Clip Slippage Research Articles

Failure mechanisms and load paths in a standing seam metal roof under extreme wind loads

In this paper, the failure sequence and load sharing for standing seam metal roofs (SSMR), up to the limit state, were investigated using full-scale experiments. The tested SSMR system had full-scale dimensions and boundary conditions, which provided the opportunity to investigate the performance of SSMR systems under realistic conditions. The results show that there is a linear relationship between the wind pressure and clip reaction under low wind pressure (less than 500 Pa). Load redistribution happens along with the deformation of roof panels with greater load transfer to the ridge and eaves of the roof at higher pressure. Near the corner of the roof, between 27 and 46 % of the applied load is transferred to edges of the eaves and gable end. Away from the roof corner, between 17 and 23 % of the applied load is transferred to eave edge. Global buckling of panels occurs before connection failures and the initial location of global buckling is near the seam and in the middle of two adjacent clips. Two failure modes for the connections, clip slippage and fastener failure, were observed during the tests. However, the failure modes vary with the clip arrangement and boundary conditions.

Intracranial Aneurysm "Clip Anchoring": Technical Note.

Clip slippage and displacement during or after intracranial aneurysm surgery is associated with morbidity and can be detrimental. We report the usage of concomitant aneurysm clips and artery clips aiming to avoid this complication in a patient undergoing elective aneurysm surgical clipping.

The application of high-resolution vessel wall imaging in the in situ bypass surgeries for complex anterior cerebral artery aneurysms

ObjectiveComplex anterior cerebral artery (ACA) aneurysms are still technically challenging to treat. Bypass surgery is needed to achieve aneurysm obliteration and ACA territory revascularization. Severe atherosclerosis of aneurysm walls can cause clip slippage, intraoperative rupture, postoperative ischemic events. How to assess the atherosclerotic changes in vascular walls by high-resolution vessel wall magnitude resonance imaging (VWI) is the key question in complex ACA aneurysm surgical management. MethodsThis retrospective single-center study included eight patients diagnosed with complex anterior cerebral arteries admitted to our hospital for bypass surgery from January 2019 to April 2022. We discussed the application of VWI in aneurysms treated with in situ bypass and reviewed previous experience of revascularization strategies for complex ACA aneurysms. ResultsIn this study, we treated 8 cases of complex ACA aneurysms (3 communicating aneurysms/5 postcommunicating aneurysms) over the prior one year. In situ side-to-side anastomosis (1 A2-to-A2/6 A3-to-A3) was performed in seven cases, and trapping combined with excision was performed in another case. Following bypass, complete trapping was performed in 4 cases, and proximal clipping was performed in 3 cases. No surgery-related neurological dysfunctions were observed. The final modified Rankin scale was 0 in seven of the eight cases and 2 in one case. ConclusionHigh-resolution VWI, as a favorable preoperative assessment tool, provides insight into patient-specific anatomy and microsurgical options before operations, which can help neurosurgeons develop individualized and valuable surgical plans.

Incidence of Postoperative Cerebral Aneurysm Clip Slippage: Review of a Consecutive Case Series of 115 Clipped Aneurysms

Although delayed postoperative clip slippage has been reported in previous case reports and case series, its true incidence with high rate of follow-up imaging has not been reported. We attempted to determine the incidence of clip slippage in a cohort of consecutive aneurysm clippings. We performed a retrospective review of a prospectively maintained database of 115 consecutive saccular aneurysm clippings at a single institution. Postoperative imaging was reviewed for clip slippage within 24 hours and at 3-12 months. Eighty-six aneurysms (75.8%) were exclusively clipped with Sugitaclip (Mizuho Medical, Tokyo, Japan) Titanium II clips, 16 aneurysms were exclusively clipped with Yaşargil (Aesculap, Center Valley, PA) titanium clips (13.9%), 5 aneurysms were only clipped with Sugita aneurysm clips (4.3%), and 3 aneurysms were only clipped with Peter Lazic (Peter Lazic Microsurgical Innovations, Tuttlingen, Germany) clips (2.6%). In this cohort, 94.7% of clipped aneurysms had follow-up imaging within 24 hours, and 51.3% had delayed follow-up imaging within 3-12 months. We identified 3 cases of clip slippage in 115 consecutive aneurysm clippings, resulting in an incidence of 2.6%. The average cumulative closing force of clips per aneurysm across the study was 2.32 N, and the median number of clips placed was 1. Two of the 3 cases of clip slippage had a closing force <2.32 N and only placement of a single clip. Because our series showed a 2.6% incidence of clip slippage, clipped aneurysms should be monitored with early and delayed vascular follow-up imaging. Lower cumulative clip closing force, single clip placement, and oversized clip blade length may be risk factors for postoperative aneurysmal clip slippage.

