Metal Clip Techniques Utilizing Pistol Grip Appliers

Walker Reynolds, Jr., MD, MS (Surg), FACS, Anniston, Alabama

In 1917 Harvey Cushing reported the invention of a hemostatic clip. The clip was used chiefly in intra- cranial operations. A new hemostatic clip was in- troduced by Samuels et al [I] in 1966; made of bio- logically inert tantalum, it was malleable and as strong as stainless steel. This hemostatic clip is shaped as a U, closes at its tip first and then forms a diamond before final closure. The occlusive surface has a longitudinal groove running down the center which is crossed at intervals by transverse depres- sions. These hemostatic clips are available in four sizes: large, medium large, medium and small. The advantage of using hemostatic clips is that one is able to accomplish rapid and secure hemostasis in surgical procedures. The Hemoclipk (manufactured by Edward Week and Company, Research Triangle Park, North Carolina) are nonreactive. The method of application is simpler and more rapid than the use of ligatures, particularly suture ligatures. The first Hemoclip appliers were of the conventional type similar to the ring type forceps, with specially de- signed jaws to accommodate the clips. In addition to the conventional ring type forceps, three other types of pistol grip appliers (also manufactured by Edward Week and Company) are now available: one applies a single Hemoclip, one applies two Hemoclips par- allel to each other, allowing space to cut between the two and the third holds a cartridge containing 20 medium-sized Hemoclips that can be applied singly and quickly. A matching pistol grip scissors is also available (Figures 1 and 2).

A pistol grip Hemoclip applier was designed after the development of a technique of hemorrhoidec- tomy utilizing Hemoclips. It was discovered that the use of medium-sized Hemoclips instead of ligatures in performing hemorrhoidectomy made it become a simple and rapid procedure. Postoperative pain was decreased and hospital recovery time shortened. It was noted on anoscopic examination within a few weeks that no Hemoclips remained in the anorectal canal. It was then decided that the same basic He- moclip techniques would be adaptable in controlling hemostasis in the removal of rectal polyps. Since the

From the Department of Surgery, Northeast Alabama Regional Medical Center, Anniston, Alabama.

Requests for reprints should be addressed to Walker Reynokts, Jr., MD, 14 Rendalia Road, Anniston. Alabama 36201.

available ring type Hemoclip applier would not pass the rigid sigmoidoscope, there developed a need for a pistol grip Hemoclip applier, similar to a biopsy forceps, which could be passed through the sig- moidoscope. In 1972 the first single application pistol grip hemoclip applier was developed, and I used it successfully to remove rectal polyps through the rigid sigmoidoscope. This led to the development of a shorter pistol grip applier for the Hemoclips of dif- ferent sixes used in general surgical procedures. It was found useful in all types of situations where the ring type applier had previously been used.

With special techniques the double Hemoclip applier has certain advantages over conventional methods now used. The advantages of the pistol grip applier over the ring applier are as follows: The pistol grip applier is better balanced and makes it easier to take a firm grip. It is easier to aim the instrument into a small, deep cavity and place the clip with precision on a blood vessel or duct. The loaded hemoclip can be seen more easily on the end of the pistol grip ap- plier than on the ring applier because of the ob- struction of sight by the wide arms of the forceps type applier. After one sights down the barrel of the pistol grip applier and fires the applier there is a definite sense of occlusion of the Hemoclip and one does not have the feel of rebound as with the ring applier.

The single or automatic pistol grip applier is used when necessary to apply only a single Hemoclip. In certain situations, an additional Hemoclip is desired when two Hemoclips have already been applied with the double applier on the proximal end of a blood vessel or the distal end of a duct. In most cases deal- ing with tubular structures such as the cystic duct, the vas deferens and the blood vessels, it becomes advantageous to use the double Hemoclip applier, which may be fired in three different positions de- pending on how many clips one wants to place on the distal end of the structure. There are three methods of applying double Hemoclips: (1) a single applica- tion of two Hemoclips cutting through the center; (2) four Hemoclips applied with two firings cutting be- tween one and two with three of the Hemoclips re- maining on the proximal side, as would be desirable in ligating a large artery, and (3) two Hemoclips ap- plied equally on the proximal and distal ends, cutting in the center for double reinforcement, as might be desired with the cystic duct. Which of the three ap-

274 The American Journal of Surgery

Metal Clip Techniques Using Pistol Grip Appliers

Double Hemocltp Appler

Figure 1. Slqle pistol grip Henwcllp applier. The Insets show ihe double Henwcllp applier and the scissors, which use the same type of handle and shaft.

