Plastibell Circumcision with a Frenulum-Sparing Technique

Plastibell circumcision with frenulum-sparing technique

Ismael Zamilpa MD and Madison Haraway

Introduction: The penile frenulum connects the prepuce to the glans on the underside of the penis. Although the frenulum plays a role in sexual arousal, it can cause painful erections when its length is too short. Conventional neonatal circumcision techniques involve removing the entire foreskin covering the glans, often with division of the frenulum (1). Recently, tissue-sparing approaches have become a matter of interest to reduce the risk of complications, such as bleeding, altered glans sensitivity, and meatal stenosis.

Methods: We describe a frenulum-sparing technique in combination with the Plastibell method. Lysis of preputial adhesions near the frenulum is performed carefully. Selection of an appropriately sized bell is paramount as oversize or undersize can cause bell migration and tissue necrosis (2). The bell should fit snugly over two-thirds of the glans of the penis and fall off spontaneously within 3-7 days.

Results: The patient is a 2-month-old male who presented to Arkansas Children’s Urology with phimosis, which is preputial tightness that prevents foreskin retraction over the glans. He was born at 37 weeks gestation and was not circumcised at birth due to concern for heart murmur. After obtaining cardiac clearance and parental consent, Plastibell circumcision was performed with good preservation of the frenulum, and the patient tolerated the procedure well.

Discussion/conclusions: There is current controversy over the ideal extent of preputial preservation during circumcision. Several publications have highlighted the frenulum’s function in penile erection, owing to its innervation by fine-touch sensory receptors, such as Meissner’s corpuscles (1).

By leaving the frenulum intact, we aim to reduce the risk of complications, particularly meatal stenosis, which is the narrowing of the urethra in circumcised children (3). These children commonly present with symptoms of high-velocity stream (usually upwards), dysuria, and urinary frequency after toilet training.

In conclusion, this tissue-sparing approach potentially reduces complications, improves cosmesis, and retains sensitivity.

References:

Shenoy SP, Marla PK, Sharma P, Bhat N, Rao, AR. Frenulum Sparing Circumcision: Step-By-Step Approach of a Novel Technique. Journal of clinical and diagnostic research. 2015; (9)12: PC01-3. doi:10.7860/JCDR/2015/14972.6860.

Nagdeve NG, Naik H, Bhingare PD,Morey SM. Parental evaluation of postoperative outcome of circumcision with Plastibell or conventional dissection by dorsal slit technique: A randomized controlled trial. Journal of Pediatric Urology. 2013; 9(5): 675-682. doi:10.1016/j.jpurol.2012.08.001.

Abid AF, Hussein NS. Meatal stenosis posttraditional neonatal circumcision-cross-sectional study. Urology annals. 2021; 13(1): 62-66. doi:10.4103/UA.UA_30_20.

Sudden Cardiac Arrest from Epicardial Lead Compression

Institution: University of Arkansas for Medical Sciences

Authors: 

Monroe McKay mpmckay@uams.edu

Ashley Wilson

Christian Eisenring

Brian Reemtsen

Lawrence Greiten

Jump Graft Repair of Coarctation of the Aorta

This is a video showcasing a jump-graft repair for Coarctation of the aorta.

Coarctation of the aorta is one of the most well-known and documented congenital heart defects. Innovations in the field have led to a several options for surgical repair. However, patients with coarctation of the aorta remain at high risk for a number of morbidities including recoarctation aortic aneurysms and dilations, and sudden death. Our video showcases a jump graft repair, which is an underutilized approach for coarctation repair. Our goal is to educate others in the field on the proper technique and utility of this operation.

Aortic Valve Replacement via the Ross Procedure

A brief patient history is provided, followed by preoperative imaging, intraoperative repair, and postoperative imaging.

Inferior Oblique Myectomy

Inferior oblique myectomy is a type of strabismus surgical procedure that aims to weaken an extraocular muscle by transecting it. The patient is a four old with a history of inferior oblique overaction and vertical strabismus, which can be corrected by resection of the inferior oblique muscle.

