(16) Apply tight diaper for 1 hour.

(17) For 24 hours after circumcision, check (or

instruct parents to check) for bleeding, excessive swelling, and difficulty voiding.

(18) Until circumcised area is completely healed,

do not immerse in water; give sponge bath.

b. Use of Plastibell

(1) Follow steps 3 to 5 of E11a.

(2) Select bell of correct size (see C).

(3) Cone should fit snugly without pressure on

glans.

(4) Grooved rim of bell should be just distal to apex

of dorsal slit.

Chapter 47 ■ Circumcision 349

Fig. 47.3. Circumcision. A: Marking the position

of the coronal sulcus. B: Dilating the preputial ring.

C: Separating the prepuce from the glans penis.

D: Grasping the prepuce with mosquito hemostats in

preparation for the dorsal slit procedure. E: Dorsal slit.

A

B

D

E

C

350 Section IX ■ Miscellaneous Procedures

(5) If necessary, cut small segment out of cone so

that it clears frenulum.

(6) Hold prepuce firmly in place over cone (Fig.

47.5A).

(7) Tie suture tightly around rim of bell so that prepuce is firmly compressed into groove.

(8) Trim prepuce distal to ligature with tissue scissors. Use outer rim of cone as guide.

(9) Break off cone handle. Tissue beneath ligature

will atrophy and separate from bell in 5 to 8 days

(maximum 10 to 12 days) (Fig. 47.5B).

c. Observe and care for circumcision as in steps 17 and

18 of Gomco clamp (E11a).

F. Management of Postoperative

Bleeding

Postoperative bleeding usually stems from inadequate

hemostasis (e.g., unrecognized neonatal hepatitis (14) or

hereditary clotting disorders). Rarely, anomalous vessels are

responsible.

Continuous Ooze

1. Apply manual pressure for 5 to 10 minutes.

Check that the string on the Plastibell is in place

and is sufficiently tight.

2. Assess bleeding site. If continued oozing

A B

C

Fig. 47.4. Circumcision with a Gomco clamp. A: Placing the stud over the glans. B: Placing the baseplate of the clamp over the stud until the stud engages with the baseplate (inset). C: Gomco clamp in

position for circumcision.