Journal of Minimal Access Surgery

ORIGINAL ARTICLE
[Download PDF]
Year : 2019  |  Volume : 15  |  Issue : 3  |  Page : 192--197

Clip-stone and T clip-sinus: A clinical analysis of six cases on migration of clips and literature review from 1997 to 2017

Liwei Pang1, Jindong Yuan1, Yan Zhang1, Yuwen Wang2, Jing Kong1,  
1 Department of Biliary and Minimally Invasive Surgery, China Medical University Shengjing Hospital Shenyang, Liaoning, China
2 Department of Surgery, The Sixth People's Hospital of Shenyang, Liaoning, China

Correspondence Address:
Jing Kong
Department of Biliary and Minimally Invasive Surgery, China Medical University Shengjing Hospital Shenyang, No. 36, San Hao Street, Shenyang 110004, Liaoning
China

Abstract

Introduction: With the development of laparoscopic skills, the laparoscopic common bile duct exploration (LCBDE) and laparoscopic cholecystectomy (LC) has become the standard surgical procedure for choledocholithiasis. We usually use Hem-o-lok clips to control cystic duct and vessels, which is safe on most occasions and has few perioperative complications such as major bleeding, wound infection, bile leakage, and biliary and bowel injury. However, a rare complication of post-cholecystectomy clip migration (PCCM) increases year by year due to the advancement and development of LC, CBD exploration as well as the wide use of surgical ligation clips. Materials and Methods: Six patients whose clips are found dropping into CBD or forming T-tube sinus after laparoscopic surgery in our department. Results: Six patients whose clips are found dropping into CBD (clip-stone) (3/6) or forming T-tube sinus (T clip-sinus) (3/6) after LCBDE or LC. Conclusions: PCCM is a rare but severe complication of LCBDE. A pre-operative understanding of bile duct anatomy, the use of the minimum number of clips and the harmonic scalpel during the surgeries is necessary. Considering clip-stone or clip-sinus in the differential diagnosis of patients with biliary colics or cholangitis after LCBDE even years after surgery, the detailed medical history and pre-operative examination are inevitable, especially for these patients who had undergone LCBDE.



How to cite this article:
Pang L, Yuan J, Zhang Y, Wang Y, Kong J. Clip-stone and T clip-sinus: A clinical analysis of six cases on migration of clips and literature review from 1997 to 2017.J Min Access Surg 2019;15:192-197


How to cite this URL:
Pang L, Yuan J, Zhang Y, Wang Y, Kong J. Clip-stone and T clip-sinus: A clinical analysis of six cases on migration of clips and literature review from 1997 to 2017. J Min Access Surg [serial online] 2019 [cited 2019 Aug 22 ];15:192-197
Available from: http://www.journalofmas.com/text.asp?2019/15/3/192/233170


Full Text

 Introduction



Gallstone disease is one of the most common benign diseases, and laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) have become the standard surgical procedure for it.[1] Various clips (Hem-o-lok clips in our department) are used to control vessels and the cystic duct, which is a safer and more efficient way when compared with conventional surgery. However, there is still a high possibility of complications, and the common complications include bile duct injury, bile leakage, infection, gastrointestinal injury, bleeding,[2] deep venous thrombosis of the lower extremity, air embolism, subcutaneous emphysema, etc. In addition, rare complications such as postcholecystectomy clip migration (PCCM), bile duct dysfunction, and bilirubin metabolism disorders have also been reported.[3] The first case of PCCM was reported in 1978 by Walker,[4] which resulted in the formation of CBD stone. Similar cases had been reported afterwards. However, rare clip migration after LCBDE whose clips dropping into CBD or forming T-tube sinus had been reported. Thus, we report six patients whose clips are found dropping into CBD (clip-stone) (3/6) or forming T-tube sinus (T clip-sinus) (3/6) after LCBDE or LC in our department to explore the reasons of it and find a more effective and safe way ligating cystic duct and gallbladder vessels. And also we review the literature from 1997 to 2017 to introduce the characteristics and treatment outcomes of these cases. (We did not search the articles earlier than 1997 considering the technology gap between these two epochs).

