The lost sponge: patient safety in the operating room

Abstract

A 43-year-old woman presented to the emergency department with acute nausea and vomiting. She was admitted by the general surgery team with a suspected obstruction of the small bowel. Examination and imaging revealed an enlarged uterus (18 × 9 × 16 cm) with fibroids. Nine years earlier, she had undergone a uterine myomectomy by means of midline laparotomy, after which postoperative pancreatitis and bleeding had occurred followed by repeat laparotomy.The next morning (midweek), a laparotomy was performed to identify and treat the source of the obstruction. An incision from the base of the sternum to the symphysis pubis was made, followed by dissection of some minor adhesions next to the terminal ileum. No discrete bands were identified that could explain the obstruction. The gynecology service was then consulted to manage the fibroid uterus.Upon arrival, the staff gynecologist was informed by the senior surgery resident that no cause of the obstruction was found. The resident then left the operating room. The gynecology team completed a subtotal hysterectomy, after which the sponge count was incorrect. The abdomen and pelvis were explored, but no sponges were found. A radiograph of the abdomen showed no signs of a retained sponge (Figure 1). The abdomen was closed and the patient transferred to the recovery room.The circulating nurse remained concerned about the incorrect sponge count and followed up with the gynecologist the next day. The gynecologist requested a computed tomography (CT) scan, and the patient was informed of the incorrect sponge count. At the time, the institution's policy did not require a routine follow-up CT scan if the count was incorrect. The CT scan showed a radiopaque marker indicating a sponge in the lesser sac below the greater curvature of the stomach (Figure 2).The gynecology team performed an exploratory laparotomy. A packing sponge was found and removed from the lesser sac. No other concerns or complications arose, and all sponge counts were correct. The patient made an uneventful recovery.

Intravesical gossypiboma: our experience and the need for stringent checklist and training!

“…This also highlights the need for consistent guidelines and count policies. Henceforth, institutions should amend their policy on sponge and count 16…”

Retained textile foreign body: A rare cause of acute abdomen

“…Several factors have been associated with gossypibomas, such as operations performed as emergencies; inaccurate recording of swab counts; unexpected intraoperative events, findings, or adjustments; and patient factors, such high body mass index (BMI) and female sex. 5 The clinical picture may include abdominal pain, abdominal mass, rectal bleeding, intestinal obstruction, fever, diarrhoea and weight loss 6 ; the time of presentation and duration can vary from 3 days to 40 years, 7 which makes early diagnosis difficult.…”

Interventions for the Prevention of Retained Surgical Items: A Systematic Review

“…•The nature of the intra-operative procedure [8,9] •Noncompliance with protocols [10][11][12] •lack of conducting a surgical count [8] •Incorrect surgical counts [4,13,14] •Higher body mass index [3] •More than one sub-procedure [4,8] •More than one surgical team [8] •Longer duration of surgery [13] •Emergencies with unplanned changes in [2,3,13] •Equipment failure [15] •Elements of teamwork including leadership, human factors, and communication [12,14,16] •Distraction, multitasking, and time pressure [9][10][11] •An increased number of perioperative personnel and specialty teams involved [2] Search methodology…”

“…The ratings on the different items were used by the reviewers to assess the risk of bias in the study due to flaws in study design or implementation. A score was given to classify the quality of each paper as poor (0-6), fair (7)(8)(9)(10)(11), or good (12)(13)(14)(15)(16). In general terms, a ''poor'' rating indicated significant risk of bias, a ''fair'' study indicated some bias deemed not sufficient to invalidate its results, and a ''good'' study had the least risk of bias, so that the results were considered to be valid.…”