Circumcision using the Plastibell Device

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Subject: Circumcision using the Plastibell Device

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Introduction

The practice of infant male circumcision predates recorded history. It is likely the most common operation in worldwide surgery. Throughout the world, millions of circumcisions are performed for religious and cultural reasons. Muslim and Jewish infants routinely undergo religious circumcision. 
The Plastibell procedure was first introduced in the United States but has become the most common method of circumcision is England. It has more than 45 years of successful clinical use that has demonstrated its safety and effectiveness. The ligature minimizes bleeding and eliminates the need for postoperative dressings. The design of the Plastibell anchors the ligature securely, protects the glans, and allows for visual inspection through the device. Cosmetic results with the Plastibell are similar to other methods. A study in England by Palit et al. found 96% satisfaction rate with the use of this device. 
The Plastibell device is supplied in individual presterilized packages. It comes in six sizes: 1.1, 1.2, 1.3, 1.4, 1.5, and 1.7 cm. Because it is disposable, it eliminates the need for sterilization required of stainless steel clamps. It also eliminates the potential problem of lost or mismatched parts that may occur with other systems. Determining the appropriate size of the device is important because a fit too small can cause tissue strangulation and necrosis, and one too large may result in too much foreskin being removed. The bell should be just large enough to completely cover the glans penis without overly distending the foreskin. 
The shape of the handle is different for each size of the device. This makes it easy to identify different sizes by the shape of the handle. The handle allows for easy positioning of the bell. The ligature applied over the grooved bell completely cuts off circulation so there is no open wound to cause seepage. There is no need for dressings or special postoperative care. After the procedure is completed, the handle is easily snapped off. No part of the remaining bell projects beyond the glans to cause pressure or necrosis. Urination is unaffected, and the baby can be diapered in a normal way. 
Plastibell complications are reported to be about 2% to 3%. Most complications are minor, related to bleeding. There has also been a report of a slight increase in infections compared with other methods. However, rare case reports of significant complications have been documented, including necrotizing fasciitis, urine retention, and ischemic necrosis of the glans. 

Equipment

  • Sterile drape

  • Two small forceps

  • A probe

  • A pair of scissors

  • Prep materials (see Appendix E)

  • The Plastibell device and ligature

Indications

  • Medical indications, including phimosis, paraphimosis, recurrent balanitis, extensive condyloma acuminata of the prepuce, and squamous cell carcinoma of the prepuce (all rare in neonates)

  • Parental request

  • Religious reasons

Contraindications

  • Routine circumcision is contraindicated with the presence of urethral abnormalities such as hypospadias, epispadias, or megaurethra (i.e., foreskin may be needed for future repair or reconstruction).

  • Less than 1 cm of penile shaft is visible when pushing down at the base of the penis (i.e., short penile shaft).

  • Circumcision should not be performed until at least 12 hours after birth to ensure that the infant is stable. Circumcision in infants who are ill or premature should be delayed until they are well or ready for discharge from the hospital.

  • Bleeding diathesis, myelomeningocele, significant prematurity, or imperforate anus.

  • When there is a family history of a bleeding disorder, appropriate laboratory studies should be done to identify any bleeding abnormalities in the baby.

The Procedure

Step 1

Prep the area with alcohol, and inject with 1% lidocaine (without epinephrine) in a dorsal penile block (see Field Block Anesthesia). Consider the use of a restraint board/device to gently restrain the infant’s legs during the procedure. Clean the penis, scrotum, and groin area with povidone-iodine or chlorhexidine solution, and sterilely drape the area (see Appendix E). Inspect the infant for gross anatomic abnormalities. Drape the baby’s torso (but not head) with a fenestrated drape. 
  • PEARL: Some providers prefer a topical anesthetic cream (such as 2.5% prilocaine and 2.5% lidocaine [EMLA]) in place of a dorsal block.

  • PEARL: Use a pacifier dipped in 25% sucrose to reduce infant discomfort and crying.

  • PITFALL: Anesthesia failure is often the result of failure to wait the necessary 5 minutes for the block to take effect. Avoid this problem by administering the block before draping the area, and then gently massage the area while waiting the 5 minutes required for maximum anesthetic effect.

Step 2

Grasp the end of the foreskin on either side of the dorsal midline at the 10 and 2 o’clock positions with two hemostats. Make sure to avoid the glans and the urethral meatus. 

