Tuesday, February 19, 2008

Pleasin' Squeezin'



From my prior comments about my love for bowel surgery and for the old-fashion method of hooking the ends together, one might draw the erroneous conclusion that I eschew all forms of operative shortcuts. Untrue. While not the top priority, speed is an issue, and I've written about that, too. My reasons for preferring hand-sewing over staples -- aesthetics, cost savings, connection to the history of surgery -- don't apply when it comes to clamping and tying blood vessels. Surgical clips, particularly the old-style individually loaded ones (as opposed to the fancy disposable multi-fire guns) are cheap as dirt, simple as hell, and save lots of time.

For the first thousand years or so, surgical clips were made of stainless steel. More recently, and mainly because of concerns about clips being pulled off by MRI machines, they come in titanium or, most lately, are made of absorbable material. Whatever the composition, the idea is straightforward: shaped like the marriage-bed issue of a V and a U and grasped in the jaws of whatever instrument, the open part is slid across a vessel or duct, the holder-handles are squeezed, and the clip flattens into two legs tightly pressing the tubular structure in question and rendering it closed. Depending on size, pressure, and tightness of one's own sphincter, more than one clip might be closed onto the business end before cutting. Either way, it saves several seconds over clamping and tying; over a long operation with need for many ligatures, it adds up.

Blessedly uncommon, one teensy problem can occur: if the jaws of the applier are out of alignment, instead of bringing the "legs" of the clip properly together, they may overlap in such a way as to turn it into a scissor, cutting when the intent had been the opposite. Depending on where and what, it can fall anywhere along that line which connects "nuisance" with "disaster."

Practically every patient who's had his/her gallbladder out in recent years will have had two little clips placed, one on the artery to the gallbladder, and one on the duct that drains from it into the main bile duct. By the pattern and location, you can tell a person has had the operation just looking at a plain belly Xray. Consequently, I've had many patients return to me upset because their chiropracter took one of their infamous whole-body Xrays and told them that those clips near their spine are causing all sorts of problems, likely requiring monthly manipulations for the rest of their life. I'm guessing the regular reader will not have to wonder what I think of that. It did, however, lead me to be sure to inform everyone in advance, pointing out that we leave chunks of steel the size of doorknobs in hip sockets, and pacemakers aplenty, big as a pocket watch and housed happily.

Mother of all general surgical operations, the Whipple procedure (about which I've written here and in my book) affords many opportunities for applying clips, and I've always done so liberally. One such patient brought me an amazing story, which I'd never heard before and haven't since.

Other than being the color of a daffodil, when I met him he was a very healthy and vigorous man, in his sixties and in need of a Whipple, which I did promptly, slick and quick. His recovery was rapid (much more so than indicated in the preceding link) and he returned in short order to his major pleasure, golf. One day, several weeks after the operation, golfing as usual and on a dog-leg left, long par four, he explained, he felt a strange tickling sensation on his belly. Lifting his shirt and looking down, he noticed some activity at the small and previously healed scar from where I'd placed, and left for a few days, a drainage tube. He got his hand to the area in time to catch a whole series -- fourteen, to be exact -- of steel clips exiting out the former hole in single file like little tin soldiers, blip, blip, plop, plop. He brought them to me in a baggie.

84 comments:

Patrick said...

Dear, God, Sid. The "scissor" comment made me squirm. And in way I *never* did as an EMT . . .

rlbates said...

I find it marvelous how the body will either encapsulate a foreign material or "spit" it out! Great story, Dr Sid!

Bongi said...

seriously wierd. in my mind i can't help seeing the bad guy in the movie the mask who gets shot a whole bunch of times. he gathers the bullets up, finally in his mouth and spits them out , shooting all his would be assassins. was anyone on the golf course injured be high speed clips?

make mine trauma said...

Awesome, how did you do that?!

AlisonH said...

Oh my goodness! And now you've got a song suddenly stuck in my head--the one with the chorus that goes, "One tin soldier rides away..."

Onehealthpro said...

And I thought it was odd when a stich surfaced months after my dad's bypass surgery. Don't know whether it's true, but I've heard stiches can still surface years later.
Onehealthpro

Sid Schwab said...

Pro: it IS true. Years later. When I was in training, in our clinic we had crochet hooks we used to fish out old sutures that had become infected or rejected. Because absorbable sutures are much stronger and longer lasting than they used to be, those sorts that would stay around forever and occasionally spit out aren't used very much, so the problem is disappearing.

gay CME guy said...

Another great post, Sid.
Alisonh: The song's title is, "One Tin Soldier", recorded by Coven. It was from the movie, "Billy Jack" from the early 70's. It's the first song that taught me the transforming power of music.

I'm actually surprised some artist/group hasn't re-recorded it, as it's a great peace promoting song regarding war.

Anonymous said...

Have you ever had a patient come back and state the clips are causing irritations and bleeding?

Had anyone requested the clips to be removed?

Sid Schwab said...

The clips to which I referred are placed internally, far from any surface where they could cause such symptoms. The case I describe at the end of the post is very unusual, and relates to an extremely large operation and the use of a long-standing drainage tube.

kitkat said...

