Confidential Peer Review: Infant Circumcision

Here is one example of what a degloving circ looks like. Is this what we are talking about here? This is one that was done by Mogen. Excessive force  squeezing the foreskin through the Mogen slit was the likely mechanism.

Wm MacMillan  Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
Medicos para  la Familia
Memphis, Nashville and rural Tn.
(http://www.psot.com)

In response to the following (wmr):

I write because ....unknowingly had a cuff of the foreskin folded back under itself over the bell. The result was a "ring of the treebark" with the under lying mucosal surface not cut  through.  It was discovered the following morning on rounds. The  distal skin was intact and healthy. Urology and plastics resutured the cut  edges of the outer skin and cut a small dorsal slit to relieve pressure.  All appears to be healing well now.

....... have never before seen this complication, but admit I do not recall seeing it in print. Was wondering if any of your proceduralists have done it this way or if you know of a reference. We utilize the procedure for stretching and retraction with the Mogan clamp routinely, without a dorsal  slit.

David A. McClellan, MD
Program Director, Progra Family  Medicine Residency

Jack  Pfenninger wrote: 

Hi David…I have seen the squamous epithelium  “skinned off” the mucosal tissue several times if that’s what happened, and it happens even with the dorsal slit. Not sure if anyone does the circs without the dorsal  slit. Will send it out for a response!  If so, maybe we’ll have to  print it up as a variation in the circ chapter!!

NEXT COMMENT CAME FROM Paul W. Davis,MD:
Chair, Dept of Family  Medicine, PAMC;Director of Surgical  and Procedural
Training Alaska Family  Medicine Residency[Associate Clinical  Professor
University of  Washington School of Medicine[President, Alaska  Academy of
Family  Medicine

I think that I can  visualize what happened from the description.  I have never done a circ without a dorsal slit (and have done many ‘freehand’ circs on older children and  adults using just scalpel, cautery, and interrupted sutures after the dorsal  slit). I would theoretically think that with the tight neonatal  physiologic phimosis, stretching the foreskin would be tougher than just cutting  the DS.  In addition, I think that you get a better view & can review  your work before trimming off the excess foreskin if a DS has been cut.

I suspect that the ventral prepucial foreskin got ‘hung up’ on the edge of the Gomco bell while pulling it forward again after placing the bell and base.  This the ventral forskin is hidden in your approach, the redundancy was not seen. In any event, it’s no “biggie”, easy to correct, no significant or permanent  sequelae.

Jack and  Dave:

Two or three times in the last 10-11 years I was call because "we do not know what to do" and there was the near intact "fold" of mucosa over the  glans. Always with Dorsal Slit. I cut it after I stretch it with 2 hemostats and do hemostasis. The first I asked one of the urologist if I "have to call" and he refused. "it will heal fine" answer as always.

The few that I assist fellow attendings where always with Gom-co. They looked much more "even" and smooth than this. I agree with Paul that you do it as an "older" Circ.

Eduardo UIC
-Rockford,  Il

Index --Circumcision

Comments

[NTV/NAT Group, Ltd.]

http://www.doctorsopposingcircumcision.org/video/prepuce.html
The function and the VALUES of the male foreskin! :-)

[Kier]

You people who do these mutilations on children should be round up and skinned alive.

[Mike]

No "biggie" if it's someone else's penis it happens to I suppose. What a shame this is even legal.

[Eth]

Please, stop this madness, non-therapeutic circumcision violates a physician's duty to the infant patient:

http://www.cirp.org/library/ethics/AAP/
"
Thus "proxy consent" poses serious problems for pediatric health care providers. Such providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. Although impasses regarding the interests of minors and the expressed wishes of their parents or guardians are rare, the pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent.
"

How can anyone simultaneously recognize that there is no medical justification, yet still be willing to remove the foreskin (and risk complications) from a boy based on parental choice alone?

Please, good doctors, make it clear that this is unacceptable professional behavior!

[Anne Hudson]

Why?

Why is genital mutilation legal, and why do you carry out such a horrible disfiguring surgery on a poor defenceless baby, who cannot give his consent, just because his parents want you to.

Do you do nose jobs and face lifts on babies too?

Horribly unethical. One day, it's likely those boys you've carried out this damaging surgery on, for no medical reason, will come back and sue you. Especially now they have knowledge of what you've done to them (Go look at what they're saying about circumcision on the teen boards if you don't believe me). Not your grubby little $$$ generating secret any more. Hope your insurance is adequate, there have been a few compensation claims to date, and it will only accelerate.

Apart from that, would you do the same operation on a girl (remove her clitoral hood) just because the parents wanted it? If not, why not?

[JorgeM]

Even when done "properly", being circumcised is awful. I can only imagine what sex should feel like. Its too bad my parents' doctor unloaded a whopper of a lie on them to get them to consent so he could get his BMW payment.

The only time any unnecessary cosmetic body modification should be allowed is when the adult owner of the body requests it. If I had been given a choice at age 18 instead of simply being strapped to a board, I would have said no way.

[Tandy]

Gential mutilation (male AND female) violates EVERY tenet of modern medicine.. PHYSICIANS, heal thyselves!

[Chava]

Wow, this is medical malpractice at its finest. How is genital REDUCTION surgery on a healthy newborn remotely ethical according to a Doctor's number one sacred dictum, prenum non nocre "First Do No Harm" (the Hippocratic Oath)? Are men truly born defective? I don't think so. Given that my boys are smart enough to remember Retract Rinse Replace for a retractable foreskin, they got to keep ALL their body parts. Folks, these doctors actually believe a man is better off with LESS penis. They are callous and ignorant. You're witnessing a "Semmelweis Reflex".

