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Tuesday, November 16, 2010

What I Learned in the Operating Room

I have had the privilege of observing pediatric surgeons, pediatric urologists, and adult urologists operate in the operating room. Sometimes it was at their invitation, sometimes at my request, and sometimes at the insistence of the parents.

With the adult urologists (I use the term to differentiate from pediatric urologists - all urologists are adults), I learned much about the anatomy of the penis, the foreskin, the mucosal membrane underneath the foreskin, the glans, and the delicacy and intrigue of the male organ from a medical standpoint.

With the pediatric urologists and surgeons, I was present when the circumcision to be done was extremely complicated,
requiring a reconstruction of the penis due to its natural abnormal development in the womb (I either saw these babies and informed their parents of the necessity of the surgery, or the parents were informed of it by their physicians - in all cases, I did not do any form of circumcision or skin tissue removal), or if the child required other surgeries, such as hernia or double hernia, and the parents made the personal choice to have all surgeries, circumcision included, done while the baby was under general anasthesia.

[As an aside, in most of the latter cases - tacking the circumcision onto the other surgery - I disagree with their choice. A bris includes a surgical removal of the foreskin, but if the baby is otherwise healthy and small enough (as a baby) to have his bris done by a mohel, I believe that is the better choice as far as fulfilling the mitzvah according to Jewish law -- in retrospect, you'll soon see why I believe I am right even more than I felt I was before entering the operating room.]

When the circumcision was a normal case, just being tacked on to the surgical team's responsibilities while the baby was "out," my presence there was to advocate for the baby and make sure it was done properly. Except in one case (when I feel the surgeon did everything right), the surgeons I watched viewed the circumcision as an afterthought of surgery. While they were delicate with the hernia, marking every spot before making their incisions, isolating the vas deferens to make the sure the baby could one day be a father, etc. the foreskin was not marked and was simply picked up (thumb and forefinger grab), roughly estimated, and clipped off.

I had to tell the more arrogant surgeon that she had not removed enough foreskin, that the child would not look like he had a bris - even if he might look "circumcised" (at least partially, anyway) according to the medical textbook. I said, "The parents are looking for a different outcome. We do not want them - they have been through so much with this baby - to have to come back and have the bris 'corrected.' Please take off more foreskin!" Thankfully, she complied.

A different doctor was so gracious, he asked me every step of the way "Is this good, Rabbi? Am I doing it the way you want me to?" Except that he didn't mark the foreskin, and cut on a slight angle, it was OK.

The beauty of being a surgeon, after all, is that you can take all the time in the world, suture everything nice and pretty and come out with a cosmetically beautiful circumcision.

But the best circumcision I ever attended was when the surgeon had to reconstruct the penis, whose entire shaft was stuck inside the belly.


While reconstructive surgery is not my field, there are elements of that baby's original anatomy that have come up over and over through my mohel experiences.

In addition to cutting elements of the baby's skin in a manner that would serve the reconstruction, the surgeon removed layer after layer of what looked like inner membrane tissue. He told me this was all "webbing" and it was holding the shaft back from emerging the way it needs to.

While this is not common, it is a natural development which does occur every now and then. I have since had to deal with a number of babies who had this webbing, and have dealt with it as quickly and gently as possible under the circumstances.

I am grateful to these doctors and their hospitals for allowing me to come in, observe, learn and prepare for more challenges that may come up in the future.

I am a better mohel because of these experiences, and I cherish them whenever I think of them.

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