The ointment was applied to the cornea. Forced ductions were performed and identified restriction of the inferior oblique. A conjunctival incision is made in the fornix. Tenon’s capsule is dissected to expose the Inferior Oblique. The inferior oblique muscle is isolated using a Stevens tenotomy hook followed by Jameson muscle hooks. The inferior rectus was identified on a steven’s hook medially to the inferior oblique. The lateral rectus was then identified on a steven’s hook laterally to the inferior oblique. This was done to ensure that neither muscle was incorporated with the portions of the inferior oblique muscle to be cut. Wescott scissors were used to cut both ends of the muscle. Bipolar cautery forceps were used to cauterize the resected proximal and distal ends of the inferior oblique muscle. The two ends were released and the remaining muscle ends were allowed to retract into the orbit. The conjunctiva was closed using a plain gut suture.

No complications arose during the procedure. Postoperatively, the patient had a subconjunctival hemorrhage, injection, and pain that decreased over the following week. Neomycin-polymyxin-dexamethasone drops were applied daily to prevent infection and inflammation. At the one follow-up, the redness and pain had resolved.

Inferior oblique myectomy effectively treats inferior oblique overaction and vertical strabismus associated with this condition.

Repair of a Non-coronary Sinus of Valsalva Aneurysm Rupture

A brief patient history is given, followed by preoperative imaging, intraoperative repair, and postoperative imaging.

Minimal incision Partial Sternotomy ASD Repair

This video showcases a minimal incision, partial sternotomy exposure for complete ASD patch repair performed at Arkansas Children’s Hospital.

Pulmonary Valve Replacement

This video highlights a pulmonary valve replacement in a patient with Tetralogy of Fallot. 

RV-PA Conduit Replacement in d-TGA

Replacement of a stenotic/irregular right ventricle to pulmonary artery Gore-Tex trileaflet graft with a novel KONECT RESILIA Aortic Valved Conduit. This is the only tissue valved conduit currently in use. This patient has d-transposition of the great arteries along with ASD, VSD, pulmonary stenosis, bovine left arch and aberrant right subclavian arteries.

His previous operations include MBTS 4mm Gore-Tex graft, urgent shunt revision secondary to thrombosis and subsequent conversion to a 4mm central shunt, right atrial thrombectomy secondary to indwelling right atrial catheter, takedown of central shunt, primary pledgeted closure of pulmonary valve, Gore-Tex patch closure of ASD/VSD, Rastelli procedure with 24mm Gore-Tex trileaflet with bulging sinuses graft.

Superior Rectus Recession

Introduction

Muscle recession is a type of strabismus surgical procedure that aims to weaken an extraocular muscle by adjusting its insertion posteriorly closer to its origin. The patient is a 14-year-old with dissociated vertical deviation, which can be corrected with recession of the superior rectus muscle.

Methods

A conjunctival incision is made in the fornix. Tenon’s capsule is dissected to expose the superior rectus muscle. The superior rectus muscle is isolated using a Stevens tenotomy hook followed by a Jameson muscle hook. After the remaining Tenon’s attachments are cleared, the muscle is secured at both poles with a double-armed 6-0 VicrylTM suture and double-locking bites. The muscle is then disinserted from the sclera with Manson-Aebli scissors. A caliper is used to mark the predetermined distance of muscle reinsertion. Next, the muscle is reattached to the sclera with partial thickness bites and then tied down to its new location. The conjunctival incision is closed with 6-0 plain gut sutures.

Results

No complications arose during the procedure. Postoperatively, the patient had subconjunctival hemorrhage, injection, and pain that decreased over the following week. Neomycin-polymyxin-dexamethasone drops were applied daily to prevent infection and inflammation. At the three-month follow up, the redness had resolved. The dissociated vertical deviation had improved.

Conclusion

Superior rectus recession is a safe procedure that can effectively treat vertical strabismus.

By: Michelle Huynh

College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

mhuynh@uams.edu

Surgeons:

Brita Rook, MD

Arkansas Children’s Hospital – Department of Ophthalmology, Little Rock, Arkansas, USA

BSRook@uams.edu

Joseph Fong, MD

Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

JFong@uams.edu

Video was performed at Arkansas Children’s Hospital, Little Rock, AR, USA.

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