I just recently found out that I had 6 surgical clips left in me due to my gallbladder surgery 5 years ago. I've been experiencing high levels of pain in the same area on my front right side where the gallbladder used to be. I also have right flank pain in my back as well. I've been experiencing nausea and fatigue also. Why would the surgeon leave that many clips in?? Can these be removed easily? I just need answers.

Sid Schwab said...

kitkat: as I said in the article, we leave clips in all the time, and they are totally inert and do no harm. We use them because they are quick and safe.

Removing them would be a much bigger deal than the operation that put them in; and there's no reason to do it. Without knowing your specific situation I can't say what might be the explanation for your symptoms. There are many possibilities, and you should see your docs to figure it out. I can say, however, that it's as certain as can be that it has NOTHING to do with the clips that are there.

Anonymous said...

You said to someone claiming the pain can not be related to steel surgical clips and I must disagree - My sister had her gall bladder removed about 17 years ago and has had severe pain in her rib area - A radiologist did an MRI showing mirgration of the clips to the right upper quadrant as well as abdomen. Is this just conisidence that where the clips migrated to are also in the same exact area of her pain.? She is suffering so badly due to this pain with NO ryme or reason. Her PCP believes it is the clips causing that pain. ??

Sid Schwab said...

It would be interesting to know what the PCP's theory is; ie, in what way the clips are causing pain.

Anonymous said...

Sid,
actually, she thinks the clips might be "tearing" through her insides as the pain she is describing is a tearing sensation. My sister does have leasions that are now showing through ultrasound but cant get any rhyme or reason for them and God for bid she gets a Doctor to do exploratory surgery to look and just "try" to help her.. We are very frustrated at this point as she is just suffering too much. There are SOOOOO many others out there who had their gall bladders removed and suffering and some stories do turn out that migrated clips WERE the cause of their pain. I have been researching for years..MedHelp.com has quite a few stories that end that way....thank you for allowing me to vent that out.. :O)

Anonymous said...

http://www.kpvi.com/global/story.asp?s=7411611

Not sure if you can open this link, but here is a story of a man who claims its the clip left inside causing soo much pain.. How can so many people with these clips left behind be wrong about "their" pain...There has to be something we can do..NOONE should ever suffer with pain...

Sid Schwab said...

Well, there's a whole industry of people who think autism is caused by vaccines, despite reams of evidence that it's not. There are people who believe that water has "memory," that you can heal people by waving your hands over them, that echinacea cures colds. Belief, in this context, isn't proof.

All I can say is what I've already said: we use metals of all sorts in many different kinds of surgery. It is inert. I guess I can't say there's no way a given clip could cause pain, because there's no way to test it. But there's no plausible explanation, to me anyway, how it could be so.

Anonymous said...

Husband had liver resection surgery in November, 2009. December, 2009 got an abscess. They cut the abscess to let it drain. January, 2010 surgical clip spit out of wound. February, 2010 another clip came out. Just waiting for more as he has many clips!

Sid Schwab said...

Something to look forward to, I guess.

Summer said...

My Dad has had a history of peripheral vascular disease and was admitted to a hospital in Dec of '08, underwent right ileofemoral endarterectomy and left femoral to anterior tibial bypass graft. In Jan '09 he underwent limited flexible sigmoidoscopy and suggestive of ischemic colon. He also had surgical clips in both inguinal regions (right upper quadrant and both groins).He had six (6) operations during this time. He also had consistent illeus througout hospital and long term care nursing facility.

Are the clips suggestive of malpractice, causing him to die in January, 2010, causing illeus and obstruction in his colon?


Would anesthesia (due to excessive surguries) be indicative of paralytic ileus?

Sid Schwab said...

Summer: I'm sorry to hear about your dad. But as you can see from my post, we use clips all the time and it's most certainly NOT malpractice to do so.

Paralytic ileus is not rare after abdominal surgery. Even more so in someone with significant vascular disease. There are many factors, including the handling of bowel, anesthesia, narcotics, circulation, etc.

KC the professional pt. said...

I've got 2 clips surfing my guts & I am not discounting peoples' claims of pain, but being that I am a "professional patient" (thanks to a raging auto-immune disease) & having a full understanding of psychology, I have to contemplate that some folks who proclaim the surgical clips to be causing them pain are suffering from a psychosomatic sort of response. I remember when I had a crazy flare up of gut pain approximately 2 years after my lap. cholecystectomy, some x-ray or CT scan showed those cruising clips & one cut happy surg. res. was all too damned eager to slice me from stem to stern to get at them. I basically told him to cram walnuts & demanded I get to speak to the head honcho, who actually took the time to listen & speak with my other docs & just as I suspected it was, he proclaimed my hurting & inflamed guts to be of the auto-immune freak incident I am known for producing from time to time. Folks, esp. the sue happy sort, please listen to the doc here when he says that the clips are BENIGN! While there may be a slim chance (think snowball in hades) that your body is reacting to the clips, it most likely has absolutely NOTHING to do with what ails you or your loved ones. My clips are happy to swim in my belly, checking out the sights, & bumping into assorted things, but they can not hurt me. If you know anything about psychosomatic responses, it's not that you don't have pain, it's your brain that has conjured it up because of the correlation you'd made. I hope people will find comfort in knowing that there are millions of us with "transient clips" that are fine & dandy.

