Figure 2a.
Placement of mosquito clamps for
performing circumcision
with the Gomco clamp.

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.

Figure 2b.
Tissue scissors are used to cut the
dorsal slit through the middle
of the crushed area.

Figure 3a.
Gomco bell in place. The bell protects
the head of the penis from injury
during removal of the foreskin.

Figure 3b.
Excision of the foreskin distal to the
junction of the Gomco bell and the clamp.

Figure 3c.
Appearance after removal of Gomco
clamp. The foreskin will stick to the bell
because of the crush.

Figure 3d.
Appearance of circumcision with the
Gomco clamp and bell.