I have written about this before, in the context of a discussion about arrogant mohels, and in the context of a bad story I was told by a baby nurse I worked with, and I hinted to it when I recounted a conversation I had with a urologist-grandfather with whom I worked directly. And I mentioned here why I would personally do my research in this regard were I to look for a mohel myself. Alas, being a mohel, I knew who was going to circumcise my sons.
But now I am calling it what it is.
Showing posts with label shield. Show all posts
Showing posts with label shield. Show all posts
Sunday, May 6, 2012
Monday, March 26, 2012
So.... Do you use a Clamp?
I get this question a lot, and I think it's time to clarify what the tools of the trade are.
The answer to the question, by the way, is NO. I don’t use a clamp. Keep reading, to learn what it is and why some do use it.
[The following links were added to the post below at a later date (based on when I blogged about them). While the links below address the "tools"/Bris Milah instruments that I use, what follows after the links is not addressed in the "SHIELD" blog post linked immediately below, so the remaining content of this blog post is still quite informative, even if you choose to follow the specific links that immediately follow]
MARKER GLOVES NUMBING
The links to the specific "tools of the trade blog posts" are here - each which will give you a great overview of each item and how it is utilized.
SHIELD TUBE KNIFE PROBE HEMOSTATS
SHIELD TUBE KNIFE PROBE HEMOSTATS
MARKER GLOVES NUMBING
continuing the original blog post here....
I have blogged about the different methods utilized in bringing about the coveted circumcision result.
Here I will simply distinguish between the largely rabbinically approved, lauded and recommended device which is called a מגן - a Magen - a shield (in Hebrew). And the "Mogen Clamp" developed by the mohel, Rabbi Harry Bronstein in the 50s (or thereabouts).
Here is a link to photos of shields. The basic gist is that a shield is a solid metal plate (once made of silver, but now more often made of steel) with a thin slit that divides the shield in half.
The foreskin is grasped with the thumb and index finger, and the shield is applied so that only the foreskin is drawn out - while the glans remains protected below the metal, and the foreskin is excised along the shield.
THIS IS THE ONLY KIND OF SHIELD FOR THE GLANS THAT I USE.
I DO NOT OWN ANY OF THE FOLLOWING DEVICES
Tuesday, March 20, 2012
In Talking to a Urologist
At today's bris, the mohel was actually the baby's grandfather, a Urologist by profession. I served as the facilitator and the bandager, setting things up and taking care of the baby afterwards [see here, where I describe what is done when I play this role, in the context of a father who "blanked" in the heat of the moment].
Just a few observations from a Urologist who has been around the block a few times, with whom I chatted for a few minutes afterwards.
Just a few observations from a Urologist who has been around the block a few times, with whom I chatted for a few minutes afterwards.
Monday, March 5, 2012
This Type of Thing Should NEVER Happen
At today's bris, as I was changing the bandage post-bris (in the Private Room), I was chatting with the baby nurse. She is relatively new in the field, and so all of her experiences are very clearly etched in her memory.
She told me that the last baby she cared for was brought to the hospital after the bris, because the mohel cut too much. I could not get a sense of the gravity of the details in question, though she indicated that the baby's glans had been seriously nicked. In either case, she said, "There was so much bleeding. It was a horror."
I asked her if she had accompanied the baby to the hospital. She did, with the baby's parents and their other child.
She told me that the last baby she cared for was brought to the hospital after the bris, because the mohel cut too much. I could not get a sense of the gravity of the details in question, though she indicated that the baby's glans had been seriously nicked. In either case, she said, "There was so much bleeding. It was a horror."
I asked her if she had accompanied the baby to the hospital. She did, with the baby's parents and their other child.
Wednesday, July 21, 2010
Don't Use the Mogen Clamp!
An article in the Atlanta Journal-Constitution has reported on a lawsuit against the makers of the Mogen clamp. (text of article produced below)
I have never been a fan of this clamp (see method 1 here), and even the FDA has issued warnings against clamps because of their potential of irreversible damage
Simply put, no step in the circumcision procedure should be irreversible until the actual removal of the foreskin. Once the shield is in place, it is important to double check that the proper area of skin is ready to be excised. In the event the shield was initially applied incorrectly, it can simply be removed and repositioned - no harm done.
