What the Anesthesiologist Should Know before the Operative Procedure

The most common indications for circumcision are phimosis, balanitis, and parental preference. This procedure can be accomplished under local, regional, or general anesthesia. In neonates and adults, circumcision may be performed under local anesthesia. In infants and children, circumcision is most commonly performed under general anesthesia. Postoperative bleeding is the most likely complication of circumcision surgery.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Circumcision is typically an elective procedure; therefore, the patient’s condition should be optimized prior to the operation. If an infant is a former pre-term baby who is less than 50 to 60 weeks post-conceptual age (PCA), he will require postoperative apnea monitoring. Therefore, the surgery should be delayed until this risk is minimized and it can be performed safely on an outpatient basis.

Emergent/Urgent: Circumcision is rarely, if ever, an urgent or emergent procedure. However, in the rare event that it must be performed urgently such that appropriate pre-operative fasting is not possible, a rapid sequence induction should be performed.

Elective: Routine preoperative evaluation and standard anesthetic techniques should be performed.

2. Preoperative evaluation

A thorough, routine preoperative evaluation should be performed including birth history, surgical and anesthetic history, medical conditions, medications, allergies, and family history of anesthetic problems. The patient or his family should be queried regarding a history of bleeding or clotting abnormalities encountered in past procedures. The patient’s family history should also be reviewed to evaluate underlying familial bleeding disorders which may complicate the circumcision and postoperative management. The presence of an undiagnosed bleeding disorder could potentially lead to significant blood loss during the surgery, necessitating resuscitation or transfusion.

Medically unstable conditions warranting further evaluation include: a history of bleeding/clotting abnormality in patient or his family.

Delaying surgery may be indicated if work-up for bleeding disorder is needed (or relevant information or recommendations are not available) or patient is not medically optimized (e.g. wheezing should be treated prior to general anesthesia for circumcision), or patient is a former premature infant who is not yet 50-60 weeks’ PCA.

3. What are the implications of co-existing disease on perioperative care?

Circumcision is a relatively minor procedure that poses no hemodynamic compromise in most patients. Therefore, patients with stable coexisting disease can undergo this procedure safely. Nonetheless, patients presenting for any operative procedure should undergo a detailed preoperative history and physical examination to identify conditions that may place them at risk from anesthesia or surgery. In case of circumcision such conditions would include a bleeding diatheses, a history of prematurity, underlying uncorrected or unstable congenital heart disease and an evolving respiratory illness.

b. Cardiovascular system:

Acute/unstable conditions

Children with congenital heart disease warrant careful evaluation. The anesthesiologist must gain an understanding of the specific heart defect, presence of right to left or left to right shunts, presence of cyanosis, a history suggestive of heart failure and exercise intolerance. Exercise intolerance in young infants may manifest as shortness of breath or diaphoresis during feeds or poor feeding. Patients should be optimized cardiovascularly prior to circumcision. Antibiotic prophylaxis for subacute bacterial endocarditis is no longer recommended by the American Heart Association in children with congenital heart defects undergoing circumcision.

c. Pulmonary:

Reactive airway disease (asthma)

A comprehensive history of reactive airway disease including recent exacerbations, use of preventive and/or rescue medications, and recent disease activity should be undertaken. In addition, a history of prior visits to the emergency department, admission to the hospital and/or to the intensive care unit, and need for steroid bursts will provide valuable information regarding the severity of asthma. Patients should be optimized from this standpoint prior to circumcision surgery and should be instructed to continue their medications up to the time of surgery. Patients who are actively wheezing on the day of surgery should have surgery postponed until they have been optimized.

History of prematurity

Patients born prior to 37 weeks gestational age are susceptible to apneic events after anesthetics. Patients who are not 50-60 weeks post-conceptual age require close monitoring for apnea after surgery. Therefore, circumcision should be postponed until the infant is older and the risk of post-operative apnea is decreased, making outpatient surgery a safe option.

d. Renal-GI:

N/A

e. Neurologic:

N/A

f. Endocrine:

N/A

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

As described above, underlying coagulation disorders may place patients undergoing circumcision at risk for bleeding during or following the procedure. Furthermore, the presence of a coagulopathy would be an absolute contraindication to the use of regional anesthesia, particularly neuraxial blockade.

