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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 3  |  Page : 116-121

Experience with Gomco Clamp circumcision in male neonates: technique and review of the literature


1 Department of Surgery, College of Health Sciences, University of Abuja; Division of Urology, University of Abuja Teaching Hospital, Abuja; Department of Surgery, Garki Hospital, Abuja, Nigeria
2 Division of Urology, University of Abuja Teaching Hospital, Abuja, Nigeria

Date of Submission30-Jul-2019
Date of Decision30-Oct-2019
Date of Acceptance03-Nov-2019
Date of Web Publication04-Feb-2020

Correspondence Address:
Dr. Terkaa Atim
Garki 900001, FCT Abuja
Nigeria
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DOI: 10.4103/ssajm.ssajm_25_19

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  Abstract 


Introduction: Neonatal male circumcision is routinely carried out in most places in Nigeria, sub-Saharan Africa. The main reasons why parents bring their sons for circumcision are religious and cultural with a few medical indications like phimosis, paraphimosis and balanitis also being noted. Several techniques of this age long practice have been described and options range from the non-device to device techniques. Circumcision with the Gomco clamp (GC) is not yet as popular in this part of the world even though it has been reported to be safe. Aims and Objectives: To describe our experience and technique using the gomco clamp (GC) for neonatal male circumcision in our environment. Materials and Methods: A retrospective study of 63 newborn boys whose parents gave consent and who were assessed and found fit for circumcision from August 2015 to November 2015 was carried out. They all had circumcision by the same surgeon using gomco clamp at Garki hospital Abuja, Nigeria. Data obtained from patients’ medical records included age, indication, size of gomco clamp and any procedure related complications. They were followed up at 6weeks in the surgical outpatient clinic and then 1year by telephone call to their parents. Results: The average age of the male neonates at circumcision was 10.8 +/- 4.38 days (range from 6 to 26 days) and median age 8days. The indications for circumcision were religion (43, 68%) and cultural (20, 32%). The only early procedure-related complications observed was mild bleeding in two (3.2%) boys and this succumbed to simple pressure. Long term complications included one (1.6%) each penile skin bridge following adhesions between the prepuce and glans and redundant foreskin which were corrected by free hand dorsal and ventral slit circumcision at 8months. Conclusion: Male circumcision can be performed at any age, but there are cost and safety benefits of doing this procedure during the neonatal period. Circumcision using the Gomco clamp (GC) is simple to learn.

Keywords: Balanitis; cultural; device; religious


How to cite this article:
Atim T, Buba A. Experience with Gomco Clamp circumcision in male neonates: technique and review of the literature. Sub-Saharan Afr J Med 2019;6:116-21

How to cite this URL:
Atim T, Buba A. Experience with Gomco Clamp circumcision in male neonates: technique and review of the literature. Sub-Saharan Afr J Med [serial online] 2019 [cited 2020 Sep 24];6:116-21. Available from: http://www.ssajm.org/text.asp?2019/6/3/116/277782




  Introduction Top


Circumcision is a surgical procedure which involves excision of the prepuce (foreskin) either in whole or in part.[1] Arguably the oldest surgical procedure in the world, it could be performed at any age.[1],[2] Circumcision is more predominantly carried out in male neonates for religious, cultural, and some medical reasons especially of public health concerns of late.[1],[3],[4] Religious circumcision is a notable practice among Jews, Muslims, black Africans, Australian aborigines, and so many other ethnicities scattered around the world.[5],[6] Circumcision within the neonatal period or first couple of months is generally regarded as cheaper, simpler, and safer when compared to older boys and men.[7] The commonest medical reason for performing circumcision in the developed world is phimosis. Others include paraphimosis, balanitis, posthitis, localized condylomata acuminata, and localized carcinoma.[1],[8] Its role in reducing the risk of urinary tract infection and the rate of transmission of sexually transmitted infections including HIV infections[9],[10] has been documented in recent decades. This evidence has resulted in the scaling up of male circumcision in numerous sub-Saharan African countries.[9],[11],[12],[13] Contraindications to circumcision include prematurity, bleeding disorders, congenital problems of the penis such as hypospadias, epispadias, and any such condition whose further treatment might be made more tasking if prior circumcision was carried out.[8]

