Missed Instrument and Surgical Sponge (Gauze and Pack)

Abstract

Retained surgical instruments or sponges as small gauze and packs are unusual but dangerous complications of abdominal surgery. A missed instrument remains silent and is discovered accidentally because it is sterile and inert while the sponge produces infection and usually presents as local or general peritonitis. Ten cases of missed operative instruments and sponges were recorded during the last 8 years. Presentation and complications of these 10 cases, and how to prevent that in the future, are discussed. INTRODUCTION To perform any laparotomy requires, beside the surgical team, a set of surgical instruments of that special laparotomy, a set of swabs, packs and tubes for suction and irrigation and other accessory instruments for cauterization. Missing one of the surgical instruments, swabs or packs during laparotomy is a mistake for the surgical team especially the scrub and circulating nurses. But this has happened especially under the following conditions: Difficult surgery, especially emergency surgery at 1. night 1 Surgery for obese patients 1 2. Excision of a big abdominal tumor 3. Necessity to arrest massive intro-abdominal 4. bleeding using multiple instruments and packs Bad general condition of the patient during G.A. 5. and need to cut short the operation. Presence of an untrained or newly trained nurse 6. Absence of the circulating nurse. 7. Absence of a swab and instrument counting system 8. Many teams sharing in the surgical operation 9. Improper lighting in the theater with bad surgical 10. theater environment PATIENTS AND METHODS During the last 8 years, 10 patients of different age groups, 3 males and 7 females with history of previous laparotomy presented to us with features of acute abdomen and presenting symptoms and signs as in table No. I: Figure 1 Table 1: Presenting Signs and Symptoms Urgent plain X-Ray of the abdomen with U/S examination was done in some of them. The diagnosis was reached before surgery in 3 cases while the others were considered acute abdomen and emergency laparotomy was done for them. RESULTS The result of 10 laparotomies was found to be missed instruments, swab gauze and packs. The details are given in table No. II: Missed Instrument and Surgical Sponge (Gauze and Pack) 2 of 5 Figure 2 Table 2: Three of our cases were diagnosed pre-operatively. CASE NO. 1 A 20-year-old male patient with a history of laparotomy for excision of a big abdominal tumor one year ago, presented to us with colicky abdominal pain and mild fever (37.5°C). On examination his abdomen was soft but there was slight central abdominal tenderness and no mass was palpable. His plain X-Ray of the abdomen (fig. 1) showed a big artery forceps missed from previous surgery. This forceps was taken out by re-laparotomy and the patient was discharged well from hospital after a smooth postoperative period.