Once a clamp is put in place, anything in its clamping mechanism is essentially dead skin, and the excision/amputation which follows is irreversible.
PLEASE TELL ALL YOUR FRIENDS AND FAMILY - DO NOT ALLOW A MOHEL TO USE THIS DEVICE ON YOUR BABY, UNLESS HIS TRACK RECORD IS PERFECT WITH IT!
*****************************************************************************
Atlanta lawyer wins $11 million lawsuit for family in botched circumcision
By Ty Tagami
The Atlanta Journal-Constitution
Monday, July 19, 2010
The maker of an instrument used in circumcisions claimed that injury was impossible with its use, but after an infant lost a portion of his penis during an operation with the Mogen clamp, a judge awarded $10.8 million in damages against the company.
The judgment handed down Friday in New York involves an Atlanta lawyer who has been crusading against circumcision as a dangerous and unnecessary practice.
Attorney David Llewellyn won a similar case in Atlanta last year and the injury behind that prior lawsuit in Fulton County Superior Court put the New York clamp manufacturer on notice about the danger of the device, his current lawsuit said.
The baby in the current case, identified in court documents only as L.G., lost the entire glans, or head, of his penis after it was pulled into the jaws of the clamp, according to a federal magistrate's order. On Friday, U.S. District Judge Jack B. Weinstein ordered Mogen Circumcision Instruments of New York to pay $10.8 million in compensatory and punitive damages to the Florida boy, now 3, and his parents.
The parents "are extraordinarily distraught and angered that this company tells people it can't happen," Llewellyn said.
It's unclear whether they will ever collect the money. Mogen is already in default on a $7.5 million judgment in 2007 from a Massachusetts lawsuit, Llewellyn said.
The company is going out of business, according to a woman who answered the phone at its Brooklyn headquarters Monday. The woman, who said she was a secretary and would identify herself only as D. Rotter, the person whom Llewellyn said was served papers in the lawsuit. She said increased competition has undermined their business.
"It's just kind of dwindling down to nothing," she said, adding that the phones at the Mogen office were scheduled to be disconnected Tuesday. Mogen didn't defend itself in court, and Rotter said it was because the company couldn't afford it.
She said the Mogen clamp is "painless and safe" when used properly. The case involving the Florida boy was "unfortunate," she said, adding that "any medical mishap is unfortunate."
In this case, a New York mohel, or Jewish ritual circumcisor, performed the operation in the baby's home, Llewellyn said. The mohel negotiated a separate settlement, the terms of which Llewellyn would not disclose.
Llewellyn won another circumcision case in 2009 over an operation at South Fulton Medical Center. In that case, which involved a baby identified only as D.P. Jr., the mother contended that the doctor who circumcised him removed too much tissue and that his pediatrician failed to respond when a nurse complained of excessive bleeding.
The tip of the penis was placed in a biohazard bag and might have been reattached if he'd gotten attention in time, Llewellyn said in 2009. His lawsuit in New York says D.P. Jr. lost a third of his glans.
The jury found that both the pediatrician and the physician who performed the circumcision were negligent, and awarded $2.3 million to the plaintiffs. South Fulton Medical Center was absolved of liability.
In Friday's decision, the court determined that Mogen had to pay for medical expenses and for the years of psychotherapy that will be needed. The boy suffers pain when he urinates, the court order says. He will eventually be able to have sex, but he is likely to be embarrassed and will likely have trouble forming "meaningful" relationships with girls, it adds. "At 3 years old, L.G. is aware that he looks different from other boys based on both his own observations and comments from other children which make him feel inferior ."
I have never been a fan of this clamp (see method 1 here), and even the FDA has issued warnings against clamps because of their potential of irreversible damage
Simply put, no step in the circumcision procedure should be irreversible until the actual removal of the foreskin. Once the shield is in place, it is important to double check that the proper area of skin is ready to be excised. In the event the shield was initially applied incorrectly, it can simply be removed and repositioned - no harm done.
Once a clamp is put in place, anything in its clamping mechanism is essentially dead skin, and the excision/amputation which follows is irreversible.