Placement of interlocking fenestrated clips for a large broad-based middle cerebral artery aneurysm with atherosclerosis: Technical case report

IntroductionClip ligation of a large or giant middle cerebral artery (MCA) aneurysm is sometimes challenging, since these aneurysms commonly involve the efferent arteries and often show atherosclerotic changes in the aneurysm wall. We present herein a surgical case of large MCA aneurysm with atherosclerosis, and demonstrate a technique that enables adjustment of the patency of efferent arteries and the dog-eared remnant of the complex bifurcation aneurysm by placement of interlocking fenestrated clips. Case illustrationA 63-year-old woman was referred to our hospital for treatment of a relatively large unruptured left MCA saccular aneurysm (dome height × neck width: 9.5 mm × 7.6 mm). She underwent microsurgical clip ligation of the aneurysm. Due to the atherosclerotic changes in the aneurysm neck and efferent arteries, a large amount of dog-eared remnant of the aneurysm neck or clip slippage was likely to occur following single clip ligation. The interlocking clip application technique was thus considered using fenestrated clips with high closure force at the tips, resulting in successful aneurysm obliteration without complicated replacement of the clips. ConclusionAlthough complex clip application techniques for large MCA aneurysms with atherosclerosis have been reported, the present technique could provide an alternative.

Utility of fenestrated straight clips in microsurgical clip reconstruction of an atherosclerotic middle cerebral artery aneurysm extensively involving two efferent arteries: Technical case report

IntroductionClip reconstruction of morphologically complex aneurysms is challenging. A clipping technique for an atherosclerotic middle cerebral artery (MCA) aneurysm extensively involving two M2 branches is presented. Case illustrationA 68-year-old woman was referred to our hospital for treatment of an unruptured left MCA aneurysm. Three-dimensional computed tomography angiography showed a middle cerebral artery aneurysm extensively involving two M2 branches. The aneurysm was treated by surgical clipping via a left pterional approach. Due to concern about significant remnant neck and clip slippage due to the wide-neck and atherosclerotic features, two straight fenestrated clips were applied across one M2 branch and in parallel to another M2 branch. The aneurysm was successfully obliterated without a significant remnant neck and narrowing of the efferent arteries. The patient recovered from surgery uneventfully. ConclusionParallel clip reconstruction with fenestrated clips may be a useful alternative to reduce the postclipping remnant of wide-neck and atherosclerotic aneurysms.

Experience With 15 Years of Laparoscopic Donor Nephrectomy: Review of 2500 Cases

BackgroundLaparoscopic donor nephrectomy (LDN) is considered the gold standard for live donor nephrectomies owing to lesser pain, shorter hospitalization, and earlier return to normal activities, yet it remains a technically challenging surgery. Repetition of a highly skilled task such as LDN should lead to improved performance reflected in shorter surgery times and a decrease in adverse events. MethodsThe records of over 2524 LDNs from February 2004 to June 2019 were evaluated for duration of surgery (from incision time to clamping of the renal artery) and occurrence of complications. ResultsThe mean duration of surgery ± SD from incision to clamp time for the first 100 cases at the inception of LDN was 166.13 ± 33.28 minutes whereas it was 124.59 ± 35.91 minutes for the best 100 consecutive cases in 2015 with a decrease of 41 minutes duration of surgery from incision to artery clamping. The adverse events were accessory renal artery injury (n = 10), splenic laceration (n = 2), bowel and mesocolon injuries (n = 12), venous or arterial clip slippage (n = 4), inferior vena cava tear (n = 2) pneumothorax (during stapler application, n = 1), missing gauze counts (n = 1), chylous ascites (n = 1), ureteric thermal injury (n = 2), and renal parenchyma injury (n = 3). ConclusionsLDN is a technically demanding surgery where surgeon experience appears to affect operative metrics such as operative time. The occurrence of intraoperative complications appears to be acceptably low, although serious complications are a possibility.

