Figure 2. Our modifications to the Kirkland method. In the training phase of this model, we recognized that the perception of the clip was very difficult at the second laparotomy because of the adhesion around the common bile duct (CBD). Furthermore, clip removal was markedly troublesome even if the clip was perceived. Therefore, we added the two following modifications. First, 4-0 polypropylene monofilament suture was ligated at the bottom of the U-shaped clip and cut at 2 cm from the ligation for subsequent pulling-off use (upper half). In the Kirkland method, a suture incorporated with the clip was merely sandwiched by the clip, but not ligated. Second, bioresorbable hyaluronic acid/carboxymethylcellulose membrane (Seprafilm®, Genzyme, Cambridge, MA, USA) was used. We placed it on the intra-abdominal surgical site before closing the abdomen with a 4-0 silk running suture at the first surgery. With these two modifications, the clip was easy to perceive and remove at the second surgery.