Management of Retained Surgical Clip After Laparoscopic Cholecystectomy
If a surgical clip is left inside a patient after laparoscopic cholecystectomy and cannot be located intraoperatively, document the retained clip, complete the procedure safely, inform the patient postoperatively, and monitor clinically—most retained clips remain asymptomatic and do not require intervention. 1, 2
Immediate Intraoperative Management
When a clip cannot be located during surgery:
Complete the cholecystectomy safely without extending operative time excessively searching for the clip. The priority is avoiding bile duct injury, which carries 0.4-1.5% incidence and up to 3.5% mortality, far exceeding risks from a retained clip. 3
Document the missing clip in the operative report, including the number of clips deployed, the suspected location, and attempts made to locate it. 4
Ensure the Critical View of Safety was achieved before any clipping occurred, as this minimizes the risk that the clip was placed on critical structures like the common bile duct. 3, 5
Do not convert to open surgery solely to find a missing clip, as conversion itself increases risk of major bile duct injury without guaranteeing clip retrieval. 3
Postoperative Patient Communication
Inform the patient about the retained clip immediately after surgery:
Explain that surgical clips can occasionally migrate from their placement site and that most remain asymptomatic. 1, 2, 6
Document this discussion thoroughly in the medical record. 4
Provide clear instructions about symptoms requiring urgent evaluation (see below). 7, 8
Clinical Monitoring Strategy
Most retained clips require only observation:
The majority of migrated clips remain completely asymptomatic, even decades after surgery. 1, 2
One documented case showed a clip migrating to the ovary 2 years postoperatively, causing pelvic pain but no serious complications. 1
Another case demonstrated clip migration into the common bile duct 30 years after cholecystectomy, presenting similarly to choledocholithiasis. 2
Obtain baseline imaging:
Plain abdominal X-ray to document clip location for future reference. 6
Consider abdominal CT if there is any concern about clip placement near critical structures. 7, 8
Symptoms Requiring Urgent Evaluation
Instruct patients to seek immediate care for:
Fever, abdominal pain, distention, jaundice, nausea, or vomiting—these are alarm symptoms for bile duct injury or bile leak. 7, 8
Right upper quadrant or epigastric pain persisting beyond normal postoperative recovery—may indicate clip migration causing ductal obstruction or duodenal erosion. 8, 2, 9
Cholestatic jaundice, choluria, fecal acholia, pruritus, or recurrent cholangitis—delayed presentations of bile duct injury that can occur weeks to months postoperatively. 7
Management of Symptomatic Clip Migration
If the patient develops symptoms potentially related to the clip:
Obtain comprehensive liver function tests (direct and indirect bilirubin, AST, ALT, alkaline phosphatase, GGT, albumin) and inflammatory markers (CRP, procalcitonin). 7, 8
Perform triphasic CT scan as first-line imaging to detect clip location, bilomas, or ductal dilation. 7, 8
MRCP provides definitive visualization of clip position relative to the biliary tree and can identify migration into the common bile duct. 7, 8, 2
Therapeutic interventions when indicated:
ERCP with clip extraction is the treatment of choice for clips that have migrated into the common bile duct, with high success rates. 2
Endoscopic removal may be attempted for clips causing duodenal erosion, though conservative management with proton pump inhibitors can allow spontaneous passage. 9
Laparoscopic removal is rarely necessary and reserved only for clips causing persistent symptoms in accessible locations (such as ovarian implantation). 1
Long-Term Complications to Monitor
Rare but documented complications of retained clips:
Clip migration into the common bile duct can occur months to decades postoperatively, serving as a nidus for stone formation around the clip. 2, 6
Duodenal ulceration from clips eroding through the duodenal wall, typically managed conservatively. 9
Clip migration to pelvic organs in female patients, causing chronic pelvic pain. 1
Prevention Strategies for Future Cases
Technical factors to minimize clip loss:
Avoid excessive cystic duct dissection, which increases risk of clip migration (7% at 1 month and 11% at 1 year with extensive dissection versus 1% with limited dissection). 6
Use only 4 clips total (2 on cystic artery, 2 on cystic duct) rather than multiple clips on smaller vessels. 6
Ensure adequate cystic stump length to prevent ischemic necrosis and subsequent clip migration. 6