Tubal ligation (TL) is one effective and also common method of fertility control. In the year 2009, end 24,000 to be performed in Canada alone. Hike of Filshie clips used during TL is approximated to happen in 25% of all patients; 0.1-0.6% of this patients ultimately experience symptoms or extrusion the the clip indigenous anatomical web page such together the anus, vagina, urethra, or abdominal wall. Moved clips may current as chronic groin sinus, perianal sepsis, or chronic abdominal muscle pain. These symptoms can happen as early as 6 mainly or together late as 21 year after application. We existing the case of a 49-year-old female with a 3.5-year background of intermittent dull nonradiating left upper quadrant (LUQ) ache lasting on average 2-3 days. There to be no other connected symptoms, and the longest pain-free period was 4 days. Her past medical history includes COPD, GERD, IBS, and depression. Existing medications are only remarkable for Symbicort. Pertinent past surgical history includes laparoscopic tubal ligation v Filshie clips in 1999, followed by a quality hysterectomy in 2013. Migrated tubal ligation clip was provided on an ab X-ray. The patient to be then referred because that surgical management. Subsequent CT scan confirmed a solitary clip present nearby to the left lobe the the liver. No various other abnormalities to be reported. Patient underwent laparoscopy for removal of the clip, i m sorry was determined to it is in underneath the left lobe that the liver installed in the gastrohepatic omentum. Please watch the video link provided. Postoperative pathology report shown the visibility of a Filshie clip. Patient reported complete resolution of she LUQ pain in ~ a 5-week and 3.5-month follow-up. This situation shows that although symptomatic clip migration is a rare phenomenon, it need to be given special consideration in women through unexplained chronic ab pain and also a history of TL. Additionally, remove of clip can provide resolution that symptoms.

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1. Introduction

Tubal ligation (TL) is a common an approach of fertility control in north America with over 24,000 perform in the year 2009 in Canada alone <1>. Almost 85% of these actions are reported to make use of the Filshie clip as the preferred method of tubal occlusion <2>. Filshie clip is a silicone-lined, titanium, occlusive an equipment which was very first introduced for surgical sterilization in 1981 <3>. Migration of Filshie clips after applications is a typical phenomenon and can result in failure sterilization <4>. Recent literature has likewise identified migrated Filshie clips to be the resource of pain, discomfort, and abscess formation <5>. Though moved Filshie clips room infrequently symptomatic, their frequency of use in gynecological steps makes expertise of potential adverse sequelae clinically appropriate <6>. In this report, we present the instance of a woman suffering chronic abdominal pain an additional to a moved Filshie clip complying with TL.

2. Case Report

A 49-year-old woman was referred to the general Surgery Clinic through a 3.5-year background of intermittent left upper quadrant (LUQ) pain. She described her symptoms together a dull localized pain with progressive onset lasting on typical 2-3 days. When present, the pains fluctuated in intensity throughout the day. This pain to be noncyclic and had no identifiable triggers. There to be no background of trauma to the area. The pains was no reproducible with palpation that the area. She to be unable to find any kind of provoking or palliative components or positions. She longest pain-free duration was recalled come be roughly 4 days. There to be no other linked symptoms. Before 3.5 year ago, the patient never had any kind of episodes of similar symptoms. There was no background of unintentional load loss, fevers, or night sweats. Upon physical exam, the patient’s abdomen had no rebound, guarding, or overlying skin changes.

Prior come the start of the pain, the patient had actually undergone an uncomplicated laparoscopic TL with Filshie clips in 1999 and also a quality hysterectomy in 2013. Initially, the patient’s pain was assumed to be of gastrointestinal beginning for which she underwent a gastroscopy and colonoscopy—both revealing no pathology. The patient was affiliated in a motor car accident one year prior to presentation in ~ our clinic and during workup of symptoms concerned the collision—an incidental recognize of one moved tubal ligation clip was made on plain film. The clip was listed to be current underneath the diaphragm surrounding to the stomach. A succeeding CT scan localized the clip nearby to the liver, installed in the gastrohepatic ligament the the liver (Figure 1). There was no other abdominal pathology revealed ~ above imaging.


Transverse section of a computed tomography scan of the abdomen reflecting a moved Filshie clip lying inferior to the left of the liver.

A diagnostic laparoscopy through the will of identifying and removing the clip was undertaken. The Filshie clip was seen underneath the left lobe the the liver installed in the gastrohepatic omentum and was ultimately excised making use of bipolar diathermy. No various other potential reasons of her LUQ ache were figured out during laparoscopy. The patient was contacted at a 5-week postop and again 3.5 months later and also found to be completely symptom-free.

3. Discussion

TL is one effective and common an approach of fertility manage <7>. In the year 2009, over 24,000 were performed in Canada alone <1>. Filshie clips space silicone-lined, titanium devices that have actually been routinely provided for sterilization procedures for several decades dating earlier to 1981 <3>. Complications with Filshie clips can be categorized by those concerned the surgery and also those regarded the clip itself. Complications concerned surgery are frequently related come misapplication that the clip which have the right to lead to future pregnancies. Complications related to the clip are an ext varied and often present as ache or abscess formation secondary to extrusion or hike of the clip <2>.

Migration of Filshie clips used throughout TL is estimated to occur in 25% of every patients; 0.1-0.6% of this patient subsequently experience symptoms or extrusion the the clip from anatomical sites such together the anus, vagina, urethra, or abdominal wall surface <5, 8–11>. Moved clips may present as chronic groin sinus, perianal sepsis, or chronic abdominal pain <12–14>. These symptoms can take place as early on as 6 weeks or as late together 21 years after applications <12, 15>.

The mechanism of Filshie clip migrate is thought to be closely related come its device of function. Filshie clip application occludes the surrounding vascular structures bring about avascular necrosis. 2 blind stumps of the previously consistent structure continue to be after application, v one stump containing the Filshie clip with its jaws closed. It is theorized that peritoneal growth and also adhesion development of the clip-containing stump encloses the Filshie clip avoiding migration. If this falls short to occur, migration of the Filshie clip may happen <16>. The inflammation capsule and adhesions observed bordering the Filshie clip in this situation further support the idea the a localized inflammatory organization reaction (Figure 2) <17>.


Laparoscopic image of an inflammatory capsule surrounding the migrated Filshie clip during dissection.

Our patient’s pain had been occurring for number of years and causing a good degree the discomfort. She had undergone multiple other investigations revealing no other identifiable sources of she pain. Laparoscopic investigation of the abdominal cavity failed come reveal any kind of other identifiable sources of pain various other than the Filshie clip. Furthermore, removed of the Filshie clip resulted in finish resolution the the pain and also the longest pain-free duration the patient had actually experienced in numerous years. The mix of every these components led us to think that the resource of the patient’s pain was the Filshie clip.

There has been raising trend in the direction of bilateral salpingectomies end tubal ligation for the functions of long-term contraception. This is in light of a potential preventative role in the advancement of ovarian cancer by removing fallopian tube which may be a resource of origin for epithelial ovarian cancers <18>. This trend may be a action in the ideal direction provided the high approximated rate the Filshie clip migration and potential complications that might arise together a result. This case shows that although symptomatic clip migrate is a rare phenomenon, it have to be given special factor to consider in women with unexplained chronic abdominal pain and also a history of TL. Additionally, removal of clip can provide resolution that symptoms.

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Conflicts the Interest

The writer declare the there is no problem of interest regarding the publication of this paper.

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