Tribal
Tribal circumcision has common in Africa. The commonest method is to pull out the foreskin and chop with a spear or slice with a knife against some hard substrate. The terror and pain of this seems to be part of its appeal (to the adults).
Barzel and Izmel
The izmel (Hebrew for scalpel) is a double-bladed knife, to ensure that a nervous mohel can not choose the wrong side and thereby cause (additional) pain to the baby. You might think that the wrong side could be marked, coloured or otherwise indicated quite easily, reducing both that risk and the risk of cutting some other part of the baby or the mohel himself with the back blade.
The barzel (Hebrew for iron) also known as a mogen (Hebrew for shield) s a slotted shield to protect the glans, which it may or may not do, depending on the glans' size and conformation. This one is gold-plated silver.
Forceps guided
A basic surgical method before the invention of the various medical clamps - widespread in the British Commonwealth when it was still believed to do some good. The foreskin was pulled through a pair of bonecutters, which (usually) protected the glans, and the exposed foreskin cut along the clamp's edge.
Sleeve resection
Two circular cuts and one lengthwise one are made in the shaft and a cylinder of skin is removed, then the cut ends pulled together and stitched. The outcome depends on where along the penis the cuts are made, and how far apart they are. In Japan, though it is rarely done at all, proximal cuts (close to the body, are reportedly favoured, keeping the inner mucosa and ridged band, but possibly interfering with their innervation.
This image is from a study that found 10 immediate and 8 late complications, and 20 adhesions, in 68 sleeve circumcisions.
Scissors
When non-religious circumcision of adults became a commonplace, Sir Frederick Treves used scissors.
The problem with using no clamping method was, how to keep even tension on the foreskin to give a straight cut? As the cut proceeds, the same amount of tension is concentrated in less and less skin, "so the incision at the frenulum was often deeper and uneven." (Grossman)
Smartklamp™
A non-reusable circumcision device made of plastic, similar to the Tara KLamp. Works by cutting off circulation to the foreskin, using a plastic ring clamped in place over a tube. Available in sizes up to adult.
Tara KLamp™
A non-reusable circumcision device made of plastic. Works by cutting off circulation to the foreskin, using a plastic ring clamped in place over a tube (to allow urination). Available in sizes up to adult, recently developed in Malaysia. (Capital, Kuala Lumpur = K.L., hence KLamp)
SPOILER (clicca per visualizzare)
S Afr Med J. 2009 Mar;99(3):163-9,
High rate of adverse events following circumcision of young male adults with the Tara KLamp technique: a randomised trial in South Africa.
Lagarde E, Taljaard D, Puren A, Auvert B.
Abstract
BACKGROUND: The Tara KLamp (TK) device has been claimed to enable circumcisions to be performed safely and easily in medical and non-medical environments. Published evaluation studies have been conducted among young children only.
METHODS: Following a randomised controlled trial (RCT) on 3 274 participants on the impact of male circumcision on HIV transmission, 69 control group members participated in this male circumcision methods trial and were randomised to a forceps-guided (FG) group and a TK group, and circumcised.
RESULTS: Of the 166 men asked to participate, 97 declined, most (94) refusing circumcision by the TK technique; 34 men were randomised to the FG group and 35 to the TK group, and 32 and 24 patients were circumcised by the FG and TK methods respectively, of whom 29 and 19 respectively attended the post-circumcision visit. All 12 adverse event sheets corresponded to the TK group (p<0.001) and circumcisions by the TK method. Less favourable outcomes were associated with the TK method, including any sign of an adverse event (37% v. 3%; p=0.004), delayed wound healing (21% v. 3%; p=0.004) and problems with penis appearance (31% v. 3%; p=0.001). Participants randomised to the TK method were significantly more likely to report bleeding (21% v. 0%; p=0.02), injury to the penis (21% v. 0%; p=0.02), infection (32% v. 0%; p=0.002), swelling (83%/ v. 0%; p<0.001), and problems with urinating (16% v. 0%; p=0.056). The mean score of self-estimated pain was 9.5 for participants circumcised by TK compared with 6.1 for other participants (adjusted p=0.003).
CONCLUSION: This study provides compelling evidence that strongly cautions against use of the TK method on young adults.
High rate of adverse events following circumcision of young male adults with the Tara KLamp technique: a randomised trial in South Africa.
Lagarde E, Taljaard D, Puren A, Auvert B.
Abstract
BACKGROUND: The Tara KLamp (TK) device has been claimed to enable circumcisions to be performed safely and easily in medical and non-medical environments. Published evaluation studies have been conducted among young children only.
METHODS: Following a randomised controlled trial (RCT) on 3 274 participants on the impact of male circumcision on HIV transmission, 69 control group members participated in this male circumcision methods trial and were randomised to a forceps-guided (FG) group and a TK group, and circumcised.
