title: Can We Use the Disposable Laparoscopic Clip Appliers as Suture Anchors? An In Vitro Feasibility Study.
abstract: BACKGROUND
  Intracorporeal suturing is time-consuming and could be difficult in certain operative circumstances. Instead of knot tying, specially designed clips have been introduced to anchor and secure the end of a single strand or suture. Although these clips provide a maximal required holding grip (HG), they considerably increase the cost of the procedure. The aim of this in vitro study was to identify the feasibility, and means of achieving the best HG, of commonly used disposable automatic clip appliers (LCAs) over regular strands.
  
  
  METHODS
  We placed 2-0 PDS (rigid) and 2-0 Vicryl (soft) sutures through fresh gastric wall specimens. Six different commercial-type LCAs, all having large or medium/large clips, were applied at the distal end of each suture. An IMDA manual digital force gauge was used to measure the HG of each clip at 2 positions: the middle clip position and the angle (at the crouch) position. A total of 192 measurements were taken. The results were classified into 3 HG levels measured by Newton units (N): the strongest grip (> 1 N), medium grip (> 0.5 and < 1 N), and weak grip (< 0.5 N).
  
  
  RESULTS
  The strongest HG was obtained by applying 10 to 12 mm LCAs with large or medium/large clips over PDS at an angle position (HG = 1.1 ± 0.2 to 1.6 ± 0.3 N). The weakest grip was obtained by applying any type of LCA over Vicryl at the middle position (HG = 0.08 ± 0.04 to 0.2 ± 0.06 N, P < 0.001). The latter was associated with clips freely falling off the sutures even before applying any force. In general, more force was needed to dislodge any brand clip from the PDS compared with Vicryl suture (0.8 ± 0.6 vs. 0.4 ± 0.3 N, P < 0.001). The angle position was always stronger than the middle position (0.9 ± 0.6 vs. 0.3 ± 0.2 N, P < 0.001). There was a trend for the 10 to 12 mm LCA to have a better HG than the 5 mm ones (0.65 ± 0.5 vs. 0.51 ± 0.5 N, P = 0.08).
  
  
  CONCLUSIONS
  We propose that 10 to 12 mm LCAs generate enough HG to secure a single strand when clips are placed at the angle position. This is especially true over PDS (hard) strands. The application of 5 mm LCA clips to secure the end of the Vicryl strand is not recommended. Further clinical studies are warranted.
authors.affiliation: *Department of Surgery, Herzliya Medical Center, Herzliya †Department of Surgery, Rabin Medical Center, Petach Tikva ‡Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Vered
authors.initials: V
authors.lastname: Buchholz
authors.forename: Eran
authors.initials: E
authors.lastname: Sadot
authors.forename: Hadar
authors.initials: H
authors.lastname: Spivak
mesh_terms: D004209:Disposable Equipment; D004867:Equipment Design; D005240:Feasibility Studies; D005743:Gastrectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000295:instrumentation*; D013270:Stomach / Q000601:surgery*; D053441:Suture Anchors; D013536:Suture Techniques / Q000295:instrumentation*; D013718:Tensile Strength