Ioannis Nikolopoulos, MRCS, Janakan Ghananandan, MRCS, Rajab Kerwat, FRCS
Queen Elizabeth Hospital, London, United Kingdom (all authors).
Introduction: Hem-o-lok ligation clips are widely used for the hemostatic control of major mesenteric vessels during laparoscopic colorectal resection. We report 2 rare cases of bowel obstruction and perforation requiring urgent surgical intervention after the application of Hem-o-lok clips (Weck Surgical Instruments, Teleflex Medical, Durham, NC, USA), which were used to occlude vessels and provide hemostasis during elective laparoscopic sigmoid colon resection. In both cases, the clips completely dislodged from the vessels to which they were initially applied and eventually attached to the wall of the small bowel, causing obstruction, ischemia, and perforation.
Case Descriptions: Case 1. An 82-year-old man with Duke’s C adenocarcinoma underwent an elective laparoscopic reversal of Hartmann’s procedure after an elective laparoscopic sigmoid colectomy, which was converted to a Hartmann’s procedure due to an anastomotic leak. The reversal of the Hartmann’s operation was complicated by dense adhesions of small bowel to the inferior mesenteric artery (IMA) remnant, with the Hem-o-lok clips initially used to occlude the artery embedded in the wall of the small bowel and completely dissociated from the IMA. A perforation occurred, associated with the clip-related stricture of the small bowel. Case 2. A 69-year-old woman underwent an urgent laparotomy for a small-bowel obstruction that did not respond to conservative treatment. Her surgical history of perforated diverticular disease included a laparoscopic Hartmann’s procedure that was reversed laparoscopically a few months later. She was found to have a small-bowel obstruction secondary to a Hem-o-lok clip that was completely embedded in the serosa of the bowel wall, with a perforation just proximal to it.
Conclusion: Ligation clips, when properly applied, are regarded as a reliable method of obtaining arterial hemostatic control during laparoscopic colorectal procedures. Migration of the clips, although a rare problem, can cause serious complications that may necessitate further surgical intervention. Previous case reports have shown that Hem-o-lok clips can cause vascular complications. These two cases illustrate that they can cause bowel-related complications that necessitate emergent surgical treatment. It is therefore our view that these clips should not be used for arterial ligation during laparoscopic colorectal surgery.
Key Words: Bowel obstruction, Hem-o-lok clip, Laparoscopic colorectal surgery, Perforation.