Despite current developments in bipolar or ultrasonic devices, surgical clips still remain the gold standard for the ligation of vessels and hollow organs, especially in the field of minimally invasive surgery. This is mainly due to safety, availability, speed and, not least, cost. However, this technique has one major drawback that should be addressed carefully: clips might dislocate intraoperatively either through handling (e.g. linked with further surgical steps) or through physiological movement-induced shearing forces. Their application should be monitored carefully, as an early intraoperative dislocation or late dislocation and migration may cause major complications , , , , , , . Nevertheless, ligation clips are used very frequently. This results in numerous clipped vessels and contributes to the accumulation of the risk.
The shearing forces that result in the dislocation of the clip may be either in the axial direction of the vessel or radial to the vessel or a combination of both. Theoretically, the axial pull-off force may be mainly influenced by the geometry, the material and the diameter of the clip shanks, resulting in different tissue-clip adhesion forces at the interface. Radial pull-off forces may be additionally influenced by the retention force of the hinge. The occurrence of clips bursting away from the vessels due to blood pressure appears to be a minor effect . To address this safety issue, it is not uncommon for surgeons to place a sequence of two clips on the remaining vessel stump.
This has led to the development of double-shanked (DS) clips, which allow the placement of a clip with two parallel shanks in one procedure, a technique that is already applied successfully in appendectomy , . The question arises whether these clips provide increased shear forces for removal and thereby increase the resistance of the clip to accidental or physiological displacement.
Materials and methods
The research related to animals use has been complied with all the relevant national regulations and institutional policies for the care and use of animals. After approval by the institutional review board for animal experiments, eight female German Landrace pigs weighing 51±1 kg received a two-step intramuscular premedication consisting of atropine (0.05 mg/kg) and azaperone (4.0 mg/kg) followed by midazolam (1.0 mg/kg) and ketamine (14 mg/kg). After transfer to the operating theatre and placement of a peripheral venous catheter, the animals received heparin (200 IU/kg i.v.) and were euthanised by T61 (150 μL/kg i.v.).
Preparation and clipping of vessels
Arteria saphena, arteria carotis, arteria axillaris and arteria femoralis were prepared for the application of the clips. Twenty DS-Clips (DS: DS-Clips, Aesculap AG, Tuttlingen, Germany) of each size [medium (M) and medium-large (ML)] and each pull-off direction (radial and axial) were compared to an equal number of two state-of-the-art single-shanked clip systems (S1: Ligaclip, Ethicon, Cincinnati, OH, USA; S2: Horizon Titanium Ligating Clips, Teleflex Medical, Athlone, Ireland) by a single experienced surgeon (G.M.), resulting in a total number of 240 applied clips (Figure 1). Clip dimensions were measured using a micrometre gauge (precision ±2 μm; Table 1). The vessel diameter was determined using a ruler. Clips of size M were applied to vessels of 2–4 mm and clips of size ML were applied to vessels of 3.5–7 mm. The sequence was predefined by a block randomisation protocol (DS, S1, and S2 in all six permutations). The vessels were dissected leaving 15 mm on the proximal side and 2 mm on the distal side of the clip for axial pull-off and 12 mm on both sides for radial pull-off.
Evaluation of pull-off forces
The pull-off forces were measured as described previously , . In brief (Figure 2), for the evaluation of radial pull-off forces, a ligature was placed inside the hinge of the clip, the vessel was fixed on both ends and the ligature was connected to a tension testing machine (testControl II, Zwick, Ulm, Germany). Subsequently, the clip was removed from the vessel. For the evaluation of axial pull-off forces, the proximal stump of the vessel was fixed and the clip was fixed on both sides and removed by the tension testing machine.
The tension testing machine was calibrated according to the manufacturer’s instructions. The rate of feed was set to a constant 5 mm/min. The maximum removal force was determined from the load-displacement diagram.
All results were given in mean±SEM. The groups were compared using the Tukey-Kramer test for unpaired samples, with p<0.05 considered significant. Due to the clip design (Figure 1), the cross-sectional area was counted twice for the DS-Clips. A rectangular approximation was used for the cross-sectional area (Table 1).
All possible confounding parameters were distributed homogeneously amongst the groups (Table 2). The axial pull-off force for the M-sized DS-Clip (4.6±0.2 N) was significantly higher than the single-shanked control S1 (3.3±0.2 N; p<0.05; Figure 3, left) and slightly higher than the single-shanked control S2 (4.1±0.2 N, n.s.). The pull-off force of the ML-sized DS-Clip (7.8±0.5 N) was higher than the control clip S1 (6.1±0.5 N; p<0.05) and the pull-off force of the control clip S2 (8.7±0.5) was higher than the control clip S1 (p<0.05; Figure 3, right).