Dural adhesion as a cause of late clip slippage from the medial cerebral artery aneurysm.

A properly placed clip may slip off the aneurysm during the postoperative period. Many factors have been attributed to this complication, although clip adherence to the dural stitch has not been reported. Following the single occurrence of such unusual complication, 64 similar medial cerebral artery (MCA) aneurysms were retrospectively investigated at a single institution. Clip adherence to the dura demonstrated in early postoperative computed tomography (CT) was a presumed factor of a late clip migration in this study. In the series, there were 4 (6.3%) aneurysm remnants and 1 slipped clip that firmly adhered to the dura. In this particular case, the revision surgery revealed the spring coil firmly adhering to the dura in the previous suture line. Neither the occurrence of an aneurysm neck remnant nor clip slippage were related to the clip's adherence to the dura in the analysis of the entire group (p > 0.05). On the contrary, application of a fenestrated clip did contribute to that finding in multivariate analysis (p < 0.01). Unlike the rest, two surgeons unintentionally tended to position the clip close to the dura (p < 0.01). The clip-to-dura distance measured in the follow-up CT angiography 1 year after the surgery differed from that in the postoperative CT in 83.8% of the cases and decreased by an average of 0.5 mm. Clip-to-dura adherence should be regarded as a normal finding in the postoperative CT following MCA aneurysm clipping. Surgeons should consider the possibility of clip head protrusion into the dural stitch line.

Examining the effects of Hurricane Sandy among World Trade Center Health Registry (WTCHR) enrollees using a mixed methods approach

Laparoscopic donor nephrectomy (LDN) is considered the gold standard for live donor nephrectomies owing to lesser pain, shorter hospitalization, and earlier return to normal activities, yet it remains a technically challenging surgery. Repetition of a highly skilled task such as LDN should lead to improved performance reflected in shorter surgery times and a decrease in adverse events.The records of over 2524 LDNs from February 2004 to June 2019 were evaluated for duration of surgery (from incision time to clamping of the renal artery) and occurrence of complications.The mean duration of surgery ± SD from incision to clamp time for the first 100 cases at the inception of LDN was 166.13 ± 33.28 minutes whereas it was 124.59 ± 35.91 minutes for the best 100 consecutive cases in 2015 with a decrease of 41 minutes duration of surgery from incision to artery clamping. The adverse events were accessory renal artery injury (n = 10), splenic laceration (n = 2), bowel and mesocolon injuries (n = 12), venous or arterial clip slippage (n = 4), inferior vena cava tear (n = 2) pneumothorax (during stapler application, n = 1), missing gauze counts (n = 1), chylous ascites (n = 1), ureteric thermal injury (n = 2), and renal parenchyma injury (n = 3).LDN is a technically demanding surgery where surgeon experience appears to affect operative metrics such as operative time. The occurrence of intraoperative complications appears to be acceptably low, although serious complications are a possibility.

Cotton-Assisted Surgical Clipping of Very Small Aneurysms: A Two-Center Study

Very small intracranial aneurysms (VSIAs) are challenging to treat because aneurysm tearing and clip slippage can occur during neurosurgical clipping. In this study, we introduce and share our experience with cotton-assisted clipping of VSIAs. We retrospectively analyzed the data of 20 patients with 24 VSIAs treated with cotton-assisted clipping between February 2008 and December 2014 in the Neurosurgery Departments of the First Affiliated Hospital, Soochow University and Taizhou People's Hospital. During surgery, 2 aneurysm necks were torn. To treat the tears, we wrapped rectangular cotton pads around the parental arteries at the site of rupture. The remaining 22 aneurysms were clipped after being wrapped in cotton pads. The 2 aneurysm ruptures were successfully repaired with cotton-assisted clipping. In the remaining 22 aneurysms, no cases of aneurysm clip slippage or aneurysm rupture occurred. Patients were followed up on average for 59.0 months (range, 30-113 months). Of the 20 patients, the 16 patients with preoperative Hunt-Hess grades of 1-3 recovered well after the surgery (Glasgow Outcome Scale [GOS] score, 5). Of the 4 patients with Hunt-Hess grades of 4-5, 3 had a good recovery (GOS scores, 4-5), and 1 patient died of heart disease 6 months after being discharged from the hospital; this patient had a GOS score of 4 at the time of discharge. Cotton-assisted clipping could prevent aneurysm clip slipping and aneurysm rupture and facilitate the repair of aneurysm neck tears. This technique is a useful alternative therapy for VSIAs.

