Evaluating the Impact of Instrument Choice on Pain
A number of different instruments can be used to perform circumcision, and there are advantages and disadvantages for each instrument. In a recent survey, the Gomco clamp (Allied Healthcare Products, Inc, St. Louis, MO) was preferred by 67% of physicians, whereas the Plastibell (Hollister, Inc, Libertyville, IL) was used by 19% and the Mogen clamp (The Mogen Instrument Company, Brooklyn, NY) by 10% (Fig 8). The circumciser should be proficient and comfortable with the use of the instrument chosen for the procedure. The cosmetic outcome should also be considered, but is beyond the scope of this article.
Beyond physician preference and cosmetic outcome, pain is a discriminating variable when evaluating circumcision instruments. Three studies have evaluated circumcision associated pain with the use of either the Mogen or the Gomco clamp.[57,82,83] A 1999 randomized, controlled, nonblinded clinical trial (n = 48 healthy, full-term infants) compared circumcision pain in infants anesthetized with a DPNB and circumcised with a Gomco or a Mogen clamp. The Mogen clamp was associated with the least discomfort and shortest application time (mean time for Mogen was 81 seconds v 209 seconds for the Gomco) ( Table 3 ). A similar 2000 study (n = 86) reported wider differences in circumcision times; the mean duration for circumcision with the Mogen was 55 seconds and 577 seconds with the use of the Gomco (P < 0.001). The most recent study, reported in 2002, found that circumcision took 1.9 times longer to complete with the Gomco in comparison with the use of the Mogen. All 3 investigations concluded that the length of time involved to perform a circumcision has an impact on the duration of grimacing and crying observed in the infants.
A recent randomized, prospective nonblinded study (n = 59 well full-term infants) compared pain in infants circumcised with either a Mogen clamp or Plastibell. The infants experienced similar pain per unit of time with both techniques. However, the Plastibell procedure took almost twice as long as the Mogen clamp procedure, making the Mogen clamp the preferred device to minimize pain.
The idea that surgical skill and speed make the use of anesthesia unnecessary is another argument frequently used to support unanesthetized circumcisions. The 1998 survey of circumcision practices revealed that providers using the Mogen clamp were 22% less likely to report using anesthesia than those using other devices. Although surgical speed may minimize the duration of pain, it does not diminish the intensity of the pain. Findings from a randomized, controlled trial comparing the DPNB, SQRB, and topical anesthesia stated that "although our physicians were highly experienced in performing circumcision and had excellent surgical technique, every newborn in the placebo group exhibited extreme distress during and following circumcision."
Adv Neonatal Care. 2003;3(2) © 2003 W.B. Saunders
Cite this: A Pictorial and Video Guide to Circumcision Without Pain - Medscape - Apr 01, 2003.