med 18

 

J Craniofac Surg. 2009;20(2):573.

A B

Fig. 46.2. A: Place fine hemostat as close to base of extra digit

as possible, and firmly secure ligature between clamp and hand.

B: After finger turns white, excise digit tag outside hemostat, leaving ligature in place for autoamputation of residual stump.

Fig. 46.3. Skin tags of right ear and cheek. Removal of tags this

large requires surgical excision rather than ligation for best result

and may be associated with other malformations.

Fig. 46.1. Nonfunctional extra digit on ulnar side of left hand

(note wide base; surgical excision is preferred).

346

Mhairi G. MacDonald

47 Circumcision

A. Indications

Newborn male circumcision, one of the oldest formally

recorded surgical procedures, remains controversial (1–3).

Many physicians and lay people consider circumcision routine, but complications, although relatively rare, can be

severe. Therefore, despite the perceived simplicity of the

procedure, meticulous attention to anatomic landmarks,

wound care, and follow-up is necessary.

B. Contraindications

1. Age <1 day (i.e., before complete physical adaptation to

extrauterine life has occurred)

2. Any current illness

3. Prematurity (<37 weeks’ gestation)

4. Bleeding diathesis or family history of bleeding disorder

5. Abnormality of urethra or penile shaft (foreskin may be

essential for later reconstruction [e.g., hypospadias,

chordee, very small penis])

6. Local infection

7. Lack of truly “informed” parental consent (see Chapter 2)

C. Equipment (4–7)

1. Necessary for all Methods

Sterile

a. Gown and gloves

b. Cup with antiseptic

c. 4- × 4-inch gauze pads

d. Small, flexible, blunt probe

e. Two straight mosquito hemostats

f. Large, straight hemostat

g. Tissue scissors

Nonsterile

Materials for restraint

2. Equipment for Analgesia

a. Local anesthetic: 1% lidocaine hydrochloride without

epinephrine in a tuberculin syringe with a 1.2-cm ×

27-gauge needle

Circumcision of neonates has frequently been used

as a model to study the response of the newborn to pain

(see Chapter 6) (8) However, until recently, neonatal

circumcision has been performed without anesthesia.

Since the initial report by Kirya and Werthmann in

1978 (9), there have been reports of several controlled

studies that have concluded that the use of dorsal penile

nerve block is both effective and safe

The effectiveness of EMLA (eutectic mixture of

local anesthetics; lidocaine and prilocaine) 5% cream

has also been studied. Conclusions from meta-analysis

of data from several sources has led to the conclusion

that EMLA cannot be recommended over other analgesic techniques with proven efficacy, such as regional

nerve block with lidocaine.

3. Optional Equipment

a. Sterile fine-tipped marking pen

b. Sterile gauze impregnated with petroleum jelly (e.g.,

Vaseline)

4. Additional equipment for Use with

Gomco Clamp

All equipment is sterile.

a. Gomco circumcision clamp (Gomco Surgical

Manufacturing Corp., Buffalo, New York) (4), size 1 to 2