.

  1. Place baseplate of clamp over stud (with pin perpendicular to shaft of penis) so that prepuce is sandwiched between them (Fig. 44.4B).
  2. Continue to pull upward on stud until entire prepuce is drawn through baseplate and stud engages with baseplate.
  3. Hook yoke (arm) of clamp under side arms on shaft of stud and bolt firmly to baseplate, after checking position of prepuce between stud and baseplate (Fig. 44.4C).
  4. Remove safety pin.
  5. Wait 10 minutes.

Hemostasis is produced by pressure between baseplate and rim of stud. If the clamp is removed before 10 minutes has elapsed,

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wound edge hemostasis may be inadequate. If significant bleeding occurs during the procedure, remove the device and search for bleeding vessel—avoid blindly placing sutures.

  1. Remove prepuce with scalpel held parallel to and flush with upper surface of baseplate. Never use electrocautery; however, use of an ultrasound dissection scalpel has been described as a safe alternative to electrocautery (25).
  2. Loosen bolt on clamp and remove.
  3. Optional: Dress with loose, noncircumferential sterile gauze impregnated with Vaseline.

Gough and Lawton (26) have shown that the addition of tincture of benzoin to the dressing adversely affected wound healing and the addition of topical antibiotic did not produce better results than those achieved with ordinary paraffin gauze.

  1. Apply tight diaper for 1 hour.
  2. For 24 hours after circumcision, check (or instruct parents to check) for bleeding, excessive swelling, and difficulty voiding.
  3. Until circumcised area is completely healed, do not immerse; give sponge bath.
  4. Use of Plastibell
  5. Follow Steps 3 to 5 of E.11.a.
  6. Select bell of correct size (see C).
  7. Cone should fit snugly without pressure on glans.
  8. Grooved rim of bell should be just distal to apex of dorsal slit.
  9. If necessary, cut small segment out of cone so that it clears frenulum.
  10. Hold prepuce firmly in place over cone (Fig. 44.5A).
  11. Tie suture tightly around rim of bell so that prepuce is firmly compressed into groove.
  12. Trim prepuce distal to ligature with tissue scissors. Use outer rim of cone as guide.
  13. Break off cone handle. Tissue beneath ligature will atrophy and separate from bell in 5 to 8 days (maximum 10 to 12 days) (Fig. 44.5B).
  14. Observe and care for circumcision as in Steps 17 and 18 of Gomco clamp (E.11.a).
 

FIG. 44.5. Circumcision with a Plastibell. A: The prepuce is pulled forward onto the bell. Inset: The prepuce is compressed into the groove by the circumferential suture. B: Appearance of the completed circumcision.

  1. Management of Postoperative Bleeding

Postoperative bleeding usually stems from inadequate hemostasis (e.g., unrecognized neonatal hepatitis [27] or

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hereditary clotting disorders). Rarely, anomalous vessels are responsible.

Continuous Ooze

  1. Apply manual pressure for 5 to 10 minutes.

Check that the string on the Plastibell is in place and is sufficiently tight.

  1. Assess bleeding site. If continued oozing:
  2. Apply topical thrombin (Thrombostat) on absorbable gelatin sponge (Gelfoam) or oxidized cellulose (Oxycel, Surgicel); do not use circumferential dressing.
  3. Silver nitrate and epinephrine have also been used topically to control bleeding. To avoid local ischemia or systemic effects, do not exceed a 1:100,000 concentration of epinephrine.

Active Hemorrhage or Uncontrolled Ooze

  1. Surgical assessment—ligation of bleeding vessel
  2. Consider underlying coagulopathy.
  3. Complications (Fig. 44.6A–D)

The overall incidence of complications associated with circumcision ranges from approximately 0.2% to 7% (28,29 and 30).

  1. Hemorrhage (26,27,28,29,30, and 31)
  2. Infection (32,33, 34,35, 36, and 37)

More common with the Plastibell. Most are mild and respond to wet to dry dressings and Sitz baths, but fatalities have been reported (35).

  1. Local (5,32,33)
  2. Systemic (34,36)
  3. Necrotizing fasciitis (37)
  4. Incomplete circumcision (most common complication) (38,39 and 40)
  5. Phimosis (40)
  6. Skin bridge between penile shaft and glans (commonly due to inadequate skin removal and failure to visualize the corona on follow-up examination) (40,41)
  7. Concealed penis (see also G.13) (30,40,42,43 and 44)
  8. Trauma
  9. Urethral laceration during dorsal slit procedure (avoided by keeping urethra in view at all times during the procedure)
  10. Loss of penis (most commonly due to injuries related to cautery) (45,46)/amputation of glans (17)
  11. Hypospadias/epispadias (47)
  12. Cyanosis/necrosis of glans penis caused by overly tight Plastibell, misplaced sutures, or overtight circumferential bandage (30,40,48)
  13. Urethrocutaneous fistula associated with use of Gomco clamp or Plastibell (most commonly caused by using a Plastibell or clamp of incorrect size or failure to recognize congenital megaloureter) (42,49,50)
  14. Urinary retention
  15. Tight (or occlusive) dressing or glanular prolapse through ring of Plastibell (32,40,52,53 and 54)
  16. Meatal stenosis resulting from urethral meatitis (5,40)
  17. Inflammation/ulceration of meatus (1,5,54,55,56,57, and 58)
  18. Circumcision of hypospadias (40,52)
  19. Chordee (40); most commonly is the result of dense ventral scarring from inflammation; may be due to removal of excess skin from shaft or secondary to a skin bridge
  20. Inclusion cyst of prepuce (52)
  21. Lymphedema (40,52,59)
  22. Venous stasis (60)
  23. Displacement with lodging of Plastibell around penile shaft or glans penis (18,61,62 and 63)
  24. Death
  25. Anesthetic (1,63,64)
  26. Infection (65)
  27. Wound separation/removal of excess skin (Fig. 44.6) (30,52,61,66)

Buried penis is usually the result of inappropriate circumcision in a chubby baby with a small or concealed penis. Excessive removal of skin should be treated with application of antiseptic (iodophor) daily and not with grafting or burying the penis in scrotum. The skin will grow back.

  1. Recurrence of pneumothorax (67)
  2. Reaction to epinephrine used to control bleeding (68)
  3. Tachycardia
  4. Local vasospasm (may lead to necrosis of the glans)
  5. Complications due to local anesthetic
  6. Methemoglobinemia has been reported following exposure to prilocaine, procaine, benzocaine, and lidocaine (69).
  7. Hematoma (70); those reported in neonates have resolved spontaneously.
  8. Seizures (71)
  9. Mechanical problems with Gomco clamp (72)
  10. Loss of a part
  11. Warping of the plate after multiple use
  12. Breakage of arm during tightening
  13. Grooves and nicks in bell at junction of bell and plate

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FIG. 44.6. Complication of circumcision. A: Glans injury 6 months after circumcision. B: Trapped penis following contraction of wound after circumcision. C: Penile amputation following cautery injury during circumcision. D: Cicatrix following circumcision.

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