The introduction of the Gomco clamp encouraged the practice of routine surgical circumcision in the neonate by increasing its simplicity, safety, and hemostasis. It was an advance in circumcision technique, which has been evolving over thousands of years. The major surgical instruments introduced over the years are reviewed, as are their advantages and disadvantages. The current state of the art is also discussed. (Obstet Gynecol 58:241, 1981)
Circumcision is one of the oldest known surgical procedures. For Jews and Moslems, it is a religious requirement. For others, it is prompted by hygienic and medical considerations. Although there is some opposition to routine circumcision, the trend established in the United States since World War II is to circumcise male neonates.
Early Jewish sources dealing with circumcision do not describe the procedure. There are a few references in the Bible to flint knives used as instruments, but there is no description of the technique used. Maimonides' codes contain a cursory enumeration of the basic steps: excision of the prepuce, tearing of the mucosa with the thumbnail, and exposure of the glans. Later codifiers, such as Joseph Karo, followed Maimonides' example and also do not describe the surgical technique.
Circumcision technique is more graphically described in later books, which came to be known as Sifrei-Ha Mohelim; these were handbooks tor ritual circumcisors. The prepuce was pinched up with the thumb and 3 fingers of the left hand and drawn forward, and a double-edged knife, called an "Izmel" and held in the right hand, was used to excise the prepuce with a side-to-side cut to minimize possible trauma to the scrotum. The reason for the double edge was to ensure the operator's use of the sharp edge.
The mucosa was then torn along the dorsum and peeled back below the corona. A therapeutic bandage called "Haluk" is also mentioned; it is described as an oil-saturated cloth with a central aperture. After circumcision, the glans was forced through the hole and the rest of the cloth was tied around the penis. This acted as a bandage and also prevented the skin from climbing and becoming fibrous around the glans, and possibly attaching to it.
Trauma was a major concern, especially regarding the glans. Knives made of sharp reeds were specifically prohibited because of possible injury from splinters - according to biblical law, males with injured sex organs are restricted as to whom they may marry. There is evidence in the Talmud that even the remote possibility of trauma to the glans is enough reason for an operator to refuse to do the procedure.
In the middle of the l8th century, in the Responsa writings of Jacob Emden there appeared the reference to the use of the flat shield. This was a metal plate with a middle slit. It was forced onto the stretched prepuce from front to rear, to protect the glans while the prepuce was excised. Interestingly, Nuri-Bey Risa, a famous Turkish physician at the turn of the 20th century, mentions that Moslems used to protect the glans by tying 2 strings around the stretched prepuce and making the incision between the 2 knots. He attributed this technique to Albu Cassis, the famous surgeon of Cordoba.
In the same Responsa writings of Jacob Emden, the probe is described; its function was to sever the adhesions between the mucosa and the glans, thus enabling the circumcisor to excise the mucosa together with the prepuce. Pirutinsky attributes the probe to a much earlier period. He claims that the "Seren" (rod) mentioned by Hai Gaon, who lived in Babylon in the ninth century, was a probe.
The general advancement of surgical art eventually led to the development of small clamps that were used to hold the mucosa and prepuce together along the dorsum prior to excision. This also made it easier to peel down the rest of the mucosa and expose the glans.
Despite all the innovations that accumulated over the years, circumcisors were still plagued by infection and hemorrhage in the infant. The development of sterile technique did much to prevent infection, and the advent of antibiotics gave the operators effective tools against infection once it started. Some operators use topical agents such as bacitracin or neomycin (Neosporin) prophylactically, and today infection is not a common problem in surgical circumcisions.
Early circumcisions were all done "free-handed" (ie, without clamps), and bleeding was a serious problem. Tight bandages were applied to control bleeding, yet bandaging the penis of a neonate for hemostasis is extremely difficult and requires great skill.
Reports have appeared in the literature of urinary retention and other serious complications. More recently, topical coagulants such as thrombin (Thrombostat), epinephrine, or oxidizing agents such as oxidized cellulose (Oxycel) have been used. Circumferential oxidized cellulose strips should be avoided as a bandage as they tend to constrict and are difficult to remove.
An early attempt to develop an instrument to avert bleeding was made by Moskovich in 1920 when he designed the circumcision forceps, which resembled a towel holder with 7 indentations for sutures. The forceps did not gain wide acceptance, probably because of its poor cosmetic results. However, Moskovich envisioned bloodless circumcision, which was more successfully accomplished by others later.