PLEASE TELL ALL YOUR FRIENDS AND FAMILY - DO NOT ALLOW A MOHEL TO USE THIS DEVICE ON YOUR BABY, UNLESS HIS TRACK RECORD IS PERFECT WITH IT!
*****************************************************************************
Atlanta lawyer wins $11 million lawsuit for family in botched circumcision
By Ty Tagami
The Atlanta Journal-Constitution
Monday, July 19, 2010
The maker of an instrument used in circumcisions claimed that injury was impossible with its use, but after an infant lost a portion of his penis during an operation with the Mogen clamp, a judge awarded $10.8 million in damages against the company.
The judgment handed down Friday in New York involves an Atlanta lawyer who has been crusading against circumcision as a dangerous and unnecessary practice.
Attorney David Llewellyn won a similar case in Atlanta last year and the injury behind that prior lawsuit in Fulton County Superior Court put the New York clamp manufacturer on notice about the danger of the device, his current lawsuit said.
The baby in the current case, identified in court documents only as L.G., lost the entire glans, or head, of his penis after it was pulled into the jaws of the clamp, according to a federal magistrate's order. On Friday, U.S. District Judge Jack B. Weinstein ordered Mogen Circumcision Instruments of New York to pay $10.8 million in compensatory and punitive damages to the Florida boy, now 3, and his parents.
The parents "are extraordinarily distraught and angered that this company tells people it can't happen," Llewellyn said.
It's unclear whether they will ever collect the money. Mogen is already in default on a $7.5 million judgment in 2007 from a Massachusetts lawsuit, Llewellyn said.
The company is going out of business, according to a woman who answered the phone at its Brooklyn headquarters Monday. The woman, who said she was a secretary and would identify herself only as D. Rotter, the person whom Llewellyn said was served papers in the lawsuit. She said increased competition has undermined their business.
"It's just kind of dwindling down to nothing," she said, adding that the phones at the Mogen office were scheduled to be disconnected Tuesday. Mogen didn't defend itself in court, and Rotter said it was because the company couldn't afford it.
She said the Mogen clamp is "painless and safe" when used properly. The case involving the Florida boy was "unfortunate," she said, adding that "any medical mishap is unfortunate."
In this case, a New York mohel, or Jewish ritual circumcisor, performed the operation in the baby's home, Llewellyn said. The mohel negotiated a separate settlement, the terms of which Llewellyn would not disclose.
Llewellyn won another circumcision case in 2009 over an operation at South Fulton Medical Center. In that case, which involved a baby identified only as D.P. Jr., the mother contended that the doctor who circumcised him removed too much tissue and that his pediatrician failed to respond when a nurse complained of excessive bleeding.
The tip of the penis was placed in a biohazard bag and might have been reattached if he'd gotten attention in time, Llewellyn said in 2009. His lawsuit in New York says D.P. Jr. lost a third of his glans.
The jury found that both the pediatrician and the physician who performed the circumcision were negligent, and awarded $2.3 million to the plaintiffs. South Fulton Medical Center was absolved of liability.
In Friday's decision, the court determined that Mogen had to pay for medical expenses and for the years of psychotherapy that will be needed. The boy suffers pain when he urinates, the court order says. He will eventually be able to have sex, but he is likely to be embarrassed and will likely have trouble forming "meaningful" relationships with girls, it adds. "At 3 years old, L.G. is aware that he looks different from other boys based on both his own observations and comments from other children which make him feel inferior ."
Tuesday, December 15, 2009
Methods of Circumcision
Most parents looking to have their son circumcised just want it to be done as efficiently as possible, as speedily as possible, with minimal pain to the baby.
Of course they'd prefer the circumcision be aesthetically pleasing, and that the circumcision heals sooner than later with no complications.
When doing research about ANY mohel, the end results are important. (I've written elsewhere about the demeanor and the ceremony and the need for things to be done at your speed.) And most people leave the method to achieving those end results up to the mohel, and how he feels most comfortable getting there.
However, there is not "only" one way to circumcise. And if it is important to you, it is important to ask about methods, and to inquire if the mohel can accomodate your desires.