Sid Schwab said...

Thanks, KC, for your useful and amusing comment. I'd only quibble slightly: clips pretty rapidly get incorporated into tissue and (except for the highly unusual situation I described, when they get spit out entirely) don't travel at all.

And I'd hope that surgical resident has found a nice safe job somewhere, outside of the surgical arena.

Anonymous said...

Hello, I also have clips placed on my lymph nodes (2 of the axillary nodes that were full of silicone after my implants ruptured)and I can sort of feel them in there-they are small things-about 6 of them lined up that I viewed from an x-ray my chiropractor took. I do have weakness in the arm and occasional swelling in the arm pit and around the incision site, but it seems to uncommon to place clips there instead of standard suturing but my doc told me it was the "standard of care" now. So, do you recommend me having them out or leaving them in place? Please help, as I am confused and want them out.

Sid Schwab said...

It's common procedure to use clips instead of suturing; I did it all the time in axillary dissections. Clips are extremely inert, meaning they virtually never cause reaction or other problems. I can't say whether what you are feeling are clips (maybe your surgeon could); although generally where they're used in the axilla is pretty deep relative to the skin, so I'd say it's pretty unlikely that that's what you're feeling.

In a very long career doing many thousands of operations, I've never had to remove clips, and I'd consider it rare indeed that there was ever a need.

As you saw, I mentioned chiropracters and clips; I have them raise alarms to patients on several occasions. They're wrong about that.

Anonymous said...

Maybe there are people who are suffering greatly due to the surgical clips:
http://www.topix.com/forum/health/T7022J42SEOQGCM1G

Why not go Clipless ?
http://www.ncbi.nlm.nih.gov/pubmed/19851262

Anonymous said...

Hi!
I had right hemi colon resection surgery last year. I have Lupus and have been in a flare since then. I had asked the surgeon not to use clips, he said he won't. However they are clearly seen on xrays and CT scan. I have to be so careful how I move my upper body, piercing, sharp pain, feels like something is being poked.
Also the immune reaction is constant. The surgeon is saying he didn't put them in there. Well, who did?
Lil

Sid Schwab said...

I don't know.

Anonymous said...

Thanks Doc for allowing me to post and share some articles about the metal surgical clips here. I think if a patient is given a choice, he/she will probably not choose the metal clip type of Lap Chole Surgery.

1) Hypersensitivity to titanium-clinical and laboratory evidence:
http://www.ncbi.nlm.nih.gov/pubmed/17261997

2) Chronic Urticaria Due to Surgical Clips:
http://www.nejm.org/doi/full/10.1056/NEJM199311183292121

3) Migration and slipping of metal clips after celioscopic cholecystectomy:
http://www.traveldoctoronline.net/migration-and-slipping-of-metal-clips-after-celioscopic-cholecystectomy-ODI2OTI3MQ==.htm

4) Efficacy of absorbable clips compared with metal clips for cystic duct ligation in laparoscopic cholecystectomy:
http://www.ncbi.nlm.nih.gov/pubmed/12560902


I had gallbladder problem and had to have it removed. I finally found a surgeon in the U.S. who uses suture instead of metal clips. So I had the poor gallbladder removed last week. The surgeon used the silk suture (non-absorbable). I wish I had read this below article before the surgery, then I can remind him to use the absorbable suture. Later, I was told it is very rare that the silk suture can cause any issue, but I really wish that he had used the non-absorbable suture on me. That way, I don't have to worry at all.

1) Migration of suture material into common bile duct leading to stone formation: A case report:
http://www.ispub.com/journal/the-internet-journal-of-surgery/volume-19-number-2/migration-of-suture-material-into-common-bile-duct-leading-to-stone-formation-a-case-report.html

2) An Unusual Common Bile Duct Foreign Body:
http://www.hmc.org.qa/qmj/nov2005/november2005/case/case2.htm

Wendyann Ocasio said...

I had a TAH with Bi-lateral oophrectomy because of Endometrial metatastic type cancer that was stage 1A1 on 4/5/11.

My wound was stapled and dihised (sp?) which led to wound vac treatment.

I was ultimately left with an incissional hernia which was repaired on 3/26/12.

I have had severe pain since and have had 3 CT scans since which reveal I have 4-7 metal clips inside me which I had no knowledge of and which are not mentioned in either surgical report.

My question is, why were they used, and why were they not mentioned to me?

Sid Schwab said...

I assume they were used for the reasons that all surgeons use them: they are a safe and efficient way to control blood vessels before cutting them. As I wrote in the post, they're absolutely routine and there'd have been no more reason to mention them than there'd have been to mention sutures of polyglycolic acid were used.

It sounds like you had a wound infection, which would be unrelated either to the skin staples or the internal ones. Wound dehiscence after infection is pretty common, as is the development of the incisional hernia.

I've never seen a case where clips were a source of pain, and I used them in thousands of operations. But, as you could tell from comments here, some people disagree.

Anonymous said...

Is there any nickel in surgical clips and anastomosis staples? When does the immune response end for somebody with a nickel allergy and or autoimmune disease?
Thank you so much!

Sid Schwab said...

I just googled composition of clips. Here's a list for one maker.

I don't know the answer to your allergy question. An allergist or immunologist might.

Anonymous said...

