IMPROVING
OUTCOME FROM PLASTIBELL™ CIRCUMCISIONS IN INFANTS
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ANIES MAHOMED,
INDRE ZAPARACKAITE, SAM ADAM
Department
of Paediatric Surgery, Royal Alexandra Children’s Hospital, Brighton,
United Kingdom
ABSTRACT
Circumcisions
are among the most frequently performed operations in children and numerous
techniques are employed often with varying results. Use of the Plastibell™ (Hollister
Incorporated, Illinois, USA), under local anesthetic, is popular for
cultural and religious circumcisions but is not without its problems.
Complications of Plastibell™ (slippage, migration, bleeding and
serious infection) have been reported. Described is a prospective series
of cases in which modifications to the standard Plastibell™ technique
were utilized to improve outcomes, in particular, the risk of bleeding.
Key
words: circumcision; infant; complications
Int Braz J Urol. 2009; 35: 310-4
INTRODUCTION
The
authors have undertaken cultural circumcisions under local anesthetic
in infants for several years utilizing different techniques. From our
earlier experience of the classic Plastibell™ technique (unpublished)
where the string tie, which is packaged with the device was used, complications
of Plastibell™ slippage with consequent bleeding was encountered
(1). Over the last 4 years, an amended approach has been adopted as the
procedure of choice. Described are details of the technical modifications
and the resultant outcome.
MATERIALS AND METHODS
A retrospective analysis of a prospectively held database containing
details of infant cultural circumcisions performed under local anesthetic
between 04/05 and 01/09 was undertaken. Three senior surgeons at a university
affiliated tertiary pediatric institution were involved and a standard
operative approach was utilized in all cases. Demographic and outcome
parameters were studied to assess the impact of the technical amendments
on patient performance.
CIRCUMCISION TECHNIQUE
The operation is performed by a surgeon and assistant
standing at opposite ends of the patient who is placed across the operating
table. The assistant
abducts the hips and the external genitalia area is cleansed with an
antiseptic solution. A standard ring block with 0.5% lignocaine in a
dose of 1 mg/kg is applied to the base of the penis. Once anaesthetized,
the foreskin is comprehensively freed from the underlying glans, which
is calibrated with an appropriately sized Plastibell™ device (PD),
Figure-1. Sizes between 1.2 and 1.7 cm were utilized.
The foreskin is returned to its anatomical position then grasped between 2
hemostatic clips to either side of the dorsal midline before the intervening
foreskin is crushed and divided to a depth of 1 cm. This maneuver widens the
preputial opening and facilitates placement of the PD. To prevent proximal
displacement of the internal (preputial) layer by the PD it is important for
the two layers at the apex of the cut to be approximated with a suture (4/0
silk) (Figure-2). This suture is left to a 6 cm length and held on a hemostat
to aid later retraction of the foreskin over the PD.
A pre-moistened PD is introduced through the widened foreskin opening until
it cups the glans. The orientation of the device should be with the handles
at 90 degrees to the penile frenulum to minimize injury to this structure during
detachment from the ring.
The next step draws an appropriate amount of foreskin over the PD and is achieved
with a bimanual manoeuvre involving forward traction on the 3 hemostats with
simultaneous gentle downward pressure on the handle of the PD) (Figure-3).
The surgical assistant applies two sequential silk 0 ligatures around the neck
of the PD taking care to avoid knot overlap.
Finally, a check confirming position and integrity of the ligatures is performed
after which the foreskin is divided approximately 2 mm distal to the ring (Figure-4).
Hemostasis is checked just prior to discharge about 30 minutes later. Parents
are sent home with a pack containing surgeon contact details, advice on analgesia
and information on commonly encountered problems. To save on costs, routine
postoperative visits are not scheduled.
RESULTS
Between 04/2005 and 01/2009, 130 infants underwent cultural
circumcision by the modified Plastibell™ technique. Age ranged
from 4 to 359 days with a mean of 82.37 days. There were no instances
of post circumcision
bleeding or infection requiring hospitalization however, 2 cases with
suspected infections were reviewed and the diagnosis excluded. Three
further cases were admitted within a month of the procedure for retained
PD requiring removal. Two of these were managed in the Accident and Emergency
Department and one required removal under a short general anesthetic.
A single case where parents were unhappy with the completeness of circumcision
had a revision under a general anesthetic within a year of initial surgery.
COMMENTS
One of the commonest complications of cultural circumcisions
is bleeding and rates as high as 35% have been quoted in the literature
(2). Outcomes
from Plastibell™ circumcisions are reported to be better although
bleeding is still a significant problem (3-6). From the authors earlier
experience with the classic Plastibell™ approach bleeding was problematic
and therefore a series of subtle modifications were introduced to reduce
this risk. The most significant of these was substitution of the pre-packed
string tie with silk 0 ligatures. Neither Plastibell™ slippage
nor bleeding were encountered in the current series and we are of the
opinion that silk 0 ligatures offer superior knotting and hemostatic
qualities as compared to the string. Furthermore, it is likely that application
of a double ligature and the avoidance of knot overlap afforded protection
against Plastibell™ slippage. Although ring separation times were
not specifically studied in this series, it is our opinion that the caliber
of silk 0 is such that it allows for a gradual separation of the ring.
This tended to occur anytime between 5 to 12 days post application allowing
adequate time for sealing of the circumcision margins. It is also possible
that the use of finer sutures might predispose to wound dehiscence, retraction
and sepsis from premature separation.
