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 11^th 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  If  the penis is “withdrawn” by overhanging abdominal fat pad, minimal penile skin should be excised.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