A retained surgical instrument is any item inadvertently left behind in a patient’s body in the course of surgery. There are few books about it and it is thought to be underreported. As a preventable medical error, it occurs more frequently than "wrong site" surgery. The consequences of retained surgical tools include injury, repeated surgery, excess monetary cost, loss of hospital credibility and in some cases the death of the patient.
Mistakes and consequences In any given typical surgery, an estimated 250–300 surgical tools are used. The number significantly increases to 600 when a larger surgery is performed, thus increasing the chance of the surgeon losing an instrument.
Types of forgotten instruments
There are many different types of tools that have been left behind during a surgery. Common instruments are needles, knife blades, safety pins, scalpels, clamps, scissors, sponges, towels, and electrosurgical adapters. Also retained are tweezers, forceps, suction tips and tubes, scopes, ultrasound tissue disruptors, asepto bulbs, cryotomes and cutting laser guides, and measuring devices. The single most common left behind object is a sponge.
Frequency The estimate of how often this type of mistake happens is unclear. According to the U.S. Department of Health and Human Services, it is anywhere between 1 in 100 to 1 in 5000. However a study done in 2008 reported to the Annals of Surgery that mistakes in tool and sponge counts happened in 12.5% of surgeries. Additionally, the Patient Safety Monitor Alert, announced in 2003 that 1,500 tools were stitched into patients each year. Khaled Sakhel, part of the Department of Obstetrics and Gynecology at the Eastern Virginia Medical School, reported that it is expected to occur at least once "in every 1,000–1,500" stomach surgeries. An exact count of how often this happens would be impossible to calculate. The Joint Commission on Accreditation for Healthcare Organization (JCAHO) stated that "unintentionally retained foreign bod(ies) without major permanent loss of function" (qtd. in Gibbs) are not required to be reported. Nurses have been discouraged against reporting all errors because of the threat of malpractice and liability issues. Estimates are "undoubtedly low."
Gossypiboma Gossypiboma is the official name for a retained sponge/towel after surgery. This word comes from the Latin word for cotton, gossypium, combined with the Swahili word for place of concealment, boma. It is also commonly referred to as textilioma. This word combines textile, meaning cloth, and the suffix –oma, which means growth or tumor. A case of gossypiboma can be subtle and may not be discovered until months or even years after the surgery has been performed. In rare cases, a situation can be so severe that it is noticed immediately. Some of the ways gossypiboma can present itself are as a mass in the body or as a bowel tumor. Immediately after surgery, a case of gossypiboma can commonly be mistaken for an abscess, especially when it is near a passage between organs (a "fistula"). In those cases where a sponge isn't discovered until much later, it may be impossible to tell the difference between gossypiboma and an "intra-abdominal abscess". This is because both cause air bubbles and "calcification of the cavity wall." Gossypiboma is difficult to diagnose due to vague, inconsistent symptoms and images from x-rays that provide no solid evidence and unclear results. Because it is difficult to diagnose, emphasis has been put on the prevention of the mistake. The following techniques have been put into practice to prevent gossypiboma.
Radiopaque marking: Before operation, sponges can be soaked through with "radio-opaque marker". This allows a sponge to be easily seen on plain radiographs. When the markers are noticed, it can be assumed that it is revealing a retained sponge. A.P. Zbar, Surgical Directorate at Oldchurch and Harold Wood Hospitals stated "the diagnosis is easily made by plain abdominal radiography, when a radio-opaque marker is seen". This method is flawed in that it doesn't work if the sponges have broken into smaller pieces over time. Ultrasonography- Gossypiboma can be recognized with ultrasonography by "the presence of brightly echogenic wavy structures in a cystic mass showing posterior acoustic shadowing that changes in parallel with the direction of the ultrasound beam" according to Zbar and associates. Computerized Tomography (CT)- A surgical sponge on a CT will show air bubbles on soft tissue masses. The flaw with this technique is that gossypibomas are easily confused with abscesses.
Consequences Dangers of a tool or sponge left behind range anywhere from harmless to life-threatening. Surgical tools left in the body can puncture vital organs and blood vessels, causing internal bleeding. Sponges can fester inside a body, growing increasingly dangerous over time. Additional operations may be necessary, which can be costly and also take the surgical table away from other patients with more urgent needs. Michael Blum said "The incidents observed…took an average of 13 minutes to resolve, a time lapse which can significantly impact the flow of a busy emergency or perioperative department." Another danger is a sponge can be misdiagnosed, resulting in an unnecessary extreme surgery. A radical surgery can be avoided by considering the possibility of a retained sponge or tool.
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