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Key Points

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  1. The preferred 3 techniques for pediatric circumcision are the clamp, the dorsal slit, and the sleeve resection.

  2. Clamp techniques are most applicable to the neonatal procedure while dorsal slit and sleeve resections are optimally applied to the older child or young adult.

  3. Postoperative bleeding is the most common morbidity of circumcision and is best prevented by meticulous attention to hemostasis.

  4. Careful identification of the glans penis and urethral meatus throughout the procedure is the most effective way to avoid inadvertent injury to these structures.

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…And Abraham took Isaac his son, and all that were born in his house, and all that were bought with his money, every male among the men of Abraham's house; and circumcised the flesh of their foreskin in the selfsame day, as God had said unto him.…

Genesis 17:23

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There is probably no other procedure so universally performed by pediatric surgeons as circumcision. Although seemingly mundane, circumcision takes on great personal and religious significance to the pediatric patient and his family. In addition, complications of circumcision can be devastating. Pediatric surgeons must be aware that the majority of neonatal circumcisions performed in the hospital are not performed exclusively by surgeons but that the procedure is performed by a variety of practitioners including obstetricians, pediatricians, urologists, and religious figures.

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The debate as to the potential risks and benefits of circumcision is almost as old as the procedure itself. The only universally accepted benefit is an almost absent risk of penile cancer in circumcised males. Other, less widely accepted benefits include a decreased association with sexually transmitted diseases, including HIV, a decreased incidence in urinary tract infections, and a decrease in carcinoma of the cervix in the female sexual partners of circumcised men.

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Technique

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Anesthesia

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General anesthesia is usually not used for neonatal circumcision unless the procedure is being performed concomitant with other procedures requiring a general anesthetic. Recent evidence supports using a local anesthetic cream to decrease pain; however, many pediatric surgeons will probably not perform the procedure without some form of anesthesia. A general anesthetic is advisable when the boy is more than 6 weeks of age. In adolescents and older boys, the operation is often done with local anesthesia applied as a penile block. This block is produced by infiltration of the dorsal penile nerves at the base of the penis lying between the tunica albuginea and Bucks fascia (Fig. 63-1). Local anesthetics without epinephrine are recommended because epinephrine may cause significant arterial spasm and resultant penile ischemia.

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Figure 63-1

The technique for a sensory blockade of the penis. After a dorsal penile injection, a lateral and ventral fanlike distribution of anesthetic agent infiltration is done.

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Operative Techniques

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For the purpose ...

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