1. Age <1 day (i.e., before complete physical adaptation to extrauterine life has occurred).

2. Any current illness.

3. Temperature instability.

4. Prematurity (<37 weeks’ gestation).

5. Bleeding diathesis or family history of bleeding disorder.

6. Abnormality of urethra or penile shaft since the foreskin may be essential for later reconstruction (e.g., hypospadias, chordee, very small penis). Note: The identification of a megameatus or hypospadias after retraction of an intact-appearing foreskin is not a contraindication to neonatal circumcision (6).

7. Local infection.

8. Lack of truly “informed” parental consent (see Chapter 3).

9. Prior to infant receiving vitamin K.

1. Most frequently required

a. Sterile

(1) Gloves

(2) Cup with antiseptic

(3) 4 × 4-inch gauze pads

(4) Small, flexible, blunt probe

(5) Two curved mosquito hemostats

(6) Large, straight hemostat

(7) Tissue scissors

(8) Scalpel

b. Nonsterile

(1) Infant restraint to immobilize lower extremities is usually required. Can use commercially available equipment (Circumstraint Newborn Immobilizer, Olympic Medical) (see Chapter 5).

(2) An acceptable alternative is swaddling that provides adequate genitalia exposure.

2. Analgesia

The current recommendation is that neonatal circumcisions be performed under local anesthesia (4). In the past, neonatal circumcision had been performed without anesthesia, but this is no longer recommended. Kirya and Werthmann initially reported the efficacy and safety of dorsal penile blocks in 1978 (10). A randomized controlled trial showed that anesthesia with ring block, dorsal nerve block, or EMLA cream was superior to placebo. A ring block was found to be more effective than dorsal nerve block alone or EMLA cream during foreskin separation and incision (11).

a. Equipment for injected analgesia

(1) Local anesthetic: 1 mL of 1% lidocaine hydrochloride without epinephrine in a tuberculin syringe with a 1.2-cm × 27-gauge needle.

(2) Alcohol or iodine-based skin prep.

(3) Sterile gauze.

b. Topical analgesia

(1) Topical anesthesia options include eutectic mixture of lidocaine-prilocaine local anesthetic (EMLA) and topical lidocaine 4% (LMX4) cream. Topical anesthesia has been shown to reduce neonatal stress indicators during circumcision and reduces crying time (12, 13).
LMX4 cream should be placed 20 minutes (14) and EMLA cream 60 minutes prior to circumcision (15). LMX4 may have some advantage over EMLA cream with faster onset of action and no risk of methemoglobinemia (14).

(2) Oral sucrose and oral analgesics (acetaminophen) may be similar to placebo and are not sufficient alone for procedural pain control. However, positioning and a sucrose pacifier should be used as adjuncts for pain control (4).

3. Optional circumcision equipment

a. Sterile fine-tipped marking pen.

b. Sterile gauze impregnated with petroleum jelly (e.g., Vaseline).

4. Additional sterile equipment for use with Gomco clamp

a. Gomco circumcision clamp (Gomco Surgical Manufacturing Corp., Buffalo, New York) (5), size 1 to 2 cm for average newborn glans. 1.3 cm is the most commonly used size (sizes range from 1 to 3.5 cm). Must use a size that is large enough to protect the glans (16).

b. No. 11 scalpel blade and holder.

c. A small safety pin (optional but helpful).

5. Additional sterile equipment for use with Plastibell

a. Plastibell plastic cone (Hollister, Libertyville, Illinois). 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. 52.1). Must assure that the size of the bell is not too large to prevent proximal migration of the bell with excessive loss of penile skin, nor so small that it could impair penile circulation.

b. Scissors capable of cutting through plastic.

1. Obtain fully informed consent (see Chapter 3). This includes a discussion of the expected postoperative appearance, required postoperative care, potential complications, and indications to contact their health care provider.

2. Mandatory “time-out” to confirm correct patient and procedure.

3. Never circumcise at time of delivery. The timing of neonatal circumcision is dependent upon the patient’s total gestational age, weight, and size.

4. Be sure to allow adequate time for wound observation prior to discharge.

5. Do not use local anesthetic containing epinephrine.

6. Identify the coronal sulcus and urethral meatus during the procedure.

7. Ensure that inner epithelium is completely separated from glans penis and that the prepuce can be retracted to visualize entire circumference of coronal sulcus.

8. Never use electrocautery! (17)

9. Do not use a tight circumferential dressing.

10. Recheck wound prior to discharging patient and within 1 to 2 weeks after circumcision. Residual skin should retract completely and the entire coronal sulcus must be visible to avoid postcircumcision adhesions.

11. When Plastibell is used, parents should be told to contact their health care provider if ring has not fallen off within 10 days.

12. Infants do not have to be NPO for a prolonged period prior to circumcision; however, the procedure should not be performed immediately after a feeding.

A complete description of formal surgical foreskin excision has been excluded from this discussion 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 often performed using a Mogen clamp, Gomco clamp, or some type of “shield” that protects the glans. The Mogen technique usually does not require a dorsal incision or sutures (18).

1. Immobilize the patient and prepare region under aseptic procedures (see Chapters 5 and 6).

2. Perform penile dorsal nerve block.

a. Familiarity with the anatomy of dorsal nerves of penis is required (Fig. 52.2) (9). Although only the two dorsal penile nerves are targeted by the injection of lidocaine, the ventral penile nerve is also blocked by infiltration through the subcutaneous tissue. Additional anesthesia ventrally is recommended to block the perineal nerves (a branch of the pudendal nerve).

b. Identify dorsal nerve roots at 10 and 2 o’clock positions.

c. Identify by palpation the symphysis pubis and corpora cavernosa at the penile base.

d. 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.

e. Stabilize organ with gentle traction, at an angle of 20 to 25 degrees from midline.

f. Pierce skin over one of dorsal nerves at penile root, and advance carefully posteromedially (0.25 to 0.5 cm) (see Fig. 52.2) 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.

g. Aspirate to rule out intravascular position.

h. Slowly infiltrate area with 0.2 to 0.4 mL of lidocaine (never infiltrate as needle is advanced or withdrawn).

i. Repeat procedure at other dorsolateral position. After infiltration, a small lidocaine ring forms (see Fig. 52.2). The swelling is minimal and does not interfere with the circumcision procedure.

j. Wait 3 to 5 minutes for optimal 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.

3. Locate coronal sulcus (Fig. 52.3A). Marking the position of the sulcus with ink on the outer prepuce of the penile shaft prior to the procedure can be helpful in demarcating this vital landmark but is not always necessary.

4. Use mosquito hemostat to dilate preputial ring (Fig. 52.3B).

5. Use blunt probe or the tip of the hemostat to separate inner epithelium of prepuce from glans penis (Fig. 52.3C). Failure to do this completely may result in a concealed penis.