Completing assembly of the clamp, preparing to cut. Next, while holding the stem of the bell and the safety pin with your nondominant hand, use your other hand to place the yoke of the rocker arm under the arms of the bell (see Figure 2). Make sure that the ridge on the bottom of the rocker arm fits nicely into the notch on the base plate. Double-check to make sure that the apex of the dorsal slit ends distal to the intended crush area on the Gomco clamp. If you need to adjust the amount of tissue that has been pulled through the base plate, most authorities recommend removing the rocker arm from the bell and pulling the bell away from the base plate. Failure to do this could result in shearing of blood vessels as you try to pull more foreskin through the base plate.
By this point, you have measured twice and are ready to cut once. Tighten the nut to secure the rocker arm to the base plate. With this action, you are applying 8000 to 20,000 lb of hemostatic force against the foreskin—and you are committed to what you will remove.
Removing the foreskin. You may cut the foreskin off at any time after the nut is secure (Figure 11). However, leave the clamp on for 5 minutes. You can use this time to hone your bedside manner (coo at the baby, work the pacifier). After 5 minutes, loosen the nut and disassemble the device. To coax the edge of the cut foreskin off the bell, apply pressure with gauze.
Despite the temptation to quickly appraise the result, I apply immediate pressure with gauze circumferentially and hold for 1 minute. After that, I assess for any bleeding and sometimes apply an absorbable fibrillar hemostat (although this is usually not necessary). Less expensive hemostatic agents, such as ferric subsulfate or a silver nitrate(Drug information on silver nitrate) stick, can also be used, although these tend to be messy. If all else fails, an absorbable stitch may be placed at a bleeding point. I then take a look to assess cosmesis (Figure 12). Lastly, I apply a dressing of petroleum gauze and wrap it proximally on the shaft so that it will not fall off (Figure 13). Some nurseries make sure the infant urinates before being discharged home after a circumcision, but this is probably not necessary.6