Migration of three endoclips following laparoscopic cholecystectomy

We present a well-documented case report on migration of the haemostatic clip, along with the two clips that had originally been applied on the cystic duct, into the bile duct forming the nidus of a stone after laparoscopic cholecystectomy--a unique occurrence heretofore unreported. The English language literature on the subject is reviewed. The most likely predisposing factor is improper or erratic application of clips resulting in bile leakage, either subclinical or overt. Secure and correct placement of clips could help to prevent this complication.