Plastibell

A 6 day old Plastibell Circumcision Device on a one-month-old infant.

The Plastibell Circumcision Device is a clear plastic ring with a deep groove running circumferentially designed for circumcising infant males. The Plastibell is placed onto the head of the penis during a 10-minute surgical procedure, and the device will fall off within 3 to 7 days. The Plastibell was invented by Hollister Inc in 1950, and first reported on in 1953.[1][2]

Surgical description

A baby midway through a Plastibell circumcision

The Plastibell Circumcision Device is a clear plastic ring with handle designed for male neonatal circumcision that has a deep groove running circumferentially. The elective surgical procedure to install the Plastibell device may be performed by an OB/GYN, a pediatrician, a urologist, a family physician or a pediatric surgeon. The important issue is that the medical practitioner is trained in the procedure.

The adhesions between the mucous membrane surfaces of the inner foreskin and the glans, which are normally present in most male and female children for years as both structures remain immature, are divided with a blunt probe introduced through the preputial orifice to accelerate such process and in order to introduce the other tools underneath. Then the foreskin is cut longitudinally to allow it to be retracted and the glans (the head of penis) to be exposed. The Plastibell comes in 6 sizes. The appropriate one is chosen and introduced under the foreskin to be applied over the head (the circumcision pictured at right is in this stage). The ring is then covered over by the foreskin. A ligature is tied firmly around the foreskin, crushing the skin against the groove in the Plastibell and to allow this to remain in place for days. Then the amount of foreskin protruding beyond the ring is trimmed off. Finally, the handle is broken off at the end of the procedure. The entire procedure may take five to ten minutes, depending on the experience and skill of the surgeon.[3]

As with all circumcisions, the procedure should involve adequate anaesthesia, using either EMLA cream,[4] dorsal penile nerve block, penile ring block, or a combination of these prior to operation. The ring falls off in 3 to 7 days leaving a circumferential wound that will heal over the following week. Typically, the Mucous membrane surface of the glans will appear red or yellow while it heals from the scraping process the blunt effected on it, until it has cornified in order to protect the from now on exposed membrane from contact with air and other external materials.

Advantages

The glans is protected during the procedure by the ring. Hemostasis (control of bleeding) is effective due to the ligature tie. Cosmetically, a predictable result is obtained due to the straight line of the ligature that causes the wound. It is a quick procedure for the physician to perform—once mastered.

No bandage is required, allowing easy monitoring for infection.

Healing occurs while the edges of the prepuce are secured in the ring, making skin bridges (where the foreskin's end heals to the glans' corona) unlikely.

Cosmetically, there will be little to no circumcision scar, though as usual with any circumcision, there will be a color change where the (formerly) inner and outer layers of foreskin meet.

Disadvantages

The ring must fall off before final healing can occur. Rarely, the tip of the glans may protrude through the ring and become swollen, trapping the ring in place. Blood transfusion risk 1 in 30,000 procedures (Wiswell).[5]

One study of 2000 Plastibell circumcisions found a complication rate of 1.8%.[6]

The foreskin must be slit and forced from the glans to allow entry for the plastic dome.

Furthermore, because convalescence depends on a (temporarily) affixed medical device, risks of infection or hemorrhage due to the bell slipping or otherwise failing are greater[7] than a Gomco clamp or similar entirely-supervised circumcision. There are several reports in the literature of urinary retention after circumcision with the Plastibell device.[8] Death has been reported.[9][10][11] A similar circumcision device, the Circumplast, is cylindrical in shape, reducing the chance of tight extrusion of the glans.

Other disadvantages include the risk of infection, with cases of impetigo,[12] as well as necrotizing fasciitis.[13][14] There have also been cases of necrosis of the glans penis following circumcision with the Plastibell instrument.[15]

Prevalence

The Plastibell device is one of the three most common devices used for neonatal circumcision in the United States, the other two being the Mogen clamp and the Gomco clamp.[16]

Notes and references

  1. ↑ Miller, RL; Snyder, DC (1953). "Immediate circumcision of the newborn male". American Journal of Obstetrics and Gynecology. 65 (1): 1–11. doi:10.1016/0002-9378(53)90002-7. PMID 13016660.
  2. ↑ Kariher, DH; Smith, TW (1956). "Immediate circumcision of the newborn". Obstetrics and gynecology. 7 (1): 50–3. PMID 13280246.
  3. ↑ Barrie, H.; Huntingford, P. J.; Gough, M. H. (1965). "The Plastibell Technique for Circumcison". BMJ. 2 (5456): 273–5. doi:10.1136/bmj.2.5456.273. PMC 1845746Freely accessible. PMID 14310205.
  4. ↑ Russell, CT; Chaseling, J (1996). "Topical anaesthesia in neonatal circumcision: A study of 208 consecutive cases". Australian family physician. Suppl 1: S30–4. PMID 9479796.
  5. ↑ "Risks from circumcision during the first month of life compared with those for uncircumcised boys". Pediatrics. 83 (6): 1011–5. Jun 1989.
  6. ↑ Izzidien Al-Samarrai A.Y., Mofti A. Crankson S. J The Use of Plastibell in Neonatal Circumcision. Review of 2000 cases. Surg. Gyne & Obst.167: 341-343, 1988
  7. ↑ Brennae, Mark (June 13, 2007). "Ontario boy dies after complications from circumcision". The Vancouver Sun. CanWest News Service. Retrieved 2008-07-16.
  8. ↑ Ly, L; Sankaran, K (2003). "Acute venous stasis and swelling of the lower abdomen and extremities in an infant after circumcision". CMAJ. 169 (3): 216–7. PMC 167126Freely accessible. PMID 12900483.
  9. ↑ Paediatrics & Child Health, Home Archived August 8, 2007, at the Wayback Machine.
  10. ↑ http://www.austlii.edu.au/cgi-bin/sinodisp/au/cases/vic/VCAT/2010/1772.html?stem=0&synonyms=0&query=anaesthetic[]
  11. ↑ Paediatric Death Review Committee: Office of the Chief Coroner of Ontario (2007). "Circumcision: A minor procedure?". Paediatrics & Child Health. 12 (4): 311–2. PMC 2528673Freely accessible. PMID 19030377.
  12. ↑ Stranko, J; Ryan, ME; Bowman, AM (1986). "Impetigo in newborn infants associated with a plastic bell clamp circumcision". Pediatric infectious disease. 5 (5): 597–9. doi:10.1097/00006454-198609000-00027. PMID 3763425.
  13. ↑ Bliss, David P.; Healey, Patrick J.; Waldhausen, John H.T. (1997). "Necrotizing fasciitis after Plastibell circumcision". The Journal of Pediatrics. 131 (3): 459–62. doi:10.1016/S0022-3476(97)80078-9. PMID 9329429.
  14. ↑ Woodside, JR (1980). "Necrotizing fasciitis after neonatal circumcision". American Journal of Diseases of Children. 134 (3): 301–2. doi:10.1001/archpedi.1980.02130150055015. PMID 6444778.
  15. ↑ Bode, C.O.; Ikhisemojie, S.; Ademuyiwa, A.O. (2010). "Penile injuries from proximal migration of the Plastibell circumcision ring". Journal of Pediatric Urology. 6 (1): 23–7. doi:10.1016/j.jpurol.2009.05.011. PMID 19570722.
  16. ↑ "Circumcision policy statement. American Academy of Pediatrics. Task Force on Circumcision". Pediatrics. 103 (3): 686–93. 1999. doi:10.1542/peds.103.3.686. PMID 10049981.
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