The Gomco technique
1 . Stretch the preputial ring.
2. Break preputial adhesions so that the foreskin is completely retractile. (A)
3. Retract the foreskin untiI you can see the corona. Check the glans for any hidden adhesions. If the entire preputial space is not free, you stand a good chance of pinching the glans on the bell or clamp, or of leaving adhesions behind.
4. Apply a small amount of lubricant such as petroleum jelly to the glans so that it won’t stick to the inside of the bell.
5. Apply the bell-shaped plunger over the glans. The bell should fit easily over the glans so that it covers the corona. Too small a bell may injure the glans and fail to protect the corona, If stretching the preputial ring does not allow the bell to be inserted in the preputial space and entirely cover the glans, a dorsal slit may be necessary. (B)
Pull the prepuce up over the bell. The foreskin should not be stretched or pulled too snugly over the bell. If it’s pulled up too tightly, it’s possible to remove too much shaft skin or to pull the urethra up so you get a tangential cut through the urethra as well as the skin. (C)
7. Judge the amount of the shaft skin left below the corona –, the skin should be relaxed and supple.
8. After you’re sure of the dimensions, apply the plate of the clamp at the level of the corona. (D)
9. With everything in proper alignment, tighten the clamp. This squeezes the prepuce between the bell and the clamp to make it blood-free. Be sure the weight of the clamp doesn’t distort the anatomy so there isn’t the proper amount of skin in the clamp.
10. Make a circumferential incision with a cold knife, not an electrosurgical instrument. (E)
11. Leave the clamp in place at least five minutes to allow clotting and coaptation to occur.
12. Remove the clamp and apply antiseptic ointment (Betadine) to the crush line. Apply a light dressing or loin cloth arrangement to keep the ointment from rubbing off.
13. If you remove the clamp prematurely, the crushed edges may separate and bleeding will occur. When this occurs, suture the mucocutaneous margin, being careful to avoid deep sutures that might penetrate the urethra. If the whole edge separates, treat as a freehand circumcision. placing quadrant sutures and sewing between them with fine stitches.
14. Have the baby watched overnight for any sign of bleeding.
15. If late separation occurs, it’s best to keep the wound clean and let it heal secondarily rather than to try to suture it and risk development of stricture or fistula. Skin of this area tends to re-epithelialize rapidly.
The Plastibell technique]
1. Stretch the preputial ring.
2. Break preputial adhesions with a probe or closed forceps.
3. Make a small dorsal slit of 0.5 to 1.0 cm in the prepuce. Keep the initial slit short; it can always be extended. To minimize bleeding, previously crush the line of incision with artery forceps for one minute. Take particular care not to place forceps or scissors in the urethral meatus; before cutting or crushing, lift the prepuce away from the glans and visualize the meatus. (A, B)
4. Separate the edges of the slit with a pair of artery forceps to reveal the glans. If necessary, extend the cut to expose the coronal sulcus. (C)
Free any remaining adhesions and lay the prepuce back (inside out) to expose the entire glans.
6. Slip the Plastibell of appropriate size over the glans as far as the coronal sulcus. It should slip over the glans easily; too small a bell may injure the glans.
7. Place the prepuce over the bell to hold it in place. (D)
8. Tie the ligature as tightly as possible around the prepuce on the ridge of the bell; oozing will occur if the ligature is loose.
9. After 1-2 minutes to allow for crush, trim off the prepuce at the distal edge of the ligature, using a knife or scissors. Trim as much tissue as possible to reduce the amount of necrotic tissue and possibility of infection. (E)
10. Snap off the handle of the bell, leaving the bell and ligature in place. You should be able to see an unobstructed urethral meatus. (F)
No dressing is necessary; the baby may be bathed normally; the rim of tissue under and distal to the ligature will become necrotic and will separate with the bell in 5-10 days.
12. Complications are unusual with this technique. Occasionally, however, edema will trap the plastic ring on the shaft of the penis. In this case, it’s usually necessary to cut off the ring, using a guide and ring cutter, although application of ice will sometimes reduce edema enough to remove the ring.