Recurrent choledocholithiasis after laparoscopic biliary surgery manifests as recurrent biliary tract infections, abnormal liver function, and falsely elevated CA 19–9 levels, which should be differentiated from malignant biliary tract tumors. Recurrent choledocholithiasis is a common and intractable postoperative adverse event, affected by a combination of anatomical, pathophysiological, metabolic, and surgery-related factors (2–4). In terms of surgical factors, incomplete intraoperative stone clearance (10), unreasonable biliary tract reconstruction (11), and postoperative biliary stricture induced by surgical trauma (12) are the predominant iatrogenic causes of stone recurrence. In addition to the aforementioned conventional etiological factors associated with bile stasis and surgical procedures, rare iatrogenic postoperative adverse events can also trigger recurrent choledocholithiasis, among which surgical clip migration into the biliary tract is one of the most atypical and easily neglected causes.

Surgical ligation clips have greatly enhanced the efficiency of laparoscopic biliary surgery, and have now become the most widely used surgical consumable in laparoscopic procedures. Nevertheless, existing clinical reports indicate that these clips may migrate to other aberrant anatomical sites and regions. Postoperative clip migration, although rare, sometimes carries life-threatening risks (13). When surgical clips migrate, they may become lodged in the CBD, obstruct biliary drainage, and ultimately act as a nidus for stone formation (7). Severe cases can progress to acute suppurative cholangitis and even septic shock. Given the potential severity of this adverse event, clip migration into the CBD after laparoscopic biliary surgery warrants heightened attention from hepatobiliary surgeons.

To investigate clip migration after biliary surgery, we conducted a literature review aiming to clarify the potential underlying mechanisms of this complication and summarize corresponding clinical countermeasures. We systematically searched the MEDLINE, PubMed, Web of Science, and Google Scholar databases for relevant publications from January 2005 to April 2026. The search terms included “clip migration,” “laparoscopic common bile duct exploration”, “LCBDE”, “T-tube”, “biliary complication.” We included English-language clinical case reports, retrospective studies, reviews and letters, and excluded conference abstracts and duplicate publications. Duplicate cases retrieved from different databases were manually screened and excluded. All cases underwent rigorous screening: cases involving clip migration after LCBDE were included, while cases of clip migration after LC were excluded. Ultimately, 13 eligible studies were enrolled, comprising a total of 36 clinical cases (including the present case) (Table 1). To the best of our knowledge, there have been no published dual-clip migration cases after LCBDE with T-tube drainage.

We further collected and summarized preoperative imaging findings and related diagnostic findings, and evaluated the clinical performance of different preoperative detection modalities in the diagnosis of clip migration (Supplementary Table S1). In our included cohort, only two patients received a correct diagnosis of clip migration via magnetic resonance cholangiopancreatography (MRCP). This accounts for only 25.0% of all patients that underwent MRCP examination. The primary underlying reason is that a migrated surgical clip within the CBD can readily act as a nidus for secondary stone formation. Once the surgical clip is completely encased by newly formed stones, imaging can only reveal the overall outline of the CBD stones, making it impossible to accurately distinguish between the stone and the migrated clip. Similarly, both T-tube cholangiography and ERCP depend on cholangiographic visualization to obtain diagnostic results. As a result, when the migrated surgical clip is completely embedded inside the calculus, these imaging modalities also fail to detect the clip migration. By contrast, CT scanning can directly identify migrated surgical clips, as it clearly distinguishes variations in tissue density and morphological differences. In the present case series, CT achieved a notably high diagnostic rate of 92.3% (12/13) by directly visualizing characteristic high-density clip shadows. This finding indicates that CT may be regarded as the first-line imaging modality for early detection of clip migration after biliary surgery. However, considering the potential selection bias associated with imaging examinations, CT diagnostic rates may overestimate the true real-world sensitivity, and accumulation of more clinical cases will help us more clearly define the diagnostic value of CT in detecting clip migration.

To date, there is still no unified clinical consensus on the exact pathogenic mechanism of clip migration after laparoscopic biliary surgery. Previous clinical observations have indicated that clip migration after LC isprimarily attributable to a variety of perioperative factors and local tissue-related factors. Firstly, persistent chronic local inflammation gradually leads to progressive erosion of the peribiliary tissue and the cystic duct wall. This process ultimately results in tissue defects, causing the surgical clip to gradually migrate into the lumen of the CBD (20). Secondly, the chronic inflammatory response and foreign body rejection reaction caused by the surgical clip can also damage the bile duct wall, ultimately leading to clip migration (20). Thirdly, inappropriate surgical clip application, including improper placement or misuse of Hem-o-lok clips, may initiate a cascade of adverse events: incomplete occlusion of the cystic duct subsequently leads to postoperative bile leakage and local cholesteatoma formation, which further aggravates peribiliary inflammatory adhesion and ultimately promotes clip loosening and migration (8). Fourthly, the anatomical structure of the cystic duct-CBD junction is naturally flared and structurally unstable; if the surgical clip is placed excessively close to the biliary tract during ligation, it may gradually retract inward into the CBD under continuous surrounding tissue pressure after the loss of gallbladder traction (20).

