Review
Be aware and know about the cultural background and controversy surrounding circumcisions and likely parental expectations.
Informed consent consists of:
Brief description of the procedure
Discuss potential small benefits, i.e., decrease UTI risk, possible decrease in some STDs, prevention of rare events like pathologic phimosis and paraphimosis
Parental desire for the procedure is the only routine indication for the procedure
Risks include some mild pain, infection (very rare), minor bleeding or bruising, rare major bleeding, damage to the penis, and poor cosmetic results
Indications for routine circumcisions are none. Only parental desire, after informed consent, is an indication for routine circumcision.
Contraindications are many. The main ones are: genitourinary defects or abnormalities, known blood dyscrasia, prematurity and weight less than 2500g, and severe illness.
Know the proper preparation of the infant for circumcision and supplies needed.
Adequate penile nerve block analgesia consists of blocking both the dorsal penile nerves (supplying the majority of nerve innervation to the penis) and the ventral perineal nerve branches.
The dose of lidocaine used is 1% (10mg/ml) concentration, 3.3mg/kg total dose or use the rule of thumb:
> 3 kg, use 1.0ml (10mg)
> 2.5 and < 3 kg, use 0.8ml (8mg)
Know the proper and safe technique of penile nerve block.
Before beginning the circumcision (see Circumcision with Gomco Clamp), inspect the clamp for any defects. Carefully follow the technique outlined in this module. Review, if necessary (see the Circumcision with Gomco Clamp section).
For proper cosmesis:
Place the dorsal clamp to remove ~3/4 of the prepuce and leave about 4-5mm of prepuce length left (when measuring from the corona to the tip of the hemostat).
Adequately lyse the adhesions to completely expose the corona, even ventrally, but without damaging the frenulum.
Adjust the Gomco clamp properly so that more dorsal prepuce is removed than ventral prepuce. Review the anatomy of the glans penis, if necessary.
The goal is to have the un-retracted prepuce just covering the corona.
Good postoperative care.
Explain the step for good Postoperative Care to the parents. The two main points are gentle retraction of the preputial remnant to expose the corona and placing white petrolatum ointment on the diaper, with each diaper change, until complete healing occurs at about seven days.
Know and periodically review the common problems (see Common Pitfalls and Problems) that occur and how to prevent and treat them.