What is the step-by-step procedure for a circumcision using a Gomco (Glans-over-Meatus-Clamp-Occlusion) clamp?

Gomco Circumcision Procedure: Step-by-Step Guide

The Gomco clamp technique provides a safe, effective, and relatively bloodless method for performing circumcision with excellent cosmetic results when performed correctly.

Preparation and Anesthesia

1. Anesthesia options:

   • Local anesthesia with dorsal penile nerve block using 25-32 gauge needle (smallest available) 1
   • Consider adding lidocaine-prilocaine cream for additional pain control 2
   • Oral acetaminophen and sugar-coated gauze can be used as adjunctive analgesia 2

2. Skin preparation:

   • Wash the genital area with antibacterial soap or 2% chlorhexidine 1
   • Apply 70% alcohol in circular rubbing motion for 1 minute 1
   • Apply 10% povidone-iodine and allow to dry for 2-3 minutes 1
   • Staff should wear clean gloves and follow proper hand hygiene 1

Surgical Procedure

1. Foreskin assessment:

   • Examine for any abnormalities including phimosis, adhesions, or signs of balanitis
   • Ensure the meatus is normal and properly positioned

2. Foreskin separation:

   • Gently retract the foreskin to break any adhesions between the glans and foreskin
   • Use blunt dissection to free the foreskin from the glans 3
   • Be careful not to force separation if adhesions are dense

3. Dorsal slit:

   • Place a straight hemostat across the dorsal aspect of the foreskin
   • Make a dorsal slit with scissors down to but not including the corona
   • This allows proper visualization of the glans and facilitates bell placement

4. Bell selection and placement:

   • Choose appropriate Gomco bell size that fits snugly over the glans 3
   • Place the bell over the glans, under the foreskin
   • Pull the foreskin over the bell, ensuring the glans is fully protected

5. Clamp assembly:

   • Place the base plate of the Gomco clamp over the bell stem
   • Pull the foreskin through the hole in the base plate
   • Ensure the foreskin is distributed evenly around the circumference
   • Attach the yoke of the clamp and tighten the screw gradually

6. Foreskin excision:

   • Once the clamp is fully tightened, wait 5 minutes to ensure complete hemostasis
   • Excise the foreskin distal to the clamp using a scalpel
   • Cut along the edge of the metal plate for a clean, even cut

7. Clamp removal:

   • After excision, loosen the screw and carefully disassemble the clamp
   • Gently separate the bell from the glans to avoid disrupting the crush line
   • Inspect for any bleeding points

8. Wound care:

   • Apply petroleum jelly or antibiotic ointment to the wound edge
   • Loosely wrap with sterile gauze

Post-Procedure Care

1. Immediate monitoring:

   • Observe for 1 hour post-procedure for any bleeding 4
   • Ensure the infant voids before discharge

2. Home care instructions:

   • Keep the area clean with warm water
   • Apply petroleum jelly with diaper changes for 5-7 days
   • Avoid tub baths until healing is complete (typically 7-10 days)
   • Watch for signs of infection, bleeding, or urinary retention

Common Complications and Solutions

1. Bleeding:

   • Minor oozing (4% of cases) may require reinforcement of dressing 4
   • Significant bleeding (1-2.5% of cases) may require suturing 4
   • Apply gentle pressure with sterile gauze for minor bleeding

2. Poor cosmetic results:

   • Ensure proper bell size selection 3
   • Follow the angle of the corona when placing the clamp to avoid removing excess ventral skin 5
   • Distribute foreskin evenly through the base plate hole

3. Infection:

   • Rare with proper technique and sterile conditions
   • Signs include increasing redness, swelling, discharge, or fever
   • Treat with appropriate antibiotics if infection occurs

Special Considerations

• Contraindications to routine circumcision:

  • Congenital penile abnormalities (hypospadias, epispadias)
  • Bleeding disorders
  • Prematurity
  • Acute local infection

• Advantages of Gomco technique:

  • Provides bloodless field when performed correctly 4
  • Excellent cosmetic results with proper technique
  • Procedure typically takes 3-4 minutes with experienced operators 5

• Comparison with other methods:

  • Gomco procedure takes longer than Mogen clamp (577 seconds vs 55 seconds) 2
  • Infants experience more pain with Gomco vs Mogen with combined analgesia (40% vs 18% crying time) 2

The Gomco circumcision technique, when performed correctly with appropriate anesthesia and attention to detail, provides excellent results with minimal complications. Proper training and adherence to the steps outlined above are essential for optimal outcomes.