Figure 13 – A petroleum gauze dressing is applied.
AFTERCARE AND FOLLOW-UP
Acute complications from circumcision are rare; estimates range from 0.2% to 2%.1 Bleeding and infection are the most common. Thus, I advise the parents to seek medical attention if there is any active oozing or blood stains on the diaper greater than the size of a quarter. As the cut edge of the foreskin heals, a yellowish mucoid reaction may be seen; mention to parents that this is normal. However, if there is any question about whether something they see is pus, or if they notice a foul odor, they should bring the infant in for re-examination.
I discourage bathing until the day after the procedure. Lubrication of the penis with white petrolatum(Drug information on white petrolatum) will decrease friction against the healing foreskin. I emphasize the importance— after the initial healing phase—of gentle retraction of the remaining foreskin at diaper changes to prevent new adhesions from forming between the cut foreskin and the glans. At follow-up visits, I sometimes need to use pressure with gauze to expose the corona again. I warn parents that this is mildly painful.
CONCLUSION
Despite controversies regarding the benefits and risks of the operation and nuanced preferences in technique, circumcision is a fairly straightforward and quick procedure that continues to stand the test of time. Because it does leave a memorable mark on patients, learners may first want to practice using a simulation model. Models using either a pacifier or a cocktail wiener covered by a surgical glove finger have been described in the literature and may make for a fun workshop.7,8
| • | If the genitalia just do not look right, refer to a pediatric urologist. After all, this is an elective procedure! |
| • | Wait a full 5 minutes after anesthesia before starting the procedure. |
| • | Assemble and disassemble all parts of the Gomco clamp before the procedure to make sure everything fits together properly. |
| • | It is easy to forget where the level of the corona is during the procedure. A skin marking—made before starting the procedure—can help you keep your bearings. |
| • | Avoid trauma to the urethra and glans in the initial steps by careful placement and insertion of the clamps. |
| • | Abandon the procedure and stitch the dorsal slit back up with absorbable suture if a hypospadias is discovered. |
| • | Take your time in separating adhesions between the glans and foreskin. Failure to do this is cited as a common reason for poor cosmesis. |
| • | Using the petroleum gauze dressing to lubricate the probe and clamp facilitates blunt dissection, and lubricating the edge of the bell makes it easier to remove the bell at the end of the procedure. |
| • | If bleeding occurs after cutting down the dorsal crush line, make another crush line on that bleeding edge. |
| • | Make sure equal amounts of both layers of the foreskin—skin and mucosal layers—are pulled through the base plate and over the bell. |
| • | Although some physicians prefer to make an aggressive dorsal slit to use as a landmark in making the final circumferential cut, doing so requires close inspection to make sure that the clamp is applied proximal enough to the dorsal slit to avoid a V-shaped deformity of the foreskin. Using a skin marker and a less aggressive dorsal slit can avoid this risk. |
