Circumcision is one of the most common surgical procedures performed around the world, and is performed for religious, cultural, social and medical reasons, most commonly in the neonatal period.1 Currently, it is estimated that roughly one third of all men worldwide are circumcised, especially in Muslim, Jewish and certain in African populations.2 Neonatal circumcision is almost universally performed in Pakistan as per Islamic traditions, and choice of a safe, effective and acceptable surgical technique is important clinically.3 The improvement in neonatal surgery and pain control has led to an increasing trend in circumcising children in the neonatal period due to decreased complication rates, quicker recovery, decreased procedure costs and better cosmetic results compared to circumcision during childhood.4

There are several surgical methods for neonatal circumcision such as plastibell device, gomco clamp, mogen clamp, sleeve resection and dorsal slit surgery.5 Of these, the simplest, cheapest and most easily performed is the plastibell device and dorsal slit circumcision in South Asian countries.6 A plastic ring is placed under the foreskin and then sutured in place (known as the plastibell method), which causes the distal foreskin to become ischemic and to necrose.7 Usually the plastic ring separates on its own in 4-7 days. The technique is known to typically have little blood loss during surgery, short surgery time, and good cosmetic outcome. But sometimes complications with ring separation, ring retention, infection, ring migration and urinary obstruction have been reported.

The dorsal slit technique is a traditional open surgery technique, where the foreskin is first cut down the middle, and then cut around.8 This procedure provides direct visualization of anatomical structures and allows precise control of hemostasis. It can be especially helpful with neonates who have a tight prepuce or anatomical variation. Dorsal slit circumcision does not leave the problem of retained plastibell rings, but may necessitate longer operating time, careful suturing or cauterization of the bleeding and increased postoperative wound care. Bleeding, edemas, wound infection and delay in healing are still minor risks.

Both these procedures are widely accepted and there is an ongoing debate on which of the two techniques would provide better clinical results. Previous studies have shown variable results regarding operative time, postoperative pain, bleeding, infection rates, wound healing, cosmetic appearance and parental satisfaction. Several investigations have shown that the Plastibell method is faster, and that there is less bleeding during the operation, while other investigations have shown that there are higher rates of retained rings complications.9 In contrast, dorsal slit circumcision may be associated with greater immediate postoperative pain, but is also reported to have more predictable healing.10 The results of the studies have been inconsistent due to differences in surgeon experience, patient selection, follow up time, and criteria used for assessment.

Parental satisfaction is now an important outcome measure as it is the parents who eventually take care of the wound after surgery, watch for the development of complications and assess cosmetic appearance.11 Procedural safeties, ease of postoperative care, healing time, cosmetic outcome, infants discomfort and need for more medical visits are among the factors affecting parental satisfaction. However, in many studies published, the focus has been on surgical outcome, leaving parental perceptions somewhat neglected.

Very few studies exist in countries like Pakistan where neonatal circumcision is routinely conducted in both public and private health care institutions to compare both these techniques.12 Locally generated data are crucial to help surgeons, paediatricians and parents choose the most suitable circumcision technique, which can help to ensure fewer complications and better outcomes.

Thus, the current prospective comparative study was aimed at comparing the two methods, plastibell circumcision and dorsal slit circumcision in neonates regarding their operative time, postoperative complications, healing outcomes, and parents' satisfaction. The results would yield evidence-based guidelines to best practice in neonatal circumcision and better surgical care.

Study Design The aim of this prospective comparative study was to compare the outcome of plastibell and dorsal slit circumcision in neonates. Operative duration, blood loss during operation, postoperative complications, wound healing and parent satisfaction were compared between the two surgical techniques. To provide a standardized analysis of perioperative and follow-up results, a prospective comparative design was chosen. Study location and duration. The data was collected from January 2023 to December 2024 in the Department of Pediatric Surgery, Abbottabad International Medical College and Teaching Hospital (AICTH), Abbottabad, Pakistan. All procedures were done as day care surgeries by experienced pediatric surgeons using standardised surgical procedures. Sample Size A consecutive sampling of 130 healthy male neonates for elective circumcision was included in the study. The participants were also split into 2 groups: • Group B (n = 65): Gomco clamp circumcision. • Group B (n = 65): Dorsal slit circumcision. The sample size was deemed to be sufficient to identify clinically significant differences between the two techniques in terms of operative time, postoperative complications, healing outcomes and parental satisfaction. Inclusion Criteria Inclusion criteria were male neonates aged 1–28 days with parent's request to circumcise and written informed consent. Only normal full-term neonates without congenital penile malformations were considered eligible. Exclusion Criteria Neonate with hypospadias, epispadias, chordee, buried penis, bleeding disorders, severe neonatal jaundice, local genital infection and systemic illness were excluded from the study. Surgical Procedure Preoperative clinical evaluation of all neonates was performed. Circumcision was carried out in a strict aseptic surgical environment, under ring penile nerve block with 2% lidocaine. An adequate sized plastibell ring was chosen and placed under the foreskin in the Plastibell group, tied off with a ligature and excess foreskin removed. In the dorsal slit group, a dorsal slit was opened and a complete dorsal and circular circumcision was done ensuring meticulous hemostasis. Operative time was calculated from the first surgical cut to when the dressing was finished. All parents were given standard postoperative care instructions and given oral paracetamol. Data Collection Preoperative demographic data, such as age and body weight, were collected. Operative time, intraoperative bleeding, postoperative complications (bleeding, infection, edema, retained plastibell ring, delayed healing, re-intervention), wound healing and parent satisfaction were primary outcome measures. The neonates were followed up on postoperative day 3, 7, 14 and 4 weeks. Parental satisfaction was conducted at the fourth postoperative week using a structured questionnaire with 5 point Likert scale (1 = very dissatisfied & 5 = very satisfied). Statistical Analysis IBM SPSS Statistics software version 26.0 was used for data entry and analysis. Data for continuous variables were reported as mean ± standard deviations while the categorical variables were expressed as frequencies and percentages. Independent Student's t-test was applied for continuous variables and Chi-square or Fisher's exact test was applied for categorical variables. A p-value < 0.05 was considered statistically significant. Ethical approval was obtained from the Institutional Research Ethics Committee of Abbottabad International Medical Collegebefore commencement of the study. All participating neonates had written informed consent of their parents or legal guardians.