Approximately one in three males worldwide is circumcised with near universal coverage in some settings as well as very low prevalence in others.[1],[10],[14],[15] In the United States each year, an estimated one million newborn males undergo circumcision. This rate is as high as 70% in the United States while it is only 6% in the United Kingdom. In most of Europe, China, and Latin and South America, ritual male circumcision is not common.[7],[14] In Nigeria, circumcision rate is estimated to be 87% or even higher (97%) in the south eastern region.[2],[16]

The surgical approaches to circumcision are extremely varied and like any other operative procedure complications may occur. In the hands of unskilled personnel with lack of correct instrumentation, complication rates could be quite high and devastating.[2] Circumcision can be classified into one of the following: dorsal slit, shield and clamp, and excision. The shield and clamp methods adopt the use of devices to perform the procedure.[1],[17] The device method has become the commonly used method of circumcision over time. The three commonest device-based methods of male circumcision for the neonates include: the plastibell device, the Gomco clamp, and the Mogen clamp.[1],[3],[6],[7],[16],[17],[18] The Gomco clamp is very popular in the United States.[3] Its use has been proven to be safe with excellent cosmetic results and minimal complications.[3] While the rates of neonatal circumcision complications vary widely between studies, the generally accepted rate is between 0.2% and 0.6% of operations.[3] Very high rates have been quoted in studies in Nigeria.[2] Complication rates among the three devices (Mogen, plastibell, or Gomco) are similar and the choice among the devices is based on the surgeon preference, availability, and expertise.[3] The WHO recommends all three of this device-based methods in addition to dorsal slit for neonatal circumcision.[7]


  Aims and objectives Top


To evaluate the use and safety of Gomco clamp in neonatal male circumcision in our setting, method of anaesthesia and procedure-related complications.


  Materials and methods Top


A retrospective analysis of 63 newborn boys whose parents gave consent and who were assessed and found fit for circumcision from August 2015 to November 2015 was carried out. They all had circumcision by the same surgeon using Gomco clamp at Garki hospital Abuja, Nigeria. Data obtained from patients’ medical records included age, indication, size of Gomco clamp, and any procedure-related complications. They were followed up for six weeks in the surgical outpatient clinic and then one year by telephone call to their parents. Outcome measures used were the indication for the procedure, size of the Gomco clamp used, type of anaesthesia, and nature of complications and parents’ satisfaction with the outcome. Analysis was carried out using Microsoft Excel 2013 edition and presented as charts and tables.


  Technique Top


The procedures were performed using the Gomco clamp [Figure 1] in the minor theatre of the hospital. The babies were restrained in supine position by a nurse with the legs apart. The genital area was painted with 10% povidone iodine and the area draped with towels. All babies had local anesthesia administered by the authors using the standard dorsal penile nerve block injecting 0.5 ml of 0.5% lignocaine at the 10 O’clock and 2 O’clock positions at the base of the penis [Figure 2] and allowing about 5 minutes before commencing the circumcision. This was immediately followed by insertion of acetaminophen suppository 15 mg/kg for additional analgesia.
Figure 1 Parts of the Gomco clamp.

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Figure 2 Administering the dorsal penile nerve block.

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The penile anatomy was then inspected in details for any anomalies after retracting the prepuce and cleaning off the smegma with iodine-soaked gauze. At this point, the inner preputial skin is also gently teased down to free preputio-glanular adhesions down to the coronal sulcus. The line of circumcision is scratch marked using a needle to ensure that adequate foreskin is excised. A dorsal slit on the foreskin is made at 12 O’clock position about 5 mm short of the line of circumcision between two laterally placed hemostats after crushing the area with a hemostat to achieve hemostasis [Figure 3]. An appropriately sized Gomco bell is then inserted through the dorsal slit to cap the glans [Figure 4]. The foreskin is pulled upwards through the hole of the base plate using two hemostats until the level of circumcision earlier marked is reached [Figure 5]. This is aided by using a tissue forceps to pull up the foreskin circumferentially over the bell. One of the hemostats is now used to approximate the cut ends of the prepuce tightly over the bell to prevent slippage of the foreskin through the hole of the base plate. The nut of the clamp is then screwed tightly and the complete Gomco assembly left in place for 10 minutes to crush the foreskin at the line of circumcision [Figure 6]. A scalpel is used thereafter to excise the foreskin distal to the base plate and around the line of crush. Afterwards the nut is unscrewed and the Gomco clamp dismantled allowing the remaining circumcised penile skin to fall back in place around the coronal sulcus of the penis [Figure 7]. The area is inspected for bleeding and then cleaned with 10% povidone iodine and dressed with petroleum jelly. We observe the babies in the recovery room for about 30 minutes for any bleeding before discharging home with the instruction that petroleum jelly should be applied to the area at home and warm baths commenced the following day. Two of the babies had some minor bleeding after the clamp was removed and this settled with simple pressure packing to the oozing surface of the glans.
Figure 3 Crushing the prepuce dorsally using a hemostat.