Another potential source of bleeding with the standard Plastibell™ technique
is from the inner/preputial layer at the apex of the dorsal slit especially
when this is forced proximally by the PD. This problem can be averted by a
stitch applied to this point to approximate internal and external layers of
foreskin. If the suture is left to adequate length, the apex of the cut can
be retracted over the ring and distal to the hemostatic ligature hence excluding
this as a cause for bleeding.
A less critical reason for hemorrhage is injury to the frenulum by the sharp
edges of the handle of the PD when detaching from the ring. This hazard is
minimized by ensuring that PD orientation is such that the handle is perpendicular
to the frenulum when applying the hemostatic ligatures.
Adequate foreskin excision is fundamental to a successful circumcision and
suboptimal excision will result in parental dissatisfaction and certain come
back. It is often the case that too little rather than too much is taken. However,
the problem can be minimized if at the time of ligature application, adequate
foreskin is drawn over the PD. The technique of applying opposing pressure
to the handle of the PD and the hemostats works well as the operator is able
to adjust the length of foreskin to be sacrificed. Surgeons working solo may
have serious difficulty with ensuring adequate circumcision as critical to
this step is the application of the ligatures by a skilled assistant when instructed
to do so by the operator. Rarely, despite this manoeuvre, instances of incomplete
circumcision as was our experience with one case may occur. At particular risk
are patients with a large amount of prepubic fat with partially recessed penises
and mature judgment here is vital to a satisfactory outcome. Clearly where
there is doubt on the amount of skin to be excised cases should be deferred
until later in life or alternatively performance under a general anesthetic
might be considered. Absolute contraindications to cultural circumcisions include;
buried penis, hypospadias and epispadias.
Ring retention around the corona was the most frequent complication in this
series and has been documented by others (6). We suspect that this may be due
to the application of excessive tension on the foreskin during PD placement
and in combination with this and contrary to the opinion of others, to be due
to a selection of a smaller rather than a larger PD (7,8). Calibration with
a suitably sized PD device is therefore crucial and erring on a slightly larger
than smaller device would seem sensible. The PD usually detaches within 12
days and a surgical assessment is mandatory if separation has not occurred
by day 15. Retained rings can be removed under sedation by simply applying
traction on the device. However, if this fails it may be necessary to divide
the ring with a pair of strong scissors. Very rarely this may require a general
anesthetic.
With this series, we have demonstrated that with modifications to the original
Plastibell™ technique that infant circumcision can be offered with relatively
few complications. The most frequent of these is post circumcision bleeding
which can be reduced substantially.
CONFLICT OF INTEREST
None declared.
REFERENCES
- Hollister Plastibell: Available from: http://www.circlist.com.
- Williams N, Kapila L: Complications of circumcision. Br J Surg.
1993; 80: 1231-6.
- Shah T, Raistrick J, Taylor I, Young M, Menebhi D, Stevens R: A
circumcision service for religious reasons. BJU Int. 1999; 83: 807-9.
- Manji KP: Circumcision of the young infant in a developing country
using the Plastibell. Ann Trop Paediatr. 2000; 20: 101-4.
- Holman JR, Lewis EL, Ringler RL: Neonatal circumcision techniques.
Am Fam Physician. 1995; 52: 511-8, 519-20.
- Lazarus J, Alexander A, Rode H: Circumcision complications associated
with the Plastibell device. S Afr Med J. 2007; 97: 192-3.
- Sörensen SM, Sörensen MR: Circumcision with the Plastibell
device. A long-term follow-up. Int Urol Nephrol. 1988; 20: 159-66.
- Mousavi SA, Salehifar E: Circumcision Complications Associated with
the Plastibell Device and Conventional Dissection Surgery: A Trial
of 586 Infants of Ages up to 12 Months. Adv Urol. 2008: 606123.
____________________
Accepted after revision:
February 5, 2009
_______________________
Correspondence address:
Dr. Anies Mahomed
Department of Paediatric Surgery
Royal Alexandra Children’s Hospital
Eastern Road, Brighton
BN2 5BE, United Kingdom
Fax: + 1273 523-120
E-mail: anies.mahomed@bsuh.nhs.uk
EDITORIAL COMMENT
Circumcision performed by Plastibell™ method is
a well-proven method, which compares well with standard open circumcision
with respect
to results and complications. This is an interesting paper with modifications
of standard Plastibell technique. The authors should be commended of
such low complication rates
The application of suture to the apex of the cut seems to be a practical
technique where the inner layer has some chance of bleeding. This is
a reasonable modification
to reduce bleeding complications. The author’s claim for silk sutures
to have superior knotting techniques and allows more secure hemostasis is probably
true but should be substantiated by evidence.
I do not think the slippage of the ring was a major problem in the largest
Plastibell series and though tying two silk ligatures theoretically should
provide additional safety - it is probably unnecessary.
There are few important distinctions when comparing this paper with one of
the largest series from Bradford - firstly the procedure was performed by nurses
with consultant urologist available in Hospital in case of any problem. Secondly,
the maximum age in that series was 14 weeks (the present series max age is
359 days). Penile block was used along with ring block for local anesthesia
whereas only ring block was used in the present series.
Dr. Victor Palit
Yorkshire Deanery
Royton, Oldham, Lancashire
United Kingdom
E-mail: victorpalit@yahoo.co.uk
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