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Circumcision using the Mogen Clamp

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. ‚

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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.