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 (10).

b. No. 11 scalpel blade and holder

c. A small safety pin

5. Additional Equipment for Use with Plastibell

All equipment is sterile.

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. 47.1). 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.

b. Scissors capable of cutting through plastic

Chapter 47 ■ Circumcision 347

D. Precautions

1. Obtain fully informed consent (see Chapter 2).

a. 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.

b. Be aware of laws pertaining to ritual circumcision

(e.g., Jewish brit milah) and the complications of

the practice of orally suctioning the blood after cutting the foreskin (oral metzitzah) (11).

2. Never circumcise at time of delivery. Circumcise long

enough before discharge to allow adequate wound

observation.

3. Do not use local anesthetic containing epinephrine.

4. Specifically locate coronal sulcus and urethral meatus.

5. Make sure that inner epithelium is completely separated from glans penis and that prepuce can be retracted

to visualize entire circumference of coronal sulcus.

6. Never use electrocautery.

7. Do not use circumferential dressing.

8. Recheck wound prior to discharging patient and 1 to 2

weeks after circumcision. Residual skin should retract

completely, and the entire coronal sulcus must be visible to avoid postcircumcision adhesions, the most common complication.

E. 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 (5); 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.

a. Be familiar with anatomy of dorsal nerves of penis

(Fig. 47.2) (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. Some have advocated additional anesthesia ventrally, blocking 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 angle of 20