The Gomco device consists of 4 main pieces (Figure 2):
|•||The distal penis protrudes through the base plate.|
|•||The bell fits over the glans but under the foreskin (bells come in a variety of sizes, including 1.1 cm, 1.3 cm, and 1.4 cm). A thoughtful engineer also designed the bell with a small hole; this allows for the passage of urine, should the infant void during the procedure.|
|•||The rocker arm has a yoke in which the arms of the bell rest.|
|•||The nut secures the other end of the rocker arm to the base plate.|
The device is designed to crush the foreskin between the bell and the base plate. Before beginning the procedure, make sure that all of the parts of the device fit together properly; mismatched parts sometimes get autoclaved together.
Marking the foreskin to guide removal. Determining how much foreskin to take off often presents difficulties for learners. The edge of the foreskin should end up nice and tidy around the corona. Marking the foreskin at the level of the corona before the procedure can eliminate some of the guesswork (Figure 3).
Separating the foreskin from the glans. Apply 2 clamps—at the 2 o'clock and 10 o'clock positions on the distal foreskin—taking care to avoid the glans. Using your nondominant hand, hold these clamps under gentle traction to keep the preputial orifice open. At this point, it will be evident whether the anesthesia is working. If you have waited a full 5 minutes since the lidocaine(Drug information on lidocaine) injection, the anesthesia is almost certain to have taken effect. However, if the anesthesia is not good, I usually avoid giving additional lidocaine because of toxicity risks; instead, I focus on completing the procedure quickly.
Next, blunt dissect the foreskin away from the glans using either a blunt-edged probe or a clamp. I lubricate the tip of a probe with the petroleum gauze that will later be used as a dressing, then insert the probe into the foreskin opening at the 12 o'clock position. I use the probe to make a track down to the coronal ring while tenting the skin upward to avoid entry into the urethra (Figure 4). After the track is created, I insert a lubricated clamp and open it in gentle sweeping motions around the glans to break up adhesions (Figure 5). Each time I spread the blades of the clamp open, I gently withdraw them from the penis in order to close them under visualization (to avoid a crushing injury to the glans). Blunt dissect circumferentially all the way to the frenulum at the 6 o'clock position, but do not dissect away the frenulum; it has a little arteriole and will bleed.