RESULTS: Of the 166 men asked to participate, 97 declined, most (94) refusing circumcision by the TK technique; 34 men were randomised to the FG group and 35 to the TK group, and 32 and 24 patients were circumcised by the FG and TK methods respectively, of whom 29 and 19 respectively attended the post-circumcision visit. All 12 adverse event sheets corresponded to the TK group (p<0.001) and circumcisions by the TK method. Less favourable outcomes were associated with the TK method, including any sign of an adverse event (37% v. 3%; p=0.004), delayed wound healing (21% v. 3%; p=0.004) and problems with penis appearance (31% v. 3%; p=0.001). Participants randomised to the TK method were significantly more likely to report bleeding (21% v. 0%; p=0.02), injury to the penis (21% v. 0%; p=0.02), infection (32% v. 0%; p=0.002), swelling (83%/ v. 0%; p<0.001), and problems with urinating (16% v. 0%; p=0.056). The mean score of self-estimated pain was 9.5 for participants circumcised by TK compared with 6.1 for other participants (adjusted p=0.003).
CONCLUSION: This study provides compelling evidence that strongly cautions against use of the TK method on young adults.
Sunathrone
The Sunathrone, made in Malaysia, described as "the Superb Bio-Engineering Innovation Envisioned and Derived from Aerospace Technology" offers "non-invasive circumcisions" - which would be quite a feat. It replaces the suture of the Plastibell with a hard outer clamp that is applied with a plier-like device called a Sunalever and locks shut like a handcuff. The chess-queen-like cone is broken off after the foreskin has been cut away.
Kirve Clamp
The Kirve clamp resembles the Shang ring, but with a placement device with a handle and a bayonet fitting so that it can be removed from the inner ring after placement and cutting.
Kirve is Turkish for "uncle".
PrePex
Very similar to an Elastrator, the PrePex system cuts off circulation and kills the foreskin with an elastic ring that crushes it into a grooved ring. Claimed to be bloodless and not to require anaesthetic or a sterile environment. Being tested in Rwanda in 2011.
Ismail Clamp
The Ismail clamp uses a screw to apply pressure instead of levers.
It claims to be "readily removable" which means it can be re-used, with a risk of cross-contamination.
Ali's Clamp
Ali's clamp is the only devide to recognise that the cut is on an angle to the axis of the penis, and hence not circular.
It makes the slightly less inaccurate simplifying assumption that the penis then has an elliptical cross-section.
Ecraseur
In Paris in 1920, Doyen used what he called an écraseur or crusher on both adults and babies.
Circumcision forceps
Invented by a Dr Moskovich in 1920, apparently for adult circumcision, but they look more as though they should be used to blow bubbles.
The top ring was introduced into the preputial cavity - somehow - and the foreskin fanned out between the two rings. After cutting round it, seven sutures could be made in the notches. It had the obvious problem of the place where the forceps attach to the rings. The rings also left a collar of skin round the glans. Less obvious, it can't apply much pressure over so large an area, but it was the first circumcision device to acknowledge that the prepuce is, more or less, circular.
Harris Clamp
The Harris Clamp (1932) certainly didn't consider the actual shape of the foreskin. It looks as though you'd need two thumbs to work it.
The third arm, C, drives a blade up through a slit in both the haemostat arms. The problem with that is that the blade gets blunt with repeated use.
Gomco™ clamp
A device invented in 1934 by Hiram S. ("Inch") Yellen, M.D. and Aaron A. Goldstein (and reportedly based on the tyre-lever used for Model T Fords, according to Julian Wan's sickeningly worshipful history of the device). It consists of a metal bell placed over the glans (requiring a slit in the foreskin first) and a flat plate with a hole in it placed over both, to define the position of the cut. They are brought together by a screw to apply circular crushing and fusing force (of 8000 to 20,000 pounds, according to Wan) at the position of excision. It leaves a characteristic dark line at the excision scar.
Varney's Midwifery says its disadvantages are that "it involves more parts, requires more steps in the procedure, and it takes more time." Under that enormous pressure, a groove wears in the bell with prolonged use, making it ineffective. The clamp is made in a set with different-sized bells and rings and there is a danger of mixing parts of different sizes. In 2001, the FDA issued a warning against clamp injuries. A video for the rival Accu-circ demonstrates how these injuries can occur.
In 2009, Dr David Tomlinson endeavoured to reduce this risk by adding coded holes to the lever and corresponding studs on the plate, and differently sized shafts on the bells, matched to differently sized notches on the lever.
The bell has been found to develop grooves and nicks following repeated use with surgical blades. There have been reports of the bell breaking where it presses against the baseplate as pressure is applied. A ring of metal breaks off and is left inside the preputial cavity and the clamp is rendered useless. There have also been reports of glans injury if the scalpel cuts through the bell.
The Gomco can obviously not be left on the penis, in fact it is removed as soon as the skin is cut off, giving a risk of bleeding.
Nutech Clamp
This is even more true of its offspring, the Nutech Clamp invented by Rabbi Harry Bronstein, which looks like a hacksaw, but is actually held the other way around:
Circumstat
A more obvious descendent of the Gomco is the Circumstat, invented by Rabbi Irving Grossman in 1962.
The cam is apparently quicker and simpler than the screw of the Gomco.