Please note that I use Method #2 presented below and as described at the end of this post.
There are some methods which are questionable according to some (in some cases, many) rabbinic opinions. There are others which are standard - even if the "innovation" in them is "only" hundreds of years old. And there is old-school, bare bones (literally), which is advocated by few.
Sadly, those who advocate the latter method often knock everyone else, even going so far as to declare other circumcisions "unkosher" and requiring hatafat dam brit - a ceremonial drawing of blood from the circumcision scar that would "kosherize" the bris. This is not only a form of lashon hara and rechilut (talebearing), but is a lie, a form of fear-mongering, and does nothing but increase hatred amongst Jews.
Hmmmmm. That last paragraph was a mouthful. Take a deep breath and let's move on to methods:
INTRODUCTION
Bris Milah has three steps:
1. Milah - the removal of the foreskin
2. Priah - the removal of the membrane that is found between the foreskin and the glans
3. Metzitzah - drawing of "distant" blood
The foreskin is drawn forward and removed. The membrane is often removed with the foreskin. If it is not completely removed, then it is torn and folded back beyond the glans. Finally, blood is drawn from the wound.
In the interest of space, the methods described will not include metzitzah, which will be the subject of different posts.
And I will leave the issue of whether the mohel is wearing gloves up to you, the parents, as well. I've addressed this in a number of posts already. [Search "sterility" in the keywords]
Method #1. Clamp
Of course they'd prefer the circumcision be aesthetically pleasing, and that the circumcision heals sooner than later with no complications.
When doing research about ANY mohel, the end results are important. (I've written elsewhere about the demeanor and the ceremony and the need for things to be done at your speed.) And most people leave the method to achieving those end results up to the mohel, and how he feels most comfortable getting there.
However, there is not "only" one way to circumcise. And if it is important to you, it is important to ask about methods, and to inquire if the mohel can accomodate your desires.
Please note that I use Method #2 presented below and as described at the end of this post.
There are some methods which are questionable according to some (in some cases, many) rabbinic opinions. There are others which are standard - even if the "innovation" in them is "only" hundreds of years old. And there is old-school, bare bones (literally), which is advocated by few.
Sadly, those who advocate the latter method often knock everyone else, even going so far as to declare other circumcisions "unkosher" and requiring hatafat dam brit - a ceremonial drawing of blood from the circumcision scar that would "kosherize" the bris. This is not only a form of lashon hara and rechilut (talebearing), but is a lie, a form of fear-mongering, and does nothing but increase hatred amongst Jews.
Hmmmmm. That last paragraph was a mouthful. Take a deep breath and let's move on to methods:
INTRODUCTION
Bris Milah has three steps:
1. Milah - the removal of the foreskin
2. Priah - the removal of the membrane that is found between the foreskin and the glans
3. Metzitzah - drawing of "distant" blood
The foreskin is drawn forward and removed. The membrane is often removed with the foreskin. If it is not completely removed, then it is torn and folded back beyond the glans. Finally, blood is drawn from the wound.
In the interest of space, the methods described will not include metzitzah, which will be the subject of different posts.
And I will leave the issue of whether the mohel is wearing gloves up to you, the parents, as well. I've addressed this in a number of posts already. [Search "sterility" in the keywords]
Method #1. Clamp
The foreskin and membrane are grasped with a hemostat and a clamp is applied to the foreskin. There are two kinds of clamps that have been utilized by mohels over the last sixty years. The first is the Gomco (on the right in the photo), which is often the method of choice for doctors in hospitals, but is not largely used by mohels. The second is the Mogen or Bronstein clamp (on the left), which is the method of choice for many mohels in the US (though most Orthodox mohels, including me, do NOT use it). The foreskin and membrane are then removed together in one incision, with a scalpel or bris knife.
Method #2. Shield
The foreskin and membrane are grasped either with a hemostat (as in method #1) or skillfully with the fingers. A metal plate with a thin slit is applied to the foreskin, leaving the foreskin resting above the plate, with the glans safely shielded below. A scalpel or bris knife is used to excise the foreskin.
If the membrane is removed along with the foreskin, metzitzah follows.
