Technique for freehand newborn circumcision

A freehand technique for neonatal circumcision offers some advantages over the use of a clamp. Commonly used for adult circumcisions, the freehand procedure permits constant visualization of the anatomy, and reduces edema and pain by not crushing tissue. Additionally, exposure to the freehand technique teaches the anatomy of the prepuce, which is useful information in the event of a mechanical failure occurring during a clamp circumcision. Recently, we encountered a Gomco clamp failure halfway through a circumcision. Because of the anatomical knowledge we had acquired by means of experience with the freehand technique, we safely completed the procedure.

Despite these advantages, the freehand technique is in danger of becoming a lost art. Holman's recent review of circumcision techniques[1] does not include any mention of the freehand method, and a MEDLINE search of the literature over the last 30 years identified no articles addressing the technique except in the historical context.[2,3]

The technique of freeing adhesions is the same as in all other circumcision methods. A dorsal slit is prepared by estimating approximately two thirds the distance from the preputial ring to the corona, crushing the foreskin in the anterior midline with a straight hemostat (Figure, top row, left):then dividing it with small scissors (top row, middle). The prepuce is pushed back over the corona, exposing the partially adherent inner epithelium (top row, right). The foreskin is then pulled forward over the glans, and the anterior portion of the preputial ring reapproximated with the tip of a hemostat (middle row, left). The tip of the frenulum is grasped with another hemostat, and with one hand, both instruments are pulled forward, stretching the foreskin (middle row, middle). The glans is identified and easily avoided by palpating its position within the foreskin. The line of division for the foreskin is established by identifying the glans by palpation and placing a small, straight hemostat just distal to it. The heel of the hemostat is placed at the frenulum and its tip just beyond the apex of the dorsal slit, using caution to avoid incorporating skin from the glans (middle row, right). Using a No. 15 blade, the foreskin is carefully "shaved" off along the proximal face (the glans side) of the hemostat (bottom row, left). This step exposes two triangles of mucous membrane. The tip of each triangle is grasped with a forceps and stretched away from the corona (bottom--row, middle). The intact edge is then cut with a small curved scissors (bottom row, right). Usually, there are only one or two bleeding points: one on either side of the dorsal midline in the remnant mucous membrane, and occasionally one at the frenulum. Most bleeding can be controlled by applying direct pressure for 1 to 2 minutes. If bleeding persists, a small caliber free tie of absorbable suture or a light touch with a battery-operated "eye" cautery should be used. A hemostatic dressing should be applied if any oozing continues. This technique produces a very nice result and is safe in experienced hands.

Although we still teach Gomco clamp circumcision as the primary method in our residency, we make sure that all residents are exposed to the freehand method and instructed in the technique if desired.

Acknowledgment

Photos courtesy of Larry M. Wellenstein, MA.

References

[1.] Holman JR, Lewis EL, Ringer. Neonatal circumcision techniques. Am Fam Physician 1995; 52:511-8. [2.] Grossman E, Posner NA. Surgical circumcision of neonates. Obstet Gynccol 1981; 58:241-6. [3.] Kaptan GA. Circumcision--an overview. Clin Probl Pediatr 1977; 7(3):3-33.

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