Neonatal & Paediatric Circumcision – How I do it
CCM Lei
Kidney & Urology Centre, Normah Hospital,
Kuching, Malaysia
Egyptian mummies which are about 4300 years old were
circumcised. Circumcision was the 11th AM Ismail oration of the
College of Surgeons of Malaysia in 1984.
The preferred technique of circumcision is the dorsal slit technique
(with scissors) and outer and inner preputial incisions with a knife. This gives precise margins and clear view of
the glans penis and meatus. It also
allows any excess inner foreskin (especially in cases of severe phimosis) to be
excised while preserving the outer penile skin, as well as preserving the
variable intervening penile tissue.
Bipolar diathermy may be used if necessary. The inner foreskin and glans can then be
cleansed properly with Povidone Iodine.
The skin is closed with
interrupted plain Catgut 4/0. Eye
ointment and an apron gauze dressing may be applied. 1% Lignocaine dorsal penile block (avoiding
the dorsal vessels) and skin block are preferred. The patient may be given a Diclofenac or
Paracetamol suppository for postoperative discomfort. If the
penis is “withdrawn” by overhanging abdominal fat pad, minimal penile skin
should be excised. Where possible, the
base of the penis can be sutured to the inner penile skin to prevent the penis
from “disappearing” when the patient returns to the ward! Postoperative wound
inspection and care should be readily available, at least within the first few
days.
Neonatal circumcision is increasing practised in Malaysia,
possibly as a result of influence from the expatriates from the Middle East and
not necessarily a Muslim practice. It is best done within the first 7 days of
life when the baby is still protected by the mother’s immunoglobulin and
coagulation factors. ½ cc of 1%
Lignocaine with a 26G needle may be used for a ring block. The child may be “sedated” with 20% glucose
during the procedure. It is important that not only fine instruments are used
but the surgeon should also use an ocular magnifying loop.
Circumcision complications – cases, pitfalls and
medico legal consequence
Clarence Lei
Kidney & Urology Centre, Normah Hospital,
Kuching, Malaysia
The Borneo Post of 19.3.2016 reported the arrest of a doctor
following a “botched circumcision”. The
doctor was arrested for “causing grievous hurt by an act which endangers life,
under Section 338 of the Penal Code”. A part
of the penis was missing and the boy was brought to the general hospital for
further treatment. The postoperative pictures were also posted on
social media! In another case, about half the penis was brought to the
hospital but it was not re-attached. It is important that the amputated organ
be kept in two plastic bags with ice (e.g. from 7-11 Stores) in outer bag. It
may be re-attached within 48 hours. The
vessels and nerves should preferably be re-attached by micro-surgical
techniques, if available. In 1992, there was a similar medicolegal case when
the boy had a circumcision by an attendant in a general hospital. Thereafter,
there were regulations to the effect that circumcision should only be performed
by medically qualified personnel and in medical institutions. The recommended technique is that of dorsal
slit technique and not the guillotine technique. It was reported in a MPS case
book where 2 doctors were guilty of serious professional misconduct “for
failing to follow correct procedures around male circumcisions”. In 1 case, a suture was inserted into the
glans penis. The General Medical Council has “Guidance for doctors who are
asked to circumcise male children”. In
2002, a mass circumcision in South Africa resulted in 24 deaths and over 100
admitted for sepsis when unsterilised equipment were used for the circumcision. The following complications occurs:
submeatal urethral fistula, meatal stenosis, arterial bleeding, haematoma, penile infection
and wound breakdown. These are
especially so if the patient has any underlying haematological disorder,
diabetes or if there is ongoing local infection. In an unfavourable environment or if the
patient is uncooperative, there may be inadequate circumcision resulting in
scarring and requiring corrective penile surgery. General anaesthesia may be required for most
children under the age of 10. For elder
children, consent of the child under local anaesthesia must be agreed upon
before the surgery. Whenever possible,
only bipolar diathermy is used. Some prefer to be uncircumcised. If the patient has an obvious chordee or
hypospadias, circumcision should not be performed as a separate operation. Severe para-phimosis should be treated
urgently.
Annual Surgical Meeting, 15 May 2016, College of Surgeons Malaysia, page 23
http://csamm.asm.org.my/files/CSAMM2016_AbstractBook.pdf
