Tools of the Trade VI - Forceps

Of course there are different kinds of forceps!  (Why are you thinking of these ?)

This is not a bris instrument

These forceps (the ones I use) look more like large tweezers to most people - and that's what they are.

Some people might use it to grab skin they need to contend or deal with in the scheme of bandaging.

I use them as the sterile go-between from my hands, to pick up or move sterile instruments or
bandages when I'm setting things up before I've put gloves on.

Because a bris takes places in stages - prep, circumcision, checking baby afterwards - there is a lot of shifting between gloves and sterility to non-sterility. As a result, there are times when it is helpful to have an extension of the hand whose tip touches nothing but sterile items, while its handle comes in contact with a clean-but-not-sterile hand.

Tools of the Trade V - Hemostats and Scissors

Straight Hemostat

I know, I know. They all look like scissors. And while one of them certainly IS a pair of scissors (see below), I assure you that the others ones are not cutting implements. Or instruments, for that matter.

So what are they for?

The straight hemostat is the key ingredient that allows for this form of bris to take place. Its job is to grab the foreskin and the membrane beneath it at the same time so the circumcision can take place in one-step.

Blunt edged scissors

Bent Hemostat

The bent hemostat and the blunt scissors are sometimes used, to remove the "tzitzin ha'm'akvin" - the extra membrane, or the inexact skin that may have resulted from the bris. This is not specifically the mohel's fault or the result of a job poorly-done, as much as it is just the circumstances and the reality. (Sometimes it might be the mohel's fault, but he is taking the opportunity to fix it in a manner that he can). Why blunt? So it doesn't poke or stab the baby - our goal is foreskin and membrane removal, nothing more.

Remember that the mohel's job is to produce an as-beautiful-as-possible circumcision. And he does not have the benefit of the privacy of the operating room to do that. This is why some cases produce the need for the two-step process, which is probably better presented as "making things pretty."

Simply put, these are primarily the back-up instruments the mohel carries in his bag-of-tricks, which come in handy sometimes or often.

Of course, there are mohels who will claim to never use them. They are either VERY expert mohels, or they are not sharing everything about themselves. :)

Tools of the trade IV - Probe

The Probe is used to separate the mucosal membrane from the glans before circumcision.

A quick anatomy lesson is in order - I will explain using a simple model.

Imagine you are wearing a cuffed shirt and a jacket. Pull both sleeves - of shirt AND jacket - over your fist. The fist = the glans of the penis, your shirt cuff = the mucosal membrane below the foreskin, your jacket over the shirt cuff = the foreskin. Now imagine your sleeve is attached to your fist through natural adhesions.

In a "kosher bris" circumcision, the goal is to get both the foreskin and membrane removed completely from the glans. This is why the term Or HaPriah (עור הפריעה) is used for the membrane - it is the "skin" (mucosal membrane really) that must be removed (after the foreskin is removed) in order to completely uncover (פרע) the glans.

Were we to only circumcise your jacket, the cuff of your sleeve would remain. Your fist would appear uncircumcised, and, in fact, your jacket might grow back.

This is why both the foreskin AND the membrane must be removed. The first step in achieving the goal of removing the membrane is breaking apart the adhesions that attach the membrane to the glans. This is accomplished with a probe.

The probe is inserted through the front of the foreskin and is moved around the outer edge of the glans (with care taken not to enter the meatus (the hole of the glans)) so the adhesions can be separated. this allows for the mohel to grab the foreskin and most (or all) of the membrane in one fell swoop.

Some old school mohels do not use a probe and they try to accomplish the same thing with their fingernails. They claim it is less painful to the baby to work mostly with fingers and less with "instruments."

I say, We all want to minimize discomfort to the baby. But we should also want to give the baby the best circumcision possible, while following the dictates of our law in using recognizably useful instruments. So whether a mohel uses a single-tipped or a double-tipped probe, it is an instrument which is helpful, important, and advisable to use to help that membrane be accessed easily.

