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Publication history, Reflections & comments
A small tantalum clip, the "Hemoclip", was used to secure the cystic artery during cholecystectomy on over 100 occasions during a three-year period in a busy -general surgical unit. The advantages of this Innovation, a description of which was published abroad four year earlier, are noted, and its wider applications discussed.
IntroductionA haemostatic tantalum clip, for general surgical use described by Samuels et alii in 1966, deserves to be much better known. Use of the "Hemoclip" allows shorter surgical operations without causing complications of it: own, and it is therefore of benefit to the individual patients and to the work of a surgical team as a whole. This report refers to securing the cystic artery during cholecystectomy over a three-year period in one busy general surgical unit It has other important possibilities indicated by the experience of its inventor.
DESCRIPTION OF APPARATUS
The hemoclip, its applier, and a holding rack have been described in detail by Samuels. Briefly, it. Is a small, thin piece of tantalum formed into a diamond opened at one angle to. give parallel open arms
(Figure 1).
FIGURE 1: A "Hemoclip". Before use there is an opening 2-5 mm wide between the `tips
of the two arms. The clip is picked up from the rack in a special applier,
with two little grooves in its jaws to hold the clip securely
(Figure 2).
FIGURE 2:
Picking up a "Hemoclip The rest of the applier resembles a long pair of Spencer-Wells forceps but. with a strip to keep the handles and- jaws open instead of having a ratchet. The applying forceps are made in.three sizes, 6 in. (15 cm), 8 in (20 cm) and 10.5 in. (27 cm) long (Figure 3), with three different clip sizes now available.
FIGURE 3:
The applying forceps. Clips are supplied in lots of 25 on a disposable plastic "cartridge" which can be autoclaved, and which is slid onto a base to hold it steady
(Figure 4).
FIGURE 4:
A cartridge of clips, partly used. The applying forceps have to be held at the joint, by the thumb and index finger, when the jaws are slid over the clip to be picked up, as some accidental squeezing of the clip might otherwise take place. Only the middle size of clip has been evaluated.
METHOD OF USE
This study deals mainly with clipping of the cystic artery, which replaces the usual ligation with catgut or silk.
The artery is identified and dissected out in the usual way. When there is about half a centimetre of its origin cleared, usually from the hepatic artery, two clips are applied and the artery between them is severed with fine dissecting scissors.
Often there are other additional strands of tissue clipped in this way, because they may have contained smaller blood vessels. Occasionally a clip has been applied directly to a vessel (usually a small vein) that was bleeding freely. The advantages of this technique are that only one of the surgeon's hands is needed instead of both for tying a knot, the other remaining free to maintain good exposure of the area without altering the positions of the assistants; the applying hand does not enter the abdomen, application being swift, sure and safe under direct vision and without traction on the vessel.
Application of the clip to veins on the surface of the common bile duct or to the cystic duct was avoided because of occasional reports of a common bile duct stone forming about a silk ligature originally applied to the cystic duct (Silvennionen and Asp, 1966).
CLINICAL EXPERIENCE
The "Hemoclip" was first used in this study in July, 1967. Over the following three-year period, 103 cholecystectomies have been-performed by one surgeon and a number of registrars in surgical training. In practically every, case the cystic artery and incidental bleeding points have been secured by the clip alone, without conventional ties.
During this time there have been no complications that could be attributed to the use of the clip. In no case has there been any hint of displacement or erosion through some other structure.
On no more than three occasions a clip has fractured before closure, without ever any hint of: a masked delayed break. Sometimes an operating theatre sister not familiar with the equipment has had trouble loading the clip or accidentally squeezing it between the jaws prematurely.
Two other surgeons at the same hospital have used the same "Hemoclip" equipment for lumbar sympathectomy, cervical sympathectomy, and vagotomy during operation for duodenal ulcer, comprising altogether over twenty procedures. They have noted no complications and appreciated the advantages of the clip.
OTHER OBSERVATIONS
After cholecystectomy, the cystic artery was dissected further off the removed specimen of gallbladder and further "Hemoclips" were applied on several occasions. Very considerable force was needed to shift the clip, and for practical purposes there was no doubt about this security and no worry about it cutting through the artery. Even with practically no stump beyond the clip, there was no tendency to loosen on the vessel.
DISCUSSION
Using the "Hemoclip" appears the method of choice for securing the cystic artery in most cases of cholecystectomy. There has been no reason to doubt its safety, and there is saving of time through economy of action and not through haste.