 Materials and Methods



The first three patients underwent LCBDE due to the gallbladder and CBD stones, and we found clips forming T-tube sinus. Patient one, female, 31-year-old, the diameter of the CBD of whom is about 1.2 cm and there are a lot of stones like fine sediments within it, was indwelled with 22#T. Cholangioscope was conducted after 4 months, and we saw a small stone whose diameter was about 8 mm. Much to our surprise, we found the clips had formed a part of the sinus. We removed the stone with the reticular basket. Reviewing the pre-operative computed tomography (CT), we could see a part of sinus was consisted of by Hem-o-lok clips [Figure 1]. During these 4 months, the patient did not have cholangioscope, she was still symptom-free.{Figure 1}

Patient two, female, 60-year-old, the diameter of the CBD of whom is about 1.1 cm, and there are a lot of small stones within it, was indwelled with 20#T. Cholangioscope was carried out after 3 months, and we saw a small stone whose diameter was around 4 mm. We also found the clips had formed a part of the sinus. Accordingly, we removed the stone with the reticular basket. Reviewing pre-operative CT, we could see a part of sinus was made up of the Hem-o-lok clips. During the whole disease process, the patient was as well symptom-free.

Patient three, female, 83-year-old, the diameter of the CBD is about 1.0 cm, and there is about 1.2 cm stone within it, was indwelled with 20#T. Cholangioscope was implemented after 6 months and we saw two small stones whose diameter was both about 3 mm. We as well found the clips had formed a part of sinus. We removed the stones with the reticular basket. Reviewing the pre-operative CT, we could see a part of sinus was consisted of by the Hem-o-lok clips. During these 6 months, the patient was symptom-free.

Patient four, this 61-year-old woman presented with repeated episodes of jaundice and upper right quadrant abdominal pain with a history of LC for chronic cholecystitis. Laboratory indices were as follows: WBC 16300/mL and total bilirubin 2.7 mg/dL. Abdominal ultrasound indicated the diameter of the CBD of is 1.1 cm, and there is a about 2.8 cm stone within it. Roux-en-Y was performed, and a clip-stone (8 mm × 22 mm) was found in CBD.

Moreover, the following two patients underwent LCBDE due to the gallbladder and CBD stones, and we found clips dropping into CBD. Patient five, female, 72-year-old, the diameter of the CBD of whom is about 1.3 cm and there are a lot of stones ranging from 0.8 cm to 1.2 cm within it, was indwelled with 22#T. Cholangioscope was conducted after 4 months and we saw two small stones. We removed the stones with the reticular basket, and we also pulled out her T tube. However, she felt pain in her right upper quadrant as before after 1½ years. Her CT scan showed a stone about 1.3 cm in CBD. We then performed exploratory laparotomy, bile duct exploration and J tube drainage because her abdominal pain aggravated and she even appeared chills and fever. We cut the stone and saw a Hem-o-lok clip inside [Figure 2] and [Video 1]. The J tube was removed under endoscope after 2 weeks, and she discharged without pain or fever.{Figure 2}

[MULTIMEDIA:1]

Patient six, female, 64-year-old, the diameter of the CBD of whom is about 1.5 cm, and there are two large stones (one about 1.2 cm and the other about 1.4 cm), was indwelled with 24#T. However, she appeared symptoms including fever, jaundice, skin itching and so on after 2 months. We performed T-tube cholangiography and we found that the CBD was thickened and the thickest diameter reached 1.4 cm while the lower end of the CBD became thinner and narrowed. The digital subtraction angiography of the biliary tract revealed the narrowing of the CBD and a clip drops into CBD [Figure 3] and Video 2]. As a result, percutaneous transhepatic biliary drainage and stent implantation was performed to relieve her symptoms.{Figure 3}

[MULTIMEDIA:2]

Literature review

We searched through the PubMed, EMBASE, Cochrane, CNKI, Wangfang database using the keywords 'clip migration' and 'bile duct stones' from 1997 to 2017. We excluded the cases that could not provide adequate details or they were from the same institution. Finally, 53[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57] publications reporting 64 cases were reviewed.

