Testing the pressure capacity of cystic duct closure devices on the biliary system

BACKGROUND: In suspected choledocholithiasis, surgeons must choose whether to perform preoperative endoscopic retrograde cholangiopancreatography (ERCP) to clear the stone or proceed directly with laparoscopic cholecystectomy, accepting the possibility of postoperative ERCP if a stone is found, but some surgeons may be hesitant to request ERCP in the immediate postoperative period after cholecystectomy because of concerns that elevated biliary pressures could exceed the competency of the cystic duct closure device. We sought to evaluate the integrity of commonly used cystic duct closure devices and to compare their resistance with the maximum biliary pressures observed during ERCP. METHODS: We used 20 swine gallbladders to evaluate the biliary system burst pressures of various closure devices, including Hem-o-lok plastic clips (Weck), metal clips, and the Endoloop Ligature (Ethicon). We measured the maximum capacity pressure of the closure devices using synthetic intravenous tubing. RESULTS: We found that Hem-o-lok plastic and metal clips had capacity pressures that significantly exceeded pressures generated by ERCP, while the Endoloop closure device did not. CONCLUSION: When properly applied, both metal and plastic clips withstand pressures exceeding those generated by the ERCP procedure. A properly placed closure device should eliminate the hesitancy to avoid ERCP following cholecystectomy.