Introduction
The Jewish people have practiced
ritual circumcision for the last 4,000 years. The method to be used in
ritual circumcision is not specified in the Torah or Bible. The Mogen
clamp was invented in 1954 by Rabbi Harry Bronstein, a Brooklyn mohel (a
Rabbi who performs circumcisions). For many years, it was used only in
Jewish ritual circumcision in a ceremony called a bris.
Now, providers are using the clamp more frequently in medical settings
for newborn circumcision. ‚
A properly working Mogen clamp will
only open to 3.0 mm, minimizing the chance of trapping the glans. It
locks closed with great force along a narrow crush line. Although
commonly misperceived as a guillotine, it does not cut, it only crushes.
In fact, "Mogen " ¯ is Yiddish for "shield, " ¯
and the Mogen clamp shields the glans from the scalpel. ‚
View OriginalView Original
The Mogen clamp has a low incidence of
complications, and the method requires few surgical instruments compared
to other methods. The surgical time is short, typically <10
minutes for an experienced provider. There is good control of the amount
of the prepuce removed, which allows the Mogen clamp to be used on a
small penis. The inflammatory process usually starts to resolve by 72
hours. ‚
Equipment
- Blunt edged probe
- One or two small,
straight Kelly hemostats - A scalpel
- The Mogen clamp
- Scissors
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
The first step in any
circumcision is a dorsal ring block. Dorsal penile nerve block using
about 1 mL of 1% " ‚lidocaine through a
30-gauge needle provides excellent 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.
Step 1 View Original Step 1 View Original
Step 2
Clean the penis, scrotum,
and groin area with Betadine or chlorhexidine solution and sterilely
drape the area (see Appendix E). Inspect the infant
for gross anatomic abnormalities. A pacifier dipped in 25%
sucrose also appears to reduce infant discomfort. ‚
- PEARL: Chlorhexidine may provide better
preparation and be less irritating to tissues (see Appendix
E).
Step 2 View Original Step 2 View Original
Step 3
The dorsal tip of the
foreskin is grasped with a fine hemostat for traction, and another
fine hemostat or probe is used to open the plane between the glans
and the foreskin all the way back to the corona. Take care keep the
tip of the dissecting hemostat tenting the skin at all times. This
keeps the hemostat out of the urethra. The ventral area is not
dissected to avoid bleeding from the artery in the frenulum. ‚
- PITFALL: Safeguard the frenulum by
swinging the hemostat or probe right and left laterally not
circularly.
Step 3 View Original Step 3 View Original
Step 4
Placed another hemostat on
the dorsal midline with its tip about 3 mm short of the corona and
locked it in place to create a crush line. ‚
Step 4 View Original Step 4 View Original
Step 5
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. Use the blunt probe to release any
adhesions up to the corona, then gently pull the foreskin back over
the glans. ‚
Step 5 View Original Step 5 View Original
Step 6
A key step in Mogen
circumcision is the safe placement of the clamp. The Mogen clamp is
opened fully. The surgeon 's thumb and index finger pinch the
foreskin below the dorsal hemostat to push the glans back out of the
way. The Mogen clamp is then slid across the foreskin from dorsal to
ventral, following along the same angle as the corona. The hollow
side of the clamp faces the glans. More foreskin is removed dorsally
than ventrally. Before locking the Mogen clamp shut, the glans is
manipulated to be sure it is free of the clamp 's jaws. If it
is free, the clamp is locked. Note the triangular shape of the
foreskin to be excised since the corona angle is followed. ‚
- PEARL: Clamps should be checked
periodically to ensure that the opening is no more than 3.0
mm, and they should sent for repair or discarded if they do
open wider.
Step 6 View Original Step 6 View Original
Step 7
Once locked, the foreskin
is excised flush with the flat surface of the clamp with a 10-blade
scalpel. The clamp is left on for 1 minute to insure hemostasis,
then unlocked and removed. The crush line covers the glans fully
with penile shaft skin. ‚
- PEARL: If the infant is more than 6 months
old, the clamp should remain closed for no less than 5
minutes. - PITFALL: If the clamp is removed
prematurely, the crushed edges may separate and bleeding may
occur. If this occurs, suture the skin margins, being
careful to avoid deep sutures that might penetrate the
glans, urethra, or corpus. If the whole edge separates,
place quadrant sutures and close simple interrupted
stitches.
Step 7 View Original Step 7 View Original
Step 8.
The glans is liberated by
thumb traction at the 3 and 9 o 'clock positions that pulls
the crush line apart. ‚
Step 8 View Original Step 8 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 age 6 are given
anesthesia 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 or petroleum jelly after each diaper change to prevent
infections and adhesions. - Report any signs of
infection to your provider.
Coding Information
‚
View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 54150 Circumcision using a clamp or other device $427.00 0 Note: CPT code 54152 " “
"Circumcision using a clamp or other device, other
than newborn " ¯ has been deleted. Use code 54150 for
all circumcisions.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.
ICD-9 Codes
Phimosis/Paraphimosis 605,
Routine circumcision V50.2 ‚
Suppliers
Clamps and instruments may
be ordered from surgical supply houses such as: ‚
- Spectrum
Surgical Instruments Corp., 4575 Hudson Drive, Stow, OH
44224, Phone: 800- 444-5644; Web site: http://www.come-and-hear.com/editor/br-clamps/index.html. - Surgicaltools.com, 404-A Walnut Avenue SE, Roanoke, VA
24014, Phone: 800-774-2040 Web site: http://www.surgicaltools.com.
Restraint boards may
be ordered from: ‚
- Olympic
Medical Corp., 5900 First Avenue S., Seattle, WA 98108,
Phone: 800-426-0353, Web site: http://www.natus.com
Bibliography
1Holve ‚ RL, Bromberger ‚ PJ, Groveman ‚ HD,
et al. Regional anesthesia during newborn
circumcision: effect on infant pain
response. Clin
Pediatr. 1983;22:813 " “818. ‚ [View Abstract] 2Kaplan ‚ GW.
Complications of
circumcision. Urol Clin North
Am.
1983;10:543 " “549. ‚ [View Abstract] 3Kaweblum ‚ YA, Press ‚ S, Kogan ‚ L,
et al. Circumcision using the mogen
clamp. Clin
Pediatr.
1984;23:679 " “682. ‚ [View Abstract] 4Reynolds ‚ RD.
Use of the Mogen clamp for neonatal
circumcision. Am Fam
Phys. 1996;
54:177 " “182. ‚ [View Abstract] 5Schlosberg ‚ C.
Thirty years of ritual
circumcisions. Clin
Pediatr.
1971;10:205 " “209. ‚ [View Abstract] 62008 MAG Mutual Healthcare
Solutions,
Inc. 'sPhysicians '
Fee and Coding Guide. Duluth,
Georgia. MAG Mutual
Healthcare Solutions,
Inc.2007.