Dear Dr. Schwab!
Were surgical clips used in 1973 (hysterectomy)?
When I had surgery last year (colon resection) my surgeon did not write the post surgery report until 7 weeks after the surgery, he was upset with me for asking for it and finally came up with it. Is that unusual?
Thank you so much Dr. Schwab for answering my questions.

Anonymous said...

Dear Doctor!
Is it true that pictures are taken of the patient after the surgery is complete to show incision etc. If yes, does the surgeon or hospital keep them
thank you

Sid Schwab said...

I'm pretty sure clips were used in 1973, but not as frequently as now.

It's bad form to wait 7 weeks to dictate an operative report.

I suppose some surgeons might routinely take pictures of completed incisions (plastic surgeons, maybe), but I've never seen it done.

Anonymous said...

Thank you Dr. Schwab for answering my questions. You are very kind!!!

Anonymous said...

Dr. Schwab: I love your posts and I seemed to have lost you for a while. So glad to find that you are still actively posting. As re the clip frenzy, I enjoyed your story (and, as a critical care nurse, I am still trying to figure it out) and I am sorry that the comments have taken on the flavor of clip-o-chondriacs gone wild.

Anonymous said...

Sigh. Clip-o-chondriacs gone wild.

Wendy said...

Hi. I also am having pain from clips. When ever so slight pressure is placed on hard area aka "clips" or bending or moving certain ways or God forbid sleeping on my right side HURTS!!! I'm also haing upper right side back pain. I was unaware at first what these "hard" spots were and why they were hurting me. About the 3rd week after surgery...I ened up in the emergency room with the worst pain I've ever endured! I've been through labor and other surgeries so it wasn't a case that I'm intolerant of pain. I was not informed that thse clips were going to be used. Too bad for I would have done the research and discovered all these other people in this nightmare! I certainly would have demanded good old stiches....what ever happen to those?? All thses folks, including myself can't be mistaken about the same symptoms regarding pain. Has any doctor under gone this proceedure with clips? I hope soon that the medial world stops using this proceedure and stop inflicting pain. At this time, I want them removed so that I may get back to my life! Wendylk7 @ hotmail

Sid Schwab said...

I'm sorry to hear of your problems, Wendy, but from what you describe it seems literally impossible that clips have anything to do with it. Clips are virtually never used near the surface, so whatever hard spots you're noting, they're not clips. Unless your surgeon did something very uncommon.

And, yes, surgeons who've had surgery have clips in them as much as anyone else. I'd be happy to have them used on me.

"Post hoc ergo propter hoc." A logical fallacy. It's not to say that no one has ever had problems related to clips. People die from penicillin, from driving in cars. But clips are used every day everywhere; the number of people who've had problems with them rounds off to zero.

mehc said...

Looking through the 'clipochondriac' links, I'm floored by the number of people stating: "I had invasive surgery and there was postoperative pain, so it must clearly be the fault of clips!"

While they do look rather striking on an x-ray, I'd say that an even more striking source of pain would be the large incision, removed tissue, and/or internal rearrangement necessary in surgery. "I have pain in this area and there are clips there" isn't even an argument for clips causing pain...it's an argument that surgically related things (such as pain and clips) will both be present in the area of surgery. Or perhaps that the surgery didn't fully fix the problem.

Anyway, another great post, Dr. Schwab...I've read through all of them, from the beginning, over the past few days, and was waiting for comments posted this year so that I could let you know how much I've enjoyed the material!

Sid Schwab said...

Nice! Thanks.

RobynK said...

I too had my galbladder removed this past March, and also have surgical clips left behind. I am experiencing the same symtoms at the people above, pain in the general area of the surgery that feels like pinching and tearing when I try to do things, nausea and the fatigue. It has caused me to loose my job and has greatly decreased my life style..I thought I'd come on the internet to see if others have the same issue..and volla, many of you.."not in my head" needing phyciatric care kind of pain. Just had my CT scan results back,and of course there are clips in the gallbladder fossa, hmmmmmmm I didn't know there would be metal staples left inside me..this explains alot, now how can this be changed that I might get my life back!!! Please

Sid Schwab said...

Sorry to hear of your troubles, Robyn, but my opinion is the same: it's highly unlikely that the clips have anything to do with them. So unlikely that it's nearly impossible. Whatever is going on needs a good evaluation and, hopefully, an explanation.

But, in my opinion (which is based on lots of experience and that of many colleagues, but can't be based specifically on your issues, of course) clips aren't it. I hope you can find out for sure.

Anonymous said...

I had my appendix removed in November 2008. The postoperative pain was so terrible that I screamed at the top of my lungs all the way from the PACU to the room on the med-surg floor, and for much of the next 24 hours.

I suffered from severe pain for most of the next year. The pain was intermittent and only occurred some time after I had eaten food. I could avoid being in pain as long as I did not eat anything. It was hard to sleep at all at night. I became a heavy drinker to cope with the agony of eating dinner. I also had severe problems with vomiting, including fecal vomiting, for which I took zofran.

Finally, almost a year to the date of the initial surgery, two surgical clips were noted on CT scan, to which I replied that I have a nickel allergy. The clips were removed and I have had no vomiting since, although I continue to have mild abdominal pain and can no longer tolerate fried foods.