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Figure 4 Insertion of the bell over the glans after dorsal slit has been made.

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Figure 5 Pulling the foreskin upwards through the hole on the base plate and adjusting the bell to the circumcision line.

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Figure 6 Final assembly with the upper plate positioned and the nut screwed tightly.

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Figure 7 Circumcised penis.

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  Results Top


The mean age was 10.8+/−4.3 days and median age was 9 days (IQR 5) with range from 6 to 26 days. The complications observed are as shown in [Table 1].
Table 1 Frequency distribution of complications of Gomco clamp circumcision

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Religion as the indication for circumcision accounted for 43 cases (68%) whereas culture was the reason in 20 cases (32%) [Figure 8]. Overall, there were 51 (81%) Christians and 12 (19%) Muslim parents in our series and 8 (67%) of the Muslim parents circumcised for religious reasons while 4 (33%) did so for cultural reasons. Majority of the Christian parents, 36 (71%), chose religion as their reason for circumcising their sons whereas 15 (29%) indicated cultural reasons. The most common size of the Gomco clamp used was 1.2 in 41 babies (65%) followed by 1.3 in 19 (30%) and only 3(5%) patients required size 1.4 [Figure 9].
Figure 8 Reasons for neonatal male circumcision.

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Figure 9 Frequency distribution of different Gomco clamp sizes used for neonatal male circumcision.

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The parents were satisfied with the procedure in all but two of the babies, one with redundant foreskin and the other with peno-glanular Skin Bridge which became obvious with time.


  Discussion Top


The practice of neonatal male circumcision is common in sub-Saharan Africa including our setting which is multi-cultural and multi-religious.[2],[10],[14],[16],[19] There are also documented medical indications and benefits for circumcision[1],[8],[9],[11],[12],[13] but none of these was found to be an indication in our series. Religion is a strong influence for opting for circumcision in our setting and this is not surprising because the majority of Nigerians are very passionate about religion.

Various methods of male circumcision have been described with varying complications rates based on the expertise and techniques used.[1],[2],[3] The Gomco clamp is one of the frequently used instruments for male circumcision in the United States and it has been reported to be safe and simple to use with excellent cosmetic appeal.[1],[3],[6],[7] However, its use is not yet popular among Nigerian circumcisionists.[5] The Gomco clamp unlike the plastibell device can be sterilized and reused several times which makes it cost effective especially in a poor resource setting like ours. The fact that no foreign device is left on the baby’s penis (the plastic ring of plastibell device) which is expected to fall off after some days reduces the anxiety of parents when Gomco device is used for circumcision since the appearance is immediately obvious. The procedure of circumcision in the neonatal period or first couple of months is regarded as being cheaper, simpler, and safer when compared to when it is done in the older age groups.[7] Moreover, its use in the older child beyond 6 months has been discouraged by some authors.[22] Bhat et al[3] however, described a modification of technique using Gomco clamp in the older child which requires suturing the skin edges. The two bleeding complications seen in our series were minor, requiring only simple pressure dressing. This is similar to that reported in other series.[1],[3],[10] Peno-glanular skin bridge, a known complication [8],[18] as seen in one of the patients, might have resulted from adhesions which could have formed during healing after Gomco circumcision. Redundant foreskin [14],[18] a common complication which required re-circumcision was reported in one of the patients in our series. Significant complications such as urethra-cutaneous fistula and glans amputation could occur in the unskilled hands and this has been reported in our setting involving traditional barbers. [2],[7],[8]

The use of anesthesia is still not common in some parts of the world whereas this trend has long changed in the developed world.[7],[8] Circumcision in neonates is a potentially painful procedure and in all our patients we administered local anesthetic using the dorsal penile nerve block.[6],[15]


  Conclusion Top


Male circumcision is mostly performed for religious reasons in our environment and it can be performed at any age. It is however obvious that there are cost and safety benefits of doing this procedure during the neonatal period rather than later in life when demands for general anesthesia become imperative. Circumcision using the Gomco clamp is safe and simple to learn, gives good cosmetic outcome in trained hands, and the device is reusable after sterilization.