If the membrane is not completely removed along with the foreskin, it will either be cut with scissors, or the mohel will tear it with his sharpened thumbnails - in both cases to reveal the entire glans.
Method #3. Free hand
Without using any device other than a blade, the mohel will estimate the length of the foreskin, grasp it with the thumb and forefinger of one hand and excise the foreskin with the knife in his other hand.
Membrane removal will follow that of method #2. Metzitzah will follow.
PROS AND CONS OF THE METHODS
Obviously, the "con" of the baby having skin tissue removed and being subject to the pain of circumcision, and any bleeding are a given. If you are having your baby circumcised, it is assumed you understand that this is the down side (if you even view it as a downside) of the spiritual, national and Jewish significance attached to this procedure - which is the fulfillment of a commandment.
The pro: Baby bears the mark of the covenant established between God and Abraham, and all of the Jewish people, which established God as our only God, and we, the Jewish people, as His firstborn, the chosen people who have a mission on this earth to spread monotheism and ethics to as many people as we can.
Pros and Cons of #1 (Clamp)
Benefits include:
* Usually a bloodless circumcision.
* The mohel may not even need to use a bandage.
* If applied correctly, the glans is protected.
Cons:
* Usually a bloodless circumcision. (Blood is an essential element of the bris)
* Estimating the end of the foreskin along the shaft is inexact
* The FDA has issued severe warnings about the use of the clamp, as it could grasp and amputate the glans or the tip of the glans.
* The pain of the crushing of the foreskin is immense
* Once the clamping mechanism is applied, the estimation of the foreskin is irreversible. Even if one were to remove the clamp and then reapply it correctly before excising the skin, the skin tissue that remains would be dead, and would liekly either become the equivalent of a growth or fall off on its own.
* In order to achieve its desired effect, the clamp usually needs to be on for a significant amount of time - from 30 seconds to five or ten minutes. This is significantly longer than the next methods which take 3-4 seconds.
* Rabbinic approval is scant.
While Reform and Conservative mohels will often use this device, Orthodox mohels who use it usually do not have rabbinic dispensation to do so. Many will use it out of their own convenience (in other words, not because they have the baby's best interests in mind) so they need not come back and check the baby. This is not nice - every baby should be checked after the bris. No matter the method used.
Those who use it usually swear by it. I think they feel this way because of the lack of necessity to follow-up. But I may be wrong.
Pros and Cons of #2 (Shield)
Pros:
Quick procedure
* There is blood (necessary component of the bris)
* No chance of anything happening to the glans
* Until the actual incision is made, nothing is irreversible
Cons:
* Estimating the end of the foreskin along the shaft is inexact
* While the foreskin is not crushed, it is squeezed tightly for a few seconds.
The shield is an innovation which dates back at least four hundred years. It's purpose was (and remains) to protect the glans which is at great risk of being cut or amputated when a bris is done by anyone other than an extremely skilled operator. Like in the previous method, once the shield is in place, the actual removal of the foreskin - cutting along the shield, is the easiest part of the job.
Pros and Cons of #3 (Free-hand)
Pros:
* Quickest procedure
* Relatively painless
Cons:
* Estimating the end of the foreskin along the shaft is inexact
* There is no chance to second guess because the mohel never gives himself a chance to double check before excising the foreskin
* The possibility exists that the blade might cut the glans
* If done by anyone other than a skilled operator, the outcomes could be disastrous
The only people who still do brisses this way are some Chassidic Jews. While each person is entitled to have an opinion, those who do it this way are the most outspoken about - and against - any other form of circumcision.
THEREFORE
You may have noticed that the con that reads "Estimating the end of the foreskin along the shaft is inexact" was on every "con list." This is because many mohels were never taught to use a surgical pen to mark the edge of the foreskin before beginning the procedure. If the mohel's initial estimation is marked with a pen or marker, the "con" is removed from each list, as long as the mohel makes sure to cut along the mark.
I wrote about pain in the last few sections of this post. In simple terms, I think it is important to numb the area before the bris, but I think injections are not the way to go about doing it. There are topical methods out there that do just as good a job, and don't cause the baby pain from three "shots."