F&fore 2. Automatic pistol grip He- moclip applier. The tnstrument holds a dlsposabk cartridge contalntng 20 medium-sized ttemocllps, whkh are fired shtgly and qulckty with an auto- matic trigger action.

plications to be used depends on the anatomic sit- uation. In lieu of the second firing of the double He- moclip applier, one might use the firing of a single Hemoclip on the desired proximal or distal end with the single Hemoclip applier. A pistol grip scissors has been developed with the same length and balance as the pistol grip Hemoclip applier, which is useful in cutting between the Hemoclips (Figure 1). I have used the single pistol grip applier clinically since 1972 and the double Hemoclip applier since 1975. The automatic Hemoclip applier was introduced for clinical use in 1981 (Figure 2).

Techniques

Hemorrhoidectomy (Figure 3): Hemoclip hemor- rhoidectomy has been used in approximately 200 cases with excellent results /Z-4]. There have been no postoperative

hemorrhages requiring surgical intervention and no re- operations for hemorrhoids. Postoperative complications have been related to fissures and genitourinary complica- tions which have prolonged postoperative pain and hos- pitalization; however, there have been few of these and the average number of postoperative analgesic injections has been two or less in the posthemorrhoidectomy patient. The patients have been in the hospital an average of 4 days. The basic hospital stay could be reduced to 2 to 3 days if it were not customary to keep the patient in the hospital until they have had their first bowel movement.

In this technique an Allis forcep is used to grasp the primary hemorrhoidal group in the right anteroposterior and left lateral positions and apply single and double He- moclips to the base of the hemorrhoidal pedicle to secure hemostasis in the larger hemorrhoidal vessels in the in- ternal hemorrhoidal groups before dissection The external hemorrhoidal tissue and skin are severed elliptically, re- moving the excessive skin and external hemorrhoids and

Volume 143, February 1992 275

Reynolds

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Ei I Hemoclips on mucosa

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Ftgure 3. HM@ny. Ths hemodWldalpedkle in~ktdlng the fnvxlmal skin, extemal and internal hemohMs are awaiting the final application of the double Hemocllps. 77m hemorrhoidal petlick will then be fmed by cutting between the Hemocllps. The same pvcedufe is perhmed In the right antemposterlor and the left lateral posltlons.

carrying the dissection inward toward the original hem- orrhoidal base. Medium hemoclips are applied along the edge of the mucosa to control bleeding as the dissection is performed. This is accomplished by using both single and double Hemoclip appliers. The main objective of the op-

eration is to avoid injury to the anal musculature, and therefore no clips are placed in the muscle unless absolutely necessary for hemostasis. Minimal sites of external hem- orrhage are controlled with electrocautery.

Cholecystectomy (Figure 4): The Hemoclip is valuable in gallbladder surgery because the cystic duct can be partly occluded with a Hemoclip holding a catheter in the duct for cholecystography. The single and double appliers are also valuable in applying Hemoclips to bisect the cystic duct and cystic artery. Other operations I commonly per- form in which pistol grip Hemoclip appliers are advanta- geous include appendectomy, colectomy, gastrectomy, polypectomy, radical mastectomy, saphenous vein ligation, splenectomy, thyroidectomy and vasectomy [4].

Summary

Hemoclips applied with pistol grip single, auto- matic and double appliers may be placed with speed and precision to occlude blood vessels and ducts in surgical procedures. Techniques using Hemoclips are described, including hemorrhoidectomy and chole- cystectomy. Hemoclip techniques can also be used in appendectomy, polypectomy, radical mastectomy, saphenous vein ligation, splenectomy, thyroidectomy and other miscellaneous procedures.

References

1. Samuels PB, Roedlery H, Katz R, et al. A new hemostatic clip. Ann Surg 1966;163:427-31.

2. Reynolds W. Hemorrhoidectomy. Hemoclips. Long Island Cii, NY: Edward Week, 1973: 14.

3. Reynolds W. Sutueless hen%Mlok%ctomy. Sllrg Gynecol Cbstet 1972;134:842-3.

4. Samuels PB, Parris EB, Reynolds W, et al. Hemoclips. Long Island City, NY: Edward Week, 1973.

non duct

Figure 4. Cholecystectomy. Double hemocllps are being applied to the cystk duct. in some in- stances, as shown In A, the doubk Hemocllp a@arwlllbefhdtwlce,ptachgtwol-lemd& plvxhnally&utdtwodWanywnfIthelMtsevweti between numbers two ad three. 6, a partly occluded Hemocllp holding a catheter In ptace for an operative cholanglogram.

276 The Amerkan Journal d Surgery