Post-Cholecystectomy Clip Migration-Induced Acute Pancreatitis: A New Case and Review of the Literature

Acute pancreatitis (AP) after laparoscopic cholecystectomy (LC) prompts a search for an inciting cause including stone/sludge, hypertriglyceridemia, drugs and genetic abnormalities. Our aim is to report a case and review the literature on post-cholecystectomy biliary clip migration as a cause of “unrecognized” AP. A 61 y/o man with a history of aortic stenosis, diabetes mellitus, & hyperlipidemia underwent uncomplicated LC for cholelithiasis with cholecystitis. He had 2 episodes of AP 15 & 19 months post-LC. He denied alcohol, smoking & family history of AP. His labs values at the time of diagnosis of AP are unknown. CT from first AP episode showed endoclips at the cystic duct stump and 1 endoclip within the distal end of the bile duct. After the first episode, he underwent ERCP without significant findings. At the time of his second episode of AP, an endoclip was noted in the duodenum. (Figure 1). Subsequent EUS revealed normal bile ducts & pancreatic parenchymal lobularity & honeycombing. He has been managed conservatively with no further AP episodes.1326_A.tif Figure 1: AP Secondary to Biliary Clip Migration1326_B.tif Figure 2: Image on left shows clip in bile duct (arrow) at first episode of AP. Image on right shows clip in duodenum (arrow) at second episode of AP.Proposed mechanisms for biliary clip migration induced AP include dehiscence at the cystic duct & clip slippage & migration or inadvertent clip placement into the bile duct with passage through the Ampulla of Vater. Clips within the biliary tree may also become a nidus for stone formation. This clip/stone combination can pass through the ampulla without incident or cause obstructive pathology such as recurrent AP or cholangitis. Review of the literature revealed 4 cases associating clip migration with AP (Table 1). Clip migration should be considered as a cause of AP in patients post-LC presenting with AP or recurrent AP with or without elevated liver enzymes. Diagnosis can be suggested by comparison of abdominal X-Rays to prior images to assess for changes in the number or location of clips. ERCP is a successful therapeutic option.

Feasibility and Efficacy of Using Hem-o-lok Polymeric Clips in Appendicular Stump Closure in Laparoscopic Appendectomy.

Laparoscopic appendectomy is becoming the gold standard for the management of acute appendicitis. Appendicular stump closure is a critical step in this procedure, and several methods have been used to secure the appendicular stump during laparoscopic appendectomy. We highlight the feasibility and efficacy of ‘Hem-o-lok’ polymeric clips in securing the base of the appendix. We selected 20 consecutive patients who underwent laparoscopic appendectomy using a single or double ‘Hem-o-lok’ clip to secure the base of the appendix for acute appendicitis from October 2011 to August 2013. Thirteen study participants were men, and seven were women. There were no instances of clip slippage, obstruction due to adhesion to the clip or postoperative collections. Laparoscopic appendectomy using polymeric ‘Hem-o-lok’ clips to secure the base of the appendix is a feasible and efficacious option.

Management of Recurrent Cerebral Aneurysm after Surgical Clipping : Clinical Article.

