An 11-week-old male infant, was admitted with a history of accidental glans amputation during a circumcision performed by a health personel. The infant, born at 38 weeks gestation with a birth weight of 3.1 kg, had initial APGAR scores of 8 and 9 at 1 and 5 minutes, respectively. He was sent, by his parents, to a local non-surgeon, non-doctor for out-of -hospital circumcision. Following the circumcision (see Fig. 1), the infant experienced uncontrolled bleeding from the penis and was unable to urinate initially: but later passed urine. He was rushed to a nearby district hospital where haemostasis was secured using haemostatic sutures; after which he was referred to us at the teaching hospital (Fig. 1). There was no past personal history of bleeding disorders.
Upon admission, the infant appeared pale (Hb = 7.2g/dl) but well-hydrated. Temperature was 36°C, a pulse of 78 bpm, and an SpO2 was 99% on room air. Physical examination revealed a 1 cm flush-amputation of the glans penis (visible absorbable haemostatic sutures in the wound bed) with no active bleeding. The patient was a male infant with no dysmorphic features. He had bilateral fully descended testicles, and no congenital penile anomalies. No family history of bleeding diasthesis known, platelet count and clotting profile were normal.
At the emergency department where they were received, the patient was administered intravenous antibiotics, and tetanus prophylaxis, and a surgical consultation was promptly sought. During the course of the management, the patient required a transfusion of 90 mls of concentrated red blood cells to optimize him. No transfusion adverse reaction was experienced.
For the definitive management, the infant underwent buccal mucosa graft glansoplasty, with meatoplasty. The surgical procedure involved the use general anaesthesia with cuffed endotracheal tube. A 2 cm by 1.5 cm buccal mucosa graft was harvested from the left cheek (Fig. 2), with care to safeguard the Stensen's duct. The graft was de-fatted and used to repair and re-fashion the amputated glans, using absorbable sutures [polyglactin 910 (Vicryl), size 3 − 0]. A meatoplasty was also done apposing the inner border of the buccal mucosa graft and the distal aspects of the remnants of the nacent urethra (see Figs. 3, 4, 5).
An 8-French urethral catheter was passed to safeguard the meatoplasty until adequate healing was achieved (day 10). Postoperative care included regular vitals-check, wound dressing and, 120 hours of intravenous third generation cephalosporins, metronidazole and anaelgesia.
The infant experienced mild complications of slightly laboured breathing post-extubation, managed with respiratory support and adjusted medication. Over the following days, the patient’s condition improved significantly, with normal breastfeeding with adequate oral occlusion at suctioning, and satisfactory wound healing, at both the donor and receipient sites (Figs. 6 and 7). Graft take was good. Donor site edema was minimal. Client’s parents were satisfied with the outcome.