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Circumcision using Gomco Clamp and Dorsal Penile Block


Introduction


Circumcision is the most common procedure performed on male children younger than 5 years of age. The Gomco clamp is the instrument most commonly used in performing nonritual circumcision in the United States. It is designed to circumferentially crush a 1-mm band of foreskin, allowing hemostatic removal of the foreskin while protecting the glans from injury. The Gomco clamp is popular because of its ease of use and long safety record. ‚  
The Jewish faith ritual circumcision (Berit Mila) dates back 5,000 years to Abraham. This ceremony usually occurs on the eighth day of an infant boy 's life and is usually performed by a ritual circumciser known as a mohel. Premature infants or infants who are ill may have the ceremony deferred until they are able to safely undergo circumcision. Checking with a local rabbi is a good way to find out about traditions and options for Jewish families. ‚  
Infant feedings are suspended for 1 to 4 hours before the procedure to reduce the risk of aspiration. The infant is usually restrained in a molded plastic restraint device. Many infants urinate soon after being placed in the restraint, and the practitioner may have to move quickly to avoid the stream. An infant warmer should be considered if the room is cool. ‚  
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Anesthesia is usually obtained using a dorsal penile nerve block. Multiple studies document a decrease in pain perceived by neonates during routine circumcision when a dorsal penile nerve block is used. A 1:10 mixture of 1% " ‚sodium bicarbonate and 1% " ‚lidocaine may decrease the pain caused by the acidic pH of the anesthetic solution. Dorsal penile nerve blocks have been performed since 1978 without any major complications reported in the literature. The most common problem associated with it is occasional failure to provide adequate analgesia. Minor complications such as local bruising, hematoma, and excessive bleeding at the injection site are rarely reported. The use of epinephrine is contraindicated in any procedure involving the penile shaft. Although topical prilocaine and lidocaine (i.e., EMLA cream) have been demonstrated to help, avoid the use of prilocaine in children younger than 1 month of age. ‚  
One of the most difficult parts of the procedure for novice practitioners is deciding how much foreskin to remove. Usually, about two thirds of the distal foreskin is removed. The amount of shaft skin that will remain after circumcision should be carefully assessed after the clamp is placed but before the screw is tightened. If it is necessary to adjust the amount of foreskin to be removed after the clamp is in place, disassemble the device, and pull the bell away from the base plate. If the foreskin is adjusted while the clamp and bell are still assembled, there is a risk that vessels between the foreskin and the underlying mucosa will be damaged and cause bleeding. ‚  
The penis should be inspected after the procedure for signs of bleeding or lack of union of the clamp line. Apply a dressing of petroleum jelly or petroleum gauze to the cut line, which may be removed in 12 to 24 hours. Most nurseries require that the infant urinate before undergoing circumcision, but barring complications during circumcision, this is probably not necessary. Warn parents that some swelling may occur, that a crust will often form on the incision line, and that small blood spots may be found in the diaper. Ask them to report any bloodstain greater than a quarter or any signs of infection. If soiled, the area may be gently cleaned with soap and water. ‚  
Rarely, the glans is not visible 30 minutes after the procedure. This indicates the presence of "concealed penis, " ť which results from inadequate removal of foreskin or underlying mucosa. The penile shaft and glans are pushed back into the scrotal fat, and the penis is buried. There is no need for further procedure at this time as long as the baby is able to urinate without problems. However, a revision of the circumcision by a urologist may be necessary at a later time. ‚  
The decision on whether to offer circumcision for newborn males is controversial. The Task Force on Circumcision of the American Academy of Pediatrics in 2005 restated their position that newborn circumcision is not recommended and that the procedure is not essential to the child 's current well-being. However, there is compelling evidence that newborn circumcision protects against penile cancer, local infection, phimosis, urinary tract infection, human papilloma virus (HPV) infection, and human immunodeficiency virus (HIV) infection. A recent study concludes that, overall, after adjusting for covariates, uncircumcised men have a more than threefold greater risk of contracting sexually transmitted infections (STIs) than circumcised men. The American Academy of Family Physicians recommends physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son. ‚  

Equipment


  • Blunt-edged probe
  • Two or three small straight Kelly hemostats
  • A scalpel
  • Gomco clamps

Indications


  • Medical indications, including phimosis, paraphimosis, recurrent balanitis, extensive condyloma acuminata of the prepuce, and squamous cell carcinoma of the prepuce (all rare in neonates)
  • Parental request
  • Religious reasons

Contraindications


  • Routine circumcision is contraindicated with the presence of urethral abnormalities such as hypospadias, epispadias, or megaurethra (i.e., foreskin may be needed for future repair or reconstruction).
  • Less than 1 cm of penile shaft is visible when pushing down at the base of the penis (i.e., short penile shaft).
  • Circumcision should not be performed until at least 12 hours after birth to ensure that the infant is stable. Circumcision in infants who are ill or premature should be delayed until they are well or ready for discharge from the hospital.
  • Bleeding diathesis, myelomeningocele, significant prematurity, or imperforate anus.
  • When there is a family history of a bleeding disorder, appropriate laboratory studies should be done to identify any bleeding abnormalities in the baby.

