Circumcision

The foreskin covers the glans of the penis.

Circumcision is the removal of the foreskin .

Anesthetize the penis with a "Ring Block" of no more than 1.0 cc of 1% lidocaine, injected circumferentially around the base of the penis. DO NOT USE EPINEPHRINE!!!

Inject just beneath the skin, and above Buck's Fascia.

Use a blunt instrument to free any adhesions between the glans and the foreskin.

Use a straight hemostat to crush the foreskin (not the glans). The crushed area should encompass about 2/3 the length of the foreskin.

Use a straight scissors to cut the crushed area. This is a "dorsal slit."

Insert the bell of the circumcision clamp underneath the foreskin, covering the glans and protecting it.

Screw down the clamp, so that the metal surrounding the bell crushes and isolates the distal 2/3 of the foreskin.

Cut away the isolated foreskin, then remove the clamp.

Some couples request circumcision for religious reasons, others for health or cleanliness reasons. Circumcision is probably effective at reducing the later risk of:

• Infections occurring beneath the foreskin
• Penile cancer
• Cervical cancer among their female partners

However, infections are infrequent and usually easily treated, penile cancer is very rare, and the marginal increased risk of cervical cancer is small. While there are a few medical reasons for performing circumcision, the medical benefits are thin.

Complications from this surgery are quite rare. They include bleeding from the incision site, infection, and injury to the glans or shaft of the penis.

The use of circumcision remains controversial. While a few parents feel strongly about either having it done or not having it done, most individuals are somewhat ambivalent about it. The medical benefits are small, but the risks are also small.

Watch a Video on Circumcision

Circumcision Candidates
For the most part, any infant whose parents want a circumcision performed on their newborn son can be accommodated. The exceptions include:

• Febrile infants or those with known infections
• Infants with clotting disorders
• Hypospadias
• Ambiguous genitalia
• Infants who are so small that the procedure becomes technically dangerous.

Restrain the infant
It is important that the infant not move during the procedure. Most effective are soft restraints found on "circumcision boards." Alternatively, support staff can physically restrain the infant, but they must be careful to neither allow infant movement, nor injure the infant from their restraints.

Anesthesia
Historically, anesthesia was rarely used as it was felt to be unnecessary, and a potential source of complication. Currently, anesthesia is much more likely to be used.

Most effective is the "Ring Block," shown here. 1% lidocaine is injected around the base of the penis, just beneath the skin, raising a tiny weal. When the base has been completely encircled by subcutaneous lidocaine, the distal penis will be anesthetized. Other techniques (dorsal penile block, topical anesthetic creams, etc. may give satisfactory results).

Don't use epinephrine in the lidocaine. If you do, there is a moderate likelihood that the resulting vasoconstriction will lead to necrosis of the shaft and glans of the penis, a disastrous result.

Limit the total dose of lidocaine to less than 1.0 cc. This is well within the safe limit for a newborn and provides more than enough volume to complete the ring block.

Don't inject too deeply. The anesthetic needs to go just beneath the skin and above Buck's fascia.

Use a 1 cc tuberculin syringe with a tiny (#27) needle.

Use your own eyes to visually check the lidocaine vial to confirm that it is 1% concentration, and contains no epinephrine.