A total of 130 healthy male neonates were included in the study. The Plastibell group (n = 65) and the Dorsal Slit group (n = 65) were equally divided. There were no significant differences (p > 0.05) in baseline demographic characteristics between the two groups and they appeared well matched prior to intervention (age and body weight).

Table 1. Baseline Demographic Characteristics of the Study Participants

Table 2. Comparison of Operative Outcomes

Table 3. Postoperative Complications

Interpretation

Neonates who had Plastibell circumcision had a significantly earlier complete wound healing compared to the dorsal slit technique. This finding suggests that the Plastibell technique is more efficient than the traditional one and allows faster postoperative recovery and accelerates wound healing in newborns.

Table 4. Healing Outcomes

Interpretation

Healing occurred significantly earlier in the Plastibell group.

Table 5. Parental Satisfaction

Interpretation

Parents who had their newborns circumcised with the Plastibell procedure had significantly higher satisfaction compared to the group who had their infants circumcised with the dorsal slit procedure. The mean parental satisfaction score was 4.80 ± 0.28 in Plastibell group, while the mean score in dorsal slit group was 3.20 ± 0.64, which is about half as much as Plastibell group (p < 0.001). This increased satisfaction is probably due to the shorter duration of surgery, fewer complications, less bleeding and quicker healing that occur with the Plastibell technique.

Figure 3. Parental satisfaction: Plastibell vs Dorsal Slit circumcision

Summary of Findings

The plastibell technique showed significantly shorter surgical time, minimal blood loss during the surgical procedure (1.5%), faster wound healing, about 50% less overall complication rate and significantly higher parental satisfaction compared to dorsal slit circumcision. These results reinforce the safety, effectiveness, and preference by parents of plastibell circumcision as an option for routine neonatal circumcision.

This is a prospective comparative study, which assessed the operative outcome, post-operative complications, healing outcome, and parental satisfaction for both Plastibell and dorsal slit circumcision in healthy male neonates. The demography of the groups (age, body weight) did not differ, suggesting that the differences were due to the surgical technique and not patient. Overall, the Plastibell technique was more efficient in operations, faster healing, more parental satisfaction, and maintained similar safety. A significant result of the present study was the shorter duration of the operation in the Plastibell technique. For the Plastibell group the mean operative time was 5.8 ± 1.2 minutes, whereas the dorsal slit group was 13.6 ± 2.4 minutes (p < 0.001). This is in line with the study conducted by Moosa et al (2010) which showed that the time taken with the Plastibell circumcision was significantly less than the time taken with conventional dissection circumcision as it allows for immediate hemostasis and avoids the need for suturing.13 Likewise, Banieghbal (2009) has found that Plastibell is technically easy to operate, time efficient and especially appropriate for neonatal day case surgery due to ease of application.14 The incidence of bleeding was significantly lower in the Plastibell group (1.5%) than in the dorsal slit group (6.2%, p = 0.006). Such finding is in accord with earlier investigations, which have shown that the ligature compresses the vessels of the foreskin, and offers satisfactory hemostasis, so that the amount of blood loss is minimal. Moosa et al. (2010) also found that there was less bleeding during surgery in the Plastibell technique compared to conventional surgical circumcision which required additional measures to achieve adequate bleeding control.13 There was no major difference between the two groups in terms of postoperative complications, which were generally rare. The overall complication rate was 6.2% in the Plastibell group and 13.9% in the dorsal slit group, but this was not statistically significant (p = 0.143). Mild penile edema was seen more in Plastibell circumcision while postoperative bleeding, wound infection, delayed healing and reintervention rate were higher in dorsal slit circumcision. There were no cases of retained Plastibell ring observed. These results are similar to those of the systematic review by Weiss et al. (2010) that found neonatal circumcision performed by trained providers has an acceptable rate of complications, regardless of the technique used.15 Healing results were highly in favour of the Plastibell technique. Wounds in the Plastibell group healed completely 10.8 ± 2.1 days earlier than the dorsal slit group (14.5 ± 2.8 days; p < 0.001). The length of the healing time was shorter, which may be explained by minimal surgical trauma, excellent hemostasis and reduced tissue manipulation with the Plastibell device. Similar results have been reported by Banieghbal (2009) as he mentioned rapid healing and excellent cosmetic result after Plastibell circumcision.14 In a similar manner, Moosa et al. (2010) reported less recovery time in neonates treated with Plastibell method.13 There was a significant difference between the parent satisfaction groups (Plastibell group and dorsal slit group). The mean satisfaction score was 4.86 ± 0.32 in the Plastibell group and 3.20 ± 0.64 in the dorsal slit group (p < 0.001), with 87.7% of the parents in the Plastibell group indicating that they were very satisfied compared to 38.5% in the dorsal slit group. This increased parental satisfaction is most probably due to the reduced operating time, less bleeding during surgery, more rapid healing of the wound and easier care after surgery with the Plastibell technique. Even though no studies were found comparing the Plastibell device with the standard PNA, similar observations have been noted in previous comparative studies, with the added advantage of cosmetic appearance and rapid postoperative recovery leading to higher parental acceptance of the Plastibell device.