The radial pull-off force of the DS-Clip in both sizes (2.1±0.1 N for the M size and 3.0±0.2 N for the ML size) was significantly elevated compared to the single-shanked clips (p<0.05 for all comparisons; Figure 4).
Irrespective of the anatomical vessel, clip size and manufacturer, there was a linear correlation (R=0.982) between the radial pull-off forces of single-shanked clips and material thickness. With the DS-Clip, higher pull-off forces were obtained even with a lower material thickness (Figure 5, left). This was in good correlation to the observations of significant differences between S1 and S2 groups (Figure 4). A comparably linear correlation (R=0.992) was observed between the cross-sectional area of the clip and the axial pull-off force (Figure 5, right).
The variation coefficient of pull-off forces of the DS-Clip applier of the M size in the radial pull-off setting was 22% compared to 38% in the S1 group and 36% in the S2 group (Figure 6, right). For the ML-sized clip applier in the same setting, the variation coefficient of the DS-Clips was 27% compared to 44% in the S1 group and 35% in the S2 group. The variation in axial pull-off forces was comparable in all clip types for the M size (Figure 6, left).
Addressing the removal safety issue, it became obvious that the radial pull-off force is less than half the force needed for axial pull-off. In accordance with in vitro results, it can be concluded that the radial type of shear stress can be expected to be crucial in clip dislocation , . The Nelson et al. study using silicon tubes resulted in a 1.8-fold axial removal force compared to radial removal force and was comparable to the results of the present study in the animal model (2.2-fold). With respect to the radial pull-off force, the DS-Clip provides a clear advantage over single-shanked clips.
The axial pull-off force obtained in this study was comparable to that obtained by an axial pull-off study on cystic duct stumps . The axial pull-off force of the DS-Clip is higher than one single-shanked clip (S1) and comparable to the other single-shanked clip (S2).
The usage of non-perfused vessels of dead animals as a limitation of the model may be regarded of only limited importance for two reasons. First, in all laparoscopic and open-surgical interventions, the second and potential further clips are placed on non-perfused vessels as well. Second, it is not likely that the stop of the blood flow will change the biological and physical properties of the vessel.
In general, it was observed that the crucial radial retention force has a linear correlation to the horizontal thickness of the tested clips, explaining the differences between S1 and S2 groups. During the bending process, the tapering of the material on the outside and compression on the inside in the hinge region influences the retention force. One might consider surgical clips with an asymmetric material distribution resulting in a higher material thickness in that crucial region. The axial retention force is correlated to the combination of horizontal and vertical thicknesses. Taking into account the fact that materials, surface structures and jaw parts were comparable amongst the tested clips, it could be considered that an increase in safety might be achieved only by increasing material thickness. This may, however, be limited by the force needed to close the applier.
A lower variation coefficient for radial pull-off forces of the DS-Clips was observed. These results were obtained despite all the clippings being performed by a highly experienced surgeon. This may be due to the defined catch in the applier of the DS-Clips. These findings have to be confirmed by a cross-sectional study involving a larger cohort of surgeons with different professional experience, hand size and force. One might expect that the catch significantly contributes to the reproducibility of clip application.
The old saying “more is better” is an obvious truth in surgical clip application. The DS-Clip expanded the linear correlation of material thickness and cross-sectional area and led to higher safety. Although a safe vascular closure can be obtained with thinner and single-shanked clips, the wider DS-Clip is more resistant against removal. The defined catch in the applier may help to standardise application forces and may help surgeons to gain reassurance regarding closing forces.
Research funding: This study has been carried out in cooperation with and sponsored by Aesculap AG, Tuttlingen, Germany. Conflict of interest: Authors state no conflict of interest. Material and Methods: Informed consent: Informed consent is not applicable. Ethical approval: The research related to animals use has been complied with all the relevant national regulations and institutional policies for the care and use of animals.
Data retrieval: Gottfried Mueller, Tim Oliver Greiner, Christine Fahrner; Revision of the manuscript: Gottfried Mueller, Alfred Koenigsrainer, Christian Thiel; Approval of the manuscript: Alfred Koenigsrainer.
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The article (DOI: 10.1515/iss-2016-0003) offers reviewer assessments as supplementary material.
About the article
Published Online: 2016-06-15
Published in Print: 2016-09-01
Citation Information: Innovative Surgical Sciences, Volume 1, Issue 1, Pages 41–46, ISSN (Online) 2364-7485, DOI: https://doi.org/10.1515/iss-2016-0003.
©2016, Martin Schenk et al., published by De Gruyter.. This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License. BY-NC-ND 4.0