Chapter 237 Circumcision (Male; Newborn and Infant)
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
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.
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