The Procedure


Step 1
Perform a dorsal penile nerve block by tenting the skin at the base of the penis and injecting 0.2 to 0.4 mL of 1% " ‚lidocaine (without epinephrine) as shown in Field Block Anesthesia. Consider the use of a restraint board/device to gently restrain the infant 's legs during the procedure. Drape the baby 's torso (but not head) with a fenestrated drape. ‚  
  • PEARL: Some providers prefer a topical anesthetic cream (such as 2.5% " ‚prilocaine and 2.5% " ‚lidocaine [EMLA]) in place of a dorsal block.
  • PITFALL: Anesthesia failure is often the result of failure to wait the necessary 5 minutes for the block to take effect. Avoid this problem by administering the block before draping the area, and then gently massage the area while waiting the 5 minutes required for maximum anesthetic effect.

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Step 2
Clean the penis, scrotum, and groin area with povidone-iodine or chlorhexidine solution and sterilely drape the area. Inspect the infant for gross anatomic abnormalities. A pacifier dipped in 25% sucrose also appears to reduce infant discomfort. ‚  
  • PEARL: Chlorhexidine may provide a better prep and be less irritating to tissues. See Appendix E.

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Step 3
The size of the bell of the Gomco clamp used for the circumcision is selected based on the diameter of the glans (not the length of the penile shaft). The bell should be large enough to completely cover the glans penis without overly distending the foreskin. ‚  
  • PITFALL: A bell that is too small will fail to protect the glans and may cause too little foreskin to be removed.
  • PITFALL: Check the base, rocker arm, and bell of the Gomco clamp to make sure they all fit together. The bell and base from a 1.45-cm clamp will close but will not seal the skin properly if used with the rocker arm of a 1.3-cm set. Check to make sure that there are no defects in any of the parts.

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Step 4
Grasp the end of the foreskin on either side of the dorsal midline at the 10 and 2 o 'clock positions with two hemostats. Make sure to avoid the glans and the urethral meatus. ‚  
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Step 5
Carefully insert a closed hemostat or blunt probe into the preputial ring, and separate the foreskin from the glans down to the level of the corona. Slide the instrument down to the right and left sides to break up adhesions between the inner mucosal layer and the glans. Carefully avoid the ventral frenulum, because tearing it often causes bleeding. ‚  
  • PITFALL: Failure to completely free mucosal adhesions from the glans is the most common reason for a poor cosmetic result. If the adhesions are not completely separated, not enough mucosa will be removed, and phimosis may result.

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Step 6
Create a crush line on the dorsal aspect of the foreskin using a straight hemostat. ‚  
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Step 7
Cut the crushed skin with scissors, taking care to avoid the glans. The cut should proceed down the center of the crush line to avoid bleeding, which occurs if the cut strays laterally. ‚  
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Step 8
Finish breaking any remaining adhesions between the glans and foreskin all around the corona except at the frenulum. Examine the penis to make sure hypospadias or megameatus are not present. ‚  
  • PITFALL: Make sure the crush line is far enough above the coronal sulcus that it will be completely removed in the circumcision. If the cut extends too far onto the penile shaft, the proximal portion of the incision (apex) cannot be pulled into the Gomco clamp.
  • PITFALL: If hypospadias or megameatus are present, terminate the procedure because any subsequent repair of these congenital anomalies may require the use of foreskin tissue.

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Step 9
Insert the bell of the Gomco clamp under the foreskin and over the glans. Bring the two hemostats that are holding the edges of the foreskin together over the bell. Place an additional hemostat directly through the hole in the base plate. Then use the hemostat to draw the edges of the dorsal slit together over the flare of the bell, and remove the original hemostats. ‚  
  • PEARL: Should bleeding occur, it is best to proceed with the procedure because once the Gomco clamp is in place, bleeding from the dorsal slit will stop.
  • PEARL: If bleeding interferes with continuing the procedure, a hemostat can be used to create a second crush line overlying the area of bleeding.

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Step 10
Pull the hemostat, foreskin, and stem of the bell through the hole in the base plate. Make sure that equal amounts of mucosa and foreskin are brought through the base plate. ‚  
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Step 11
Alternatively, insert a small safety pin through both edges of the dorsal slit and bring the edges together over the flare of the bell. The safety pin may be passed through the hole in the base plate along with the stem of the bell. ‚  
  • PITFALL: Be careful not to cause inadvertent injury to yourself or the infant with the sharp end of the safety pin.

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Step 12
Determine if the amount of foreskin above the baseplate is appropriate for removal and that the remaining shaft skin is adequate. The amount and symmetry of the skin may still be adjusted at this time. The rocker arm of the Gomco clamp is then attached and brought around into the notch of the base plate. The arms of the bell are settled into the yoke, and the nut is tightened, crushing the foreskin between the bell and the base plate. Leave the clamp in place for 5 minutes. ‚  
  • PITFALL: Make sure the apex of the dorsal slit is visible above the plate before putting the arms in the yoke and excising the foreskin.
  • PITFALL: Make sure the rocker arm is well settled into the notch of the base plate. The clamp may be tightened outside of the notch, but it will not seal the skin well and will risk causing a degloving injury.