[Tandy]

Actually, any doctor that does non-therapeutic circumcisions has replaced the Hippocratic oath with a Hippocritic oath--one driven by greed and/or ignorance, not ethics or medicine.

[Fredrick J Hollenbeck]

I only can say Disgusting

[Concerned Mom]

Can you please explain how the removal of normal, healthy tissue benefited this infant? Did the informed consent form mention risk of degloving, was this explained to the patient's parents?

In fact, I am wondering why surrogate consent is accepted for this procedure in the first place. Can you please address the ethics?

[Ron Low]

If this had never been done or heard of before, and someone tried to introduce circumcising (on its merits), that person would be deemed dangerously insane.

[robertandenith]

No a la circuncisión! This should be illegal, point!

[Laura MacDonald]

Has it occurred to you to wonder why when an American hospital suggested carrying out just a preputial dorsal slit on female babies in response to parental demand there was an overwhelming public outcry?

Would it be because a (female) baby owns her body and is entitled to be protected from any form of sexual harm whether or not it might improve her hygiene?

You doctors who cut babies' sexual parts shame us all. NEVER does parental preference justify a genital mutilation.

[Hugh]

A file has opened at http://www.sueeasy.com/litigants.php?class_action_case_detail=258 for a class action by men who resent having had the most sensitive part of their penis cut off without any medical indication. Some of them are pretty mad about it.

[John Dalton]

I am a victim of circumcision "for medical reasons" when I had no symptoms. I am a member of a research ethics committee and a trustee of a charity set up to represent the patient's right to avoid medically unecessary circumcision.

Over the last 10 years we have received countless letters from men who have been damaged by circumcision or who are denied less invasive treatment for their medical condition.

Non-therapeutic surgery to remove a normal body part from a normal unconsenting child breaches all the normal principles of law, ethics and human rights that we claim to hold dear in Western society.

The doctors writing here still have not learned the lesson of these complications: if it aint broke, don't fix it. The normal penis must be left alone.

Every man has the right to a penis which is normal in its appearance and retains the normal sensory and mechanical functions. This right is denied to every man circumcised in childhood.

[Nate]

How very sad. How can you doctors live with yourselves? Clearly this is a gross violation of the rights of the child victim.
This is sick. Infant circumcision is as useful as blood letting by leaches. You all should know better. Have you no shame?
DO NO HARM! Why do you resist this? DO NO HARM.

In the end, you circumcisers are simply stubborn,"know-it-alls". Get over yourselves and face truth: Infant circumcision is brutal mutilation without medical benefit.

Have you no empathy? No mercy? No sense of the obvious?

How very sad.

[Tandy]

"Have you no empathy? No mercy? No sense of the obvious?"

You forgot "sense of ethics and morality"!

[Revenge is my middle name]

The circumcisers who are only sued by their victims will be the lucky ones. I almost cut the throat of the one who circumcised me. Not doing it was one of the hardest things I've ever done in my life.

[Lawrence Wade]

I was circumcised when I was 22 because of constant problems with the foreskin. I had independently researched the hell out of the subject and decided that I wanted to be circumcised.

It took me a long time to be able to find a doctor willing to perform my circumcision. Finally I met one who would not only do my circumcision, but the way I wanted it done - Gomco clamp, for the clean cosmetic results.

He refused to do it until I'd taped back my foreskin for at least a month, so I could get a good idea of what it felt like. The first week was itchy as hell, but I persisted. Taping back the foreskin gives an exceptionally good idea of what it's like to be circumcised.

Gomco clamp, local anesthetic, and I was dancing on a speaker at a nightclub a little more than 24 hours after I was circumcised.

No loss of sensitivity. No pain or itchiness at the scar. No ill effects whatsoever. And I vastly prefer being circumcised.

Sex is amazing. There's the IN stroke and the OUT stroke. During the IN stroke, the foreskin is pushed off the head. During the OUT stroke, the foreskin is pulled back over the head and you don't feel a damned thing. Now, without my foreskin, I have to pace myself because it's so much better.

All you whiners who were lucky enough to be circumcised at birth, it's not the cause of your male pattern baldness, your inability to satisfy your wives, or your inability to hold a job. It's five minutes of pain you don't even remember which has quietly benefited you for your entire life.

To all the doctors out there, you are doing a good deed. Do each circumcision with the utmost care and respect for the baby's comfort and for the cosmetic outcome. Promote circumcision as the life-long gift that it is. And as a man who was circumcised as an adult, I feel deprived of the benefits of circumcision for the first 22 years of my life.

Pants make the foreskin redundant and cause its liabilities to exceed its benefits. Since society requires that I wear pants, I'm vastly better off not wearing a foreskin.

Any son born to me will, without question, be circumcised at birth. I'll ensure a competent doctor, a Gomco clamp, the best anesthetics available, and I will hold his hand while it's being done.

[Gwyn Jenkins]

With reference to Lawrence Wade account, he is young and has done a rash thing like having his foreskin cut off. When he is older, and his glans has been numbed by years of friction with his underwear, not to mention the drying out of the delicate mucous membrane covering his glans, he may well come to regret his decision. But at least it was HIS decision, but to compel his possible future male offspring to a lifetime of the same, is callous in the extreme. Perhaps it will be as well if he has only daughters, or no children at all.