4. What are the patient's medications and how should they be managed in the perioperative period?

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

No.

i. What should be recommended with regard to continuation of medications taken chronically?

All chronic medications should be continued prior to circumcision, except antiplatelet medications. Antiplatelet medications must be stopped prior to surgery particularly if a regional block is planned for postoperative pain control.

j. How to modify care for patients with known allergies

N/A

k. Latex allergy – If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

N/A

l. Does the patient have any antibiotic allergies – Common antibiotic allergies and alternative antibiotics

N/A

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia (MH)

Documented: Avoid all trigger agents such as succinylcholine and inhalational agents. Follow a proposed general anesthetic plan: total intravenous anesthesia with propofol ± opioid infusion ± nitrous oxide. Ensure an MH cart is available [MH protocol].

Local anesthetics/ muscle relaxants

In patients with a history of allergy to local anesthetics, regional anesthesia should be avoided and analgesia should be provided with oral or IV opioids. Oral or IV acetaminophen may be used as adjuvant analgesics. Muscle relaxants should be avoided in children with unknown neuromuscular disorders such as the myopathies or if there is a documented allergy. Additionally, succinylcholine should not be used in patients susceptible to MH.

5. What laboratory tests should be obtained and has everything been reviewed?

Routine laboratory tests are not indicated prior to circumcision.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Circumcision can be successfully performed under local, regional, or general anesthesia. While it is commonly performed under local anesthesia in neonates, circumcision in infants and children is typically performed under general anesthesia. Regional anesthesia may also be considered for older patients who are able to cooperate for block placement, and in patients in whom general anesthesia is contraindicated. Additionally, regional techniques may be used in conjunction with general anesthesia to provide postoperative analgesia.

a. Regional anesthesia –

Neuraxial

Benefits: May enable provider to avoid airway instrumentation as well as inhalational anesthetics and sedatives.

Drawbacks: In children and adults, may result in an undesirable motor block of the lower extremities and urinary retention postoperatively. Additionally, children may be unable to cooperate for block placement and may have difficulty remaining motionless during the procedure despite an adequate block.

Issues: Patients must have stopped antiplatelet agents for appropriate amount of time prior to neuraxial technique, and must be cognitively appropriate in order to cooperate for block placement (i.e. older children and adults).

Peripheral nerve block

Benefits: May provide adequate pain control without compromising motor function or causing urinary retention post-operatively, but may be inadequate as the sole anesthetic for the procedure in children who are unable to cooperate during the procedure.

Drawbacks: May not completely anesthetize area of interest, necessitating sedation or general anesthesia.

b. General anesthesia

Benefits: Allows provider to render patient immobile for the procedure, which may otherwise be difficult, especially with infants and children.

Drawbacks: Requires the administration of medications and sedatives which may depress respiration, especially in pre-term neonates and those who are less than 50-60 weeks post-conceptual age.

c. Monitored Anesthesia Care

Benefits: May decrease the overall amount of medications given, and therefore may hasten recovery. May allow provider to avoid airway instrumentation.

Drawbacks: Patients, especially small children, may be unable to lay still for the procedure, which may make operating conditions difficult for the surgeon.

6. What is the author's preferred method of anesthesia technique and why?

For infants and small children, mask induction with oxygen/nitrous oxide/sevoflurane is preferred. In older children, IV inductions are a possibility. Following induction, the airway may be managed with an LMA in patients who do not present an aspiration risk, or with an ETT in cases where a more secure airway is desired. For post-operative pain, a penile nerve block provides excellent pain control, while minimizing post-operative nausea and vomiting and motor block. A caudal also provides effective post-operative analgesia, but may cause an undesirable motor block.

What prophylactic antibiotics should be administered?

No current recommendation on standard antibiotic choice/dosing for circumcision, per SCIP.

What do I need to know about the surgical technique to optimize my anesthetic care?

Patients are positioned supine on the operating table; therefore, both LMA and ETT are appropriate airway management techniques.

What can I do intraoperatively to assist the surgeon and optimize patient care?

Postoperative bleeding may be increased in patients who are painful or agitated at the end of surgery, therefore smooth emergence and adequate pain control are important.

What are the most common intraoperative complications and how can they be avoided/treated?

