The patient was circumcised at about 3 weeks of age by his delivering obstetrician. The OB's description of the procedure says it was "peformed in the standard manner using the Gomco 1.3 clamp," and a "non-adherent dressing was applied." The record states that the baby "tolerated the procedure well," and that the "6 oclock edge... was mildly bleeding" but resolved with use of a silver nitrate stick.
Two days after the surgery, the baby's mother became concerned that the tip of his penis was "light purple" and brought him in to see his pediatrician's PA. The PA took off the bandages and noted: "Dorsal surface of the shaft is missing skin in a triangular pattern halfway up the shaft of the penis ... The ventral surface of the penis is missing most of the skin...." The PA also noted signs of infection, for which she prescribed oral and topical antibiotics. She referred them to a pediatric plastic and reconstructive surgeon at a specialty children's hospital.
The children's hospital arranged for the baby to be seen first in the pediatric urology clinic, where the doctor noted there was "deficient ventral skin" and "penoscrotal webbing," as well as bilateral hydroceles. The urologist recommended meeting with plastic surgery "for planning of combo case in the event that the z-plasty technique will not provide adequate skin coverage for the penile shaft."
The plastic surgeon noted "moderate deficiency of ventral skin at site of previous circumcision, which tethers glans inferiorly upon superior retraction of the penis." He recommended "release of ventral scar tissue and local tissue rearrangement versus full thickness skin grafting." He also recommended waiting 6 months to do surgery, and then things were further delayed because of Covid.
Eventually, surgery was done at 12 months of age. The operative note describes that after degloving and repair of the buried penis, there was "essentially no ventral skin," so z-plasty was not possible. The baby received a full thickness skin graft from the left lateral groin crease instead.
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Do you believe there might have been medical error?
Gomco circumcisions are fairly easy to perform, and you should be able to see everything prior to clamping - and you should be able to take down any of the adhesions TOO prior to closing the clamp - this is very much UNLIKE the Mogan clamp which is a blind procedure.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Perhaps the obgyn did not do a complete look prior to clamping. I am also trying to figure out WHY this was done at 3 weeks by an obgyn and not a pediatric urologist at this age of the infant.
What makes you a good expert for this case?
A good expert is someone who has perform different types of circumcisions such as gomco, mogan and plati-bell. Also an pediatric urologist would make a good case expert.
How often do you encounter cases similar to this one in your practice?
Well - this is almost never the case because when I did circumcisions - I taught them to ob/gyn residents TOO - I would teach what to look for and pitfulls you should look for prior to clamping and cutting the skin.
Do you believe there might have been medical error?
Denuding the ventral skin excessively leads to scar tissue formation which was the proximal cause to the complications suffered by this child. When there is excessive skin removed and there is also excessive bleeding and need for treatment for bleeding, even more scar tissue can form.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
1. The bleeding was likely due to the fact that excessive skin was removed. 2. The surgeon failed to recognize the cause of the excessive bleeding. 3. The treatment with silver nitrate did not remedy problem #1. 4. The delay in promptly referring the baby for additional intervention resulted in excessive scar tissue formation. 5. This was an avoidable complication. The standard of care would have been to refer the baby out for additional care. To a high degree of medical certainty, the provider's negligence resulted in harm to the baby.
What makes you a good expert for this case?
I've performed circumcisions on newborn babies for over 22 years. I've supervised medical residents performing circumcisions. I've seen and health with circumcision complications.
How often do you encounter cases similar to this one in your practice?
This is an extremely rare and unfortunate complication. In supervising residents, I know that this complication results from over aggressive denouement of the ventral skin on the penile shaft.
Do you believe there might have been medical error?
A Gomco clamp, appropriately applied is capable only of removing the foreskin (or prepuce). It's impossible to remove the skin from the ventral surface of the penis with a Gomco.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I can think of no other explanation for the injury described than an ineptly perfomed circumcision.
What makes you a good expert for this case?
I have delivered between 6,000 and 7,000 babies, half of which were males. I was asked by the parents to circumcise nearly all of the males. I used a compco clamp for nearly all of the circumcisions that I performed.
How often do you encounter cases similar to this one in your practice?
I have never seen what is described.
Do you believe there might have been medical error?
There are several worrisome aspects to the case described. The baby was 3 weeks old, suggesting that this was done in the office on an older infant, placing the infant at higher risk of bleeding complications. Scrotal webbing was diagnosed by the pediatric urologist and is a congenital condition which is a contraindication to newborn circumcision as it can place tension on the circumcised skin and deglove the shaft. In addition, sunken penis was described, which also would be a contraindication to circumcision if it had been present at the time of the procedure, but may have developed afterwards due to the inflammatory response to the degloving. The surgery was delayed by Covid, but eventually was performed and was too extensive for local repair and required skin graft. The penis likely will show permanent scarring from the repair.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Scrotal webbing is a contraindication for newborn circumcision and likely caused the degloving.
What makes you a good expert for this case?
I am not a good expert for this case
How often do you encounter cases similar to this one in your practice?
I encountered one case of degloving after circumcision in expert review, never in my medical practice.
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