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Chapter 2 Index
A. Evaluation by system B. Other categories of illnesses:
1. Metabolic and Endocrine
2. Collagen-Vascular Illnesses
3. Chromosomal Abnormalities
4. Generalized
5. Sexual Abuse
6. Hematology 7.
Trauma and Surgery
--Surgery in
Pediatrics: Timing and Indications for Procedures
--Fractures in Children
--Evaluation of Ankle Injuries
--Splinting and Casting
--Suturing by the Pediatrician |
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Plastibell Circumcision
David Rogers, MD - Pediatric Surgery
Introduction: There are several methods of performing
circumcisions. Dr. Rogers prefers the plastibell rather than the Gomco
method after one week of age (too much bleeding with Gomco after
one-week-old). Plastibell can be used up to 3 months of age. If circ
needed after that, must wait until one year of age to have general surgery.
Many circs that Dr. Rogers performs are second tries: therefore, we as
pediatricians need to know how to do them correctly from the beginning.
Indications for doing circumcision vary with geography,
ethnic background, and even the country child born in. Medical reasons for
circumcisions in older children include: urinary obstruction, glans caught
by foreskin and adhesions, paraphimosis. Public health advantages include
decreased incidence of STDs (including AIDs), decreased UTIs, no foreskin
carcinoma, prob. decrease cervical carcinoma in wives of circumcised males.
Contraindications: Megalourethra, hypospadius, and
epispadius
Actual Procedure of Plastibell Circumcision:
- Prep with alcohol and inject with 1% lidocaine (without epinephrine).
Use <2cc and use a ring block around the base of the penis, rather than a
dorsal nerve block. Must be patient and wait awhile to have good
anesthesia. (7-10 minutes). Alternative: use lidocaine-prilocaine cream (NEJM
97;336:1197-1201.
- Prep the foreskin with betadine
- Separate the foreskin away from the glans
- Prep the glans with betadine
- Check for urethral abnormalities: it is a disaster to do a circ on
someone with hypospadius as it may limit reconstructive options.
- Select the proper size of plastibell: each unit costs $0.35 apiece --
the proper fit is a bell that fits halfway down on the glans.
- Place a hemostat on each side of the foreskin
- Crush the skin on the dorsum of the foreskin and divide it
- Place the plastibell on the glans
- Secure the string in the groove visible on the plastibell - make sure
it is secure; it should not slip up and down.
- Remove the handle
Parental Education:
- Wound care: bathe the next day; use topical antibiotic such as
Bacitracin - more as a lubricant to keep penis from sticking to the
diaper.
- Pain control: usually unnecessary for newborn; Acetaminophen for older
infant
- Potential Complications: ring should separate after two weeks - if
present after that return. Can also have bleeding, infection, early
separation, or slippage. If the ring slips behind the glans, it can
result in venous congestion and necrosis.
- All babies should be rechecked by the person doing the circumcision.
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