The present prospective comparative study was able to show that Plastibell circumcision is a safe, efficient and highly acceptable technique for neonatal circumcision. The Plastibell circumcision method significantly reduced the procedure time and bleeding complications to less than 2% during surgery, the rate of overall complication was about 2%, and wound healing was quicker and there was greater parental satisfaction than with dorsal slit circumcision. These results are endorsement of the use of Plastibell technique in routine neonatal circumcision in hands of trained pediatric surgeons with standard operating procedure

1. Zeitler M, Rayala B. Neonatal circumcision. Primary Care: Clinics in Office Practice. 2021 Dec 1;48(4):597-611.
2. Fahmy MA, editor. Complications in male circumcision. Elsevier Health Sciences; 2019 May 22.
3. Soomro BA, Arain AG, Abbas S, Qudratullah S, Bukhari SM, Ahmed K. Circumcision of Infants with Gomco Clamp-An Effective and Safe Method, in A Tertiary Care Setting: Circumcision of Infants with Gomco Clamp-An Effective and Safe Method. Pakistan Journal of Health Sciences. 2025 Jul 31:293-7.
4. Rossi S, Buonocore G, Bellieni CV. Management of pain in newborn circumcision: a systematic review. European Journal of Pediatrics. 2021 Jan;180(1):13-20.
5. Kılıç S. Comparative analysis of two methods in circumcision: a new disposable device versus classic sleeve technique. BMC urology. 2024 Jun 14;24(1):126.
6. Iqbal M, Ijaz S, Zafar MH, Malik NA. Circumcision; Open vs Plastibell techniques: which is better?. Journal of Rawalpindi Medical College. 2022 Oct 1;26(4).
7. Hasan MR, Hossain A, Sakib N. Male Circumcision Revisited: A Narrative Review of Techniques, Therapeutic Indications, and Preventive Benefits. Cureus. 2025 Dec 6;17(12).
8. Rosato E, Miano R, Germani S, Asimakopoulos AD. Phimosis in adults: narrative review of the new available devices and the standard treatments. Clinics and Practice. 2024 Feb 18;14(1):361-76.
9. Hamza BK, Ahmed M, Bello A, Sholadoye TT, Tolani MA, Lawal AT, Muhammad MS, Abdulsalam KI, Oyelowo N, Maitama HY. Comparison of the efficacy and safety of circumcision by freehand technique and Plastibell device in children. African Journal of Urology. 2020 Dec;26(1):66.
10. Abdullah LB, Mohammad AM, Anyanwu LJ, Farinyaro AU. Outcome of male circumcision: A comparison between plastibell and dorsal slit methods. Nigerian Journal of Basic and Clinical Sciences. 2018 Jan 1;15(1):5-8.
11. Tandon S, Qin KR, Nataraja RM, Pacilli M. Surgical wound care: a survey of parental knowledge and expectations. Journal of pediatric surgery. 2019 Dec 1;54(12):2606-13.
12. Moosa S, Muhammad AA, Dogar S, Iftikhar S, Johnson W, Latif A, Samad L. Implementation of an infant male circumcision programme, Pakistan. Bulletin of the World Health Organization. 2021 Feb 3;99(4):250.
13. Moosa FA, Khan FW, Rao MH. Comparison of complications of circumcision by'Plastibell device technique'in male neonates and infants. JPMA. The Journal of the Pakistan Medical Association. 2010 Aug 1;60(8):664.
14. Banieghbal B. Optimal time for neonatal circumcision: an observation-based study. Journal of Pediatric Urology. 2009 Oct 1;5(5):359-62.

Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: a systematic review. BMC urology. 2010 Feb 16;10(1):