Poor circumcision technique or inappropriate postoperative care after a newborn circumcision, can lead to problems such as: penile skin bridges, concealment, adhesions, redundant foreskin, or meatal stenosis.
These complications could be greatly reduced by following these 3 key steps for achieving a perfect circumcision:
1. Expose the penoscrotal and penopubic junction completely
Recently, during a lecture I gave to pediatric residents, we started talking about Gomco circumcisions. I showed them a few pictures of how much skin to leave behind, and one of the students noticed that the scrotum was visible on the picture.
Turns out that the residents were being taught to keep the scrotum under the drapes and just to get the tip of the foreskin through the drape hole! I could not believe what I heard. How in the world could you know how much skin to take out or leave if you don’t see the penoscrotal and penopubic junctions?
All of a sudden, I understood why we see so many patients with redundant foreskin, and why I have seen other patients where too much skin was removed ( I have seen 3 patients where the entire ventral foreskin was removed).
I have no doubt that the most important step of a circumcision is a clear exposure of the entire penoscrotal and penopubic junctions.
A perfect circumcision has the same amount of foreskin on the top, bottom, left and right. This prevents removing too little or too much skin, as well as adhesions/bridges, which are more common when too much skin is left behind.
Circumcision drapes should have a big enough hole to allow the entire scrotum to be seen. If the hole is not big enough, then it should be enlarged with scissors.
2. Pull down all the adhesions until the corona can be seen completely, dorsally and ventrally.
When adhesions are not completely released ventrally, the penis can appear to have hypospadias. This, in turn, can lead practitioners to stop a circumcision unnecessarily. A tight frenulum that is not released can cause a suboptimal cosmetic outcome (but not a big deal).
The frenulum can be released by just putting traction on it with a gauze; rarely it has to be gently cut with a knife. Releasing the frenulum results in some bleeding, but rarely requires any special means to stop it.
3. Take care of the circumcision postoperatively
The postoperative care of newborn circumcisions can really make a difference. I have an entire post on this.