Techniques for neonatal circumcision
- David G Weismiller, MD, ScM
David G Weismiller, MD, ScM
- The Brody School of Medicine at East Carolina University
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Laurence S Baskin, MD, FAAP
Laurence S Baskin, MD, FAAP
- Section Editor — Pediatric Urology
- Frank Hinman, Jr., MD, Distinguished Professorship in Pediatric Urology
- Chief Pediatric Urology
- Professor of Urology and Pediatrics
- UCSF Benioff Children's Hospital
Circumcision (Latin circumcido, to cut around) is an elective surgical procedure in which the prepuce or foreskin (skin covering the glans penis) is removed. The three major techniques for performing neonatal circumcision are use of the Gomco clamp, Hollister Plastibell, or Mogen clamp. These techniques will be reviewed here. A detailed discussion of the risks and benefits of neonatal circumcision can be found separately. (See "Neonatal circumcision: Risks and benefits".)
NORMAL DEVELOPMENT AND ANATOMY
The penis consists of a proximal root, middle body (corpus or shaft), and distal head (glans). The prominent circumferential rim where the glans begins is called the glans corona, and the constriction just below the corona is the coronal sulcus (figure 1).
The skin of the body of the penis starts to grow over the glans between 10 and 18 weeks of gestation, eventually covering the entire organ . The prepuce is a specialized, junctional mucocutaneous tissue that forms the transition between the mucosal epithelium of the glans and the keratinized epithelium of the penile shaft, analogous to the eyelids. The double sheet of prepuce covers the glans for a variable distance and consists of several thin layers: inner squamous epithelium (mucosa), lamina propria, dartos muscle, dermis, and outer keratinized stratified squamous epithelium (figure 2) . The frenulum is a ridge of tissue that extends from the base of the prepuce at the coronal sulcus to a point just inferior to the external urethral orifice (meatus) (figure 3). It is supplied by the frenular artery and vein, which can cause significant bleeding if disrupted during circumcision.
At birth, the prepuce is fused to the glans by filmy adhesions that prevent retraction (congenital or physiological phimosis). These adhesions resolve over time due to desquamation and epidermal keratinization. The resulting separation of the prepuce and the glans is called the preputial space and allows easy retraction.
Separation is completed in 50 percent of boys by age 3 years, 95 percent by age 5 years, and 99 percent by adolescence. In a small number of uncircumcised males, partial adhesions leading to accumulation of smegma may persist throughout childhood, and even into adolescence.
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- NORMAL DEVELOPMENT AND ANATOMY
- After circumcision
- TIMING OF CIRCUMCISION
- Bleeding diathesis
- Congenital anomalies
- PARENTS' FINANCIAL OBLIGATION
- PREOPERATIVE PREPARATION
- INFORMED CONSENT
- PAIN CONTROL
- Instrumentation and materials
- Patient preparation
- Gomco clamp
- Plastibell device
- Mogen clamp
- POSTCIRCUMCISION CARE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS