PSOTBLOG: To Plastibell or Not To Plastibell?

May 2012

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Comment for the STFM procedure list dialog on Circumcison Techniques.

I have been unhappy with the Plastibell device which I view as unnecessarily cumbersome. It also extends the time to completion by 5-14 days. Basically it is a Med-Peds circumcision technique which avoids the need to use standard skin surgery instruments.

Mogen is the easiest and fastest with excellent safety, but lack of fundamental skills with needle and thread intimidate many from being able to do these procedures past the newborn period.

Since we started Medicos, we have stopped doing circumcisions in the hospital. Our group concensus is that these are cosmetic procedures performed due to cultural influences within the family. We encourage family to consider them carefully and weigh the decision carefully. The immediate newborn period is a complex one in an artificial environment. We do circumcisions at the first
visit which ranges from 2d to 2 months. I will perform Gomcos and Mogens up to 2 years of age with the occasional need to use sutures for bleeders.

Wm MacMillan Rodney MD
Adjunct Professor of Family Medicine
Adjunct Professor Surgery/Emergency Medicine
Meharry/Vanderbilt School of Medicine

Medicos para la Familia
Memphis and Nashville, Tn.
www.psot.com

REPLY from PFENNINGER 2 years? How do you tie the little tykes down? Do you sedate them? After about 2 months they are too big for the papoose board. I too do them in the office if they aren’t done in the nursery. Gomco. Hospital wants $700 to do in day surgery!!! So, I just bought the instruments and board for the office. As they get older, I find it harder to do….to keep them from squirming all over.JP

REPLY-WMR Haven't you gotten a copy my book on health care for the Uninsured? In addition, Rodney's Manual of Redneck Medicine suggests that children can be successfully restrained using John Deere blankets and an assistant named Bubba. Local anesthesia remains effective from 2 through 102[ see the section on Geriatric Circumcision}. “The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.”
George Bernard Shaw
Merry Christmas yall!

REPLY MF-MD I would still vote that residents need to learn Plastibel, too. I did more Plastibels than Gomco's in residency, and am much more comfortable with them, and faster. A Urologist that has helped us with complications we've had with Gomcos said he sees far more complications with Gomco's than Plastibel's. And I've had 2 situations lately where we started one procedure, and for various reasons switched to the other (one each way!). And sometimes you go to do a Gomco and find the size you need isn't available... Just my thoughts. Mary

REPLY -WMR I've never seen a long term complication from a Gomco, but continue to believe that the procedure is not medically indicated. What are the complications you witnessed that required care of a urologist, and could you give me an estimate of their frequency?

REPLY MF-MD
I see residents differentially pull too much of the outer skin through, leading to a "de-gloving" problem which distresses the parents. I've also see residents inadvertently separate the two layers as they get the skin off the bell, again leading to bleeding and a "de-gloved" appearance. Obviously this is a teaching issue, and we work to prevent it. I see/hear this about once a year, overall. The only complication I've had with a Plastibel in 18 years (18 years mine and 3 years residency teaching() was once when we probably used a ring that was slightly too large and it slipped up onto the shaft after it separated and required some imagination to get it off! Mary

REPLY-FORMAN The only complication I used to get from a Gomco was the occasional bleeding, easily sutured with some gut suture.

REPLY WMR--WE have seen the degloved effect once every 70 Mogens in the hands of inexperienced physicians, but it is easily identified. It does not require urological consultation, but you do need to identify the correct anatomical plane and reapply the clamp. Every 50 or so I intentionally use some vicryl suture as a "teachable moment". I choose Vicryl because it is soft and I
believe its ends are less traumatic than gut which is bristly. Every once and awhile I will do some free hand circ technique[DR. 90210] under the guise of making a more beautiful penis. These moments are used to demonstrate common hemostatic techniques with suture material can apply to this procedure as easily as to perineal repair.

As family physicians I would be willing to lead a study giving informed consent to parents [I'll show you mine at 2 days if you'll show me yours at 2 days], and ask the average parent to choose which technique they would prefer. If we did a true informed consent about the medical benefits versus risks, they would probably choose neither. However using the standard consent, I imagine there would be a statistically significant preference for the nonPlastibell methods.

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To Plastibell or Not To Plastibell?

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