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Key differences between newborn circumcision and adult circumcision

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Key differences between newborn circumcision and adult circumcision

July 2017

Neonatal circumcision is performed utilizing one of a number of clamp devices which remove the redundant foreskin, stop bleeding arteries and veins by crushing them, and bond the skin edges without the need for sutures. The most common devices used are the GOMCO (acronym for Goldstein Manufacturing Company) introduced in 1934, The Mogen clamp introduced in 1954, and the Hollister PlastiBell clamp introduced in 1950. Each one of these creates a pressure bond to hold together the skin edges so that their is no need for sutures. These devices provide an adequate wound closure for infants because they do not have powerful enough erections to pull apart the skin edges. The bond created by these clamps at the skin edges consists of the clamp crushing the two opposing skin edges together. The force of a powerful erection would pull apart the wound edges resulting in wound 'dehiscence' or opening up of the wound thus making it an inadequate wound closure for a circumcision in an older child or adult. Adults require a suture closure (stitches) to provide a secure enough closure to allow the wound to remain intact despite the force of erections. Also, it should be mentioned that careful suture closure leads to a much finer scar once the healing is complete. Sutures guide the healing edges of the wound close together so that the end result is a very fine line. I have performed some circumcisions in which I did not suture (stitch) the wound. The results were scars that were wider than ones I create with suture closure.

Neonatal circumcisions are done with minimal local anesthesia or no anesthesia. Using a clamp device, a neonatal circumcision is a quick, five minute procedure. An adult circumcision is a more lengthy procedure and requires a more elaborate anesthetic. Many urologists perform adult circumcisions with general anesthesia. This is a more complicated and expensive procedure than local anesthesia. I perform almost all of the procedures for my patients utilizing local anesthetics. This involves a series of injections around the base of the penis to encircle the penile circumference with the anesthetic agent. The injections are not particularly painful since the injections are just beneath the skin surface. After the anesthetic is injected, I allow five to ten minutes for the effect to occur and then check the patient’s sensation to ascertain that he is not able to feel pain. I use the sleeve resection technique in which I remove the redundant foreskin with a scalpel. This involves making an incision on the outer surface of the foreskin at the level where the edge of the glans (corona) is visible making an impression through the foreskin. I then retract the foreskin and make an incision in the inner (mucosal) surface of the foreskin following the contour of the glans. I mark the incision lines before making any incision and make measurements to be certain that the incisions will result in removing enough foreskin to meet the patient’s cosmetic preferences and allow for comfortable erections. An adult circumcision should be crafted to accommodate the dimensions of the erect penis. I simulate erect length by stretching the penis. I mark incision lines with an ink marker and then stretch the penis and move the two incision lines into proximity. I want these two points to come together without excessive tension. This will avoid uncomfortable erections. Once I have determined the correct location of the incision lines, I make the outer incision, retract the foreskin and make the inner incision and remove the foreskin as one piece of tissue. Bleeding points are identified and cauterized with electrocautery. The frenulum is then removed if the patient desires this to be done. I then close the wound with fine sutures, placed in a very precise manner so that suture marks and tunnels will not occur, and finally apply a compression bandage to the surgical site. Typical outcome images can be viewed on the circumcisioncenter.com Website.

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