Step 3

Carefully insert a closed hemostat or blunt probe into the preputial ring, and separate the foreskin from the glans down to the level of the corona. Slide the instrument down to the right and left sides to break up adhesions between the inner mucosal layer and the glans. Carefully avoid the ventral frenulum, because tearing it often causes bleeding. Create a crush line on the dorsal aspect of the foreskin using a straight hemostat. 

Step 4

Cut the crushed skin with scissors, taking care to avoid the glans. The cut should proceed down the center of the crush line to avoid bleeding, which occurs if the cut strays laterally. 

Step 5

Finish breaking any remaining adhesions between the glans and foreskin all around the corona except at the frenulum. Examine the penis to make sure hypospadias or megameatus are not present. Select the proper size of Plastibell. The proper fit is a bell that fits halfway down on the glans. Place the Plastibell on the glans. 
  • PITFALL: Make sure the crush line is far enough above the coronal sulcus that it will be completely removed in the circumcision. If the cut extends too far onto the penile shaft, the proximal portion of the incision (apex) cannot be pulled into the clamp.

  • PITFALL: If hypospadias or megameatus are present, terminate the procedure because any subsequent repair of these congenital anomalies may require the use of foreskin tissue.

Step 6

If the bell tends to slip out of the foreskin, cross the forceps or place an additional forceps across the top of the foreskin and handle of the Plastibell. 

Step 7

Secure the string in the groove visible on the Plastibell. It should not slip in any direction once tied. 
  • PITFALL: Improper placement of the ligature may increase bleeding complications.

Step 8

After a minute has passed, cut the foreskin just above the ligature. 

Step 9

Snap off the handle, leaving the bell in position. 

Complications

  • Pain, infection, bleeding.

  • Phimosis or ring retention (urinary blockage secondary to swelling).

  • Urethral stenosis, urethrocutaneous fistula, hypospadias and epispadias formation, necrotizing fascitis, penile amputation, and necrosis (all very rare).

  • Early separation.

  • If the ring slips below the glans, it can result in venous congestion and necrosis.

  • Ring migration/incomplete/delayed separation.

  • Excess foreskin removed.

Pediatric Considerations

This procedure is only indicated in neonates. Older children and adults need to have circumcision performed in the operating room under general anesthesia. 
Children older than 6 years are dosed like adults except that the maximal dose is based on weight. The recommended maximum dose for lidocaine in children is 3 to 5 mg/kg, and 7 mg/kg when combined with epinephrine. Remember that 1% lidocaine is 10 mg/mL. Children 6 months to 3 years have the same volume of distribution and elimination half-life as in adults. Neonates have an increased volume of distribution, decreased hepatic clearance, and doubled terminal elimination half-life (3.2 hours). 

Postprocedure Instructions

Instruct the child’s caregiver to bathe the infant the next day and to use a topical antibiotic such as Bacitracin or petroleum jelly on the glans and cut-line as a lubricant to keep penis from sticking to the diaper. Pain control is usually unnecessary for newborns, but acetaminophen may be used if desired. The skin under and distal to the ligature becomes dry and atrophic in 4 to 7 days. The ring should separate within two weeks. 
Warn the baby’s caregiver that some degree of swelling is expected, as well as a clear crust on the area. A small amount of blood also may normally be seen on the diaper. Active bleeding and blood spots larger than an inch should be reported to the provider. Also report if the Plastibell device has not fallen off within 12 days, if signs of infection develop, or if urination has not occurred within 1 day. 

Coding Information and Supply Sources

Supplies may be obtained from medical supply houses and at USA Hollister Incorporated, 2000 Hollister Drive, Libertyville, IL 60048 (phone: 1-800-323-4060; Web site: http://www.hollister.com). 

Bibliography

al-Samarrai AY, Mofti AB, Crankson SJ, et al. A review of a Plastibell device in neonatal circumcision in 2,000 instances. Surg Gynecol Obstet .  1988;167(4):341–343. [View Abstract]
Barrie H, Huntingford PJ, Gough MG. The Plastibell technique for circumcision. Brit Med L .  1965;2:273–275. [View Abstract]
Gee WF, Ansell JS. Neonatal circumcision: a ten-year overview with comparison of the Gomco clamp and the Plastibell device. Pediatrics .  1976;58:824–827. [View Abstract]
Palit V, Menebhi DK, Taylor I, et al. A unique service in UK delivering Plastibell circumcision: review of 9-year results. Pediatr Surg Int .  2007;23:45–48. [View Abstract]
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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