My Method
In addition to marking the end of the foreskin, I use Method #2 for a host of reasons. While I personally do not agree with methods #1 and #3, I believe that the bris is kosher if the operator is fit to be a mohel. I also think that parents should know what they are getting in to when hiring a mohel, and that the method which best suits your needs should be employed for your son.
When I circumcise, I aim to remove the foreskin and membrane at the same time, to minimize pain to the baby and the need to bother him too much. I always check the baby later, either a few hours after, the evening after, or the day after the bris. I wear gloves. I package all my instruments and bandages and sterilize everything in an autoclave machine - unless it is sterile in its packaging, e.g. gloves and drapes.
I hope this has been helpful to you. As always, feel free to contact me by email with any questions, or call me
* Rabbinic approval is scant.
While Reform and Conservative mohels will often use this device, Orthodox mohels who use it usually do not have rabbinic dispensation to do so. Many will use it out of their own convenience (in other words, not because they have the baby's best interests in mind) so they need not come back and check the baby. This is not nice - every baby should be checked after the bris. No matter the method used.
Those who use it usually swear by it. I think they feel this way because of the lack of necessity to follow-up. But I may be wrong.
Pros and Cons of #2 (Shield)
Pros:
Quick procedure
* There is blood (necessary component of the bris)
* No chance of anything happening to the glans
* Until the actual incision is made, nothing is irreversible
Cons:
* Estimating the end of the foreskin along the shaft is inexact
* While the foreskin is not crushed, it is squeezed tightly for a few seconds.
The shield is an innovation which dates back at least four hundred years. It's purpose was (and remains) to protect the glans which is at great risk of being cut or amputated when a bris is done by anyone other than an extremely skilled operator. Like in the previous method, once the shield is in place, the actual removal of the foreskin - cutting along the shield, is the easiest part of the job.
Pros and Cons of #3 (Free-hand)
Pros:
* Quickest procedure
* Relatively painless
Cons:
* Estimating the end of the foreskin along the shaft is inexact
* There is no chance to second guess because the mohel never gives himself a chance to double check before excising the foreskin
* The possibility exists that the blade might cut the glans
* If done by anyone other than a skilled operator, the outcomes could be disastrous
The only people who still do brisses this way are some Chassidic Jews. While each person is entitled to have an opinion, those who do it this way are the most outspoken about - and against - any other form of circumcision.
THEREFORE
You may have noticed that the con that reads "Estimating the end of the foreskin along the shaft is inexact" was on every "con list." This is because many mohels were never taught to use a surgical pen to mark the edge of the foreskin before beginning the procedure. If the mohel's initial estimation is marked with a pen or marker, the "con" is removed from each list, as long as the mohel makes sure to cut along the mark.
I wrote about pain in the last few sections of this post. In simple terms, I think it is important to numb the area before the bris, but I think injections are not the way to go about doing it. There are topical methods out there that do just as good a job, and don't cause the baby pain from three "shots."
My Method
In addition to marking the end of the foreskin, I use Method #2 for a host of reasons. While I personally do not agree with methods #1 and #3, I believe that the bris is kosher if the operator is fit to be a mohel. I also think that parents should know what they are getting in to when hiring a mohel, and that the method which best suits your needs should be employed for your son.
When I circumcise, I aim to remove the foreskin and membrane at the same time, to minimize pain to the baby and the need to bother him too much. I always check the baby later, either a few hours after, the evening after, or the day after the bris. I wear gloves. I package all my instruments and bandages and sterilize everything in an autoclave machine - unless it is sterile in its packaging, e.g. gloves and drapes.
I hope this has been helpful to you. As always, feel free to contact me by email with any questions, or call me
Monday, October 12, 2009
The Danger of Arrogance
Before you read this, please note: I share this conversation with you not to scare you, but to help you become aware of the possibilities out there, and to know there are ways to avoid many of the problems discussed here. My suggestions appear at the end of this entry, so please make sure to read through to the end.
Over the weekend I had an interesting conversation with a pediatrician friend of mine. Our discussion drifted towards the topic of this blog (circumcision) and he shared with me some horrific stories of circumcisions that came to his attention after the fact, when there was a problem.
