What type of clips are recommended for use in laparoscopic cholecystectomy (LC) for controlling the cystic duct and artery?

Laparoscopic Cholecystectomy Clips: Recommended Types

Titanium (metal) clips remain the conventional and recommended standard for securing the cystic duct and artery during laparoscopic cholecystectomy, though alternative methods including ultrasonic devices, absorbable clips, and intracorporeal suture ligation are safe and effective alternatives. 1, 2

Standard Approach: Metal Clips

The World Society of Emergency Surgery guidelines emphasize that during standard laparoscopic cholecystectomy, only the cystic duct and cystic artery should be identified, isolated, clipped, and divided after achieving the Critical View of Safety 1. Metal clips (typically titanium) are the conventional choice for this purpose and have been the gold standard for decades 2, 3.

Critical Safety Principle

Before any clipping or transection occurs, you must achieve the Critical View of Safety, which mandates visualization of only 2 structures entering the gallbladder: the cystic duct and the cystic artery 1. The hepatocystic triangle must be cleared with no exposure of the common bile duct 1. This is non-negotiable—clipping the common bile duct represents a major bile duct injury requiring complex reconstruction with Roux-en-Y hepaticojejunostomy 4, 1.

Alternative Clip and Ligation Options

Ultrasonic Scalpel (Harmonic Scalpel)

• The ultrasonic scalpel can be used as a sole instrument for sealing both the cystic duct and artery without clips 2, 3
• Meta-analysis demonstrates that ultrasonic devices enable significantly shorter operative time and hospital stay compared to conventional clips 2
• Bile leak rates are comparable: 1.75% with ultrasonic scalpel versus 0.66% with clips, showing no statistically significant difference 3
• Conversion rates, perforation rates, and overall morbidity are equivalent between ultrasonic devices and clips 2

Absorbable Clips

• Absorbable clips are as effective as metal clips for hemostasis of the cystic artery and cystic duct ligation 5
• A randomized controlled study showed no difference in operative time, hospital stay, or postoperative complications between absorbable and metal clips 5
• These eliminate potential long-term clip-related complications 5

Intracorporeal Suture Ligation (Clipless Technique)

• Single ligation of both cystic artery and duct (SLAD) with silk 2/0 suture is a safe, simple, and economical alternative 6, 7
• This technique eliminates clip-related complications entirely 6
• Ligation time averages 2-3 minutes and does not significantly increase operative time 6, 7
• No bile leaks or complications related to ligature have been reported with proper technique 6, 7
• Cost is substantially lower: silk suture costs $0.62-0.92 versus $12.28-15.55 for clips 7

Common Pitfalls to Avoid

Never clip major vascular structures like the right hepatic artery—this represents a vasculobiliary injury requiring specialized management 1. If you encounter severe hemorrhage, a second cystic artery, or a large artery posterior to the cystic duct, stop and reassess your anatomy 4.

If you cannot achieve the Critical View of Safety due to inflammation or fibrosis, do not proceed with standard clipping 4, 8. Instead, consider bailout procedures such as fundus-first approach or subtotal cholecystectomy 4, 8.

Practical Algorithm for Clip Selection

1. Standard cases with clear anatomy: Use conventional titanium clips (fastest, most familiar) 1, 2
2. Cost-constrained settings: Use intracorporeal silk suture ligation 6, 7
3. Desire to minimize clip-related complications: Consider ultrasonic scalpel or absorbable clips 2, 5
4. Acute cholecystitis or inflammation: Any method is acceptable once CVS is achieved; ultrasonic devices may offer time advantage 2

The choice between these options depends on surgeon experience, equipment availability, and cost considerations, as all methods demonstrate equivalent safety profiles when proper technique is employed 2, 5, 3, 7.