Lindex #1573

Reynolds RD

Use of the Mogen Clamp for Neonatal Circumcision

American Family Physician

1996; 54(1):177-182

The nature and employment of the Mogen clamp in circumcision is described. The review includes anatomic considerations, operative candidates, instruments and procedures and postoperative care.

The term mogen is derived from the Hebrew term shield or guard and was designed in 1954 to protect the glans from the scalpel during circumcision.

The closed cleavage plane between the glans and the foreskin is opened, the plane separated and the foreskin excised. The inner mucosal surface of the foreskin must be excised. The child must be healthy and devoid of anatomic abnormalities including hypospadias, epispadias, and chordee. Necessary instruments in addition to the Mogen clamp include two fine, straight mosquito hemostats, a blunt-tipped probe and a no. 10 scalpel blade. The infant is placed in a supine position and a dorsal penile nerve block administered which can consist of one mL of plain 1 percent lidocaine. A 0.5-in, 30-gauge needle is employed and is introduced into the skin in the dorsal midline at the root of the penis, just overlying the suspensory ligament. The needle tip remains subcutaneous and superficial to the two corpora.

The tissue between the foreskin and the glans is then lysed with a blunt probe. A hemostat is inserted between the skin and mucosa and advanced 3 mm distal to the corona in order to hold the layers together dorsally. Once the hemostat is locked and left in place, the Mogen clamp is opened fully. The open clamp is slid across the foreskin from the dorsal to ventral, following the angle of the corona. The long axis of the Mogen clam is positioned parallel to the frenulum along the dorsal-ventral axis of the penis.

It is of utmost importance not to trap the glans in the jaws of the clamp. This is accomplished by employing the nondominant index finger and thumb to pinch the foreskin together, ventral to the dorsal hemostat, with traction applied along the axis of the penis. This procedure retracts the glans out of the way. The clamp is then slid across the foreskin, beginning at the tip of the hemostat and angling distally as it approaches the ventral side. The glans should be mobile prior to excision. Excision is accomplished with the belly of a no. 10 scalpel. The clamp is left in a locked position for one minute in order to avoid bleeding.

Once the Mogen clamp is removed both thumbs are employed to push down on the skin at the nine o'clock and three o'clock positions liberating the glans. The distal edge of the penile skin is grasped at the nine o'clock and three o'clock position and pulled laterally. The glans is then inspected to ensure that the mucosa has been liberated fully to the corona circumferentially. Cleavage may be completed by use of a blunt probe. Absorbable gelatin sponge material (Gelfoam) is applied to the area in cases of minor bleeding while brisk bleeding is attended to by clamping a nd tying with 5-0 plain gut or chromic suture. Oral acetaminophen may be given.

The infant is observed during the following four hours and should void prior to discharge. Gauze should be removed within 24 hours should it become soiled and petroleum jelly applied on the glans until it is epithelialized fully.