Manual for Male Circumcision under Local Anaesthesia

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Male circumcision under local anaesthesia Version 3.1 (Dec09) referred to a specialist centre. The circumcision team should enquire about the health of the baby or young boy. Neonatal circumcision (within the first 28 days of life) should be undertaken only if the birth was a full-term delivery and the baby has had no significant medical problems. Known haematological disorders and jaundice are contraindications to circumcision. Thus any baby with yellow sclera or purpuric skin lesions should not be accepted for clinic-based circumcision. Any congenital abnormality of the genitalia is a contraindication to circumcision. Only babies with a normal physical examination and an intact, completely normal appearing penis and foreskin should be considered for male circumcision. This is because the foreskin may be needed for plastic surgical repair of the abnormality. CONSENT In all cases, the procedure can be undertaken only with the full consent of the parent or legal guardian. The parent or legal guardian should be fully informed about how the procedure will be done, what type of anaesthetic will be used, what complications are possible, and what type of postoperative care should be provided. A summary of the information that needs to be provided is given in Appendix 6.1. The consent of the child should also be obtained, if he is able to give it (Chapter 3 addresses this issue in more detail). An example of a consent form is given in Appendix 6.2. PREPARATION Before the procedure, the baby should be clean and have a clean, freshly-laundered or new disposable nappy. Because mothers may need to travel some distance to the clinic, any clinic offering infant circumcision should have facilities for washing babies and changing nappies. ANAESTHESIA Anaesthesia is recommended for paediatric circumcision. Many studies have shown that babies react to pain, and that an effective method of providing local anaesthesia is with dorsal penile nerve block. a The maximum safe dose of lidocaine in children is 3 mg/kg of body weight. For a 3-kg baby, this corresponds to 0.9 ml of 1% solution or 1.8 ml of 0.5% solution (see Table 5.1). Anaesthetic solutions containing epinephrine (adrenaline) should never be used. a Kirya C, Werthmann MW Jr. Neonatal circumcision and penile dorsal nerve block: a painless procedure. J Pediatr. 1978;96:998-1000. Infant and paediatric circumcision Chapter 6 - 2
Male circumcision under local anaesthesia Version 3.1 (Dec09) Safe injection of local anaesthetic It is the surgeon’s responsibility to check the vial of anaesthetic, to ensure that the correct agent at the correct concentration has been selected, and to check the expiry date. It is important to verify that the anaesthetic is clear and that there are no visible particles, which may suggest that the vial is contaminated. Using a fine needle (e.g. 27-gauge), injections are made at the 10 and 2 o’clock positions. Before injecting any local anaesthetic, the surgeon should gently aspirate to make sure that no blood enters the syringe. This is to ensure that anaesthetic is not injected into a blood vessel. This safety precaution should be repeated each time the needle is moved and before any additional local anaesthetic is injected. A B Fig. 6.1: Injection of local anaesthetic for a dorsal penile nerve block at the 2 and 10 o’clock positions. b . A: The injection at the base of the penis. B: Diagram of an infant penis, to show the anatomy of the dorsal nerve as it passes under the pubic arch, and the position of the anaesthetic in relation to the dorsal penile nerve and pubic symphysis. [NOTE TO ARTIST: AMEND B TO LOOK MORE BABY-LIKE, can use model above to locate landmarks in infant] Local anaesthesia alone can be used for most infants (under one year of age) who can be held during the procedure so that b Butler-O’Hara M. LeMoine C. Analgesia for Neonatal Circumcision: A Randomized Controlled Trial of EMLA Cream Versus Dorsal Penile Nerve Block. Pediatrics. April 1998; Vol. 101 No. 4 Infant and paediatric circumcision Chapter 6 - 3
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Manual for Male Circumcision under Local Anaesthesia

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