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Invited Commentary

Sean J. Mulvihill, MD
Arch Surg. 1995;130(4):441. doi:10.1001/archsurg.1995.01430040103023.
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Secure occlusion of small blood vessels is a technical demand common to all fields of surgery. In biliary surgery, occlusion of the cystic duct is also required. In most operations, vessel or cystic duct occlusion is undertaken effortlessly with ligatures. Metallic clips are used by most surgeons on occasion in open surgery, but in laparoscopic surgery they are used nearly universally. Concern has been raised regarding the security of these clips. Most surgeons have had the experience of finding previously applied clips loose in the operative field in open procedures involving extensive dissection and retraction. A few published case reports, examples of which are cited by Deans and colleagues, demonstrate the effects of clip dislodgment or migration. In laparoscopic surgery, the main concerns have related to early postoperative hemorrhage or bile leak from clip dislodgment from the cystic artery or duct and late presentation of common duct abnormalities related to


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