ObjectiveSurgical clipping of the cerebral aenurysm is considered as a standard therapy with endovascular coil embolization. The surgical clipping is known to be superior to the endovascular coil embolization in terms of recurrent rate. However, a recurrent aneurysm which is initially treated by surgical clipping is difficult to handle. The purpose of this study was to research the management of the recurrent cerebral aneurysm after a surgical clipping and how to overcome them.MethodsFrom January 1996 to December 2015, medical records and radiologic findings of 14 patients with recurrent aneurysm after surgical clipping were reviewed retrospectively. Detailed case-by-case analysis was performed based on preoperative, postoperative and follow-up radiologic examinations and operative findings. All clinical variables including age, sex, aneurysm size and location, type and number of applied clips, prognosis, and time to recurrence are evaluated. All patients are classified by causes of the recurrence. Possible risk factors that could contribute to those causes and overcoming ways are comprehensively discussed.ResultsAll recurrent aneurysms after surgical clipping were 14 of 2364 (0.5%). Three cases were males and 11 cases were females. Mean age was 52.3. At first treatment, nine cases were ruptured aneurysms, four cases were unruptured aneurysms, and one case was unknown. Locations of recurrent aneurysm were determined; anterior communicating artery (A-com) (n=7), posterior communicating artery (P-com) (n=3), middle cerebral artery (n=2), anterior cerebral artery (n=1) and basilar artery (n=1). As treatment of the recurrence, 11 cases were treated by surgical clipping and three cases were treated by endovascular coil embolization. Three cases of all 14 cases occurred in a month after the initial treatment. Eleven cases occurred after a longer interval, and three of them occurred after 15 years. By analyzing radiographs and operative findings, several main causes of the recurrent cerebral aneurysm were found. One case was incomplete clipping, five cases were clip slippage, and eight cases were fragility of vessel wall near the clip edge.ConclusionThis study revealed main causes of the recurrent aneurysm and contributing risk factors to be controlled. To manage those risk factors and ultimately prevent the recurrent aneurysm, neurosurgeons have to be careful in the technical aspect during surgery for a complete clipping without a slippage. Even in a perfect surgery, an aneurysm may recur at the clip site due to a hemodynamic change over years. Therefore, all patients must be followed up by imaging for a long period of time.

Proposed solution for dorsal internal carotid artery aneurysms: Suggestion of a novel new clip design.

Dorsal internal carotid artery (ICA) aneurysms are notorious for their high morbidity and mortality. They have an extremely fragile wall and have a high chance of rupture and clip slippage during the intraoperative and postoperative period. Strategies proposed to mitigate these problems encompass including part of the normal ICA wall in addition to neck of aneurysm in clip blades, as well as the use of encircling materials (silicon, cellulose, Weck's clip) over a clip. The Achilles' heel of the problem is to take an appropriate thickness of the normal ICA in clip blades. Too less or too much of this can spell disaster. This is easier said than done during an actual surgical procedure. So, in this difficult situation, is there any better method of clipping? We propose a fenestrated clip in which the clip blades are placed just at the beginning of fenestration and at right angles to the clip. This occludes the aneurysm taking part of the normal ICA wall in the clip blades. The fenestration hugs the ICA and prevents clip slippage. This has been explained with appropriate figures in the two and three-dimensional format. There cannot be a single stop solution for a complex disease like dorsal ICA aneurysm. The present proposed design is an attempt to provide a better clipping chance in these difficult aneurysms. Future work on this design can prove its usefulness.

