The Gomco clamp is the instrument most commonly used in performing nonritual circumcision in the U.S. (Fig. 45-1).
It is designed to circumferentially crush a 1-mm band of foreskin, allowing hemostatic removal of the foreskin while protecting the glans from injury.
The clamp is popular because of its ease of use and long safety record.
Infant feedings are suspended for 1–3 hrs before the procedure to reduce the risk of aspiration.
The infant is usually restrained in a molded plastic restraint device. Many infants urinate soon after being placed in the restraint, and the practitioner may have to move quickly to avoid the stream.
Consider an infant warmer if the room is cool.
The penis, scrotum, and groin area are typically cleaned with Betadine or a similar disinfecting solution and sterilely draped. Inspect the infant for gross anatomic abnormalities.
Anesthesia is usually obtained using a dorsal penile nerve block. Use of epinephrine is contraindicated in any procedure involving the penile shaft. While topical prilocaine and lidocaine (i.e., EMLA cream) have been demonstrated to help, avoid use of prilocaine in children aged <1 month.
Usually, about two-thirds of distal foreskin is removed. The amount of shaft skin that remains after circumcision should be carefully assessed after the clamp is placed but before the screw is tightened. If it is necessary to adjust the amount of foreskin to be removed after the clamp is in place, disassemble the device, and pull the bell away from the baseplate. If the foreskin is adjusted while the clamp and bell are still assembled, there is a risk that the vessels between the foreskin and the underlying mucosa will be damaged and cause bleeding.
Inspect the penis after the procedure for signs of bleeding. Apply a dressing of petroleum jelly or petroleum gauze, which may be removed in 12–24 hrs, to the cut line. Most nurseries require the infant to urinate before undergoing circumcision, but barring complications during circumcision, this is probably unnecessary.
Warn the parents that some swelling may occur, that the crust will often form on the incision line, and that small bleeding spots may be found in the diaper. Ask them to report any bloodstain greater than a quarter or any signs of infection. If soiled, the area may be gently cleaned with soap and water.
Rarely, the glans is not visible 30 mins after the procedure. This indicates the presence of a "concealed penis," which results from inadequate removal of the foreskin or underlying mucosa. The penile shaft and glans are pushed back into the scrotal fat, and the penis is buried. There is no need for a further procedure at this time as long as the baby is able to urinate without problems. However, a revision of the circumcision by a urologist may be necessary at a later time.
Indications⬆⬇
Medical indications, including phimosis, paraphimosis, recurrent balanitis, extensive condyloma acuminata of the prepuce, and squamous cell carcinoma of the prepuce (all rare in neonates)
Parental request or religious reasons
Contraindications⬆⬇
Presence of urethral abnormalities—e.g., hypospadias, epispadias, or megaurethra (i.e., foreskin may be needed for future repair or reconstruction).
<1 cm of penile shaft is visible when pushing down at the base of the penis (i.e., short penile shaft).
Delay circumcision in infants who are ill or premature until they are well or ready for discharge from the hospital.
Bleeding diathesis, myelomeningocele, or imperforate anus.
Procedure⬆⬇
Perform a dorsal penile nerve block by tenting the skin at the base of the penis and injecting 0.2–0.4 mL of 1% lidocaine (without epinephrine) into subcutaneous tissue on either side at the dorsal base of the penis. A pacifier dipped in 25% sucrose also appears to reduce infant discomfort. Drape the baby's torso (but not head) with a fenestrated drape.
The size of the bell of the Gomco clamp used for circumcision is selected based on the diameter of the glans (not the length of the penile shaft). The bell should be large enough to cover the glans penis completely without overly distending the foreskin. A bell that is too small fails to protect the glans and may cause too little foreskin to be removed.
