Newborn circumcision is often described as a relatively simple procedure, but achieving a consistent result requires precise assessment of how much tissue should be removed before an irreversible incision is made. Inadequate or excessive skin removal, asymmetry, adhesions, and the need for later revision remain recognized complications of circumcision.¹⁰,¹¹ Contemporary U.S. claims data demonstrate that although immediate complications are uncommon, approximately 2.5% of newborns undergo a secondary procedure within two years following circumcision.⁸
One of the simplest strategies for improving precision is also one of the oldest: establishing the intended circumcision incision location before tissue is removed.
In 1983, pediatric urologist George W. Kaplan emphasized prevention of circumcision errors by identifying the level of the corona on the external penile skin before incision.¹ Several years later, the American Academy of Pediatrics specifically included preoperative marking of the coronal sulcus with a surgical marking pen among techniques that may reduce postoperative complications.²
The rationale is straightforward: decide how much tissue should be removed before applying the device or making the incision, mark the location, and then use the mark as an objective reference throughout the procedure.
From Dr. Tomlinson: Where the surgical pen mark began
Early in the development of the AccuCirc® device, I was fortunate to meet Dr. Anthony Caldamone, then chief of pediatric urology at Hasbro Children’s Hospital and an internationally recognized expert in pediatric urology. Dr. Caldamone agreed to evaluate the AccuCirc® in his operating room at Hasbro Children’s Hospital. When we began working together, I noticed something that became an important part of how I thought about circumcision: he started every case by marking the foreskin with a surgical pen at the level of the corona.
That simple step made the intended endpoint visible before any tissue was removed. Dr. Caldamone and I subsequently authored the surgical chapters of the World Health Organization Manual for Early Infant Male Circumcision under Local Anaesthesia.¹³ The manual incorporated preoperative surgical marking into its standardized approach to early infant circumcision. For me, the lesson from those early cases has remained remarkably durable: decide where the incision should be made while the anatomy can still be assessed normally, mark the location, and use the mark to guide the procedure.
From surgical judgment to a predetermined reference point
Traditional newborn circumcision techniques require the operator to estimate how much external skin should be removed. That assessment can be affected by foreskin mobility, penile anatomy, tissue tension, device positioning, and provider experience.
A surgical pen mark creates a visible reference point before those variables are altered by traction, tissue positioning, or application of the circumcision device.
This concept was articulated clearly by pediatric urologist George W. Kaplan in his 1983 review of circumcision complications:
“Prevention of these errors is best achieved by marking the site of the corona on the skin surface prior to any incision.”¹
Kaplan’s recommendation captures the fundamental principle behind surgical marking: determine the appropriate level of tissue removal while the anatomy can still be assessed normally, mark that level before making an incision, and use the mark to guide the procedure.
More than four decades later, that same principle remains highly relevant to newborn circumcision. This principle is incorporated into the published AccuCirc® technique. A surgical pen mark is placed “on the foreskin at the level of the corona,” and the device’s adjustable foreskin holder is then used to position the tissue according to that mark before the clamp is applied.⁴
The surgical pen mark does not replace clinical judgment. It gives the provider a visible reference for translating that judgment into precise tissue positioning before the foreskin is removed.
The recommendation is not new
The importance of surgical marking in circumcision has been recognized for decades.
Six years after Kaplan's 1983 recommendation, the American Academy of Pediatrics incorporated the same concept into its 1989 Task Force report. In its discussion of surgical technique, the AAP identified “using a surgical marking pen to mark the location of the coronal sulcus on the shaft skin preoperatively” as one of the techniques that may reduce postoperative complications.²
Later neonatal circumcision research reached a similar conclusion. Investigators comparing neonatal circumcision techniques recommended use of a surgical pen to mark the corona and penile landmarks before the procedure specifically to reduce the likelihood of removing too little skin.³
WHO guidance on surgical marking
The importance of identifying the intended level of circumcision before tissue removal was also incorporated into the World Health Organization's Manual for Early Infant Male Circumcision under Local Anaesthesia.¹³ The surgical portions of the manual were developed with input from clinicians experienced in newborn circumcision and underwent international expert review before publication by WHO and Jhpiego in 2010.