In these cases, the female was in the majority (n = 35, 54.6%) and the average age at presentations is 59.75-year-old (range 31–93 years). Most of the initial operations are LC (n = 43, 67.1%), some are LCBDE, OC and others. Types of operations are shown in [Table 1]. The median time of PCCM is 24 months (the average time of PCCM is 55.4 months) (range 1 day to 20 years). Some cases of PCCM caused the corresponding symptoms although hadn't formed to stone, always in the early 3 months after the operation. The common clinical symptoms of PCCM were right upper abdominal pain, jaundice, fever and rare cases included pyaemia and shock [Table 2]. The median number of the migrated clip was one (range 1–4), and the common migration is to CBD and duodenum [Table 2]. Pre-operative imaging diagnosis varied from US, CT, magnetic resonance cholangiopancreatography to endoscopic retrograde cholangiopancreatography (MRCP to ERCP) [Table 3]. Moreover, the management of PCCM is also multiple. Based on current evidence, ERCP should be the modality of choice with surgery or PTC reserved as rescue procedures, especially in the presence of difficult biliary strictures or large stones [Table 3]. As for T clip-sinus, choledochoscope is the first non-invasive choice with satisfactory results.{Table 1}{Table 2}{Table 3}

 Discussion



LCBDE is a relatively safe way to deal with stones in CBD. Overall, PCCM is rare. However, it is possible that the true incidence of PCCM with resultant biliary complications is underestimated.[58] In this paper, clips had migrated into the CBD or formed the T-tube sinus. Common symptoms varied from abdominal pain, obstructive jaundice to fever[58] while rare complications included acute pancreatitis, embolism of the clip and so on.[14],[27],[39] The etiology of clips migrating into the CBD or forming T-tube sinus remains unclear. As for clip migration, some authors held that the clips were applied improperly so that the cystic duct remained patent due to ineffective clipping resulting in biloma with bile leakage.[23],[32],[59] However, others deemed that it is inevitable in that even well-placed clips may migrate due to localised inflammatory.[23] In a nutshell, there are many factors that contribute to the migration process and the aforementioned factors include inaccurate clip placements with resultant bile duct injuries, local suppurative inflammatory processes, bile leak with resultant biloma formation, local infective processes as well as the number of clips.[37] Moreover, we found the clips near the T tube and they did not drop into CBD at first while they migrated to CBD once the T tube was removed. As for T-tube sinus, there was no related literature involved about the formation process. We speculated that the distance between the T-tube and the clips might be the main cause. A short distance between them allowed the clips to gradually from the fibrous tissue of T-tube sinus and it is because both of them are foreign matters simultaneously wrapped by fibrous capsule so that we could see the clip inside sinus through choledochoscope. The angle between the two, chronic inflammation and mechanical compression from the surrounding tissues may also prompt the clips to approach the T tube.

The diagnosis primarily relied on some non-invasive examinations, such as ultrasound, CT scan, MRCP and T-tube radiography.[45] Imaging will be required to distinguish between post-cholecystectomy primary CBD stones from PCCM-related biliary complications. Simple abdominal radiography may show abnormal positions of the metal clips.[58] In our cases, diagnosis was based on the abdominal CT scan and was further confirmed by choledochoscope. And with the development of endoscopic technology, ERCP (for clip-stone) and choledochoscope (for T clip-sinus) gradually become the preferential way to deal with clip migration because they are faster, more economic with fewer traumas and complications.[10],[60] Performing an adequate EST is necessary and important as it may facilitate spontaneous passage to excrete stones even if the initial ERCP extraction had failed. Surgeries will be operated to handle the difficult clip-stones or acute, serious patients.[23],[58] Based on our past experience, bile duct exploration and J tube (a kind of ureteral catheter) drainage (primary suture the CBD) is better than T-tube drainage when tackling a single clip-stone and avoiding the migration again. After 2 weeks, we could remove the J tube with an endoscope to prevent the patients from long-term pains in the T tube.

To prevent surgical clip migration, some put forward that the blind application of clips must be forbidden and it is better to use the minimum number of clips: (1) avoid blind application of clips to control bleeding; (2) limit the length of the residual cystic duct at 0.5 cm–1.0 cm; (3) keep clips away from T-tube as much as possible.[18],[23],[58] Others deemed that absorbable clips could be used and they emphasised that synthetic, absorbable sutures or other suture materials should be used for biliary surgery to reduce inflammatory reaction.[17],[37],[61]