The introduction of the Gomco clamp and the development of the bloodless technique by Yellen in 1935 and Brodie in 1939 have encouraged the practice of routine circumcision. These factors have made the operation safer, reduced the chances of infection, and practically eliminated hemorrhage. This has been corroborated by the studies of Speert and Hovsepian.
The Gomco clamp is made up of 4 parts: a plate, a stud (bell), an arm (yoke), and a nut (to tighten the clamp). The bell is introduced into the preputial cavity and the prepuce is drawn over it. The plate is then placed over the bell so that the prepuce is sandwiched between them. The arm is fitted into its proper place, and when the nut is screwed on tightly, it exerts a crushing force on the prepuce at the junction of the bell and plate. The clamp is left on for 5 minutes to achieve hemostasis, and the prepuce is excised.
In its original design, which has remained unchanged to date, the Gomco clamp involved several cumbersome aspects. Schlosberg reports, "Several obstetricians have complained to me about their difficulties with this clamp." As this clamp is the most widely used circumcision instrument, its deficiencies are well known: 1) The Gomco clamp is made of many parts, making assembly difficult. The loss of a part, usually the nut, renders the clamp useless. 2) As with any screwing mechanism, the threads must be kept absolutely clean or difficulties in applying or removing the clamp will be encountered. 3) The Gomco clamp is known to lose its clamping power after prolonged use and age due to warping of the plate. 4) The junction where arm and plate meet is a wide trough. It is possible to assemble the clamp with the arm not properly resting in the trough, ie, with part of it out of the trough. After the nut is applied for pressure, the arm can slip into its proper place, depriving the instrument of its clamping and hemostatic effects. 5) Most important, the Gomco clamp is made of chrome-plated brass and is prone to wear through at its weakest point-the junction of the bell and plate. The bell has been found to develop grooves and nicks after repeated use with surgical blades. Therefore, Gomco bells should always be examined prior to use to prevent accidental cutting through the bell and possible injury to the glans.
Many attempts to replace the Gomco clamp have been described in the literature. Leff apparently did not like the Gomco clamp and decided to improve on the old shield technique. He designed a prepuce holder that resembled a hinged paper clip. Although it improved the operator's ability to hold the prepuce, the prepuce holder did nothing to control bleeding.
AI Akl designed the preputome. It resembled a hemostat with a bell and baseplate at its ends. As the bell pressed against the baseplate from above, there existed the possibility of including a piece of glans.
Tibone designed a bell at the end of a screw device, which had a C-shaped baseplate. The bell/screw fits into the open end. It was difficult to apply the bell as it had to fit into the 2 holes in the baseplate. The baseplate itself got in the way when the prepuce was excised.
Maryan designed the "improved bloodless circumcision clamp," a combination of the Tibone and Gomco techniques. It had a baseplate with 3 different-sized apertures, 3 different-sized bells with screw thread tops, an inverted U-shaped yoke, a washer, and a nut to tighten the clamp. With all these parts, the clamp was obviously difficult to assemble. The aperture in the yoke was in the center of the inverted U, instead of in the open ends, allowing the arms to interfere with the maneuverability of the operator. It had all the disadvantages of the Tibone and Gomco clamps.
Kantor's clamp is a shield attached to a hemostat. Problems with hemostasis have been experienced. More important, as the clamping device is straight, the crushed-skin "dog ears" at the front and back of the penis created by the use of the clamp do not always disappear, leaving a poor cosmetic result. The clamp also makes no provision for the escape of urine should the infant urinate during the procedure. The bells should have a small hole for this purpose.
Bronstein, a Brooklyn Mohel (ritual circumcisor), invented the Nutech clamp. Made up of only 2 parts, a bell and a base device, it was a combination of the Gomco clamp and Al Akl's preputome. The instrument was large and difficult to use. He also invented the Mogen clamp, a variation of the Kantor clamp. Instead of crushing the tissue by the attached hemostat, the Mogen shield acts as the clamp. It has all the shortcomings of the Kantor clamp, plus 1 uniquely its own: with the glans below completely out of sight, there is a chance that the tip of the glans might be caught in the clamp. Another Mohel, Weider, from the Bronx, designed a shield with a very narrow central slit. When this shield is forced onto the stretched prepuce and left in place for a few minutes, some hemostasis occurs. This device also has the same problems as the Kantor clamp.
There have been attempts to introduce disposable plastic devices. Hollister marketed the Plastibell, which is a plastic bell with a groove close to the edge. The bell is inserted into the preputial cavity and the prepuce is tied around it with a tight string. After several days, the prepuce necrotizes and falls off. The plastic bell remains tied around the glans for days during the necrotic process.
