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Smartphone Technology - The Way Forward in Improving Aftercare for Cultural Circumcision

Waseem Rawdah¹, Raj Lahiri¹, Anies Mahomed²

¹Department of Paediatric Surgery, Royal Alexandra Children’s Hospital, Brighton, UK

²King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia


Anies Mahomed

Department of Pediatric Surgery

King Faisal Specialist Hospital and Research Center

P.O.Box 40047, Jeddah 21499

Saudi Arabia

Phone: +966 (12) 667-7777

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.


Cultural circumcisions are a significant component of paediatric surgical practice worldwide. Varying techniques, under local or general anesthesia are employed. Post-operative follow up is critical to ensure the optimum outcome. This often involves hospital attendance by both parent and surgeon. This paper highlights the impact of smartphone technology on the post-operative management of a prospective cohort of cultural circumcisions managed over an eight year period. We demonstrate how the use of the smartphone improved healthcare delivery by reducing the number of hospital visits for suspected wound complications. Advantages for the surgeon included a reduced need for hospital assessment as well as enhanced efficiency in processing these patients with time and potential cost savings.

Keywords: cultural circumcision, plastibell technique, smartphone, circumcision complications



Approximately one in three men are circumcised globally. Male circumcision is one of the most commonly performed operations in children worldwide, and is practiced for cultural, medical and more recently, as a long-term HIV and sexually transmitted infection prevention strategy. Cultural circumcisions are performed by varying techniques, under both local and general anesthesia, in diverse settings and in different age groups. Our institution offers cultural circumcisions, under local anesthesia for patients younger than a year, on a fee for service basis. Post-operative, in hospital review, is minimized to curtail costs.

The aim of this study was to determine whether the use of smartphone post-operative images of suspected complications following cultural circumcisions by the Plastibell™ technique, will impact on the need for physical assessment of these cases.

Patients and Methods

A prospective database of cultural Plastibell™ circumcisions performed by a standard technique on infants under local anesthesia between March 2005 and February 2013 was analyzed. Basic demographic data were collected including reported and confirmed complications. In the initial five years of the study, parents communicated their concerns to the consultant surgeon telephonically who, depending on his assessment of the gravity of the problem, arranged for a hospital review. During the last two-and-a-half years of the study, concerned parents were encouraged to send two digital images of the surgical site, preferably at different angles, to the surgeon, via smartphone. The merit of a hospital review was made on the basis of the relayed images. All parents were informed that sensitive data pertaining to their child would be confidential and reassurances were given about the security of data handling. Recruitment in the study was aided by emphasizing the logistic and cost benefits of the technology to the parent. All images were sent to a single surgeon (senior author) who following assessment promptly erased the images.


A total of 341 circumcisions, with a mean age of 90 days, were performed using the Plastibell™ technique, during the period of study. In the initial 5 year period (n=179), between 10-15 acute parental concerns required formal physical assessment in hospital, annually. For the most part, simple reassurance was needed. However, one patient with a wound infection required a course of antibiotics, while three others required surgical intervention for removal of a retained Plastibell.

In the later 2.5 years of the study (n=163), a total of 24 calls were received, 19 of which provided supporting images, the majority of suitable quality. All those patients who sent images were reassured over the phone without a need for further review. These included two cases of suspected infection, one of suspected bleeding and one of a semi-retained plastibell. Of the five calls that did not provide images, subsequent assessment in hospital was necessary. One case required reassurance for a suspected infection, two needing removal of retained plastibell in Emergency Department, one had a retained plastibell that fell off prior to an attempt at removal, and the last case was reassured and discharged with topical chloramphenicol for a superficial wound infection.


Circumcision is one of the oldest procedures described. Over 60% of neonates are circumcised in the United States and this is one of the commonest operation that a paediatric surgeon and urologist will undertake in their practice [1, 2]. There are many techniques of performing circumcisions and these may be broadly categorized into: a free hand technique or that involving the use of a device. For its simplicity and ease of performance we have utilized exclusively the Plastibell technique for cultural circumcisions and have previously described the technique [3].

There is a recognized 3.5% complication rate with circumcisions which include: infection, bleeding, device retention/slippage and inadequate circumcision [3-6]. Excessive skin loss, urethra-cutaneous fistulae and partial necrosis of the glans are rarer complications which for Plastibell circumcisions are primarily thought to be due to the incorrect size of device being applied [6-8]. Our Institution has offered cultural circumcisions under local anesthesia as an outpatient procedure in the last decade. The operation was delivered on a fee for service basis and all subsequent patient episodes had a cost implication. Consequently, it was in the parent’s best interest that post–operative hospital visits be curtailed but without compromise to the health of the child. The smartphone was introduced in this context, principally to facilitate follow up and as a means of cost containment.

Comparing the outcomes of both patient groups of this study highlights the smartphone’s potential in patient monitoring during the post-operative period. However, in this context, this technology does have limitations and foremost is the risk to patient confidentiality during transmission and processing of the images. This is particularly so when a smartphone device is owned by the user rather than an organization and subjected to less vigorous levels of encryption. Here, consideration must be given to where this information is stored, how it is transferred and for appropriate and sensible controls to be put into place for the processing of sensitive data.

The emerging role of smartphones and similar technology in monitoring patients, has the potential to improve patient care and is likely to be beneficial in other areas of healthcare including telediagnosis. Over the past decade, the widespread adoption of mobile devices has led to the increasing popularity of medical reference applications (apps). These apps have proven to be a beneficial professional tool providing access to drug guides, medical calculators, treatment algorithms, and general medical knowledge [9-15]. New apps are providing patients with information such as the locations of nearby emergency departments, and doctors by specialty, provide emergency department wait times and can allow for registration via the app [10]. As an extreme example of its versatility, when hospital generators failed to light up the operating room during a recent blackout in the public Hospital of Samos, the torchlight from the large screens of smartphones allowed the surgeon to complete the procedure safely [15].

Whilst there are many benefits to the clinical use of smartphone technology, there are some downsides. The use of certain apps which are new and unreliable run the risk of patients prompting inappropriate self-diagnosis [16]. Moreover, with improved diagnostic applicability of these devices, user technological expertise and medical acumen is a prerequisite and could serve as a deterrence to regular usage. A rudimentary must for all apps is internet connectivity and if this fails both parents and clinicians could be left with no communication.

The use of smartphone technology reduces the number of hospital visits for suspected wound complications during the follow-up of cultural circumcisions. Parents were offered a prompt opinion mainly in the comfort of their domestic environment and were spared the inconvenience of travelling to a Medical Centre. There were similar advantages for the surgeon including en-hanced efficiency in processing patients with postoperative complications. The possibilities of this technology in modern day medical practice is only just being realized and could improve healthcare delivery whilst saving on costs.


The use of Smartphone technology has the potential to become an invaluable asset in modern day medicine by providing anxious parents with a means of obtaining quick advice regarding after-care following cultural circumcisions. This can potentially save money and improve service provision through prevention of unnecessary hospital visits. This practical hand-held device is readily available and accessible and the full potential of its application is only just being realized.




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