 Conclusions



PCCM is a rare but severe complication of LCBDE. A pre-operative understanding of bile duct anatomy, the use of the minimum number of clips and the harmonic scalpel[62] during the surgeries is necessary. Considering clip-stone or clip-sinus in the differential diagnosis of patients with biliary colics or cholangitis after LCBDE even years after surgery, the detailed medical history, and pre-operative examination are inevitable, especially for these patients who had undergone LCBDE. Moreover, we are bound to have a better understanding of the disease as time goes on.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Ellison EC, Carey LC. Cholecystectomy, cholecystostomy and intraoperative evaluation of the biliary tree. In: Baker JR, Fishcer JE, editors. Mastery of Surgery. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2001.
2Huang X, Feng Y, Huang Z. Complications of laparoscopic cholecystectomy in China: An analysis of 39,238 cases. Chin Med J (Engl) 1997;110:704-6.
3Wolf AS, Nijsse BA, Sokal SM, Chang Y, Berger DL. Surgical outcomes of open cholecystectomy in the laparoscopic era. Am J Surg 2009;197:781-4.
4Walker WE, Avant GR, Reynolds VH. Cholangitis with a silver lining. Arch Surg 1979;114:214-5.
5Bradfield H, Granke D. Surgical clip as a nidus for a common bile duct stone: Radiographic demonstration. Abdom Imaging 1997;22:293-4.
6Venu RP, Brown RD, Rosenthal G, Deutch SF, LoGuidice JA, Pastika B, et al. An impacted metallic clip at the ampulla causing ascending cholangitis. Gastrointest Endosc 1997;45:435-6.
7Yu SC, Yuan RH, Ho MC, Lee WJ. Duodenal endoclip migration after laparoscopic cholecystectomy: Report of a case. Endoscopy 1997;29:339.
8Cetta F, Lombardo F, Baldi C, Cariati A. Clip migration within the common duct after laparoscopic cholecystectomy: A case of transient acute pancreatitis in the absence of associated stones. Endoscopy 1997;29:S59-60.
9Herline AJ, Fisk JM, Debelak JP, Shull HJ Jr., Chapman WC. Surgical clips: A cause of late recurrent gallstones. Am Surg 1998;64:845-8.
10Alberts MS, Fenoglio M, Ratzer E. Recurrent common bile duct stones containing metallic clips following laparoscopic common bile duct exploration. J Laparoendosc Adv Surg Tech A 1999;9:441-4.
11Ng WT, Kong CK, Lee WM. Migration of three endoclips following laparoscopic cholecystectomy. J R Coll Surg Edinb 1999;44:200-2.
12Mansoa A, Martins A, Brito E Melo M, Coito P. Surgical clips as a nidus for stone formation in the common bile duct. Surg Endosc 2000;14:1189.
13Matsumoto H, Ikeda E, Mitsunaga S, Naitoh M, Furutani S, Nawa S, et al. Choledochal stenosis and lithiasis caused by penetration and migration of surgical metal clips. J Hepatobiliary Pancreat Surg 2000;7:603-5.
14Ammann K, Kiesenebner J, Gadenstätter M, Mathis G, Stoss F. Embolism of a metallic clip: An unusual complication following laparoscopic cholecystectomy. Dig Surg 2000;17:542-4.
15Reis LD. Surgical clips incorporated into a duodenal ulcer: A rare complication after elective laparoscopic cholecystectomy. Endoscopy 2000;32:S3.
16Petersen JM. Surgical clip choledocholithiasis. Gastrointest Endosc 2002;56:113.
17Dell'Abate P, Del Rio P, Soliani P, Colla G, Sianesi M. Choledocholithiasis caused by migration of a surgical clip after video laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A 2003;13:203-4.
18Hai S, Tanaka H, Kubo S, Takemura S, Kanazawa A, Tanaka S, et al. Choledocholithiasis caused by migration of a surgical clip into the biliary tract following laparoscopic cholecystectomy. Surg Endosc 2003;17:2028-31.
19Angel R, Abisambra N, Marin JC. Clip choledocholithiasis after laparoscopic cholecystectomy. Endoscopy 2004;36:251.