Tools of the Trade III - Double Edged Knife

Traditional Izmel - double-edged knife

Modern Innovation - the Double-Edged Scalpel

Tehillim (Psalms 149)

6Lofty praises of God in their throats and a double-edged sword in their hands,

ורוֹמְמוֹת אֵל בִּגְרוֹנָם וְחֶרֶב פִּיפִיּוֹת בְּיָדָם

What are we supposed to use to excise the foreskin?

שולחן ערוך יורה דעה הלכות מילה סימן רסד: סעיף ב

בכל מלין, ואפילו בצור ובזכוכית ובכל דבר הכורת, חוץ מבקרומית של קנה, לפי שקסמים נתזים ממנו ויבא לידי כרות שפכה. יז] ומצוה מן המובחר למול בברזל, בין בסכין בין במספרים, ונהגו למול בסכין. 

The Shulchan Arukh YD 264:2 says: We circumcise with anything: even a stone, glass, or anything that cuts. Except for a reed, because it has splinters with may cause damage [to an important tube]. It is an enhanced form of the mitzvah to do the circumcision with steel - whether with a knife or with scissors. But the custom is to use a knife. 

The Midrash attaches the above verse from Tehillim to the concept of Bris Milah, suggesting that the knife that should be used should be like a double edged sword. 

The problem with the more "traditional" knife is that it needs to be sharpened, and then sterilized. But the sterilization then makes the knife less sharp. So one is faced with the Catch-22 of wanting the knife to be as sharp as possible, and also wanting it to be sterile and still sharp.

As a result, the double edged scalpel was created in recent years, to maintain the Midrashic custom of a double edged sword, while at the same time allowing for a scalpel that is for one time use, that is sharpened in the best way (with a laser?) and sterilized. 

Many mohels (including I) use a single-edged and single-use scalpel blade because it removes the need to sharpen or sterilize (scalpel blades come that way) and it allows for the swiftest (and hopefully least painful) circumcision. I have seen mohels use a back-and-forth motion (shudder!) while really all that is needed is a smoothe incision.

Could I look into getting the double-edged scalpel? I suppose. But it's not necessary. At most it is a (likely kabbalistic) stringency. The main mitzvah is to have the foreskin removed.

[I've joked in the past that the need to have a double-edged scalpel is good for the mohel who can't otherwise see, and is not sure which side is the sharp one. Of course if the mohel can't see....]

Tools of the Trade II - The Metzitzah Tube

Metzitzah - previously unknown outside of the insular world of bris milah, now a household word. What is it? Why is it done? Isn't it barbaric? Is it safe? 

I've addressed all these questions - and several essays on the subject appear on the Metzitzah Page. There is also a youtube video linked there in which the two methods of metzitzah are demonstrated.

In this posting, we are going to understand what the tubes featured so beautifully in this picture I borrowed from these guys is for, and how it is used. 

The goal of metzitzah is to draw "distant bloods" from the spot of the circumcision. While some accomplish this through squeezing the fresh circ with sterile gauze, the more traditional way to do metzitzah is with the power of the mouth. Metzitzah B'feh is often translated to mean "Suction with the mouth" and it is accomplished in one of two ways.

1. Putting the mouth directly on the wound (yes - you read correctly)

2. Putting a sterilized tube over the penis, creating a vacuum, and using the tube like a straw (goal is to draw blood out, not to get blood in mouth)

The bottom part of the photo is where the mohel puts his mouth. The top part of the photo is the part that fits easily over the baby's organ immediately post-foreskin-excision.

In my case, I put gauze in the tube to avoid any transfer of fluids between parties. It does not deter the vacuum power created when the tube is applied properly.

For traditional Jews who continue to practice metzitzah (much longer discussion for why - see Metzitzah page), this should be the preferred method over placing a mouth on a fresh wound, as putting a sterile tube on an open wound is no different than putting a sterile gauze pad on the fresh wound.

