Circumcision is the most common procedure performed on male children younger than 5 years of age. The Gomco clamp is the instrument most commonly used in performing nonritual circumcision in the United States. It is designed to circumferentially crush a 1-mm band of foreskin, allowing hemostatic removal of the foreskin while protecting the glans from injury. The clamp is popular because of its ease of use and long safety record.
The Jewish faith ritual circumcision (Berit Mila) dates back 5,000 years to Abraham. This ceremony usually occurs on the eighth day of an infant boy's life and is usually performed by a ritual circumciser known as a mohel. Premature infants or infants who are ill may have the ceremony deferred until they are able to safely undergo circumcision. Checking with a local rabbi is a good way to find out about traditions and options for Jewish families.
Infant feedings are suspended for 1 to 3 hours before the procedure to reduce the risk of aspiration. The infant is usually restrained in a molded plastic restraint device. Many infants urinate soon after being placed in the restraint, and the practitioner may have to move quickly to avoid the stream. An infant warmer should be considered if the room is cool. The penis, scrotum, and groin area are typically cleaned with Betadine or a similar disinfecting solution and sterilely draped. Inspect the infant for gross anatomic abnormalities.
Anesthesia is usually obtained using a dorsal penile nerve block. Multiple studies document a decrease in pain perceived by neonates during routine circumcision when a dorsal penile nerve block is used. A 1:10 mixture of 1% sodium bicarbonate and 1% lidocaine may decrease the pain caused by the acidic pH of the anesthetic solution. Dorsal penile nerve blocks have been performed since 1978 without
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any major complications reported in the literature. The most common problem associated with it is occasional failure to provide adequate analgesia. This is often the result of failure to wait the necessary 5 minutes for the block to take effect. Avoid this problem by administering the block before draping the area, and then gently massage the area while waiting the 5 minutes required for maximum anesthetic effect. Minor complications such as local bruising, hematoma, and excessive bleeding at the injection site are rarely reported. The use of epinephrine is contraindicated in any procedure involving the penile shaft. While topical prilocaine and lidocaine (i.e., EMLA cream) have been demonstrated to help, avoid the use of prilocaine in children under 1 month of age.
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One of the most difficult parts of the procedure for novice practitioners is deciding how much foreskin to remove. Usually, about two thirds of the distal foreskin is removed. The amount of shaft skin that will remain after circumcision should be carefully assessed after the clamp is placed but before the screw is tightened. If it is necessary to adjust the amount of foreskin to be removed after the clamp is in place, disassemble the device, and pull the bell away from the base plate. If the foreskin is adjusted while the clamp and bell are still assembled, there is a risk that vessels between the foreskin and the underlying mucosa will be damaged and cause bleeding.
The penis should be inspected after the procedure for signs of bleeding. Apply a dressing of petroleum jelly or petroleum gauze to the cut line, which may be removed in 12 to 24 hours. Most nurseries require that the infant urinate before undergoing circumcision, but barring complications during circumcision, this is probably not necessary. Warn parents that some swelling may occur, that a crust will often form on the incision line, and that small bleeding spots may be found in the diaper. Ask them to report any bloodstain greater than a quarter or any signs of infection. If soiled, the area may be gently cleaned with soap and water.
Rarely, the glans is not be visible 30 minutes after the procedure. This indicates the presence of “concealed penis,” which results from inadequate removal of foreskin or underlying mucosa. The penile shaft and glans are pushed back into the scrotal fat, and the penis is buried. There is no need for further procedure at this time as long as the baby is able to urinate without problems. However, a revision of the circumcision by a urologist may be necessary at a later time.
INDICATIONS
CONTRAINDICATIONS
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PROCEDURE
Perform a dorsal penile nerve block by tenting the skin at the base of the penis and injecting 0.2 to 0.4 mL of 1% lidocaine (without epinephrine) into the subcutaneous tissue on either side at the dorsal base of the penis. A pacifier dipped in 25% sucrose also appears to reduce infant discomfort. Drape the baby's torso (but not head) with a fenestrated drape.
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(1) Start a dorsal penile nerve block by tenting the skin at the base of the penis and injecting 0.2 to 0.4 mL of 1% lidocaine (without epinephrine) into the subcutaneous tissue on either side at the dorsal base of the penis. |
PITFALL: To avoid inadvertent intravascular injection, apply negative pressure to the syringe immediately before injection to check for a backflow of blood.
The size of the bell of the Gomco clamp used for the circumcision is selected based on the diameter of the glans (not the length of the penile shaft). The bell should be large enough to completely cover the glans penis without overly distending the foreskin. A bell that is too small will fail to protect the glans and may cause too little foreskin to be removed.
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(2) The size of the bell of the Gomco clamp used for the circumcision is selected based on the diameter of the glans. |
PITFALL: Check the base, rocker arm, and bell of the Gomco clamp to make sure they all fit together. The bell and base from a 1.45-cm clamp will close but will not seal the skin properly if used with the rocker arm of a 1.3-cm set. Check to make sure that there are no defects in any of the parts.
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Carefully insert a blunt probe or closed hemostat into the preputial ring down to the level of the corona while gently peeling back the foreskin (Figure 3A). Slide the instrument down to the right and left sides to break up adhesions between the inner mucosal layer and the glans. Carefully avoid the ventral frenulum, because tearing it often causes bleeding (Figure 3B). Examine the penis to make sure hypospadias or megameatus is not present.
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(3) Carefully insert a blunt probe or closed hemostat into the preputial ring down to the level of the corona while gently peeling back the foreskin. |
PITFALL: Failure to completely free mucosal adhesions from the glans is the most common reason for a poor cosmetic result. If the adhesions are not completely separated, not enough mucosa will be removed, and phimosis may result.