Specifically for patients undergoing LCBDE, several additional procedural risk factors may contribute to postoperative clip migration. Our pooled literature review found the following observations among the 36 reported clip migration cases: T-tubes were placed intraoperatively in 33 patients (91.7%), and migration predominantly occurred in the CBD (77.8%) and the T-tube sinus tract (16.7%) (Supplementary Table S2). During choledochoscopy performed immediately after T-tube removal, migrated surgical clips were detected in the T-tube sinus tract among multiple patients (13, 14, 22). In some severe cases, the surgical clips had even migrated completely into the CBD (15, 17). Upon reviewing the CT images obtained before T-tube removal, we identified two high-density foreign bodies adjacent to the T-tube entry site of the CBD. These findings indicate that T-tube placement may be a potential risk factor for clip migration after LCBDE.

Preoperative CT scan revealed that the two Hem-o-lok clips placed on the cystic duct remained in their original position (Supplementary Figure S1). Based on these imaging findings, we hypothesize that the surgical clips placed on the cystic artery may be more prone to loosening. Given that these loose clips are anatomically proximal to the CBD and the T-tube, they may possibly become gradually embedded in the T-tube sinus tract wall. Once the T-tube has been removed, the sinus tract loses its mechanical structural support. In particular, excessive dissection of pericholedochal soft tissue further weakens the local tissue stability; we hypothesize that persistent fluctuations in intra-abdominal pressure may ultimately drive clip migration into either the sinus tract or the CBD. The potential pathogenic mechanisms underlying clip migration after LCBDE differ substantially from those after LC, particularly in patients undergoing LCBDE combined with T-tube drainage. Studies have demonstrated that absorbable clips can reduce the risk of postoperative complications such as inflammation and biliary fistula compared with conventional surgical clips, thereby lowering the incidence of clip migration (24). Clip-free techniques, reduced use of metallic clips, or application of energy devices can effectively avoid long-term clip-associated complications (25). In addition, primary biliary suture is safe and effective for specific patient populations (26), avoiding T-tube removal and maintaining a stable peribiliary microenvironment can also help reduce the likelihood of clip migration.

Such procedural discrepancies indicate that the majority of clip migration events after LCBDE may be preventable with standardized surgical manipulation. Therefore, we recommend minimizing the overuse of non-absorbable ligation materials, including Hem-o-lok and metallic clips, and adhering to the following surgical precautionary principles: 1. The cystic artery should be ligated close to its origin, avoiding proximity to the CBD incision. 2. Reserve a residual cystic duct of at least 0.5 cm in length when the duct is in a relaxed state; 3. All surgical clips should be placed sufficiently distant from the CBD incision; 4. Excessive skeletonization and dissection of pericholedochal soft tissue should be strictly avoided; 5. Primary CBD suture closure is preferred whenever intraoperative conditions permit; 6. Routine intraoperative choledochoscopy is strongly advised prior to T-tube removal. Nevertheless, the above standardized surgical protocols cannot completely eliminate the risk of clip migration, as persistent local inflammation secondary to residual biliary infection, bile fistula, and other postoperative complications may still induce clip migration. Notably, clip migration has been sporadically reported even after the application of absorbable clips (17), and this adverse event also remains an occasional possibility despite successful primary CBD closure (16, 17).

Different clinical presentations require targeted and differentiated therapeutic strategies. For surgical clips migrated into the CBD, both LCBDE and ERCP combined with EST are considered viable and effective therapeutic alternatives. For patients with an indwelling T-tube, intraoperative choledochoscopy represents the optimal approach for retrieving migrated surgical clips located within the CBD or T-tube sinus tract (13, 17). For surgical clips migrated into the digestive tract wall, conservative management with close long-term follow-up can be adopted (25). Although such embedded clips may spontaneously detach and be excreted via the intestinal tract, continuous clinical vigilance is mandatory to prevent the potential risk of gastrointestinal perforation. Given that reports of clip migration remain relatively limited, the accumulation of more clinical cases may help focus attention on technical details of LCBDE surgical procedures to reduce the incidence of postoperative clip migration.

The strength of the present case lies in its focus on clip migration after LCBDE with T-tube drainage, which will prompt surgeons to pay more attention to the details of T-tube placement and removal, as well as the precautions that should be taken during the procedure. Given that reports of clip migration remain relatively limited, the accumulation of more clinical cases may help focus attention on technical details of LCBDE surgical procedures to reduce the incidence of postoperative clip migration. Furthermore, as the follow-up period in this study was relatively short, it was not possible to assess the risk of other long-term complications or recurrence of CBD stones postoperatively.