It removes any possibility for a "problem," and it brings honor to a practice that is a vestige from an ancient time, that, unlike circumcision which has a Biblical source and continues to be a hallmark of the Jewish people's identity, metzitzah has no Biblical basis, and need not take place at all for the circumcion to be kosher. 

Tools of the Trade I - the Shield

What IS that thing?

I remember the first time I actually looked at the instruments the mohel lays out on the table, I saw that device and thought "O my God. It's an amputator!"

Of course, as I was probably around 9, I don't think I knew the word amputate yet, so this might be a little revisionist.

BUT - the truth is - that is NOT an amputator. It is actually the most important device a mohel could own. It is called a shield - in Hebrew, a "Magen" (מגן), and it's goal is to shield all the parts we don't want to cut from being nicked or otherwise by the scalpel/blade we use to excise the foreskin.

The parts we don't want to cut include the glans, the scrotum, the baby's belly, not to mention the sandak's hands.

When a traditional bris milah is performed, the foreskin is grabbed and drawn foreward, and this shield is applied in such a manner that the only thing on the outside is the foreskin, while below it is everything else. The mohel simply cuts along the shield, and the circumcision is complete.

The best way to know exactly where to apply that shield, because once foreskin is being drawn forward all the skin looks the same and can result in an uneven cut, or a taking off too much or too little cut, is to draw a line on the foreskin following the circumference of the highest point of the glans all around.

Once the line is drawn and the foreskin is drawn forward correctly, a simple (and correct) application of the shield along the surgical line will result in a beautiful circumcision, and a baby who is otherwise protected from anything beyond our stated goal of removing the foreskin.

Please note the Magen above is not to be confused with this device - called the MOGEN Clamp. I do not own a Mogen Clamp (more about clamps here) and I do not recommend its use. There are mohels who use it - hopefully with good care and with positive results. But Google "Mogen Clamp" before you allow any mohel to use it on your son.

MOGEN Clamp

Here is a picture of a silver Magen/shield (I had other pictures, but Google sometimes takes them away)

Available, With Flexibility

A sizable percentage of my recent brisses have come to me by way of the Internet, often from people who found themselves, late in the game, without a mohel.

Usually I'll get a call the day the baby is born, or the day after, but I've been seeing a trend of people calling 1, 2, or 3 days before the bris.

Weird, I know.

Sometimes they "forgot" to arrange something.

Sometimes they just realized what a bris is.

Sometimes the mohel they hired cancelled on them.

Sometimes they were waiting to call because the baby had a medical condition that delayed the bris.

No matter the reason, from a Jewish perspective, the more on-time a baby can get his bris taken care of, the better it is. If we can make it work schedule-wise and parents have the flexibility to work within my availability at such later notice (and me with them too!) the role to bring these babies into the mark of the Covenant is a role I continue to cherish.

Even at late notice. :)

Well, That Was Flattering

I got a call on Tuesday, "Hi. Are you available for a bris on Thursday?"

It isn't common to be called so late in the game, unless something happened - a mohel cancelled, or the situation is complicated.

Before I got to ask questions such as, "Is the baby ok? Is his mother Jewish?" etc., my mind starting racing... Thursday? Wait... that's.... PURIM

OK. I've had brisses on Purim before - not the most convenient day, but still, a bris on the 8th day is a bris on the 8th day.

"Where are you located?"

"North Orlando."

O.

Translate to my squeezing 6 hours worth of driving into an already full Purim-day schedule - I said I don't think I can do it. And I called a colleague, asking if he's available - I'll give them his name if he has the time.

I called back the parents, I'm not available, but my friend is.

"We'll call you back."

I get a callback from the father - to whom I had explained my Purim conflicts, and he said, well, "What if we do it at the Chabad of Melbourne, FL - a.k.a "Chabad of the Space and Treasure Coasts."

