Fig. 1
Devices used to perform circumcision. The three most common devices used to perform circumcision are the Gomco clamp, the Plastibell circumcision device, and the Mogen clamp (Source: Christopher Coppola)
(i)
General procedure guidelines:
1.
Adequate anesthesia should be obtained: Tylenol, local anesthetic, etc.
2.
Antisepsis: Sterile technique.
3.
Adhesions between the glans and the underside of the foreskin are bluntly separated.
(ii)
Gomco clamp: Most common device:
1.
Named after Goldstein Medical Company.
2.
A dorsal slit is made to allow for the bell device to fit over the glans and under the foreskin.
3.
Bell is placed over the glans.
4.
Foreskin is pulled over the bell.
5.
The bell and overlying foreskin are brought through the clamp and the yoke is tightened, clamping the vessels and skin of the foreskin.
6.
The device is removed after about 3–5 min.
7.
The excess prepuce is then excised using a scalpel.
8.
Antibiotic ointment is applied.
(iii)
Plastibell: Uses strangulation to remove foreskin.
1.
Dorsal slit is made to allow for Plastibell device to fit over glans and within the foreskin.
2.
A sterile string is tied around the foreskin at a groove in the Plastibell near the glans to cut off the innervation and blood supply.
3.
The excess skin is trimmed and the handle of the Plastibell snapped off the bell.
4.
The remaining Plastibell and foreskin will slough off in the next 1–2 weeks.
(iv)
Mogen clamp: Currently not performed due to significant complication risk (glanular amputation).
5.
Non-neonatal circumcision:
(a)
Indications:
(i)
Phimosis.
(ii)
Infection of the foreskin or glans.
(iii)
Recurrent urinary tract infections.
(iv)
Balanitis xerotica obliterans.
(b)
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Technique: Sleeve resection or “free-hand”: Performed on older patients in the operating room.
(i)
A general anesthetic is used, the patient is prepped in the typical sterile manner, and the adhesions between the glans and foreskin are bluntly taken down.
(ii)
The prepuce is placed in its usual position and marked at the level of the coronal sulcus.
(iii)
Usually dorsal and ventral slits are made.
(iv)
The prepuce is then retracted and an incision is made circumferentially along the base of the glans. Dissection is carried down to Buck’s fascia.
(v)
Hemostasis is achieved using low-amperage electrocautery.
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