Financial support and sponsorship

There was no external funding for this study.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Abdulwahab-Ahmed A, Mungadi IA. Techniques of male circumcision. Journal of Surgical Technique and Case Report 2013;1-7. Available at: /pmc/articles/PMC3888996/?report=abstract  Back to cited text no. 1
    
2.
Osifo OD, Oriaifo IA. Circumcision mishaps in Nigerian children. Ann Afr Med 2009;8:266-70.  Back to cited text no. 2
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3.
Bhat NA, Hamid R, Rashid KA. Bloodless, sutureless circumcision. Afr J Paediatr Surg 2013;10:252-4.  Back to cited text no. 3
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Mwashambwa MY, Mwampagatwa IH, Rastegaev A, Gesase AP. The male circumcision: the oldest ancient procedure, its past, present and future roles. Tanzan J Health Res 2013;15:199-204.  Back to cited text no. 4
    
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Abdur-Rahman LO, Nasir AA, Adeniran JO. Circumcision: perspective in a Nigerian teaching hospital. Afr J Paediatr Surg 2013;10:271-4.  Back to cited text no. 5
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Bellieni CV, Alagna MG, Buonocore G Analgesia for infants’ circumcision. Ital J Pediatr 2013;39:38.  Back to cited text no. 6
    
7.
WHO. Manual for male circumcision under local anaesthesia. 2009. Available at: http://www.who.int/hiv/pub/malecircumcision/who_mc_local_anaesthesia.pdf  Back to cited text no. 7
    
8.
Hutcheson JC. Male neonatal circumcision: indications, controversies and complications. Urologic Clinics of North America 2004;3:461-7.  Back to cited text no. 8
    
9.
Peltzer K, Onoya D, Makonko E, Simbayi L. Prevalence and acceptability of male circumcision in South Africa. African J Tradit Complement Altern Med 2014;11:126-30.  Back to cited text no. 9
    
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Tobian AAR, Gray RH, Quinn TC. Male circumcision for the prevention of acquisition and transmission of sexually transmitted infections: the case for neonatal circumcision. Arch Pediatr Adolesc Med 2010;164:78-84.  Back to cited text no. 10
    
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Wilcken A, Miiro-Nakayima F, Hizaamu RNB, Keil T, Balaba-Byansi D. Male circumcision for HIV prevention—a cross-sectional study on awareness among young people and adults in rural Uganda. BMC Public Health 2010;10:209.  Back to cited text no. 11
    
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Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369:657-66.  Back to cited text no. 12
    
13.
Rennie S, Muula AS, Westreich D. Male circumcision and HIV prevention: ethical, medical and public health tradeoffs in low‐income countries. J Med Ethics 2007;33:357-61.  Back to cited text no. 13
    
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Al-Ghazo MA, Banihani KE. Circumcision revision in male children. Int Braz J Urol 2006;32:454-8.  Back to cited text no. 14
    
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Moses S, Bailey RC, Ronald AR. Male circumcision: assessment of health benefits and risks. Sex Transm Infect 1998;74:368-73.  Back to cited text no. 15
    
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Ekwunife OH, Ugwu JO, Okoli CC, Modekwe VI, Osuigwe AN. Parental circumcision preferences and early outcome of plastibell circumcision in a Nigerian tertiary hospital. African J Paediatr Surgery 2015;12:251-6.  Back to cited text no. 16
    
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Hayashi Y, Kojima Y, Mizuno K, Kohri K. Prepuce: phimosis, paraphimosis, and circumcision. Scientific World Journal 2011;11:289-301.  Back to cited text no. 17
    
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Burgu B, Aydogdu O, Tangal S, Soygur T. Circumcision: pros and cons. Indian Journal of Urology 2010. p. 12-5. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2878423&tool=pmcentrez&rendertype=abstract  Back to cited text no. 18
    
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Latifoglu O, Yavuzer R, Ünal S, Sari A, Çenetoglu S, Baran NK. Complications of circumcision. Eur J Plast Surg 1999;22:85-8.  Back to cited text no. 19
    
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Tobian A a. R. The medical benefits of male circumcision. J Am Med Assoc 2011;306:1479.  Back to cited text no. 20
    
21.
Lukong CS. Dorsal slit-sleeve technique for male circumcision. J Surg Tech Case Rep. 2012;4:94-7.  Back to cited text no. 21
    
22.
Horowitz M, Gershbein AB. Gomco circumcision: when is it safe? J Pediatr Surg. 2001;36:1047-9.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
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