Problems relating to the application of the Filshie Clip and how to avoid them.

One of the most common reasons for failure is operator error. Training videos are available from Femcare. However, if a large number of doctors - i.e. 5 or more - require training, it may be possible to organise a workshop for this purpose.

It is absolutely vital that all Filshie Clip Applicators are serviced at least once a year or after every 100 cases, whichever comes first. Failure to observe this procedure could result in the Applicator performing below the required specification and standard. It is also imperative to recognise that only Femcare, or an authorised Filshie repair agent, is permitted to carry out the servicing of the equipment. This enables us to closely monitor the quality of workmanship and to ensure optimum ongoing performance of the equipment.

The following problems have been encountered whilst using the Filshie Clip System and each problem may be minimised by adopting special care at the time of the procedure.

Problem 1: Closing of the Clip during insertion of the loaded applicator down the double puncture cannula:

First check that the loaded applicator goes down the cannula immediately prior to the operation. A damaged cannula could impede insertion of the applicator thus encouraging the surgeon to grip the applicator harder thus closing the Clip. A bent applicator or a tight rubber stopper will produce a similar problem.

In order to pass the loaded applicator through the cannula it must be half closed. This is achieved by gently squeezing the handle until the moveable jaw is in the half closed position.

The handle should be squeezed just enough to allow smooth passage of the applicator through the cannula. Maintain gentle pressure to keep the Clip in the half closed position until it emerges through the end of the cannula and is visualised through the laparoscope. Slowly release the handle and the Clip will re-open ready for application.

Problem 2: Dropping the open Clip into the abdomen following insertion down the double puncture cannula or operating laparoscope:

Once the applicator end has emerged through the cannula or operating channel of the operating laparascope, the end of the applicator should be opened slowly not quickly, as the jaw of the applicator opens quicker than the Clip. It is better to open the applicator when it is in the vertical position, not when it is in the horizontal position for the same reason.

Problem 3: Retrieval of a dropped Clip in the Abdomen:

The Clip should immediately be identified, grasped with the applicator and placed safely in the anterior fornix until the operation is completed. The Clip should then be identified and grasped firmly (preferably near the hinge) and pulled to the mouth of the cannula. The applicator, holding the Clip firmly, together with the cannula, are all withdrawn from the abdomen simultaneously.

Problem 4: Wrong structure Clipped:

To avoid this problem, the fimbria should always be identified. The prehensile quality of the Clip in its applicator should be used to pick up the fallopian tube and to visualize the fimbria. Uterine elevators may also facilitate this manoeuvre.

Problem 5: Clips not locking properly:

Check that the applicator has been screwed together properly and that the serial numbers on the handle and shaft of the instrument match.

Problem 6: The top jaw may overshoot the lower jaw and not lock:

This is due to a slight straightening of the upper jaw during insertion of the loaded applicator down the cannula or operating laparascope. The straightening of the upper jaw is not enough to close the Clip. However, when the upper jaw is straightened further over the resistance of the Fallopian tube, the jaw becomes too long to lock and it over-shoots. Precautions as for (1) should be adopted and the operator should avoid squeezing the applicator handle too tightly.

Problem 7: Incomplete inclusion of the tube within the Clip:

First check that the Clip is on the isthmus and not on the ampulla. Flick the Clip upwards and downwards to check that the lumen goes through the Clip - if in doubt place a further Clip appropriately on the tube.

When applying the Clip at mini-laparotomy or at caesarean section, the endosalpinx of the isthmus may be felt like a firm cord and it may be palpated to check that the endosalpinx is clearly within the Clip.

Problem 8: Difficulty in placing the Clip over tubes when adhesions are present:

If difficulty is encountered because of adhesions then a hydrotubation may be performed. If the tube remains patent and the Clips cannot be properly applied, change the method of sterilisation (this is a rare event).

Problem 9: Tubal Transection:

This is a rare event and is usually associated with a large fallopian tube, which has been clipped too quickly. The Clip should be closed slowly to allow for the oedema to be milked away. Should transection occur, place a Clip on both ends of the transected tube.

Problem 10: Haematoma at the sight of application:

This is also a rare event. Observe the haematoma and if it becomes self-limiting no further action need be taken. If the haematoma extends this should be controlled by bipolar cautery.