PITFALL: If hypospadias or megameatus is present, terminate the procedure because any repair of these congenital anomalies may require the use of foreskin tissue.
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After the coronal sulcus is freed of adhesions, circumferentially grab the skin near the base of the penis, and pull it over the glans until the foreskin returns to its anatomic position.
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(4) After the coronal sulcus is freed of adhesions, circumferentially grab the skin near the base of the penis, and pull it over the glans until the foreskin returns to its anatomic position. |
Grasp the end of the foreskin on either side of the dorsal midline at the 10- and 2-o'clock positions with two hemostats. Make sure to avoid the glans and stay out of the urethral meatus.
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(5) Grasp the foreskin on either side of the dorsal midline at the 10- and 2-o'clock positions with two hemostats. |
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Create a crush line on the dorsal aspect of the foreskin using a straight hemostat. The crushed skin is cut with scissors, taking care to avoid the glans. The cut should proceed down the center of the crush line to avoid bleeding that occurs if the cut strays laterally.
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(6) Create a crush line on the dorsal aspect of the foreskin using a straight hemostat. |
PITFALL: Make sure the crush line is far enough above the coronal sulcus that it will be completely removed in the circumcision. If the cut extends too far onto the penile shaft, the proximal portion of the incision (apex) cannot be pulled into the Gomco clamp.
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Insert the bell of the Gomco clamp under the foreskin and over the glans. Bring the two hemostats that are holding the edges of the foreskin together over the bell (Figure 7A). Place an additional hemostat directly through the hole in the base plate. Then use the hemostat to draw the edges of the dorsal slit together over the flare of the bell, and remove the original hemostats (Figure 7B). Pull the hemostat, foreskin, and stem of the bell through the hole in the base plate (Figure 7C).
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(7) Insert the bell of the Gomco clamp under the foreskin and over the glans. |
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Alternatively, insert a small safety pin through both edges of the dorsal slit and bring the edges together over the flare of the bell. The safety pin may be passed through the hole in the base plate along with the stem of the bell.
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(8) Alternatively, insert a small safety pin through both edges of the dorsal slit, and bring the edges together over the flare of the bell. |
PITFALL: Be careful not to cause inadvertent injury to the clinician or the infant with the sharp end of the safety pin.
Make sure that equal amounts of mucosa and foreskin are brought through the base plate. Determine if the amount of foreskin above the baseplate is appropriate for removal and that the remaining shaft skin is adequate. The amount and symmetry of the skin may still be adjusted at this time. The rocker arm of the Gomco clamp is then attached and brought around into the notch of the base plate. The arms of the bell are settled into the yoke, and the nut is tightened, crushing the foreskin between the bell and the base plate. Leave the clamp in place for 5 minutes.
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(9) The rocker arm of the Gomco clamp is then attached and brought around into the notch of the base plate. |
PITFALL: Make sure the apex of the dorsal slit is visible above the plate before putting the arms in the yoke and excising the foreskin.
PITFALL: Make sure the rocker arm is well settled into the notch of the base plate. The clamp may be tightened outside of the notch, but it will not seal the skin well and will risk causing a degloving injury.
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Place a scalpel blade flat against the base plate, and cut the top of the crush line. Loosen the nut, and remove the top and base plate from the bell. The shaft skin sticks to the bell but can be peeled off using a gauze pad or blunt probe. The penis should be inspected after the procedure for signs of bleeding. Apply a dressing of petroleum jelly or petroleum gauze to the cut line. Additional infant soothing can be provided by placing hte undressed infant on the mother's chest (skin-to-skin contact) immediately following the procedure.
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(10) Place a scalpel blade flat against the base plate, and cut the top of the crush line. |
PITFALL: Cutting the foreskin at an angle into the base plate may disrupt the crush line and cause bleeding.
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CODING INFORMATION
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INSTRUMENT AND MATERIALS ORDERING
Gomco Circumcision Clamps may be obtained from Spectrum Surgical Instruments, 4575 Hudson Drive, Stow, OH 44224 (phone: 800-444-5644 or 330-686-4550; http://www.spectrumsurgical.com/catalog/instrument/circumcision.htm) or from Premier Medical Group Co. Ltd, P.O. Box 4132, Kent, WA 98032 (phone: 800-955-2774; http://www.premieremedical.safeshopper.com/).
BIBLIOGRAPHY
Anderson GF. Circumcision. Pediatr Ann 1989;18:205–213.
Fontaine P, Dittberner D, Scheltema KE. The safety of dorsal penile nerve block for neonatal circumcision. J Fam Pract 1994;39:243–244.
Holman JR, Lewis EL, Ringler RL. Neonatal circumcision techniques. Am Fam Physician 1995;52:511–518.
Lander J, Brady-Fryer B, Metcalf JB, et al. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision. JAMA 1997;278:2157–2162.
Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States: prevalence, prophylactic effects, and sexual practice. JAMA1997;277:1052–1957.
Lawler FH, Basonni RS, Holtgrave DR. Circumcision: a decision analysis of its medical value. Fam Med 1991;23:587–593.
Mallon E, Hawkins D, Dinneen M, et al. Circumcision and genital dermatoses. Arch Dermatol 2000;136:350–354.
Niku SD, Stock JA, Kaplan GW. Neonatal circumcision. Common Probl Pediatr Urol 1995;22:57–65.
Peleg D, Steiner A. The Gomco circumcision: common problems and solutions. Am Fam Physician 1998;58:891–898.
Tiemstra JD. Factors affecting the circumcision decision. J Am Board Fam Pract 1999;12:16–20.