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Gomco Clamp and Plastibell
Device
The techniques for performing circumcision with the Gomco
clamp and the Plastibell device have many of the same features. Following
preparation of the infant and inspection of the penis and scrotum as
described above, the foreskin is grasped with two mosquito clamps at the
10 o'clock and 2 o'clock positions (Figure 2a). The nondominant
hand holds these clamps and uses them to elevate the foreskin. A third
mosquito clamp is used as a probe to gently lyse any adhesions under the
foreskin from the 8 o'clock to the 4 o'clock positions and is then clamped
approximately two-thirds of the distance from the foreskin opening to the
corona. This action creates the crushed area for the dorsal slit. The
third clamp remains in place for one minute. The dorsal slit is then cut
through the middle of the crushed area, using tissue scissors (Figure
2b). The foreskin is peeled back, and any additional adhesions are
lysed using a blunt probe. Attention must be paid to preserving the
frenulum at the base of the corona, as this is the most common site of
bleeding.
Gomco Clamp
The Gomco clamp was designed to crush about 1
mm of the foreskin circumferentially, while the Gomco bell protects the
head of the penis from injury during removal of the foreskin.
The appropriate size of the Gomco clamp is
estimated, based on the circumference of the glans, and correct fit is
confirmed by placing the bell on the glans. The edge of the bell should
reach the frenulum and extend over the corona, slightly stretching the
preputial skin.
The bell is placed inside the foreskin, and
the dorsal slit is secured over the bell with a sterile safety pin
(Figure 3a). This allows the handle of the bell to pass through the
circular opening of the clamp, without the foreskin slipping out. The
foreskin can be advanced through the opening by grasping it with sterile
gauze. It is important to ensure that the apex of the dorsal slit is
visible above the rim of the bell, to prevent notching in the border of
the foreskin during removal. In addition, it is critical to check that the
crossbar at the top of the bell sits squarely in the yoke of the clamp,
otherwise pressure will not be evenly distributed around the bell and the
chance of bleeding will increase. The thumbscrew is tightened until snug,
and the visible foreskin is removed using a scalpel blade distal to the
junction of the bell and the clamp (Figure 3b). Electrocautery
devices should not be used to excise the foreskin, because of the risk of
conduction by the metal clamp. The clamp should remain secure for a total
of five minutes, to allow the crush effect to be complete. This step is
designed to reduce the incidence of bleeding after the clamp is
removed.
When the thumbscrew is loosened and the bell
gently removed from the clamp, the foreskin will stick to the bell because
of the crush (Figure 3c). The foreskin can be loosened by gently
peeling with a gauze swab to liberate the glans and show the final result
(Figure 3d). The edge of the foreskin and the corona of the penis
are then gently wrapped in precut petrolatum gauze, which remains in place
for 12 to 24 hours.
Complications
The most common complication of neonatal
circumcision is excessive bleeding. Reported incidences of bleeding vary
widely, perhaps because of the different criteria used for reporting
(e.g., time at which the bleeding was noted, extent of intervention
required to control it). Bleeding can be controlled by applying gentle
circumferential pressure with gauze or a sponge or by using absorbable
gelatin sponge (Gelfoam), topical thrombin, epinephrine soaked gauze or
sutures.
Infections may occur after neonatal
circumcision, but most are local. Major morbidity has been reported,
including staphylococcal scalded skin syndrome, necrotizing fasciitis,
Fournier's gangrene, generalized sepsis and meningitis. Most reported
mortality related to circumcision has been caused by sepsis.
Meatitis and meatal ulcers are an indirect
complication of circumcision. Because the newly exposed glans is no longer
protected by the foreskin, the meatus may be injured by a combination of
pressure and ammonia from urine. Meatal irritation is treated with
petroleum ointment applied directly to the glans.
Postcircumcision Care
Nursery personnel and parents should be
instructed in the care of the circumcised phallus. Parents should be
provided with printed patient information. They should be warned that some
degree of swelling can be expected, as well as a clear crust on the area.
The area can be gently cleansed with soap and water if it is soiled. The
parents should be told that a small amount of blood may normally be seen
on the diaper, but to call the physician if any bloodstain on the diaper
is greater than the size of a quarter.
The parents must be counseled to return to the
clinic if the Plastibell device has not fallen off within 10 to 12 days or
if signs or symptoms of infection develop.
Following any of the circumcision methods
described, a short period of observation (up to four hours) is suggested,
to check for bleeding or the infant's inability to
urinate.
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