20Chong VH, Yim HB, Lim CC. Clip-induced biliary stone. Singapore Med J 2004;45:533-5.
21Liu LF, He K, Liu JJ. A case of three titanium clips in the common bile duct after laparoscopic cholecystectomy. Chin J Hepatobiliary Surg 2005;1:30.
22Mouzas IA, Petrakis I, Vardas E, Kogerakis N, Skordilis P, Prassopoulos P, et al. Bile leakage presenting as acute abdomen due to a stone created around a migrated surgical clip. Med Sci Monit 2005;11:CS16-8.
23Ahn SI, Lee KY, Kim SJ, Cho EH, Choi SK, Hur YS, et al. Surgical clips found at the hepatic duct after laparoscopic cholecystectomy: A possible case of clip migration. Surg Laparosc Endosc Percutan Tech 2005;15:279-82.
24Khanna S, Vij JC. Endoclips as nidus for choledocholithiasis presenting 5 years after laproscopic cholecystectomy. Endoscopy 2005;37:188.
25Tan HY, Gen XQ. A case of a titanium clip in the formation of stones in the common bile duct. Peoples Mil Surg 2005;48:616.
26Alsulaiman R, Barkun J, Barkun A. Surgical clip migration into the common bile duct after orthotopic liver transplantation. Gastrointest Endosc 2006;64:833-4.
27Dolay K, Alis H, Soylu A, Altaca G, Aygun E. Migrated endoclip and stone formation after cholecystectomy: A new danger of acute pancreatitis. World J Gastroenterol 2007;13:6446-8.
28Attwell A, Hawes R. Surgical clip migration and choledocholithiasis: A late, abrupt complication of laparoscopic cholecystectomy. Dig Dis Sci 2007;52:2254-6.
29Steffen M, Kronsbein H, Wesche L. Metal clip as a nidus for formation of common bile duct stone following laparascopic cholecystectomy. Z Gastroenterol 2007;45:317-9.
30Samim MM, Armstrong CP. Surgical clip found at duodenal ulcer after laparoscopic cholecystectomy: Report of a case. Int J Surg 2008;6:473-4.
31Li HL, Liu ZM. A case of biologic clips walking to common bile duct after laparoscopic cholecystectomy. Chin J Hepatobiliary Surg 2009;15:577.
32Wang YL, Zhang GY, Wang L, Hu SY. Metallic clip migration to T-tube sinus tract after laparoscopic choledochotomy. Acta Chir Belg 2009;109:242-4.
33Brandt LJ. Surgical clip migration and stone formation in a gallbladder remnant after laparoscopic cholecystectomy. Gastrointest Endosc 2009;70:780-1.
34Goshi T, Okamura S, Takeuchi H, Kimura T, Kitamura S, Tamaki K, et al. Migrated endoclip and stone formation after cholecystectomy: A case treated by endoscopic sphincterotomy. Intern Med 2009;48:2015-7.
35Lee SL, Kim HK, Cho YS. Acute obstructive cholangitis due to foreign body in the common bile duct. Migrated endoclip. Gastroenterology 2010;139:e3-4.
36Wang ZS, Zhang BY, Wu LQ, et al. A case of intra cholecystectomy after cholecystectomy with endoscopic cholecystectomy. Chin J Gen Surg 2010;25:855.
37Gonzalez FJ, Dominguez E, Lede A, Jose P, Miguel P. Migration of vessel clip into the common bile duct and late formation of choledocholithiasis after laparoscopic cholecystectomy. Am J Surg 2011;202:e41-3.
38Molina-Infante J, Fernandez-Bermejo M, Mateos-Rodriguez JM. Migrated surgical clip-induced choledocholithiasis. Endoscopy 2011;43 Suppl 2:E350-1.
39Ray S, Bavishi Y. Endoclip migration into the duodenum: An unusual complication after laparoscopic cholecystectomy. Am Surg 2011;77:E216-7.
40Tseng CW, Wei CK, Hsieh YH. Education and imaging. Hepatobiliary and pancreatic: Clip migration after laparoscopic cholecystectomy. J Gastroenterol Hepatol 2011;26:1695.
41Rowe D, Nikfarjam M. Cystic duct clip migration into the common bile duct. Indian J Gastroenterol 2012;31:86.
42Sajith KG, Dutta AK, Joseph AJ, Simon EG, Chacko A. Tombstone of surgical clip in common bile duct. Trop Gastroenterol 2012;33:67-9.