Please take the issue of allergies to surgical clips seriously. That was the worst year of my life, and I almost didn't graduate from school on time due to the pain, vomiting, and other symptoms.

Anonymous said...

Some articles worth reading :

1) Hypersensitivity to titanium-clinical and laboratory evidence:
http://www.ncbi.nlm.nih.gov/pubmed/17261997

2) Chronic Urticaria Due to Surgical Clips:
http://www.nejm.org/doi/full/10.1056/NEJM199311183292121

3) Migration and slipping of metal clips after celioscopic cholecystectomy:
http://www.traveldoctoronline.net/migration-and-slipping-of-metal-clips-after-celioscopic-cholecystectomy-ODI2OTI3MQ==.htm

meadowcopse said...

Interesting reading from many angles regarding surgical clips.
I found this blog via a search for clip migration. The only surgery I have ever had (15 years ago), was a radial osteotomy and graft from iliac crest - my previously broken left arm was built up with a plate and bone graft from my left hip.
A recent CT scan for Crohn's Disease problems and abdominal / pelvic pain has shown a couple of surgical clips near my appendix on the right hand side of my body! (I've never had my appendix removed or abdominal surgery).

Anonymous said...

I just rececently had robotic gallbladder removal. I was apprehensive about the robotic part, but after about a week, so far so good. I watched many videos of the surgery beforehand to be comfortable with it. What I did notice was theuse of these clips in each surgery...some surgeons using approx 3 on the duct and 2 on the artery. When I asked the surgeon about these clips and what he uses, he said because the procedure is robotic, he uses a non metal locking clip and he uses one on the artery and 2 on the duct. He also stated he likes these particular clips because they lock in place. I am wondering. if you know what these clips consist of and if they are so called better because they lock? Thank you.

Sid Schwab said...

Locking is not really of value, far as I know: I've never seen nor heard of an issue related to not locking. It's like a paper stapler: once bent they stay. There are some clips made of dissolving material, probably some kind of poly-saccharide related stuff.

By the bye, in my opinion using the robot for gallbladders is the classic example of marketing over common sense. But it does succeed in getting the patients, who think they're getting something special. Sort of like when laparoscopy first came out and was used for gallbladders (which is just fine): we were told, by the companies that sold them, that if you didn't use a laser, patients would go elsewhere.

Nowadays no one uses laser for that operation, because it offers no advantage over standard electrocautery, and just adds expense. But lots of hospitals bought them. In our town, it sat in the hallway gathering dust...

Which is not to say robots have no value (still a matter of debate.) But for gallbladder? Pure marketing.

Anonymous said...

Just wondering what your thoughts are on surgical clips in relation to metal allergies and auto immune diseases

Sid Schwab said...

If a person has a known allergy to materials used in clips (there are several different material options), he/she shouldn't have that type implanted. Confirmation of such allergy is problematical, though.

As to auto-immune diseases caused or exacerbated by surgical clips: I know of no definitive studies showing a relationship. I can't say it's impossible; but the numbers of documented adverse reactions to clips of any composition are exceedingly rare; it's not really possible to draw conclusions that it exists as an entity.

Anonymous said...

Dear Doctor Schwab!
I posted here before and I thank you for the answers you gave before.
Here is a summary of what happed: In 2011 I had colon resection done-right side with anastomosis. The surgeon left 2 clips in my body. He had promised not to use any metal because I have a nickel allergy and I have Lupus, anything foreign in the body causes a never-ending immune response. He said he would hand-sew everything. Then 2 surgical clips showed up on xrays and CTscan. He said he did not leave them in my body. Well, they were not seen on any xrays or Ctscans before the surgery. He said they must have been put there when I had a partial hysterectomy in 1994. The hospital charged $8,450 for 2 different kinds of staplers and staples, also for clips. Then the hospital took the whole charge off after talking to the surgeon and they explained to me that since they charged $2,800 for cauterizing that means first they put in clips to stop the beeding and then they remove them. Well, I guess they didn't remove them. Now the problem isn't better, still shooting pain in the lower right side with any sudden move or bending over. I saw a different surgeon, he said it would be impossible to remove the surgical clips a surgery would be even worse than the first surgery. Besides, he said the pain is probably from adhesions and scar tissue and that he can remove. Then I asked if there would be new scar tissue after he removes what is there now and he said "Maybe" then he said there would be another option to see a pain specialist who could give me shots with pain medication right into the area were the surgery was done.I know this is very long, too much for you to read. But I really need your help with this. What do I do now???
Thank you for reading this. Please answer my question!!!!!

Sid Schwab said...

My opinion about clips hasn't changed. I've used them for my whole career and have never seen a problem with them, other than the case I described in the post; and that was, in my opinion, the result of a low-grade infection, and the clips just happened to be there, not the cause of it.

I also agree with the second surgeon you saw.

If you read comments here, it's obvious not all people agree with me. Perhaps you can find a surgeon willing to try to remove the clips. In my opinion, whatever is going on with you is unrelated to the clips. I base that on my experience with and opinion of them; I have no way of knowing about your particular situation; it's simply a general statement of my feelings about the use of surgical clips.

