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Circumcision is one of the most common procedures performed in the pediatric population. It is a simple procedure if performed properly, but may have serious consequences in improper hands. Minimal local data is available about safe practice of circumcision. In Pakistan circumcision is performed by quacks, barbers, technicians and also by general practitioners, pediatricians, gynecologists, urologists, general surgeons and by pediatric surgeons. The incidence of complications is very high due to lack of practicing standards. Most people consider circumcision a casual procedure which may be performed without even having basic knowledge of principles of surgery. This has resulted in serious complications in babies and even death in some cases. Circumcision by quacks is performed at all ages by various methods, using unsterilized techniques and some time dressings with animal dung. Many babies develop sepsis or tetanus and die. We therefore need to have a system where circumcision is performed safely, with minimal complications.

Methods of Circumcision:
Various methods of circumcision are used, but the two most popular methods are by using circumcision devices like plastibell or by open method. Circumcision by plastibell has excellent results, but may have complications if not done properly. It needs tight strangulation of the foreskin which sloughs off by ischemic necrosis. If appropriate size bell is not used or thread is not tight enough to cause ischemia of the foreskin or the skin is too thick as seen in older children then the chances of complication are very high. Beside this if the bell is tightly placed against the glans then also it can migrate on to the glans and may get impacted.

Circumcision by plastibell is not an option for children above two years age who have a thick skin. In my experience maximum numbers of complications are seen if circumcision is performed by plastibell in older children especially after 2 years of age .The skin is thick and bell may get impacted due to erections and prolong stay. In older children the best technique of circumcision is by open method. This has to be done under general anesthesia, proper light and observing sterilization principles. Many doctors use bone cutter, artery forceps and other crushing devices blindly. This practice has to be condemned as it is dangerous and may cause amputation of glans with serious consequences. The best method of circumcision is by open technique by marking of the incision line, haemostasis by bipolar diathermy and repair with an absorbable suture like plain catgut.

Circumcision in new born babies:
Newborn babies have a thin and soft foreskin which comes off easily and therefore shall cause least number of complications. Many surgeons however are not comfortable to perform circumcision in the newborn period and prefer to do circumcision when the baby is a few weeks old. There is also concern of haemorrhagic disorders in newborn babies. In a study of 316 consecutive circumcisions, we encountered least number of complications in newborn circumcisions. Furthermore Parents are most satisfied in babies who had circumcision in the newborn period and other family members are also available for help at home because of the delivery of the baby. All these factors make circumcision in the first week a better option rather than waiting for another time when it may be delayed for years.

The most important consideration about circumcision is that it is a surgical procedure like any other surgery and should be treated as such. It has long term implications on the life of the person and therefore, should be performed by trained personnel in theatre environment. Practice of circumcision in corridors and shop corners should be discouraged. All basic principles of surgery should be ensured while performing circumcision to get the best results. Hepatitis is a serious concern in our society and many babies can acquire this dangerous disease if basic sterilization principles are not adopted.

In summary circumcision may safely be performed within the first few weeks of life. Patients selection is however very important. Babies having congenital anomalies, sepsis, deep jaundice or other serious condition shall be circumcised when stable. Mild jaundice is not a contraindication as it is seen in many babies and settles spontaneously. It is important to note however that circumcision performed in the first few month of life had minimal number of complications so it may be performed according to the surgeon’s preference at any age during this period. Plastibell is suitable for circumcision till one year of age. After two years of age bell impaction is common and plastibell shall be avoided. Open technique gives the best result in children over two years.


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