| Abstract|| |
Background: W e present our experience of sutureless and bloodless elective circumcision in neonates and infants with Gomco clamp. Patients and Methods: From March 2008 to May 2011, 200 babies with age ranging from 2 weeks to 7 months underwent Gomco circumcision. All patients were given chlorohydrate 50 mg/kg, paracetamol suppository 15 mg/kg, and local anesthesia. Procedure was done in minor operation theatre (OT) and babies were observed for 1 h in recovery room before discharging them home. Results: Two of our patients (1%) required immediate suturing on table after Gomco clamp was removed, five patients (2.5%) were shifted back from the recovery room to minor OT for suture repair and eight patients (4%) required reinforcement of primary dressing to control the minor ooze. There was no other complication. Cosmesis was to the satisfaction of the surgeon as well as the parents. Conclusion: Gomco clamp is a bloodless, sutureless, simple, and safe method of circumcision in newborns and infants. It is cost-effective and can be performed under local anesthesia and sedation with excellent cosmetic results.
Keywords: Circumcision, Gomco clamp, sutureless
|How to cite this article:|
Bhat NA, Hamid R, Rashid KA. Bloodless, sutureless circumcision. Afr J Paediatr Surg 2013;10:252-4
| Introduction|| |
Circumcision is the most frequently performed elective surgical procedure on males in United States.  The Middle East presently contains the most crowded circumcised population.  Potential benefits of decreased incidwence of urinary tract infection and carcinoma of penis has been acknowledged by the American Academy of Pediatrics. , Higher incidence of complications is seen when the procedure is undertaken by inexperienced providers, in nonsterile settings, or with inadequate equipment and supplies.  Various methods of circumcision employed in modern practice aim at removal of shaft skin and inner preputial epithelium enough to uncover the glans so as to prevent phimosis and render the development of paraphimosis impossible.  Besides classical surgical methods, three different circumcision clamps can be used in neonates-Gomco clamp, Plastibell, and Morgen clamps. , The Gomco clamp is one of the most commonly used instruments for neonatal circumcision in United States.  The procedure with this clamp is bloodless and has proven safe with excellent cosmetic results and minimal postoperative complications. This study is to present our initial experience with circumcision using Gomco clamp.
| Patients and Methods|| |
The database for our retrospective study consisted of 200 babies who underwent circumcision with Gomco clamp between March 2008 and May 2011. Sixty were neonates with mean age of 20 days (ranging from 7 to 28 days) and 140 were infants with mean age of 3 months ranging from 30 days to 7 months. All procedures were performed in minor operation theatre (OT). Babies were kept fasting 2 h before procedure. Chlorohydrate 50 mg/kg was given 30 min before the procedure and paracetamol suppository 15 mg/kg just before the procedure. Local anesthetic agent, lidocaine 1%, was infiltrated at the base of penis. The procedure commences with freeing the glans from the inner prepuce and cleaning the smegma with betadine solution. A dorsal slit may be required in case of phimosis. Prepuce was held at 12 and 6'o clock position with two artery forceps. An appropriate size metal bell was introduced between the two artery clamps and was placed over glans [Figure 1], and the prepuce was drawn through the ring of plate. The clamp was assembled so that the prepuce is maintained between the ring and bell [Figure 2]. As the nut of the clamp got tightened, the maximum crushing force is applied to the prepuce and this was maintained for 5 min. Prepuce was excised with a surgical blade, the nut released, . The clamp was removed carefully and procedure completed with excellent cosmetic results [Figure 3] and [Figure 4]. Dressing was applied with Neosporin ointment and the babies were observed for bleeding in the recovery room for 1 h before they were discharged home. Parents were instructed to report back in case of any immediate postoperative complication. Babies were assessed for results at 7 days, 1, and 3 months postprocedure.
|Figure 1: Prepuce is held between two artery clamps and appropriate size bell is introduced between them to be placed over glans|
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|Figure 2: Clamp is assembled so that the prepuce is maintained between the ring and bell|
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|Figure 3: Prepuce is excised with a surgical blade and the clamp is removed carefully|
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| Results|| |
Two of our patients required suturing on table after the clamp was removed, five patients were shifted back from recovery room to minor OT for suture repair and in seven patients the primary dressing was reinforced to control the minor bleeding. In the rest of 193 babies, no suture was applied. The dressing was removed after 48 h and was seen 2 weeks later to avoid any adhesion formation between the prepuce and the glans. There was no further intervention required and the wound healed spontaneously with good cosmetic results.
| Discussion|| |
Gomco clamp is one of the most commonly used instruments for neonatal circumcision in United States and has proved to be simple, safe, and effective method of bloodless circumcision. 
Various techniques of doing this procedure have been described with complication rate ranging from 0.2% to 5%, with the higher complications often related to general anesthesia, difference in method used as well as the experience of surgeon. , Medical reasons for which circumcision is done in children are phimosis, paraphimosis, balanitis, and balanoposthitis,  but in our part of world it is religious unless there are contraindications like hypospadias, epispadias, buried penis, micropenis, and penoscrotal fusion.
In trained hands circumcision with Gomco clamp can be performed with excellent cosmetic results and minimal postoperative complications. The Gomco clamp circumcision beyond neonatal period has remained undefined. Horowitz and Gershbein  in 2001 did not recommend the use of Gomco clamp in patients older than 6 months; however, we are applying the Gomco clamp of appropriate size in older children also under same protocol as in neonates with suturing of the skin edges and applying crushing force to prepuce for 8 to 10 min.
Most of the procedure-related complications were minor and included bleeding, wound dehiscence, infections, and urinary retention. In one series of 98 patients, no complication was seen in patients of 1 month of age and younger.  Conversely, the complication rate increased substantially when Gomco clamp was used at 3 months of age.
Bleeding occurs at a variety of points during circumcision and can typically occur at the frenulum and as well as excised preputial line. In older children, the bleeding is localized to the vessel at skin edges due to larger caliber cutaneous vessels that requires suture ligation as has been our practice. Sometimes increased pressure from crying may lead to bleeding so we make sure baby is well-sedated and given adequate analgesia before procedure.
Significant physiologic response to pain has been documented in neonates undergoing circumcision. Choice of anesthesia technique depends on the skill and experience of the surgeon; although penile ring block may be the easiest and most effective. 
Dermabond (2-octyl cyanoacrylate) has been used as an adhesive for skin closure after Gomco clamp and sleeve techniques. It was found safe, fast, and cosmetically appealing alternative to standard interruption suture reapproximation. 
Gomco clamp is a safe method of bloodless, sutureless circumcision with excellent cosmetic results in small babies in experienced hands.
| References|| |
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Hostel A-Block Room No. S = 2, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar - 190 011, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]