Anonymous said...

thank you for your prompt answer Dr. Schwab. Do you know this? For what reason does a surgeon use surgical clips when a colon resection with anastomosis is done? Also, when those tiny staples are used for the anastomosis do they grow in the tissue or fall off?
Now, something totally differt:
I knew a Hans Schwab in Fuessen Germany, that was 1962, Hans was 20, I think most of his family lived in Augsburg.Hans and I were extras when the movie "THE GREAT ESCAPE" escape scence were filmed around Fuessen, we are both in the movie. Are you related to the Schwab family in Bavaria?
I think it is wonderful that you are doing what you are doing.
Thank you very much

Sid Schwab said...

Clips are used as a cost-effective, time-efficient way to control blood vessels before cutting them; or the duct between the gallbladder and the main bile duct. It's often easier, and quicker to do it that way than to reach in with other instruments, clamp off, then tie both ends.

Staples used for anastomosis or other purposes generally stay right where they are, forever, and don't cause problems.

I suppose all people named Schwab are related at some point, but I'm unaware of any relatives there.

Anonymous said...

Dear Dr. Schwab!
Its me again, about this colon resection, cecum and valve were removed. How close are the ovaries to this area? Now I am finding out that my ovaries are gone. In his report, which he finally did 5 1/2 weeks after the surgery, he states that there was a lot of oozing from the ovarian veins. How close is the cecum to the ovaries? What was he doing in that area? This whole thing is just insane. The pathology report states that 8 roundish tissues were in the partially open casette, probably lymphnodes, they state, and then only 3 of those were looked at. I had a ctscan done last month, no ovaries. They were still there in 2008. Can the ovaries shrink that much or did this surgeon remove them because of OOzing. He never says bleeding always says oozing.
Please let me know how close are the ovaries to the cecum and what do you make of this?
Thank you so much again. You are such a dear to provide this service.

Sid Schwab said...

The cecum can vary widely in its location. Typically it's in the right lower part of the abdomen, which means it can be very close to the right ovary and its veins.

Beyond that, I really have no comment; any operation has the potential to get into unexpected bleeding, depending on all sorts of circumstances. I think the best place to start for an explanation is your surgeon.

Anonymous said...

Happy 4th of July Dr. Schwab.
About the cecum surgery, I can't ask the surgeon any questions. He got very upset when I asked him questions a couple of weeks after the surgery. For example I tried to find out why I have 2 incision. One midline from above the navel down about 13, 14 inches and a second incision right lower abdomen about 9 inches long. Is this usually done for cecum removal??
Thank you

Sid Schwab said...

I assume he decided he couldn't do everything he planned to do though whatever incision he made first.

Anonymous said...

the reason for the surgery was to remove a 30mm benign cecal polyp. The polyp was too large to be removed via colonoscopy.
thank you for you 7/4/13 answer

yasminadlv said...

I just read this blog after researching surgical clips being left inside patients.

I still have pain in the area that my clip is, but I firmly believe that its not caused by the clip. I have a kidney condition that causes me pain all the time.

My question is...my surgeon left this clip inside me after a robotic pyloplasty 2-3 years ago. I had no idea it was left there until I was in the ER for pain, and the CT scan showed a huge mass that they thought was a kidney stone. It wasn't, it was the clip.

I can't get any answers out of my surgeon, as he is a grade a asshole, and gets defensive, thinking that I don't think his treatment was successful (which it was, 100%)...

What I want to know is...am I ok to get an MRI? I don't want this thing ripping itself out of me. lol Like I said, I've tried asking my surgeon, and he's a douchebag and will not answer me.

thoughts? comments?

Sid Schwab said...

Clips alone wouldn't be a "huge mass." They're about the size of a couple grains of long grain rice. Once they're seated in there a while, MRIs are okay, in the torso anyway. Maybe not in the brain.

I don't disagree that too many surgeons can be assholes. You deserve answers, and surgeons should provide them. When they act like arrogant assholes, it embarrasses me for my chosen profession.

Anonymous said...

Recently I had patch tests done for metal allergies. Result: Severe reaction to Silver Nitrate. Do you know if any surgical instruments, anything else used during surgery or clips used are coated in silver nitrate?
Thank you

Sid Schwab said...

Silver nitrate burns. It's used to cauterize small wounds, among other things. Put a patch of it on anyone, and you'll get a "severe" reaction, ie, a burn. It ain't allergy. It's chemistry. But no, for that very reason, there's no silver nitrate coating on anything you'd put in your body.

Anonymous said...

Hello Dr. Schwab!
I have a couple of general questions: When a person is scheduled for major abdominal surgery should blood typing be done (before hand) in case a transfusion is needed?
If a person spends several days in the hospital after surgery, who is in charge of medication? Surgeon only or also hospital staff?
Thank you

Sid Schwab said...

I think it's always good for a person to know his/her blood type. However the decision as to whether to have blood available for a particular operation is up to the surgeon, based on what he/she thinks the chances are of needing it. The choices are not to order blood at all, or to order a "type and screen" (which means determining blood type and looking for proteins that might making obtaining blood difficult), or "type and cross" for a specific number of units of blood to be available. The latter is most expensive and resource-intensive, and is generally done only when the surgeon thinks there's a high likelihood of using it.