Melges described the Glansguard, which is a disposable Mogen-like clamp. This device has a built-in scalpel and has the same problems as the Mogen clamp. Even Gomco has produced a disposable plastic clamp, the Circlamp. It is very similar to the Tibone clamp.
All these inventors unsuccessfully attempted to develop an instrument superior to the Gomco clamp.
Grossman, a Mohel from Syosset, Long Island, has developed a circumcision clamp called Circumstat, which incorporates all the benefits of the Gomco clamp without its deficiencies. This instrument has been used by several obstetricians and urologists in New York City and on Long Island. The Circumstat is easier to handle than the Gomco, assembles much faster, and avoids many of the problems. It is made of stainless steel and has only 3 parts: a bell, a baseplate with a built-in cam lever locking device, and a unique gooseneck yoke. The clamp locks and unlocks with a flip of the thumb. The yoke is designed to fit into the baseplate via a circular pivot. It can only rest in the proper position. By holding the clamp together with the thumb and index finger prior to applying the lock, the operator can manipulate the clamp via the pivot, allowing for adjustments in the amount of prepuce to be excised. The Circumstat is engineered for the proper distribution of stress. Long instrument life is ensured and the stainless steel bell is not easily cut through.
Instruments for the performance of circumcision, as those of any other surgical procedure, are constantly evolving. New instruments are expected to be introduced over the coming years. Operators should select those that minimize potential complications and maximize efficiency.
Further information can be obtained from the articles in the following bibliography.
1. Gairdner D: The fate of the foreskin. Br Med J 2:l433, 1945
2. Hovsepian D: The pros and cons of routine circumcision. Calif Med 75:359, 1951
3. Speert H: Circumcision of the newborn; an appraisal of its present status. Obstet Gynecol 2:164, 1953
4. Exodus 4:25.
5. Joshua 5:2
6. Maimonides M: Laws of circumcision 2:2, Mishne Torah. New York, reprinted by Binah Publishing. l947
7. Karo J: Shulchan Oruch, Code of Jewish Law, Yoreh Deah 264:13. New York, reprinted by Ozar Halacha Publishing, 1960
8. Hagozer J: Klalei Hamilah. Krakow, Poland, 1892
9. Hagozer GBJ: Dinei Milah, Krakow, Poland, 1892
10. Karo J: Shulchan Oruch, 264:2
11. Deuteronomy 23:2
12. Babylonian Talmud, Tractate Sabbath 135:1
13. Emden J: Migdal Oz. Altona, Germany, 1745. Reprinted Jerusalem, 1971, p 101
14. Bryk F: Circumcision in Man and Woman. NY, American Ethnological Press, 1934, p 245
15. Pirutinsky M: Sefer Habrit. Brooklyn, NY, Balshon Printing Co, 1972, p 193
16. Frand M, Berat N, Rotem Y: Complications of ritual circumcision in Israel (letter). Pediatrics 54:521, 1974
17. Moskovich M: Circumcision forceps. JAMA 74:1167, 1920
18. Yellen HS: Bloodless circumcision of the newborn. Am J Obstet Gynecol 30:l46, 1935
19. Brodie EL: Circumcision. Surgery 5:271, l939
20. Schlosberg C: Year Book of Pediatrics 1967-68. Edited by SS Gellis. Chicago, Year Book, 1968, p 268
21. Grossman I, Mohel, Syosset. New York. personal communication
22. Leff M: Technique of circumcision with a special clamp. NY State J Med 50:2721, 1950
23. Al Akl FM: New circumcision clamp. Am J Surg 68:402, 1945
24. Tibone JJ: US patent application 2,345,639, April 4, 1944
25. Maryan HO: Maryan's improved bloodless circumcision clamp. Am J Obstet Gynecol 67:442, 1954
26. Kantor HI; History of circumcision: Introduction of a new instrument. Tex State J Med 49:75, 1953
27. Barrie H, Huntingford PJ, Gough MH: The Plastibell technique for circumcision. Br Med J 5456:273, 1965
28. Johnsonbaugh RE, Meyer BP, Catalano JD; Complication of a circumcision performed with a plastic bell clamp. Am J Dis Child 118:781, 1969
29. Melges S: Newborn circumcision with a disposable instrument. Obstet Gynecol 39:470, 1972
30. Harrison JH: Campbell's Urology. Fourth edition. Philadelphia, Saunders, l978, p 659
31. Matz R: More principles of medicine. NY State J Med 77:1985, 1977