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Step 13
Place a scalpel blade flat against the base plate, and cut the top of the crush line. ‚  
  • PITFALL: Cutting the foreskin at an angle into the base plate may disrupt the crush line and cause bleeding.
  • PITFALL: Electrocautery should never be used with Gomco clamps, because the current could be transmitted to the entire penis via the metal clamp, and result in penile necrosis.

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Step 14
Loosen the nut, and remove the top and base plate from the bell. The shaft skin sticks to the bell but can be peeled off using a gauze pad or blunt probe. The penis should be inspected after the procedure for signs of bleeding. ‚  
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Step 15
Apply a dressing of petroleum jelly or petroleum gauze to the cut line. Additional infant soothing can be provided by placing the undressed infant on the mother 's chest (skin-to-skin contact) immediately following the procedure. ‚  
Step 15 View Original Step 15 View Original

Complications


  • Pain, infection, bleeding
  • Phimosis or ring retention (urinary blockage secondary to swelling)
  • Concealed penis
  • Nonunion of skin crush line (degloving injury)
  • Urethral stenosis, urethrocutaneous fistula, hypospadias and epispadias formation, necrotizing fascitis, penile amputation, and necrosis (all very rare)

Pediatric Considerations


Children older than the age of 6 are dosed like adults except that the maximal dose is based on weight. The recommended maximum dose for lidocaine in children is 3 to 5 mg/kg, and 7 mg/kg when combined with epinephrine. Remember 1% lidocaine is 10 mg/mL. Children 6 months to 3 years have the same volume of distribution and elimination half-life as in adults. Neonates have an increased volume of distribution, decreased hepatic clearance, and doubled terminal elimination half-life (3.2 hours). ‚  

Postprocedure Instructions


  • Patients may be bathed again within 24 hours after the procedure.
  • Apply antibiotic ointment after each diaper change to prevent infections and adhesions.
  • Report any signs of infection to your provider.

Coding Information and Supply Sources


‚  
View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 54150 Circumcision using a clamp or other device $427.00 0 CPT is a registered trademark of the American Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008 MMH-SI 's copyrighted Physicians ' Fees and Coding Guide.Note: CPT code 54152, "Circumcision using a clamp or other device, other than newborn, " ť has been deleted. Use code 54150 for all circumcisions.
ICD Codes
‚  
View Large Phimosis/paraphimosis 605 Routine circumcision V50.2
Suppliers
  • Gomco circumcision clamps may be obtained from Spectrum Surgical Instruments, 4575 Hudson Drive, Stow, OH 44224 (phone: 1-800-444-5644 or 330-686-4550; Web site: http://www.spectrumsurgical.com/catalog/instrument/circumcision.htm) or from Premier Medical Group Co. Ltd, P.O. Box 4132, Kent, WA 98032 (phone: 1-800-955-2774; Web site: http://premieremedical.safeshopper.com/).
  • Restraint boards may be ordered from Olympic Medical Corp., 5900 First Avenue S., Seattle, WA 98108. Phone: 1-800-426-0353. Web site: http://www.natus.com/

Bibliography


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Anderson ‚  GF. Circumcision.
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Castellsague ‚  X, Bosch ‚  FX, oz ‚  N, et al. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners.
N Engl J Med.
 2002;346:1105 " “1112. 3
Fergusson ‚  DM, Boden ‚  JM, Horwood ‚  LJ. Circumcision status and risk of sexually transmitted infection in young adult males: an analysis of a longitudinal birth cohort.
Pediatrics
.  2006:118;1971 " “1977. 4
Fontaine ‚  P, Dittberner ‚  D, Scheltema ‚  KE. The safety of dorsal penile nerve block for neonatal circumcision.
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Holman ‚  JR, Lewis ‚  EL, Ringler ‚  RL. Neonatal circumcision techniques.
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 1995;52:511 " “518. ‚  [View Abstract]
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Lander ‚  J, Brady-Fryer ‚  B, Metcalf ‚  JB, et al. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision.
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.  1997;278:2157 " “2162. ‚  [View Abstract]
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Laumann ‚  EO, Masi ‚  CM, Zuckerman ‚  EW. Circumcision in the United States: prevalence, prophylactic effects, and sexual practice.
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Lawler ‚  FH, Basonni ‚  RS, Holtgrave ‚  DR. Circumcision: a decision analysis of its medical value.
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Mallon ‚  E, Hawkins ‚  D, Dinneen ‚  M, et al. Circumcision and genital dermatoses.
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Niku ‚  SD, Stock ‚  JA, Kaplan ‚  GW. Neonatal circumcision.
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 1995;22:57 " “65. ‚  [View Abstract]
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Peleg ‚  D, Steiner ‚  A. The Gomco circumcision: common problems and solutions.
Am Fam Physician
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Tiemstra ‚  JD. Factors affecting the circumcision decision.
J Am Board Fam Pract.
 1999;12:16 " “20. ‚  [View Abstract]
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2008 MAG Mutual Healthcare Solutions, Inc. 's
Physicians ' Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc.
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