Mild Problems
In cases where the baby is a bleeder, or the mohel needs help in containing the bleeding, the baby either needs to be sutured (a couple of stitches), cauterized, or, in some cases, better pressure needs to be applied to seal the wound. In some cases, different products that are often used to help coagulation can also be applied to stop the bleeding, without the need for the stitches or cauterization.
Thank God, I have never needed to send a baby to the hospital: I ask about hemophilia in advance, and I was trained very well in the skill of bandaging.
Different Problems
There is a small margin of difference between removing too little skin and removing too much skin.
Too little
Pros: easily correctable, no long term damage, might not need a correction
Cons: Baby may look uncircumcised for a long time, may need to be corrected, Baby has to go through two procedures (One person told me a story of how his son had a second Bris because the first was considered meaningless.)
Too much
Pros: Baby will definitely look circumcised. There won't be a need for any cosmetic adjustments
Cons: circumcision scar will be enormous. Sex (as an adult) will be a less pleasurable (perhaps more painful) experience.
All in all, these are a matter of debate regarding the pros and cons. Obviously a perfect circumcision every time would be preferred. But as all mohels (like all doctors) are human and are by definition not perfect, the guarantee of perfection would be dishonest. Instead, we do the best we can.
Below, I will explain steps that can be taken to help avoid these problems.
[See this posting about the different methods for how to do a bris]
Bigger Problems
My pediatrician friend described to me examples of children he examined who had been damaged by the mohel. "Damage" does not refer to brisses which are not 100% cosmetically beautiful - those are common enough and are no cause for concern. The penis generally heals nicely and functions normally.
But when the glans is nicked in the process (through the removal of the foreskin, a bris exposes the glans to the edge of the corona), or cut or [shudder] amputated, this is real damage. If an artery that can not be controlled through simple mohel techniques is somehow cut, we have a real problem.
The DANGER of ARROGANCE
Most mohels are trained by expert mohels in Israel or the US. If they follow the instructions of their teachers and do not look for shortcuts to make the process quicker, they can do no damage to the babies on whom they operate.
But if they think they know better, and worse, declare that they are the only ones who know how to circumcise and that others do not do "kosher brisses" because of the methods they employ to protect the baby - this is not only arrogant. It is stupid.
Methods ALL Mohels Should Employ
To reduce the negative possibile outcomes of a bris significantly, there are two steps I highly recommend. Most mohels already do the first in one form or another. Very few do the second. They are:
1. Use a Shield - a device that protects the glans during the incision. Whether one uses a traditional shield, or a clamping device such as the Bronstein/Mogen clamp, if the glans is pushed out of the way when the shield or clamp is applied, it will not be damaged in any way by the circumcision. (There are FDA problems and halakhic (Jewish law) problems with some clamps)
2. Outline the edge of the foreskin with a marker before beginning the procedure - This will reduce the "margin of error" significantly, and will assure a significantly better chance of having a clean and even incision all around.
The Arrogance
If a mohel decides he can do a better job freehand (using just his fingers to hold the foreskin, and a knife to excise, without using a shield to guide his incision and protect the glans - see method 3 here), I maintain that he is a fool and should not be allowed to operate.
To suggest that "God wants it to be done this way" is arrogance of the highest order.
I am not suggesting that I know what God wants any better than someone else. As a Jew who believes in the Torah, I believe God wants us to circumcise our sons, and that there are a few other requirements as to what is supposed to take place during a bris.
But I also believe that we are to take every precaution to assure that the chances of danger to the child beyond the inherent danger of removing skin tissue (the definition of the bris circumcision) be reduced to an absolute minimum.
I repeat (and add):
EVERY mohel should use a device that guards the glans
EVERY mohel should mark the edge of the foreskin before beginning
EVERY mohel should wear sterile gloves
EVERY mohel should maintain a sterile field during the bris
EVERY mohel should not allow any part of his body to come in direct contact with the open wound during or after the bris.
With proper monitoring and education, we can minimize the negative bris stories as we take charge in taking good care of our sons.