The resulting guidance incorporated preoperative surgical marking as part of the standardized approach to early infant circumcision. Subsequent investigators applying the WHO technique specifically described the use of a surgical pen to mark the corona, noting that this step could reduce errors in the amount of foreskin removed.⁵,⁶ Thus, surgical marking became part of an internationally reviewed framework for improving the consistency and safety of early infant circumcision.
Why this matters: Circumcision revision in the United States
Revision after newborn circumcision is not merely theoretical.
A large U.S. claims analysis published in 2025 found that although only 0.96% of newborns had a complication coded within 30 days of circumcision, subsequent procedures were considerably more common. Approximately 2.5%–2.9% underwent a secondary procedure within two years, and approximately 2.9%–3.6% underwent one within five years.⁸
Importantly, outcomes varied according to the specialty of the clinician who performed the original circumcision.
Compared with newborn circumcisions performed by obstetrician-gynecologists, the adjusted odds of revision within two years were lower following procedures performed by pediatricians, urologists, pediatric urologists, pediatric surgeons, and several other clinician groups.⁸
The study provides contemporary evidence that newborn circumcision outcomes vary according to how and by whom the procedure is performed.
That observation is especially important because obstetricians remain one of the largest groups performing newborn circumcisions in the United States.⁹
AccuCirc®: Translating the mark into the procedure
A mark alone is useful only if the subsequent procedure can reliably follow it.
The AccuCirc® technique was designed so that tissue can be deliberately positioned according to the predetermined surgical mark before the clamp or tourniquet is applied.
The published AccuCirc procedure incorporates several sequential steps:⁴
A surgical pen mark is made on the foreskin at the level of the corona, as described by Kaplan.¹
Only then are physiologic adhesions released.
A protective shielding ring is positioned between the glans and foreskin.
An adjustable foreskin holder is deployed.
The foreskin is aligned within the device according to the surgical pen mark.
Tissue position can be confirmed before the clamp is applied.
The surgical mark is a reference for positioning the tissue before the tissue is removed.
In this way, AccuCirc converts a longstanding surgical recommendation into a standardized procedural sequence.
Evidence from the Zimbabwe field study
A particularly important evaluation of this approach was conducted in Zimbabwe.⁵
Four nurse-midwives were trained to perform early infant circumcision using AccuCirc. Their training included didactic instruction, practice using an anatomic model, formal assessment, and supervised clinical procedures before independent practice.
They subsequently performed 500 early infant circumcisions.⁵
The study protocol specifically required the circumcision site around the corona to be marked with a surgical pen. The pen mark was intended to help minimize excessive or insufficient skin removal.⁵
Follow-up was unusually rigorous. Infants were scheduled for examinations at days 2, 7, and 14 after circumcision, and all but one participant completed all three scheduled visits.
No infant required corrective surgery, and no circumcision revision was performed during the study follow-up.⁵
This study is particularly instructive because the procedures were performed by nurse-midwives rather than surgeons or physicians. Their outcomes demonstrate that a standardized technique, structured training, and a device designed around reproducible procedural steps can allow trained non-physician clinicians to perform early infant circumcision safely and accurately guided by a surgical marking pen and the principles described by George Kaplan.
Evidence from Kenya
A subsequent field evaluation in Kenya included 704 infants and was performed by trained clinical officers and nurses.⁷
These clinicians already had experience performing early infant circumcision with the Mogen clamp but were newly trained in the AccuCirc technique. Their AccuCirc training included classroom instruction, practice on an anatomical model, observation of procedures, supervised procedures, and demonstrated competency before independent practice.
The study reported no serious adverse events and very high parental satisfaction.⁷
This study provides additional evidence that standardized training and device-based procedural controls can produce reproducible outcomes even when the circumcision is performed by non-physician providers.
A separate study examined the preferences of Kenyan providers with experience using multiple early infant circumcision devices. The providers said they would choose AccuCirc® if another provider were circumcising their own son, primarily because of the device’s protection of the glans. When asked which device they would recommend for a national early infant circumcision program, the participants unanimously selected AccuCirc.¹²
Provider title versus procedural system
These findings raise an important question.
If trained nurse-midwives, nurses, and clinical officers can safely perform early infant circumcision using a standardized protocol, why do revision rates vary among clinicians performing newborn circumcision in the United States?
