Publication history, Reflections & comments
The "Autoclip" applier is a pair of forceps carrying up to
20 clips loaded between its handles. A spring forces these down, one at
a time, into position between the 'Honorary Medical Officer.
jaws. When the operator squeezes the jaws, the clip can grip adjoining skin edges and remain holding them firmly in place. As the jaws are released from the clip, the next one falls into place between them.
The clips are bought already threaded on an arrow-like metal strip (Figure
FIGURE 1 [to be added]
For loading, they are slid into place with the retaining cap swung to one side, and a spring is pushed in after them. The spring is compressed, slid right in with a fingernail, and the retaining cap swung back into position. The arrow-like strip is removed, and the instrument is then ready for use.
These clips each have two pairs of short teeth which grip the skin without penetrating it. The two ends o1 each clip are turned up, so that they can be opened by drawing them apart with a reverse-action pair of special removing forceps supplied with the applier. This avoids the pain of sliding an instrument between clips and skin, unfortunately found with Michel clips.
No time or motion is taken up in loading individual clips. At all times the skin edges are gripped either by the approximating tissue forceps or by the applier holding the latest clip in position, while the tissue forceps take a fresh bite (Figure 2).
Elements of motion or "therbligs" are reduced to a minimum, a desirable feature in surgical operations (Patkin, 1965, 1967). In the .absence of fumbles, clips are applied at the rate of one or two per second. A comparable rate for mattress sutures being put into skin by experienced operators is one every five to 30 seconds, although these may have saved a subcutaneous layer of catgut.
Autoclips were used for the closure of 64 skin incisions in 61 patients during 1968. The most frequent operations were appendicectomy and herniorrhaph.y, The clips were used also for hysterectomy, caesarean section, orchidopexy, biopsy excision of breast lumps and other procedures. Their use was avoided in cases of advanced appendicitis, limb amputation, repair of strangulated inguinal hernia or oversewing of perforated peptic ulcer under local anaesthesia in poor-risk subjects, Rammstedt operations, and traumatic lacerations of all types.
Healing in 57 of the incisions was excellent. In one obese patient who had undergone hysterectomy, the wound broke down in two half-inch lengths on the fourth day, as a result of unexplained heavy local infection. Healing by secondary intention was satisfactory. In one patient who had undergone a third caesarean section (Figure 3) and another who had undergone cholecystectomy, there was a little gaping at one end of the wound when clips were removed. This was easily put right with some "butterflies" of sticking plaster. In five other cases there was subcutaneous bruising which was symptomless in three and barely significant in the other two.
FIGURE 3: Healing at five days.
Clips were removed on the third to the eighth day, depending on site
and direction of wound, obesity and age. Removal was painless in all cases
except one, in which the clips had been placed too close together, and
removal of alternate clips had been directed. One patient who had previously
undergone thyroidectomy remarked on the absence of pain during removal
of the clips, by contrast with her experience with Michel clips some years
earlier. Nurses consistently noted the ease and comfort with which removal
of clips was carried out.
Cosmetic results were gratifying. Scars were thin, flat, and of course without stitch marks. In some early cases, clipmarks in the skin persisted for some weeks, owing to excessive pressure in closing the jaws of the applier (Figure 4).
Notable features were the absence of erythema often seen about stitches, the slight degree of wound induration, and the small quantity of exudate on dressings.
There were some minor troubles. A nursing sister unfamiliar with the instrument loaded the clips back-tofront on one occasion. Sometimes the clips stuck instead of moving down one at a time, but they were easily nudged into place. This may be because the clips are not exactly central, owing to inadvertent application of force in loading, once again from inexperience. When slight gaping of the skin edges occurred, this was due to inadequate subcutaneous catgut supporting skin edges in obese patients.
Surgeons vary in their technique of skin closure because of their aims and experience. Absorbable sutures are preferred by some paediatric surgeons and gynaecologists. A plastic surgeon may find better cosmetic results from his own delicate methods of suturing. An abdominal surgeon with a high proportion of emergency cases in which wounds are infected will want greater security of wound and of mind than is possible with clips.
For many elective operations, however, autoclips of the type described would appear to be the method of choice because of the superior type of healing. The saving of operating time and effort is of benefit to patient, surgeon, assistant, nurses, anaesthetist and hospital economist.
I am grateful to my partner, Dr David Freeman, for his helpful comments during the preparation of this paper, and to the nursing sisters at the Dungog and District Hospital for their aid in collating results and their patience in becoming acquainted with a worthwhile new instrument.
Jennings, W. K. (1953), "A New Automatic Skin Clip Applier and Skin
Clip Remover", Amer. J. Surg., 85: 583.
Patkin, M. (1965), "The Hand Has Two Grips: An Aspect of Surgical Dexterity", Lanoet, 1: 1384.
Patkin, M. (1967), "Ergonomic Aspects of Surgical Dexterity", Med. J. Aust., 2: 775.
AN AUTOMATIC SKIN CLIP APPLIER
MICHAEL PATKIN, M.B., B.S. (MELB.), F.R.C.S., F.R.C.S. (EDIN.), F.R.A.C.S.1
Dungog and District Hospital, New South Wales
Australasian Medical Publishing Company Limited 71-79 Arundel Street, Glebe, Sydney, N.S.W., 2037