A case of choledocholithiasis secondary to post cholecystectomy clip migration

Introduction The commonly reported risks of a cholecystectomy include bile leak, bile duct injury, infection, bleeding, and retained gallstones. Approximately 1-2% of all patients who undergo cholecystectomy have stones left in the common bile duct (CBD) that require further intervention. The use of surgical clips to ligate the cystic duct has been routine since the advent of the laparoscopic cholecystectomy as the standard of care in the 1990s. One rare risk associated with the use of surgical clips is a migrated clip that can result in an obstructed CBD. Case description The patient is a 72 year old male who presented with sudden onset, severe, right upper quadrant (RUQ) pain with associated nausea and vomiting after eating fried food. His past surgical history was significant for an uncomplicated laparoscopic cholecystectomy 7 years prior for acute cholecystitis. The patient had been having intermittent RUQ pain for 2 years prior to his presentation and had undergone an esophagogastroduodenoscopy that demonstrated mild gastritis. The patient had no other surgical or procedural history. On examination, the patient had mild tenderness to palpation in the RUQ. Of note, his labs were significant for a white blood cell count of 11000, aspartate aminotransferase of 760, alanine aminotransferase of 427 and total bilirubin of 3.0. A computed tomography scan demonstrated a hypodense lesion in the intrapancreatic common bile duct with the morphology of a surgical clip measuring 7mm. Magnetic resonance cholangio-pancreatography confirmed the CT findings. The decision was made to proceed with an endoscopic retrograde cholangio-pancreatography (ERCP) from which a clip inside a sludge ball was extracted. The patient tolerated the procedure well and underwent a routine post-procedure course. Results and Conclusions Post cholecystectomy clip migration is a rare condition that can lead to choledocholithiasis and cholangitis. Predisposing factors that have been suggested include cholecystitis, postoperative complications and the use of an excessive amount of clips. It has been theorized that the mechanism for clip migration is secondary to inadvertent placement of clips in the biliary tree, clip slippage or subclinical bile duct injuries. The appropriate treatment strategy for choledocholithiasis secondary to post cholecystectomy clip migration is ERCP.

Control of cystic artery during laparoscopic cholecystectomy: clips versus ultrasonic energy devices which is better?

Background: This study was undertaken to know whether clip usage or ultrasonic energy application, obtains better haemostasis of cystic artery during laparoscopic cholecystectomy.Methods: About 80 patients undergoing laparoscopic cholecystectomy were selected on a prospective basis and divided into two equal groups- A and B. a comparative study was done between the two group. Clips were used to control cystic artery in group A patients and ultrasonic energy device was used for the same in group B.Results: In group A, 2 patients had clip slippage intraoperatively which was dealt by reapplication of clips.in group B,1 patient had intraoperative bleeding from cystic artery few minutes after application of ultrasonic energy which was dealt by bipolar cauterization. In both the groups no, postoperative bleeding was encountered.Conclusions: During laparoscopic cholecystectomy, clip usage and ultrasonic energy application are equally competent in achieving haemostasis of cystic artery.

Surgical Outcome of Very Small Intracranial Aneurysms Utilizing the Double Clip Technique.

To report the outcome of patients with very small intracranial aneurysm (VSIA) undergoing surgical clipping using a double-clip technique. This cross-sectional study was conducted in Namazi Hospital, the main referral neurovascular center in Southern Iran during a 6-year period from September 2010 to March 2016. All patients with VSIAs (≤3 mm) undergoing surgery with double-clip technique were included. This technique reduces the clip slippage. The short- and long-term outcomes determined by Glasgow outcome score (GOS), modified Rankin Scale (MRS), and complications. Operations were performed on 32 VSIAs in 26 patients with a mean ± SD age of 55.7 ± 10.1 years. Middle cerebral artery was the most common location for VSIA (50.0%). There was no neck remnant, and the complete occlusion rate was 100%. The rate of intraoperative aneurysm rupture was 30.8%, and none of the patients experienced rebleeding. The 6-month mortality rate was 0% in ruptured VSIAs and 6.25% in unruptured VSIAs. Most of the patients had favorable outcomes (88.5%), and the overall mortality rate was 11.5%. The rate of permanent neurologic deficit was 10.0% in ruptured and 12.5% in unruptured VSIAs. Multivariate logistic regression analysis revealed no association between baseline and clinical characteristics and outcome in this series. VSIAs are difficult to treat because of their small sizes; therefore, with a double-clip technique, one can reduce complications related to the treatment of small aneurysms.

Hilar control during laparoscopic donor nephrectomy: Practice patterns in Canada.