43Song M, Kwek BE, Ang TL. Acute cholangitis secondary to a recently migrated cystic duct clip, 15 years after cholecystectomy. Endoscopy 2012;44 Suppl 2:E294-5.
44Liu Y, Ji B, Wang Y, Wang G. Hem-o-lok clip found in common bile duct after laparoscopic cholecystectomy and common bile duct exploration: A clinical analysis of 8 cases. Int J Med Sci 2012;9:225-7.
45Ray S, Bhattacharya SP. Endoclip migration into the common bile duct with stone formation: A rare complication after laparoscopic cholecystectomy. JSLS 2013;17:330-2.
46Sharma M, Singh B, Varghese R. Surgical clips in the common bile duct suspected on endoscopic ultrasound and confirmed on endoscopic retrograde cholangiopancreatography. Endosc Ultrasound 2013;2:157-8.
47Photi ES, Partridge G, Rhodes M, Lewis MP. Surgical clip migration following laparoscopic cholecystectomy as a cause of cholangitis. J Surg Case Rep 2014;2014. pii: rju026.
48Hong T, Xu XQ, He XD, Qu Q, Li BL, Zheng CJ, et al. Choledochoduodenal fistula caused by migration of endoclip after laparoscopic cholecystectomy. World J Gastroenterol 2014;20:4827-9.
49Ghavidel A. Migration of clips after laparoscopic cholecystectomy; a case report and literature review. Middle East J Dig Dis 2015;7:45-9.
50Sormaz IC, Keskin M, Sönmez RE, Soytaş Y, Tekant Y, Avtan L, et al. Obstructive jaundice secondary to endoclip migration into common bile duct after laparoscopic cholecystectomy. Minerva Chir 2015;70:381-3.
51Singh MK, Kinder KZ, Braverman SE. Transhepatic management of a migrated intraductal surgical clip after cholecystectomy and gastrectomy. J Vasc Interv Radiol 2015;26:1866.
52Cookson NE, Mirnezami R, Ziprin P. Acute cholangitis following intraductal migration of surgical clips 10 years after laparoscopic cholecystectomy. Case Rep Gastrointest Med 2015;2015:504295.
53Tang XD, Liu SH, Chen S. Two cases of Hem-o-lock clips wandering in common bile duct after laparoscopic cholecystectomy and bile duct exploration and stone removal. Chin J Dig Endosc 2015;32:565-6.
54Nagorni EA, Kouklakis G, Tsaroucha A, Foutzitzi S, Courcoutsakis N, Romanidis K, et al. Post-laparoscopic cholecystectomy mirizzi syndrome induced by polymeric surgical clips: A case report and review of the literature. J Med Case Rep 2016;10:135.
55Rawal KK. Migration of surgical clips into the common bile duct after laparoscopic cholecystectomy. Case Rep Gastroenterol 2016;10:787-92.
56Antunes AG, Peixe B, Guerreiro H. Pancreatitis and cholangitis following intraductal migration of a metal clip 5 years after laparoscopic cholecystectomy. Gastroenterol Hepatol 2017;40:615-7.
57Qu JW, Wang GY, Yuan ZQ, Li KW. Hem-o-lok clips migration: An easily neglected complication after laparoscopic biliary surgery. Case Rep Surg 2017;2017:7279129.
58Chong VH, Chong CF. Biliary complications secondary to post-cholecystectomy clip migration: A review of 69 cases. J Gastrointest Surg 2010;14:688-96.
59Tsumura H, Ichikawa T, Kagawa T, Nishihara M, Yoshikawa K, Yamamoto G, et al. Failure of endoscopic removal of common bile duct stones due to endo-clip migration following laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg 2002;9:274-7.
60Kager LM, Ponsioen CY. Unexpected bile duct stones formed around surgical clips 4 years after laparoscopic cholecystectomy. Can J Surg 2009;52:E114-6.
61Leung KL, Kwong KH, Lau WY, Chung SC, Li AK. Absorbable clips for cystic duct ligation in laparoscopic cholecystectomy. Surg Endosc 1996;10:49-51.
62Catena F, Ansaloni L, Di Saverio S, Gazzotti F, Coccolini F, Pinna AD, et al. Prospective analysis of 101 consecutive cases of laparoscopic cholecystectomy for acute cholecystitis operated with harmonic scalpel. Surg Laparosc Endosc Percutan Tech 2009;19:312-6.