Patients with laryngeal mask airways may experience laryngospasm on incision if the anesthetic depth is not sufficient. To avoid laryngospasm, patients with LMAs may require hand ventilation prior to incision to ensure adequate depth of anesthesia. Other possible complications include inadvertent intravascular injection of local anesthetics during block placement and bleeding from the surgical site.

a. Neurologic:

N/A

b. If the patient is intubated, are there any special criteria for extubation?

No. Patients should be extubated after they meet standard criteria. In patients with severe asthma, deep extubation may be considered to avoid airway irritation and bronchospasm.

c. Postoperative management

What analgesic modalities can I implement?

Postoperative pain can be managed with medications (oral and intravenous) and/or regional anesthesia techniques (dorsal penile nerve block, ring block of penis, or caudal block). A recent review found no difference among the IV medication technique, the dorsal penile nerve block technique and the caudal block technique with regard to time to rescue analgesia. Similarly, no difference was found among these groups with regard to postoperative nausea and vomiting. There are several pharmacologic options, including nonsteroidal anti-inflammatory medications such as ketorolac 0.5 mg/kg IV (discuss with surgeon prior to administering), acetaminophen (10-15 mg/kg orally preoperatively), and opioids (morphine 0.05-0.1 mg/kg IV) which can be used in combination to provide effective pain control.

In additional, the regional anesthetic techniques have been shown to provide excellent pain control postoperatively, while minimizing the use of opioid medications. As the subcutaneous ring block and the dorsal penile block both provide anesthesia to the distal two-thirds of the penis, these blocks are considered adequate for postoperative pain after circumcision surgery. However, studies have shown that the dorsal penile nerve block is superior to the ring block with regard to analgesia. Furthermore, the caudal block and the dorsal penile nerve block have similar analgesic outcomes, but the caudal block may result in an undesirable motor block postoperatively. There is also evidence that using ultrasound to place the dorsal penile nerve block results in a more effective block than a landmark-based approach. Additionally, it should be emphasized that epinephrine should not be utilized in peripheral nerve blocks of the penis, as vasospasm may occur leading to necrosis.

What level bed acuity is appropriate?

Circumcision is typically an outpatient procedure. If an anesthetic is performed on a former pre-term infant who is less than 50-60 weeks post-conceptual age (depending on institution), the patient should be admitted post-operatively for apnea monitoring for 24 hours duration.

What are common postoperative complications, and ways to prevent and treat them?

Postoperative bleeding may be increased in patients who are crying, agitated or restless in the recovery period. Providing effective postoperative pain control may decrease the incidence of this complication.

What's the Evidence?

Beyaz, SG. “Comparison of postoperative analgesic efficacy of caudal block versus dorsal penile nerve block with levobupivacaine for circumcision in children.”. Korean J Pain . vol. 24. 2011. pp. 31-5.

Cyna, A, Middleton, P. “Caudal epidural block versus other methods of postoperative pain relief for circumcision in boys”. Cochrane Database Syst Rev. 2008.

Holder, KJ, Peutrell, JM, Weir, PM. “Regional anaesthesia for circumcision: subcutaneous ring block of the penis and subpubic penile block compared.”. Eur J Anaesthesiol . vol. 14. 1997. pp. 495-8.

Sandeman, DJ, Reiner, D, Dilley, AV, Bennett, MH, Kelly, KJ. “A retrospective audit of three different regional anaesthetic techniques for circumcision in children”. Anaesth Intensive Care . vol. 38. 2010. pp. 519-24.

Weksler, N, Atias, I, Klevin, M, Rosenztsveig, V, Ovadia, L, Gurman, GM. “Is penile block better than caudal epidural block for postcircumcision analgesia?”. J Anesth . vol. 19. 2005. pp. 36-9. (These articles all provide specific regional techniques for post-circumcision analgesia.)

Blaise, G, Roy, WL. “Postoperative pain relief after hypospadias repair in pediatric patients: regional analgesia versus systemic analgesics.”. Anesthesiology . vol. 65. 1986. pp. 84-6.

Cote, CJ, Lerman, J, Todres, JI. “A practice of anesthesia for infants and children”. 2008.

Hammer, G, Hall, S, Davis, PJ, Davis, PJ, Cladis, FP, Motoyama, EK. “Anesthesia for general abdominal, thoracic, urologic and bariatric surgery”. 2011. pp. 745-85. (These article provide general anesthetic considerations for circumcision.)

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