As to who orders medications: the default situation is that the surgeon is the one. In some hospitals there are "hospitalists" who might be asked help in management, especially if there are attendant issues like diabetes or heart or blood pressure problems. Or the surgeon might ask the patient's primary care doc to be involved in such matters. It depends a lot on the details, and what services are available in a particular hospital.

Anonymous said...

in response to the idea of clips causing pain. As one who has had too many surgeries in abd region due to gall stones, appendectomy, prolapsed organs, fusion of organs to pelvic wall etc... Clips do not cause the pain. There is possible an underlying problem that cant be seen by film. Lots of items cant be seen in blood, urine or film. I've had my clips in me for 21 yrs, the sites where they are were checked each time some Dr was "in there" lol, and they were the healthiest spot. To the story, Im sooo glad that did not happen to me, as I would of passed out probably, and I have delivered 3 children the normal way, 1 completely natural. Dear Sid I would like to ask you a question though..."As a busy surgeon, which I'm sure you were, did you always put everything little/big thing you did to the patient in the surgical report?" Like was there ever a time when you didn't say what type of sutures you used, or what you used to put them in, or how many(you think you might have skipped one while counting or counted one twice) does these type of things happen? Or any other Dr.? Ever hear of Dr's shortening their notes so much because there is so much put into a report, does it happen? I mean, even though you assist in God's work(please no one get religious on me, I just mean by saving lives)you are after all human ^__^.

Sid Schwab said...

Good question at the end, anonymous. I actually addressed that at the end of my ten-part series here on the details of an operation. It was in my final post in that series.

In brief, whereas some surgeons take it to ridiculous extremes, I felt the only things that needed inclusion were ones that might be relevant later, particularly to a surgeon who might be heading back in there. In some areas, the type of suture used, for example, is important (but not the number of stitches taken.) Same with clips. I'd state I used them, but not the number or size. If a surgeon were to detail all of that she'd never have time for anything else, the transcribers would be spending enormous time typing it up, and pixels would die needlessly.

On the other hand, when I was in training, I'd occasionally come across the operative reports of one of the early guys at my institution, a true pioneer of surgery. An example: "A radical mastectomy was performed in the usual manner. H. Glenn Bell."

Before lawyers were invented, obviously.

Anonymous said...

Hi Sid, I have gallstones and the gallbladder needs to be removed. The surgeon that I've found who I seem to fit well with uses the Robotic Surgery. Are there more problems with this type of surgery rather than the 3 or 4 cut type.

I read the prior post somewhere up the line about the robotic part being a gimmick type thing. I do of course want to make the right choice, but as a lay person how do I know what the right choice is.

I'd also like to know what those plastic clips are made of and if they eventually dissolve or just stay in. Any comment appreciated as I am still at a point where I can make a change. Cluelessly Yours!

Sid Schwab said...

It's my opinion -- take it for what it's worth -- that whereas it seems robotic surgery has some advantages for some operations, there's no advantage regarding routine gallbladder surgery, and, depending on how the hospital bills and is paid, the costs are more to the patient, assuming you're responsible for a certain percentage of the charges.

Studies have been done for other operations, comparing robotic to "regular" laparoscopy, and so far, and so far as I know, no advantage has been demonstrated in terms of outcome. That could change as techniques and technology progresses.

Other than cost, i don't know of a reason to reject robotic removal, however.

Anonymous said...

Thanks for the response. That was something that we haven't discussed yet...i.e. the cost. I'd heard that it was the same price.

The difference of what is used to "tie off" where the gallbladder is clipped from might matter to me. I'd possibly rather have titanium(sp?) inside me over plastic.

Just don't want to see on T.V. a few weeks later one of those fast speaking lawyer commericals "if you've had gallbladder surgery and they used Doobop's Plastic clips and are experiencing $#^@ (imagine 80,000 different health problems) please contact the law firm of Dewy Sue M. & How.

Thanks for the fast response.

Anonymous said...

Do you know, or can you find out, how long is one under anesthesia with the Da Vinci Single Site surgery for gallbladder removal vs. the 4 site laparoscopic surgery?

In general how long is one under for either of these surgeries?

Thank You

Sid Schwab said...

Since it depends on the surgeon, and the status of the gallbladder, it's best to ask your surgeon.

Anonymous said...

Hi! After reading your posts, I'm feeling like this isn't a big deal, BUT...everyone around me seems to believe that a "loose" clip is a problem. I have a clip - presumably from a 2007 appendectomy or a 1994 gall bladder that has migrated and lodged between my uterus and bladder. There are no complications I should be worried about? Seems like a dangerous location? Thanks!

Sid Schwab said...

Most likely from the appendectomy, since that'd be right where it was placed. Hard to make it any clearer than I did in the post: not a problem in my opinion, no matter where it is.

It's also not "loose." It could have been for a while after the operation, but it is where it is now.

Anonymous said...