In his original paper, Samuels has described how closure of the clip begins at the tips and proceeds backwards, so that tissue cannot be squeezed out accidentally, as with previous types of clip. The tantalum gives rise to no tissue reaction; in two years of clinical use in over a thousand patients he could find no complications attributable to the clips, and in several re-explorations, they were found at the exact site of application, and with no inflammatory reaction.
The main uses of the clips by Samuels were for cholecystectomy (for both cystic artery and cystic duct), vagotomy, varicose vein surgery, and retroperitoneal dissection, though a wide variety of other major general surgical procedures also provided completely satisfactory use. In a second paper a year later, Samuels and Cincotti have discussed the advantages of the °Hemoclips" for major vascular operations, and found no complications in more than 300 cases.
With a novel surgical approach of this type, due caution is important; nevertheless it seems likely that most surgeons who become sufficiently acquainted with the "Hemoclip" and its applying forceps will find it of benefit to their patients and their work.
ADDENDUM
Since this paper was completed, one further instance of clip fracture, apparent immediately, has occurred. The fractured clip has been examined under a scanning electron microscope for tool-marks, porosity and inclusions, with no positive result yet. Further studies are proceeding.
REFERENCES
Samuels, P. B., Roedlino, H., Katz, R., and Cincotti, J. (1966), "A
New Hemostatic Clip: 2-Year Review of 1007 Cases" Ann. Surg 3: 427.
SAMUELS, P. B., and , Cincotti, J. J. (1968), "The Use of Hemostatic
Clips in Vascular Surgery", J.. cardiovasc. surg., 9,150
Silvenionen, E., and Asp, K. (1966) "Clinical Observations on Complications
from Nonabsor6ble suture material in Gall Bladder Surgery", Acta
chir. seand., 132: 587.
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A HAEMOSTATIC METAL CLIP FOR OPERATIVE SURGICAL USE
E. HENNESSY1 AND M. PATKIN 2
Royal Newcastle Hospital
1Director of Surgery. 2Fellow In Surgery.
Address for reprints: Dr E. Hennessy, Department of Surgery, Royal Newcastle
Hospital, Newcastle, N.S.W. 2300.
Med. J Aust., 1971, 2: 674-675.Australian Medical Publishing Company Limited 71-79 Arundel Street, Glebe, Sydney, N.S.W., 2037
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Ted Hennessy was my chief at the Royal Newcastle Hospital. He rescued me from a long life as a surgeon and general practitioner in a small town of 2000 people. Instead I became Fellow in Surgery at a large very busy regional hospital, learning to tackle regular major surgery.
The local way of doing things was prescriptive and strict and I was generally wanting to try out possibly better ways of doing things - not a great idea given my relative lack of practical experience.
I lasted two years as their first and last Fellow in Surgery. I just didn't fit into a regular environment.
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The Royal Newcastle Hospital itself was a fascinating institution. Its earliest modern surgeon, Samuel Gardiner, was not formally trained in the specialty, and had been a bricklayer. However he was a very good intuitive and practical surgeon, and many legends grew around his name.
Once he started a gastrectomy in a nun (he was popular with the nuns) and found an irremovable tumour. He left the cut end of the oesophagus open and did no more. The wide-eyed assistant asked about post-operative orders. The reply was "No spicy foods."
Another time a patient came to see him with a bad back, after seeing another doctor for this problem with no relief. Sam stood him on some paper, rubbed his back, and dropped some crystals, I forget whether sugar or salt. Sam told him he had "rubbed the crystals out of his back". The patient was relieved, but went back to his original doctor to complain that he hadn't had this successful treatment earlier.
The lirbray at the RNH was called the Samuel Gardinar Library. I read through a lot of early 20th century surgical journals there - Annals of Surgery, Archives of Surgery, SGO, and others. This was an important part of his legacy.
In the late 1950s the NSW Stte Government was helped out of an awkard enquiry at the Callan Park Mental Asylum, where there were a number of deaths. The doctor who got the government off the hook, McCarthy, was rewarded with appointment as medical director of the RNH. He said of this that they didn't know what to expect.
What McCarthy did was to drag the RNH well into the 20th century with major innovations - salaried medical staff replacing honoraries, one of the first Central Sterile Supply Departments, a clerical training school within the hospital, clinical audits, and much more.
In the 1960s there was a terrible bust-up between salaried staff and those who resigned, precipitated partly by the personality of McCarthy and partly his personal relationships. He retired to the south-east of South Australia, at Narracoorte, with his second wife, an ENT surgeon who had worked with him.
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