|Mahdian Klamp assembled||Madhdian Klamp components|
The Mahdian single-use circumcision clamp first came to Circlist's attention in November 2015, at which time it was being offered for use only within the Republic of Indonesia. Since then it has been successfully trialled by Rumah Sunatan (a major franchise chain of circumcision clinics in Indonesia) and reportedly it has also been accepted by WHO as "pre-qualified" for use in anti-HIV campaigns of VMMC (Voluntary Medical Male Circumcision). The Clamp is a 3-part plastic device that functions on the basis of ischaemic necrosis. In short, the clamp crushes the blood supply to the foreskin and so, in the course of the wear period, it causes the prepuce to die and drop off. In practice most of the foreskin is excised with a scalpel, leaving only a thin ring of tissue to be 'sealed' by the clamp. In this respect, the clamp is similar to many others in the market, such as TaraKLamp, SmartKlamp, Ali'sKlamp and Ismail Klamp. Like the Ali'sKlamp, the Mahdian Clamp has an angled clamping ring that assists the operator to achieve "anatomically correct" alignment of the circumcision scar with the shaft of the penis. Early instrument designs such as the TaraKlamp (in use since the 1990s) lack this feature, relying on the skill of the user to draw more dorsal than ventral foreskin through the clamping ring. Creating an angled ring isn't a simple matter, because of the tendency to cause unequal pressure distribution around the circumference.
The Mahdian device does not remove the frenulum. Indeed, it has a notch in the transparent inner tube that is specifically intended to preserve the frenulum. This might be considered unfortunate in cases where the principal objective is HIV prophylaxis because the frenulum contains the body's greatest concentration of Langerhans cells - the portal of entry for retroviruses. However, frenulum retention is the cultural norm in Indonesia. If frenulum removal is required, the web of tissue should be removed as a prior procedure done some weeks in advance, whereupon the preservation notch serves to avoid irritating the resulting scar on the underside of the glans. Prior removal of the frenulum helps any clamp to seat better and this clamp is no exception.
Final tightening is effected by means of a very simple leverage device slotted over the closure nut. This extra tightening of the ratchet makes the clamp tamper-proof and thus suitable for use on reluctant or meddlesome boys.
The inner, transparent tube has two longitudinal slots in it. These assist the user to grip the foreskin with forceps and draw it through the clamping ring. What's missing from the design is a means of automatically retaining the foreskin in the pulled-through position whilst the clamping ring is being closed. Thus if the style of circumcision being undertaken requires removing a significant amount of shaft skin, the procedure requires two pairs of hands - one person to draw foreskin evenly through the clamping ring using the forceps, whilst the other presses the clamp back towards the abdomen and simultaneously tightens the closure nut.
|Clamp assembled on a young boy||Clamp in place on an older boy at the completion |
of the operation.
Prevention of re-use is achieved by the ratcheted closing mechanism, which operates on much the same principle as the lid of a typical plastic bottle of drink. Cutting the clamp open at the removal stage destroys it - unlike some other designs, the closure mechanism cannot be opened any other way.
The Mahdian Clamp is available in sizes from infant to adult. The usual caveats apply as regards use on adults, unchanged from those applicable to other clamps operating on the ischaemic necrosis principle. In agricultural communities, the enhanced risks of that working environment and the slower healing of adults makes it important to ensure that the patient has a valid tetanus vaccination.
Review by Chris Eley, October 2016
|Manufacturer's website (in Bahasa Indonesia)|