Carefully insert a blunt probe or closed hemostat into the preputial ring down to the level of the corona while gently peeling back the foreskin (Fig. 45-2A). Slide the instrument down to the right and left sides to break up adhesions between the inner mucosal layer and the glans. Carefully avoid the ventral frenulum, because tearing it often causes bleeding (Fig. 45-2B). Examine the penis to make sure hypospadias or megameatus is not present.
Pitfall: To avoid inadvertent intravascular injection, apply negative pressure to the syringe immediately before injection to check for backflow of blood.
Pitfall: Check the base, rocker arm, and bell of the Gomco clamp to make sure they all fit together. The bell and base from a 1.45-cm clamp will close but will not seal the skin properly if used with a rocker arm of a 1.3-cm set. Check to make sure that there are no defects in any of the parts.
Pitfall: Failure to free the mucosal adhesions from the glans completely is the most common reason for poor cosmetic result. If adhesions are not completely separated, not enough mucosa will be removed, and phimosis may result.
Pitfall: If hypospadias or megameatus is present, terminate the procedure because any repair of these congenital anomalies may require use of foreskin tissue.
After the coronal sulcus is freed of adhesions, circumferentially grab the skin near the base of the penis and pull it over the glans until the foreskin returns to its anatomic position (Fig. 45-3). Grasp the end of the foreskin on either side of the dorsal midline at the 10- and 2-o'clock positions with 2 hemostats. Make sure to avoid the glans and stay out of the urethral meatus.
Create the crush line on the dorsal aspect of the foreskin using a straight hemostat (Fig. 45-4). Crushed skin is cut with scissors, taking care to avoid the glans. The cut should proceed down the center of the crush line to avoid bleeding that occurs if the cut strays laterally.
Pitfall: Make sure the crush line is far enough above the coronal sulcus that it will be completely removed in the circumcision. If the cut extends too far onto the penile shaft, the proximal portion of the incision (apex) cannot be pulled into the Gomco clamp.
Insert the bell of the Gomco clamp under the foreskin and over the glans. Bring the 2 hemostats that are holding the edges of the foreskin together over the bell (Fig. 45-5A). Place an additional hemostat directly through the hole in the baseplate. Then use a hemostat to draw the edges of the dorsal slit together over the flare of the bell and remove the original hemostats (Fig. 45-5B). Pull the hemostat, foreskin, and stem of the bell through the hole in baseplate (Fig. 45-5C). Alternatively, insert a small safety pin through both edges of the dorsal slit and bring the edges together over the flare of the bell. The safety pin may be passed through the hole in the baseplate along with the stem of the bell.
Pitfall: Be careful not to cause inadvertent injury to the clinician or infant with the sharp end of the safety pin.
Make sure that equal amounts of mucosa and foreskin are brought through the baseplate. Determine if the amount of foreskin above the baseplate is appropriate for removal and that the remaining shaft of skin is adequate. The amount and symmetry of the skin may still be adjusted at this time.
The rocker arm of the Gomco clamp is then attached and brought around into the notch of the baseplate (Fig. 45-6). The arms of the bell are settled into the yoke and the nut is tightened, crushing the foreskin between the bell and baseplate. Leave the clamp in place for 5 mins. Place the scalpel blade flat against the baseplate, and cut the top of the crush line (Fig. 45-7).
Loosen the nut and remove the top and baseplate from the bell. The shaft skin sticks to the bell but can be peeled off using a gauze pad or blunt probe. Inspect the penis after the procedure for signs of bleeding. Apply a dressing of petroleum jelly or petroleum gauze to the cut line. Additional infant soothing can be provided by placing the undressed infant on his mother's chest (skin-to-skin contact) immediately after the procedure.
Pitfall: Make sure the apex of the dorsal slit is visible above the plate before putting arms in the yoke and excising the foreskin.
Pitfall: Make sure the rocker arm is well settled into the notch of the baseplate. The clamp may be tightened outside of the notch, but it will not seal skin well and risks causing degloving injury.
Pitfall: Cutting the foreskin at an angle into the baseplate may disrupt the crush line and cause bleeding.