Comparison of titanium and absorbable polymeric surgical clips for use in laparoscopic cholecystectomy

Abstract

The use of hemostatic surgical clips is crucial in laparoscopic surgery. Metal clips can cause significant interference with computerized tomography, may have poor holding power, and may erode into important anatomic structures. Polymeric absorbable clips, which have advantages over metallic clips, are evaluated in this study. In vitro and in vivo studies were undertaken to evaluate the hold force, rate of degradation, tissue reactivity and safety of absorbable polymeric clips. Absorbable and titanium clips were applied across excised canine cystic ducts and both axial and transverse pull-off forces were measured. In the second phase, absorbable clips were implanted subcutaneously into male rats and the strength remaining within the clips was measured after 7, 10, 14, or 21 days. In phase 3, 30 pigs were randomized into six groups and each animal underwent a laparoscopic cholecystectomy. The cystic duct and artery were ligated with absorbable polymeric clips (experimental group) or titanium clips (control group). Animals were sacrificed at 7, 14, or 28 days and a celiotomy was performed. Intraabdominal adhesions were assessed and scored. The force required to dislodge the absorbable clip was significantly greater than for metallic clips for both axial and transverse forces. Absorbable clip strength retention decreased over time as expected with a retention of 11% original strength by the 21st day. Adhesions were highest when bile spillage occurred, but did not differ significantly between either clip type. Absorbable polymeric clips were hemostatically effective in this laparoscopic model and may offer advantages over metallic clips.

A comparison of holding strength of various surgical clips

“…Any delivery variability inherent in a crush clip application device will result in variable holding strength of clips on the tissue and may be partially responsible for our observations as well as those commented on clinically. Locking (absorbable) clips were developed to address this issue as well [4].…”

“…Despite the introduction of titanium crush-type clips for laparoscopy more than a decade ago, new surgical ligation clips and clip appliers continue to be developed [4]. This need for continuous improvement is in part driven by fear of postoperative clip failure.…”

Investigation of Experimental Wound Closure Techniques in Voice Microsurgery

“…A number of materials have been studied in the design of surgical clips in other areas. Stainless steel clips and materials such as titanium and tantalum have been used for example to ligate the cystic duct and artery in laparoscopic cholecystectomy (Charara, Dion et al 1994) However, some limitations of these materials include significant foreign body reaction, poor holding power and significant interference with roentgenologic studies like computerized tomography (CT) and magnetic resonance imaging (Klein, Jessup et al 1994;Min Tan and Okada 1999;Pietak, Staiger et al 2006;Rosalbino, De Negri et al 2010). The introduction of ligating clips manufactured from novel polymers such as polydioxanone in laparoscopic cholecystectomy helped to address these limitations.…”

“…These clips are completely absorbed in the process of ester bond hydrolysis over a period of 180 days and the by-products are excreted by urine. Moreover, these clips produce minimal tissue reactivity with good adhesion and are radiolucent (Klein, Jessup et al 1994). …”

A single-institution review of the absorbable clips used in laparoscopic colorectal and gallbladder surgery: feasibility, safety, and effectiveness

“…Cystic artery and cystic duct occlusion procedures are not completely free of risks. Short-term complications in LC include dislodgement of the clips, bile duct necrosis and post-operative bile leak, clip migration and hemorrhage [7][8][9][10][11][12][13], and, though rare, common bile duct stone growth on a metal clip moved to the common bile duct [14,15].…”