The evidence suggests that it is not the provider specialty alone that determines procedural quality.
Training, procedural volume, patient selection, anatomical assessment, device design, standardization, and the ability to define and verify tissue positioning before incision all contribute to outcome.
Precision requires more than a pen
The surgical marker itself is not the intervention.
A pen mark cannot prevent excessive or insufficient tissue removal if the tissue cannot be accurately positioned according to the mark.
The broader principle is predetermined tissue removal.
AccuCirc combines:
anatomical assessment;
a predetermined surgical pen mark;
a shielding ring protecting the glans;
an adjustable foreskin holder;
deliberate alignment of the foreskin to the mark; and
confirmation of tissue position before an irreversible incision.
That combination represents an engineering approach to a surgical problem recognized for decades: determining how much tissue should be removed before committing to the incision and then providing a reproducible mechanism for translating that decision into the final procedure.
Clinical summary
Surgical marking before newborn circumcision is not a new concept. Published surgical literature has emphasized identifying the intended level of circumcision before tissue removal for more than four decades.¹,²,¹³
Contemporary U.S. data demonstrate that circumcision revisions and secondary procedures continue to occur and that revision risk varies according to the clinician performing the original procedure.⁸
AccuCirc incorporates the surgical pen mark into a standardized tissue-positioning system. Published field studies in Zimbabwe and Kenya demonstrate that trained physicians, nurse-midwives, nurses, and clinical officers can use this protocol safely in early infant circumcision.⁵,⁷
These studies support a broader principle of precision surgery:
Decide first. Mark it. Position to the mark. Verify it. Then proceed.
References
Kaplan GW. Complications of circumcision. Urol Clin North Am. 1983;10(3):543-549.
American Academy of Pediatrics Task Force on Circumcision. Report of the Task Force on Circumcision. AAP News.1989;5:7-8.
Plank RM, Ndubuka NO, Wirth KE, et al. A randomized trial of Mogen clamp versus Plastibell for neonatal male circumcision in Botswana. J Acquir Immune Defic Syndr. 2013;62(5):e131-e137.
Plank RM, Wirth KE, Ndubuka NO, et al. Single-arm evaluation of the AccuCirc device for early infant male circumcision in Botswana. PLoS One. 2014.
Mavhu W, Larke N, Hatzold K, Ncube G, Weiss HA, Mangenah C, et al. Safety, acceptability, and feasibility of early infant male circumcision conducted by nurse-midwives using the AccuCirc device: results of a field study in Zimbabwe. Glob Health Sci Pract. 2016;4(Suppl 1):S42-S54. doi:10.9745/GHSP-D-15-00199.
Mavhu W, Hatzold K, Ncube G, et al. Early infant male circumcision using the AccuCirc device versus Mogen clamp in Zimbabwe: a randomized noninferiority trial. J Acquir Immune Defic Syndr. 2015.
Bailey RC, Nyaboke I, Mackesy-Amiti ME, et al. Field evaluation of the safety, acceptability, and feasibility of early infant male circumcision using the AccuCirc device. PLoS One. 2018;13(2):e0191501. doi:10.1371/journal.pone.0191501.
Kim DD, Hyman MJ, Modi PK, Johnson EK. Characterization of newborn circumcision revision and complication rates among privately insured boys in the United States between 2010 and 2022. Urology. 2025;200:155-162. doi:10.1016/j.urology.2025.02.017.
Johnson EK, Hyman MJ, Hardy C, et al. Growth in newborn circumcisions performed by pediatric urologists and advanced practice providers between 2010 and 2021 in the United States. Urology. 2024;184:206-211. doi:10.1016/j.urology.2023.10.033.
Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: a systematic review. BMC Urol. 2010;10:2. doi:10.1186/1471-2490-10-2.
Krill AJ, Palmer LS, Palmer JS. Complications of circumcision. ScientificWorldJournal. 2011;11:2458-2468. doi:10.1100/2011/373829.
Bailey RC, et al. What device would be best for early infant male circumcision in east and southern Africa? Provider experiences and opinions with three different devices in Kenya. PLoS One. 2017. PMID: 28196085; PMCID: PMC5308609
World Health Organization, Jhpiego. Manual for early infant male circumcision under local anaesthesia. Geneva: World Health Organization; 2010.