What are the steps for a routine circumcision procedure on a healthy newborn male?

Routine Newborn Circumcision Procedure Steps

Newborn circumcision should be performed using one of three standard techniques (Mogen clamp, Gomco clamp, or Plastibell device) with mandatory multimodal pain management including dorsal penile nerve block and oral sucrose, following strict sterile technique. 1, 2, 3

Pre-Procedure Requirements

Patient Selection and Consent

• Confirm the infant's condition is stable and healthy before proceeding 3
• Obtain informed consent from parents based on objective understanding of medical benefits, risks, and potential complications 3, 4
• Do not circumcise newborns with bilateral nonpalpable testes until disorder of sexual development workup is complete 5
• Defer the procedure if anatomic abnormalities (hypospadias, micropenis, buried penis) are present; refer to pediatric urology 6

Pain Management Protocol (Mandatory)

The American Academy of Pediatrics mandates using multiple pain management strategies before, during, and after the procedure 2, 3:

• Dorsal penile nerve block (DPNB) or ring block: Use buffered lidocaine injected slowly with a small-gauge needle (buffering reduces injection pain and remains stable for 30 days) 1, 2
• Oral sucrose: Administer 1-2 mL of 25% solution 2 minutes before the procedure, preferably with a pacifier for enhanced analgesic effect 1, 2, 5
• Adjunctive non-pharmacological measures: Skin-to-skin contact with mother or breastfeeding during the procedure reduces pain behaviors 2, 5
• Note: Topical EMLA cream alone or non-pharmacological techniques alone are insufficient as sole analgesia 3, 7

Procedural Steps

Setup and Preparation

• Establish sterile field using standard aseptic technique 4, 6
• Position infant supine with restraint (circumcision board) 4, 6
• Prepare sterile instruments and selected device (Mogen, Gomco, or Plastibell) 4, 6

Surgical Technique (Common to All Methods)

1. Examine the penis to confirm normal anatomy and identify the coronal sulcus 6
2. Retract foreskin gently to assess for adhesions 6
3. Lyse adhesions between foreskin and glans using a blunt probe 4, 6
4. Estimate amount of foreskin to remove, leaving adequate shaft skin 6

Device-Specific Execution

Mogen Clamp Technique 4, 6:

• Pull foreskin through clamp opening
• Position clamp to protect glans while crushing prepuce
• Excise foreskin distal to clamp
• Remove clamp after hemostasis achieved

Gomco Clamp Technique 4, 6:

• Place bell over glans as protective barrier
• Pull foreskin over bell
• Apply Gomco clamp to crush foreskin against bell
• Excise crushed foreskin
• Remove clamp after 3-5 minutes

Plastibell Device Technique 4, 6:

• Place plastic bell over glans under foreskin
• Tie suture tightly around foreskin over groove in bell
• Excise redundant foreskin distal to suture
• Leave device in place (falls off with necrotic tissue in 5-10 days)

Post-Excision Steps

• Apply topical emollient or lubricant to reduce friction and prevent adhesions 1
• Apply sterile petroleum jelly gauze dressing (except with Plastibell) 6
• Send all removed tissue for pathological review to identify undiagnosed lichen sclerosus, as a significant majority of children with phimosis may have this condition 1

Post-Procedure Management

Immediate Care

• Monitor for bleeding for 15-30 minutes before discharge 6
• Provide acetaminophen for postoperative analgesia (ineffective for operative pain but helps afterward) 2

Parent Education

• Instruct parents on wound care: keep area clean, apply petroleum jelly with diaper changes 3, 6
• Explain normal healing (yellow exudate is normal granulation tissue, not infection) 6
• Advise when to seek care: excessive bleeding, signs of infection, urinary retention 6

Critical Safety Considerations

Contraindications

• Prematurity or medical instability 3, 6
• Bleeding disorders or family history of bleeding problems 6
• Anatomic abnormalities (refer to urology) 5, 6
• Epidermolysis bullosa or fragile skin conditions (requires specialist consultation and subtype-specific handling) 1

Complication Prevention

• Complications occur in approximately 1 in 200 procedures when performed by trained providers 8, 6
• Untrained providers have significantly more complications than well-trained providers, regardless of professional background 3
• Most common complications: bleeding, infection, excessive skin removal, adhesions, meatal stenosis 4, 6