Over the weekend I had an interesting conversation with a pediatrician friend of mine. Our discussion drifted towards the topic of this blog (circumcision) and he shared with me some horrific stories of circumcisions that came to his attention after the fact, when there was a problem.
Mild Problems
In cases where the baby is a bleeder, or the mohel needs help in containing the bleeding, the baby either needs to be sutured (a couple of stitches), cauterized, or, in some cases, better pressure needs to be applied to seal the wound. In some cases, different products that are often used to help coagulation can also be applied to stop the bleeding, without the need for the stitches or cauterization.
Thank God, I have never needed to send a baby to the hospital: I ask about hemophilia in advance, and I was trained very well in the skill of bandaging.
Different Problems
There is a small margin of difference between removing too little skin and removing too much skin.
Too little
Pros: easily correctable, no long term damage, might not need a correction
Cons: Baby may look uncircumcised for a long time, may need to be corrected, Baby has to go through two procedures (One person told me a story of how his son had a second Bris because the first was considered meaningless.)
Too much
Pros: Baby will definitely look circumcised. There won't be a need for any cosmetic adjustments
Cons: circumcision scar will be enormous. Sex (as an adult) will be a less pleasurable (perhaps more painful) experience.
All in all, these are a matter of debate regarding the pros and cons. Obviously a perfect circumcision every time would be preferred. But as all mohels (like all doctors) are human and are by definition not perfect, the guarantee of perfection would be dishonest. Instead, we do the best we can.
Below, I will explain steps that can be taken to help avoid these problems.
[See this posting about the different methods for how to do a bris]
Bigger Problems
My pediatrician friend described to me examples of children he examined who had been damaged by the mohel. "Damage" does not refer to brisses which are not 100% cosmetically beautiful - those are common enough and are no cause for concern. The penis generally heals nicely and functions normally.
But when the glans is nicked in the process (through the removal of the foreskin, a bris exposes the glans to the edge of the corona), or cut or [shudder] amputated, this is real damage. If an artery that can not be controlled through simple mohel techniques is somehow cut, we have a real problem.
The DANGER of ARROGANCE
Most mohels are trained by expert mohels in Israel or the US. If they follow the instructions of their teachers and do not look for shortcuts to make the process quicker, they can do no damage to the babies on whom they operate.
But if they think they know better, and worse, declare that they are the only ones who know how to circumcise and that others do not do "kosher brisses" because of the methods they employ to protect the baby - this is not only arrogant. It is stupid.
Methods ALL Mohels Should Employ
To reduce the negative possibile outcomes of a bris significantly, there are two steps I highly recommend. Most mohels already do the first in one form or another. Very few do the second. They are:
1. Use a Shield - a device that protects the glans during the incision. Whether one uses a traditional shield, or a clamping device such as the Bronstein/Mogen clamp, if the glans is pushed out of the way when the shield or clamp is applied, it will not be damaged in any way by the circumcision. (There are FDA problems and halakhic (Jewish law) problems with some clamps)
2. Outline the edge of the foreskin with a marker before beginning the procedure - This will reduce the "margin of error" significantly, and will assure a significantly better chance of having a clean and even incision all around.
The Arrogance
If a mohel decides he can do a better job freehand (using just his fingers to hold the foreskin, and a knife to excise, without using a shield to guide his incision and protect the glans - see method 3 here), I maintain that he is a fool and should not be allowed to operate.
To suggest that "God wants it to be done this way" is arrogance of the highest order.
I am not suggesting that I know what God wants any better than someone else. As a Jew who believes in the Torah, I believe God wants us to circumcise our sons, and that there are a few other requirements as to what is supposed to take place during a bris.
But I also believe that we are to take every precaution to assure that the chances of danger to the child beyond the inherent danger of removing skin tissue (the definition of the bris circumcision) be reduced to an absolute minimum.
I repeat (and add):
EVERY mohel should use a device that guards the glans
EVERY mohel should mark the edge of the foreskin before beginning
EVERY mohel should wear sterile gloves
EVERY mohel should maintain a sterile field during the bris
EVERY mohel should not allow any part of his body to come in direct contact with the open wound during or after the bris.
With proper monitoring and education, we can minimize the negative bris stories as we take charge in taking good care of our sons.
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