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Vascular control with endoscopic loops, vascular clips, and intracorporeal knot tying

Energy equipment is very useful to prevent and control hemorrhage from vessels, but some surgeons and procedures prefer to use mechanical means to close vessels.

During cholecystectomy, many surgeons prefer mechanical closure of the hepatic duct using endoscopic loops of suture, vascular clips, or intracorporeally tied knots. The endoscopic loops can obtained commercially from several companies, or can be tied extracoporeally (modified Roeder knot).

Our advanced laparoscopy and thoracoscopy courses teach endoscopic knot tying and the use of commercial occlusive devices.

Above left: Intracorporeal knot tying is done within the thorax or abdomen during endoscopic surgery. Short pieces of braided suture are tied as a ligature using two endoscopic needle drivers.

Above right: To tie an extracorporeal ligature, the suture is passed around the structure to be ligated and then both suture ends are taken outside the body.

A slip knot (modified Roeder) is tied and the knot slipped inside the body to then be tighten around the structure. The extracorporeal knot (endo-loop) can also be obtained commercially.

Above: The endo clip from Covidien is an example of a disposable clip applier. Clips can be applied to vessels either prior to transaction or if they have already been inadvertently cut. Other uses are to close a thoracic duct during thoracoscopy or a cystic duct during cholecystectomy.

Above: Another clip option is the MicroLine which is re-usable applicator that can be recharged with a pack of clips. This is a 10 mm applicator.

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