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) (Fig. 47.2) into subcutaneous tissue to avoid

lodging in the erectile tissue. After entering skin,

needle should not meet resistance and tip should

Fig. 47.1. Plastibell with linen suture.

Fig. 47.2. Penis is stabilized at angle of 20 to 25 degrees from

midline. The formation of a lidocaine ring is shown (see text).

348 Section IX ■ Miscellaneous Procedures

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should be withdrawn slightly.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(never infiltrate as needle is advanced or withdrawn).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

(Fig. 47.2). The swelling is minimal and does not

interfere with the circumcision procedure.

j. Wait 3 to 5 minutes for 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.

7. Locate coronal sulcus (Fig. 47.3A). Marking the position of the sulcus with ink on the skin of the penile

shaft, prior to the procedure, is helpful in demarcating

this vital landmark.

8. Use mosquito hemostat to dilate preputial ring (Fig.

47.3B).

9. Use blunt probe to separate inner epithelium of prepuce from glans penis (Fig. 47.3C).

Failure to do this completely may result in a concealed penis (see G3c and G14).

10. Perform dorsal slit if desired.

This step is not mandatory as long as there is adequate separation of the glans from the prepuce.

a. Grasp rim of prepuce on dorsal aspect with mosquito hemostats, approximately 2 to 4 mm apart

(Fig. 47.3D).

b. Visualize urethra.

c. Place lower blade of large, straight hemostat

between prepuce and glans to within 3 to 4 mm of

corona, making sure to avoid urethra.

d. Close hemostat for 5 to 10 seconds to crush foreskin

in dorsal midline.

e. Use tissue scissors to cut prepuce along crush line

(Fig. 47.3E).