Clinical Pediatrics (Phila.), Volume 23: Page 679-682, December 1984.
Yosef Aaron Kaweblum, MD, Shirley Press, MD, Leib Kogan, MD, Mauricio Levine MD, Moises Kaweblum MD
From the Department of Pediatrics, University of Miami School of Medicine, Miami Florida and the Hospital Del Valle de Mexico, Instituto de Seguridad Social del Estado de Mexico y Municipios. Ciudad Satelite, Mexico.
Shirley Press, MD.
The Department of Pediatrics,
University of Miami School of Medicine (RI 31),
P. O. Box 016960,
Miami. FL 33101
Received for publication March 1984, revised May 1984, and accepted June 1984.
The purpose of this study was to analyze the results of 313 circumcisions using the Mogen clamp. This procedure was done between 1 day and 2 years of age in all but four patients. The complication rate was low (1.6%). Two patients had local infection, one mild hemorrhage, one concealed penis, and one postcircumcision phimosis. Circumcision using the Mogen clamp is a simple quick, and safe procedure.
Although the American Academy of Pediatrics stated in 1975 that "there is no absolute medical indication for routine circumcision of the newborn," this procedure is presently the most common surgical procedure performed in children today.1,2
The percentage of infants circumcised in the United States currently is reputed to be between 77 and 97 percent.2,3 This range of incidence has remained unchanged subsequent to the Academy's recommendation.2
The Jewish people have practiced circumcision ritually during the last 4000 years. The removal of the foreskin was the sign of the covenant between God and Abraham (Genesis 17:10). The method to be used is not specified in the Bible. Rabbis, also known as mohels, who perform circumcisions have adopted the technique of using the Mogen clamp (Fig. 1 ).4 This clamp was designed by North American Rabbi Harry Bronstein in 1954. The most widely used methods for circumcision in the United States are the Gomco clamp and the plastic bell device.5 The circumcision shield and Millers Messer (knife), the open surgical technique, and electrocautery circumcision also are employed, although much less frequently.6,7 Results of 313 circumcisions using the Mogen clamp are presented in this study.
Between September 1980 and December 1982, 313 circumcisions were performed using the Mogen clamp at the Hospital Del Valle de Mexico. Informed consent was obtained for all patients.
The patients were divided into four groups according to age.
Group I consisted of 150 newborns between 24 and 72 hours of life. All were healthy neonates weighing 2500 g or more.
Group II included 150 males between 8 days and 3 months of age. They were circumcised for religious reasons.
Group III consisted of 5 patients circumcised because of parental request and 4 for phimosis; all were between the ages of 6 months and 2 years. Four adult patients in Group IV had circumcision for medical or personal reasons.
The technique employed is as follows. The genital area is cleansed with soap, water, and povidone-iodine. Sterile drapes are placed. General anesthesia is used in patients who are older than 3 months. Some authors recommend the use of regional anesthesia by dorsal penile nerve block with lidocaine in newborns.8 The mucosa is separated with a lubricated, blunt edged probe, taking care not to damage the frenulum (Fig. 2). Anesthesia (10% lidocaine spray) is applied to the mucosa. After the mucosa is separated and anesthetized, the glans is lubricated with an antiseptic ointment. A straight Kelly hemostat is placed in the midline of the dorsal side of the prepuce approximately 5 mm proximal to the corona (Fig. 3). The prepuce is carefully pulled with the hemostat in an up and outward direction. At this time, the glans retracts towards the scrotum, avoiding accidental amputation of the glans. The Mogen clamp then is placed obliquely in a 45 [degree] angle in the dorsal ventral direction pointing outwards (Fig. 4). The jaws of the Mogen clamp then are brought together for 2 minutes in infants under 6 months of age and for 5 minutes in older males.
The prepuce then is excised (Fig. 5). The Mogen clamp is opened and slowly removed. The seal between the skin and the mucosa is separated, applying downward pressure until the glans is liberated (Figs. 6 and 7). All remaining adhesions are removed, and the penis is covered with a vaseline gauze (Fig. 8).
In cases involving a small penis, the angle of the placement of the Mogen clamp was increased according to the size of the prepuce.
Mothers and adult patients were instructed as to the postoperative care or the area. A new vaseline gauze was placed with each diaper change for 1 week. Good hygienic practices also were taught.
The penis was checked by the physician 72 hours, 1 week, and 1 month after the circumcision was performed. Overall, the results were excellent: the incidence of complications was low, and almost all of the parents and all of the adult patients were pleased with the cosmetic outcome. Patients also were instructed to return to the hospital if problems occurred subsequent to being discharged from the care of the physician.
In Group I, there were five complications: two local infections, one instance each of mild hemorrhage which responded to local pressure, concealed penis, and postcircumcision phimosis. Local infection was diagnosed by the presence of pus and erythema on the wound. These were treated by local Neosporin ointment application. No systemic antibiotics were needed. Hemorrhage was defined as bleeding from the glans for more than 4 hours after the procedure was done. In the other groups, no complications arose. The overall incidence of complications was 1.6%, none of which were life-threatening or serious. Discussion Circumcision dates back to 2400 B.C. The first known record of the procedure exists on a relic in the temple of Khan el Karnak in Egypt. The plaque depicts an actual operation.9 Archeologists believe that the custom existed before this time. In addition to Jews and Arabs, ritual circumcision is practiced among African tribes, Christian Abyssinians, Australian blacks, dwarf tribes of Gabon, Malayans, Men of Borneo, North and South American Indians, Aztecs, Mayas, Caribs, Fijians, and Samoans.9
In the United States, most circumcisions are performed for reasons other than religious beliefs. Parent's reasons for wanting circumcisions are hygiene, social custom, circumcised father, physical appearance, decreased infection, doctor's advice, and decreased cancer; some give no reason.2
The exact incidence of complications from circumcisions is unknown.5 The range of incidence is re ported from 0.2 to 38%.5,10 Life-threatening complication include sepsis and hemorrhage. Serious complications include staphylococcal scalded skin syndrome, necrosis of the glans, necrosis of the corpus spongiosum, severe trauma or injury to the glans, necrotizing fasciitis, fistulas, urinary retention, and secondary hypospadias or epispadias.9 In one series, problems resulted from circumcision of patients with an unrecognized hypospadias.10 Minor complications include mild hemorrhage, local infection, superficial laceration, concealed penis, removal of excess skin, phimosis, meatal stenosis, meatitis, and separation of the penile skin from the mucous membrane.10 Contraindications of the use of the Mogen clamp are the following: a very small penis, a penoscrotal web, a severe glandular adhesion, coronal hypospadias, and chordee without hypospadias.
Besides the low incidence of complications from using the Mogen clamp, there are other advantages to circumcision with this technique. One is the need for a minimum of surgical instruments for this procedure in comparison to other methods. The requirements are a blunt edged probe, a straight Kelly hemostat, a scalpel, and the Mogen clamp. The surgical time is short, usually 3 to 4 minutes. There is good control of the amount of the prepuce removed, which allows the Mogen clamp to be used on a small penis. Finally, the inflammatory process usually starts to resolve by 72 hours.
Circumcision by use of the Mogen clamp is an easy, quick, and safe procedure to learn.
The authors thank Drs. William Cleveland and William Rapoport for their help.
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