Keywords
hysterectomy - laparoscopic removal - retained surgical item - case report
The Canadian Patient Safety Institute defines retained foreign body (RFB) as a patient
safety incident wherein an object is inadvertently left in a body cavity or surgical
wound following a procedure.[1] Commonly reported foreign bodies that are forgotten in the abdomen include mops,
sponges, pieces of broken instruments or irrigating sets, rubber tubes, guide wires,
sharp objects such as needles, and malleable retractors.[2] Usually brought to notice by media companies, the cases involving RFB are rarely
published as they may cause legal issues and defame the institute or practitioner.
It makes health care workers hesitate to report errors for fear of losing their jobs
or fear of some other form of reprisal. The symptoms are usually nonspecific, and
some patients remain asymptomatic and are never discovered or documented. This report
presents a rare case of a retained metallic foreign body showing after 13 years following
an abdominal hysterectomy.
Case Report
A 42-year-old married female came to the general surgery outpatient department with
pain in the right lower abdomen and anterior aspect of the right thigh over 1 month.
She described the pain as continuous, sharp, and nonradiating that exacerbated with
the movements of the right lower limb. She, otherwise, denied any history of trauma,
any chronic illness, or alteration in bowel and bladder habits. On further questioning,
it was revealed that she had undergone an open abdominal hysterectomy 13 years back
for menorrhagia with an uneventful postoperative period. Clinical examination revealed
a suprapubic transverse scar healed by primary intention and tenderness on deep palpation
in the right iliac fossa with no palpable abdominal lump. There was no neurovascular
deficit in the right lower limb, and spine examination was unremarkable. Digital rectal
examination, per vaginal examination, and systemic examination were unremarkable.
Laboratory values of complete hemogram, liver and renal function tests, urine, and
blood sugar showed no deviation from the normal range. A pelvis roentgenogram revealed
a linear radiopaque shadow with a tapering end lying obliquely over the right hemipelvis
([Fig. 1]). Anticipating the foreign body as metallic, the patient underwent a contrast-enhanced
computed tomography with angiography of the abdomen and pelvis, which demonstrated
a metallic attenuation foreign body in the intermuscular plane of the adductor compartment
of the right thigh, traversing the right obturator foramen with its tip lying at S1–2
vertebral level adjacent to the ileal loops ([Fig. 2]). A three-dimensional reconstruction showed the upper half of the foreign body in
proximity to external iliac vessels with no impingement.
Fig. 1 X-ray pelvis showing a linear radio-opaque shadow in the right hemipelvis.
Fig. 2 Reconstructed image from a tomography scan of the pelvis demonstrating an obliquely
placed foreign body, with metallic attenuation, traversing through the right obturator
foramen and tip at S1–2 vertebral level.
We proceeded with a diagnostic laparoscopy using a three-port position employed in
transabdominal preperitoneal inguinal hernia repair. The ileal loops have adhered
in the pelvis below the right medial umbilical ligament. A careful adhesiolysis revealed
a metallic foreign body in the region of the right obturator foramen ([Fig. 3]), which was extracted through the right-sided 10 mm port. The RFB was identified
as a 5-inch long fragment of the uterine tenaculum hook used in gynecological surgeries
to manipulate the cervix ([Fig. 4]). The right thigh pain subsided on the same day following retrieval of the instrument.
At the same time, the abdominal pain persisted for another 24 hours. The patient was
sent home on the second postoperative day following an uneventful postoperative course.
On long-term follow-up after 1.5 years, patient was doing her routine activities without
any discomfort.
Fig. 3 Laparoscopic view of the superior part of the foreign body that was hidden behind
the adhered ileal loops.
Fig. 4 Retrieved linear metallic foreign body that had a slender sharp-tip hook, and was
identified as one of the handles of uterine tenaculum forceps.
Discussion
Retained sponges and instruments (RSIs) following surgical procedures present a unique
problem for the surgeon. In most cases, the surgeon is held responsible for the errors
of other members of the surgical team. This is the responsibility not only of the
surgeon, but of the assistant(s) and operating theater nurses as well.[3] The nature of retained object varies from sponges to sharp and blunt instruments,
needles, and threads. The clinical presentation ranges from an incidental finding
on routine radiological evaluation to catastrophic complications depending on the
type of foreign body reaction. The first type of bodily reaction is an aseptic fibrous
response, which results in the formation of a granuloma, which can later be calcified
and decomposed. The second is an inflammatory response that causes an abscess.[4]
It has been estimated that one case of a retained item postsurgery occurs at least
once a year in any hospital where 8,000 to 18,000 major procedures are performed annually.
Studies evaluating RSI rates showed sponges accounted for the bulk of retained objects
(69%) compared with instruments (31%). The abdomen, pelvis, vagina, and thorax accounted
for common sites of RSI in decreasing order of incidence.[4] The time interval for detection varied from the operating room, the immediate postoperative
period to several years following the procedure. In this case report the retained
object remained undetected for a period of 13 years following the surgery. In the
body's attempt to expel the RSI from the abdominal cavity, a myriad of presentations
including bowel perforation, formation of fistulas, and intestinal obstruction (10–22%)
can occur that may be fatal (0–2%).[5]
[6] Documents of primary surgery were unavailable and the surgeon could not be contacted.
Patient was operated 13 years back when Surgical Safety Checklist published by the
World Health Organization (WHO) had just been released and was coming into action
in most centers but not all ([Supplementary Material S1], online only). The possibility of this object being retained is that it was a part
of another instrument and there is a possibility that the instrument broke during
an unexpected torrential bleed and in an emergency setting went unnoticed by the surgeon.
Patient had no postoperative complication hence the foreign body went unrecognized
for 13 years.
Several etiological factors which could increase the operating room errors have been
explored. These include open emergency surgery, long duration procedures, higher estimated
blood loss, “after hours” surgery, change of surgical and nursing team during the
procedure, and unanticipated or unplanned changes during the surgery.[7]
[8] Owing to the iatrogenic nature of the adverse event, several interventions to reduce
this operating room error have been explored. The Surgical Safety Checklist published
by the WHO in 2008 had provided the most promising results in preventing and reducing
such errors. A 36% decrease in postoperative complications and mortality rates were
observed on strict adherence to the checklist.[9] A meticulous manual mop and instrument count comprising single and dual count before
and after the surgery respectively greatly reduced the chance of discrepancy in the
counts. Novel methods combing technological advances with conventional counting systems
like bar coding surgical sponges and radiofrequency detection system have showed promising
results upon primary evaluation.[10]
Conclusion
Iatrogenic foreign bodies are avoidable adverse events following any procedure. A
watchful eye for patients presenting with persistent or new symptoms postoperatively
can aid in early detection. In asymptomatic RFBs cases, the patient should be informed
and motivated for a reoperation. Strict adherence to the surgical safety checklist,
meticulously performed and cross-verified manual mop counts, and adjuncts for verification
of retained foreign objects can help reduce the incidence of RSI. A reduced RSI can
help decrease patient morbidity and mortality, the excess financial burden on the
health care system in terms of the additional expenses, litigations, and can reduce
unforeseen complications.
