Chronic pain from retained Hem-o-lok® clips after pediatric appendectomy: the imperative for surgical removal.

BACKGROUND

While Hem-o-lok® clips are widely used and generally safe in children, retained clips have been rarely associated with refractory chronic abdominal pain. This study aimed to investigate the association between retained Hem-o-lok® clips and refractory chronic abdominal pain following pediatric laparoscopic appendectomy and compare therapeutic outcomes between device removal and conservative management.

METHODS

A retrospective cohort study analyzed 11 consecutive pediatric patients who developed persistent right lower quadrant (RLQ) pain [Visual Analog Scale (VAS) ≥3 for >6 weeks] after laparoscopic appendectomy with appendiceal stump closure using Hem-o-lok® clips (2021-2022). Diagnostic evaluation included: contrast-enhanced computed tomography (CT) in 7/11 patients (63.6%), revealing clip-related hypodensities in all 7 cases; Serial interleukin-6 (IL-6) measurements; Quantitative pain mapping. All patients received conservative therapy [ceftriaxone + metronidazole + non-steroidal anti-inflammatory drugs (NSAIDs); mean duration 62.6±14.2 days] prior to surgical intervention. After conservative treatment failure, pain intensity (VAS) was compared between two phases: post-conservative therapy (immediately before surgery). Post-surgical clip removal (7 days postoperatively). Secondary laparoscopic exploration with clip removal and histopathological analysis [International Organization for Standardization (ISO) 10993-6:2016] were performed.

RESULTS

Conservative therapy failed to reduce pain (median ΔVAS =-0.2, P=0.47).Surgical removal achieved complete pain resolution (VAS =0) in 10/11 patients (90.9%) within 7 days (P<0.001). Histopathology confirmed granulomatous inflammation in 9/11 cases (81.8%). IL-6 levels normalized post-removal (>150 pg/mL vs. <50 pg/mL).

CONCLUSIONS

Retained Hem-o-lok® clips show a strong temporal association with chronic abdominal pain in children, mediated by foreign body reactions. Conservative management was ineffective, while surgical removal rapidly resolved symptoms and restored growth. The observational design and lack of a control group preclude definitive causal inference. The observed association, while supported by histopathology, should be interpreted as generating a hypothesis that retained clips may be a contributor to chronic inflammation in a subset of patients.