You'd be willing to drive over an hour from your home to have the bris in Melbourne, just so I can take off 2.5 hours of  my own drive, so I can make it?

"Yes. We've done our research. Really liked what we read in your blog. And we really want you to be our son's mohel."

How could I say no? I planned for the Purim bris.

Later that night, or on Wednedsay (it's all a blur by now), the father called me to tell me the baby's jaundice (bilirubin count) was rising, and that they were going to have the bris on Sunday, would I be available?

I told them what I always tell people who are concerned about a mid-level bilirubin count. "I think your baby's numbers are fine. He should have his bris on Purim. I can make it that day if you do the bris in Melbourne. It's your call."

They decided - based on the input of their rabbis, to delay the bris to Sunday. Which was today!

I left my house at 5:30am to arrive 8:15 for davening, and for the 9am bris.

I am grateful that it worked out this way, that everyone is happy (with the bris being delayed slightly, etc).  I've had phone calls before when people were "disappointed" if I wasn't available. But they usually take the next mohel's number and move on. I can't recall the last time people were willing to so accommodate their own schedule and inconvenience themselves just so I could be their son's mohel. It was quite atypical and very flattering. Thank you!

My Gratitude and Your Responsibility As a Parent

Last week I was privileged to serve as the mohel for an Israeli family living in the Aventura area. I doubt this information will be enough to identify them. :)

The baby's mother called me for the first time around 3 months ago, after scouring my website. She had a lot of questions. We talked about a lot of things, mostly sterility, track record, healing time, what happens with the baby afterwards.

To make a long story just a little shorter than it could be, they hired me. The bris went beautifully. And all is good. I am always grateful for the trust parents put in my mohel-skills, and I thank God that this is the run-of-the-mill experience we share together.

When I called around a week after the bris to see how baby is, she told me that a friend of hers just used a certain mohel - who caters to a large segment of the Israeli population in Hollywood, Aventura, etc - and the child had bleeding problems and needed to go the hospital, where he was placed on antibiotics for an infection, and kept there for 3 days.

The woman I serviced was shocked and dismayed, and I am horrified as well. Because, except in the rare case of previously undetected hemophilia, THIS SHOULD NEVER HAPPEN.

My "client" told me her friends ridiculed her for hiring me (they don't know me), and for not going with the go-to guy. The difference, she told me, is that she researched this, made many phone calls, interviewed mohels, and determined, through what she found, who was best for her family and situation. And was so pleased with our encounters that she said, "When we have our next son, I'm calling you first!"

This particular mohel in question has a track record of sending kids to the hospital. I have spoken to several doctors who have treated his patients. He might be a nice man when dealing with people. But he badmouths every mohel in South Florida, tells parents he is the only one who gives a "kosher brit," while he doesn't wear gloves or use safety techniques to protect the baby from harm. All of which, of course, is disgraceful behavior.

so here it comes; YOUR RESPONSIBILITY AS A PARENT

Do your Research
Know What Questions to Ask
Know What Answers You are Looking For
And remember, we are dealing with YOUR BABY and NOT the MOHEL'S EGO

If your mohel has an excellent track record, and babies never go to the hospital because of his work, Baruch Hashem, great.You still owe it to him to do your research.

I thank God EVERY DAY that no baby that I have circumcised has ever needed medical intervention as a direct result of the bris I have done. I bless every mohel and parent to have a similar track record.

The Photo That Went Viral

Yesterday's bris was for a baby who was born on the smaller side - around 4 lbs 10 oz - so his bris was delayed until he got a little bigger and stronger.

Immediately after the bris, his mother pulled out a shirt her friend had given her. It was super cute - and quite culturally in tune.

As of this writing it has been shared dozens of times, and seen by over 15,000 people, according to Facebook's stats. 

What do you think?

OK. This is the best shirt ever.
Posted by Rabbi Avi Billet, Mohel on Tuesday, March 15, 2016