I had a dysfunctional gallbadder laproscopically removed in 1993(no stones).I started out with mild infections,hives,cough,and fatique.Was put on antibiodics off and on this whole time.As time has passed the infections are severe now,the cough is awful and it hurts,the fatique is also really bad.I cannot even clean house hardly at all.If I even try taking a walk the pain is so bad it feels like I might not make it home.I was put on pain meds.about 5 years ago or I couldn't have made it this long.I feel now I am so sick maybe I am going to die from this and I am serious.The pain is all right sided behind my bottom ribs where the 13-24 clips are in a clump the pain feels like now somuch pressure builds up it is going to push my ribs out and break them then it wraps around to my back and in my shoulder,the swelling in my stomach is so bad I feel 8 mos.pregnant.I believe this is from the clips also and the surgeon is gone.I have had ct scans,ultra sound,ERCP that did nothing either nor could they diagnose anything no systemic disease either.I just want my life back and not suffer no more.A surgeon called me from Texas he was doing my first appt. on the phone since we lived so far away he removes the clips all the time.He said any foreign object in the body a personcan react to.think of this people react to bennadryl that is for allergies he said.Of course he is a OB-GYN and I need a general surgeon or gastro.,or liver,no such luck.I just want to be able to be a wife,mother,grandmother,daughter,sister,friend and be able to go back to work. Thank You!!!!! Diane

Sid Schwab said...

As I've said here, I've seen no instances in which clips have caused long-term problems. I can't say it doesn't happen, but if it does it's rare, and clips are used in countless operations every day.

In the typical gallbladder operation, only two to five or so clips are used. If you really had around twenty, it suggests something unusual went on during the operation and it might be worth getting hold of the operative report and have it interpreted for you.

I'm also surprised to hear there's a surgeon who "removes clips all the time." I don't know what to make of it.

It's really impossible to add more than that from this far away. I can only wish you well and hope you find solutions. I know how frustrating it can be.

Anonymous said...

Hello! I had a lap appy about a month ago. I'm healing well, but I still can have extremely sharp pains over where the one incision over the appendix is. Of course I'm imagining that it's the staples.....which it probably isn't. But what might be causing that intense sharp pain, especially when I turn to the right side in bed? Maybe the muscles around there is still healing? I've had my 2 week follow-up with the doc. I don't really want to call them yet, since I think it might (hopefully) eventually subside. Any thoughts? Thatnks!

Sid Schwab said...

Being unable to examine the area, and not knowing exactly what was done, I can only make general comments. A month is still early in the healing process so having various kinds of pains at this point is not unusual. Nerves are still raw, and muscles, as you suggest, still in the process of healing. As I've written, the one thing I'd not be concerned about is that it has anything to do with staples.

If your concerns persist the only way to get meaningful appraisal is to get back with your surgeon.

Shooting Stars said...

I know this guy, right, and he recently had an endarterectomy of his left carotid. The surgeon used a bunch of titanium clips. The guy never new the clips were in him but has had a constant infection of the surgery site ... recently this guy's GP's nurse assistant was working the pus out of his infected neck and one of the clips came out. Neither the guy NOR the GP and his assistant knew what it was. The guy visited his surgeon's office twice after the endarterectomy presenting with this infection yet never once was he told he had clips in his neck. At one point he was admitted to a hospital for a week of IV antibiotic due to the infection. How should this guy deal with his repeat infections? He doesn't trust the original surgeon... so where should he head for help? His pus-and-blood dripping neck is beginning to distress his washerwoman, nevermind his own neck pain and malaise!

Sid Schwab said...

Sad story, all right. Clips are commonly used in carotid surgery; infections of the incision are rare, and I'd say as a general rule an infection there would have been due to something other than the clips.

However, when foreign substances are present where there is infection it can be hard to eradicate the infection without removing the substance. I say that as a general principle. In this particular case, I can't comment on the need for or advisability or practicality of removing the clips.

When there is doubt, a second opinion from an experienced center is never a bad idea.

Anonymous said...

Here is a rather tragic situation from metal sutures that the 1970 appendectomy surgeon put in ( 8 in all) that when in 2005 I started having abdominal pain and x-ray showed the sutures then a ct scan showed what appeared to be an adhesion around the suture site. The surgeon went in thinking that it was the adhesion he was going to fix initially using laproscopically but instead found all the metal sutures had broken apart and were in his words "like barbed wire" and removed them by reopening the appendectomy incision. I woke up with incredible pain in the front of my thigh and ended up with femoral meralgia where the pain was 24/7 and finally moderated by Lyrica. Fast forward to 2014 and I start having abdominal pain just below the 1970/2005 incision and ct scan shows "several metal objects in the abdominal wall" ( I thought the metal sutures were all removed in 2005) so a new surgeon goes in using fluoroscopy and gets 9 pieces of the metal sutures out with one piece being the size and shape of a fish hook....aaargh! So now I am recovering from that surgery with a brand new incision just below the original.

Sid Schwab said...

Sorry to hear of your troubles. I'd have to say, however, that it's not certain that the clips had anything to do with any of it. By which I mean that scar tissue/adhesions form as a result of surgery with or without the presence of clips. Plus, the clips generally get surrounded by fibrous tissue, so the "sharpness" of them wouldn't be likely to affect much.

The neuralgia you had is a result of rooting around in there, and can happen after any operation (though not commonly), depending on the anatomy of the area.

I'm glad the objects were removed the second time around, I guess; although it's hard to know how or if they were the cause of the pain you were having. I'd probably have been reluctant to have operated to remove them, though, unless there were some sort of evidence they were causing the issue. And who knows? I might well have been wrong.