In recent years, the method of vascular control during laparoscopic donor nephrectomy (LDN) has come under scrutiny due to catastrophic consequences of a device failure. This study sought to examine the surgical preferences of Canadian donor surgeons with regards to vascular control and their perception on the safety of these modalities. We also surveyed the experience with device malfunction and their subsequent management during LDN. An online survey was sent out to donor surgeons registered with the Canadian Society of Transplantation. Surveys were anonymous and voluntary. Descriptive statistics were used to analyze the collected responses. Recollection of the sequelae and outcomes from device malfunction were also queried. Twenty-eight of 37 surgeons (76% response rate) responded to the survey. At least one surgeon from every institution in Canada performing LDN responded to the survey. Laparoscopic stapler is the most commonly used device for securing the renal artery (61%) and renal vein (67%). Overall, surgeons felt the stapler was the safest method of securing the renal artery. Stapler misfire and clip slippage were reported by eight (28.5%) and 12 (43%) surgeons, respectively. Most cases were salvageable: laparoscopically (30%), open conversion (30%), and by hand port (5%). Slippage of a plastic locking clip resulted in one emergent laparotomy on POD#1 and one stapler misfire was converted to open resulting in donor death. Although rare, hemorrhagic complications can occur from device malfunction resulting in poor outcomes for healthy volunteers undergoing LDN. Surgeons need to remain vigilant when selecting the appropriate modality for vascular control.

Operative techniques to avoid near misses during laparoscopic hepatectomy

The lack of a complete hepatic overview and tactile feedback during laparoscopic hepatectomy may result in near misses or fatal intraoperative complications despite the advantage of a magnified laparoscopic view. The aim of the study is to describe operative techniques and guiding principles with which to address near misses unique to laparoscopic hepatectomy and evaluate the intraoperative complication rate overtime. Data of 408 consecutive patients who underwent laparoscopic hepatectomy were reviewed. Representative operative techniques and guiding principles with which to address near misses and pitfalls unique to laparoscopic hepatectomy were evaluated among the patients by 2 surgeons. Most near misses were due to lack of understanding of both the laparoscopic view and anatomic aspects unique to laparoscopic hepatectomy. Operative techniques and/or guiding principles with which to address these issues were demonstrated as follows: starting parenchymal transection at the declivitous parts; no ligation of the right or left portal vein before confirming the bifurcation; dissection of the short hepatic vein using a sealing device; dissection of the root of the hepatic vein using scissors; exposure of the middle hepatic vein, which is anatomically close to the hilar plate; and identification of V8 using intraoperative ultrasonography. The intraoperative massive bleeding due to vessel injury or surgical clip slippage occurred in 25 patients (6.1%), and its rate had a significant trend to decrease with increasing years. We demonstrated operative techniques and guiding principles with which to address near misses in laparoscopic hepatectomy. The intraoperative massive bleeding rate trended to decrease over time.

Application of cotton piece-assisted clipping in micro-aneurysm surgery

Objective To investigate the management of aneurysm neck tear, the preventive effect of aneurysm clip slippage, and aneurysm rupture with cotton piece-assisted clipping in micro-aneurysm surgery. Methods From February 2008 to December 2014, the clinical data of 19 patients with 23 micro-aneurysm treated with cotton piece-assisted clipping at the Department of Neurosurgery, the First Affiliated Hospital of Soochow University and the Department of Neurosurgery, Taizhou People's Hospital were analyzed retrospectively. In the operation, 2 aneurysm necks were torn. Taking the parent arteries as the center, the parent arteries were wrapped with the small rectangular pieces of cotton. The remaining 21 aneurysms were all wrapped with cotton pieces, and then the aneurysms were clipped. Results Two parent artery ruptures were repaired successfully with the cotton piece-assisted aneurysm clipping, and 21 aneurysms wrapped with cotton pieces were clipped successfully. No aneurysm clips slippage and aneurysm rupture were observed. They were followed up by telephone and clinic visit; the follow-up period was from 2 weeks to 7 years (mean, 30.4 months). In the 18 ruptured aneurysms, 14 patients with Hunt-Hess grade Ⅰ-Ⅲ recovered well, 1 patient recovered well in 4 cases with Hunt-Hess grade Ⅳ-Ⅴ. Because of the short operation time, 3 were still in rehabilitation. There were? no operative deaths. Conclusion The cotton piece-assisted clipping plays a key role for the prevention of aneurysm clip slippage, aneurysm rupture, and repair of parent artery rupture in the operation of cotton piece-assisted clipping micro-aneurysms. Key words: Intracranial aneurysm; Microsurgery; Cotton; Treatment outcome