Lost surgical specimens

Lost, mislabeled, and mishandled surgical and clinical pathology specimens: A systematic review of published literature

OBJECTIVES

To perform a systematic review of published academic literature related to lost, mislabeled, and mishandled surgical and clinical pathology specimens during the preanalytical stage.

METHODS

The authors used Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines to search PubMed, MEDLINE, Web of Science, and Scopus for relevant articles published from January 1, 1990, to May 1, 2023.

RESULTS

The authors screened 1313 articles and identified 44 peer-reviewed, English-language articles published between 1990 and 2021 for inclusion in the final systematic review. Most articles (n = 36) reported results from US-based facilities. Articles primarily focused on general clinical and general surgical pathology. Analysis of the articles revealed that articles reported a range of methodological approaches, including incident reports, implementation analyses, case studies, and commentary recommendations. Most articles focused on mislabeling errors (61.3%) and missing or lost specimens (18.2%), while several articles combined specimen errors (20.5%). Several implementation studies (22.7%) reported using multiple interventions to mitigate errors. Implementation efforts reported between 70% and 100% reduction in pathology errors.

CONCLUSIONS

The review highlights the limited research on the topic, with an average of 2 articles per year discussing lost, mislabeled, or mishandled specimens. Intervention studies addressed The Joint Commission's patient safety goals for laboratory practice. More research is needed about error incidents and reporting in non-Western countries to gain a more global perspective on the topic.

Rethinking the Issue of Power Morcellation of Uterine Fibroids: Is Morcellation the Real Problem or Is this Another Symptom of Disparity in Healthcare Provision?

Power morcellation remains one of the most significant developments in minimal access surgery over the past decade, allowing many more patients to benefit from the least invasive surgical route. However, its use is not without controversy, particularly with regards to the risks of an undiagnosed leiomyosarcoma. Increased media and, in particular, on-going social media coverage since events in 2014 have only served to intensify the debate, culminating in the Food and Drug Administration essentially 'banning' its use in the USA. Practice however continues to vary and this technique remains widely used in Europe and in particular the UK. The aim of this article was to review the development of power morcellation in gynaecology and the underlying risks, including that of undiagnosed leiomyosarcoma, as well as appraise the evolving literature on patient awareness and informed consent and the wider implications of morcellation restriction.

"Iatrogenic" parasitic myomas: unusual late complication of laparoscopic morcellation procedures

STUDY OBJECTIVE

To describe our experience in diagnosing and managing parasitic myomas developing as an unexpected late complication of laparoscopic morcellation.

DESIGN

Observational study (Canadian Task Force classification II-3).

SETTING

University hospital.

PATIENTS

Retrospective chart review of all patients found to have parasitic myomas that developed after previous morcellation.

INTERVENTION

Laparoscopic morcellation. Review of the recent literature correlated with clinical, surgical, and pathologic features of our cases.

MEASUREMENTS AND MAIN RESULTS

Four patients had heterogeneous pelvic masses after morcellation. In 3 patients, symptoms developed between 2 and 16 years after the primary surgery. One patient had no symptoms, and was referred because of a suspect pelvic mass. Vaginal examination revealed painful pelvic masses in the pouch of Douglas in 2 patients, and painless masses fixed to the vaginal vault and anterior vaginal wall, respectively, in the other 2 patients. Laparoscopic examination confirmed the presence of parasitic masses in 3 patients. In 1 patient, the mass was excised vaginally. Histologic analysis confirmed leiomyoma fragments in all patients. A well-differentiated endometrial carcinoma was incidentally found in 1 patient after hysterectomy.

CONCLUSION

These masses probably resulted from growth of missed fragments of uterine tissue after previous morcellation, culminating in development of symptomatic iatrogenic parasitic myomas. If morcellation is anticipated or required, exclusion of malignancy is mandatory. Meticulous inspection of the abdominal cavity is necessary after morcellation. In patients with a history of morcellation who have pelvic masses, iatrogenic parasitic myomas should be considered in the differential diagnosis.

Early postoperative small bowel obstruction after laparoscopic myomectomy

OBJECTIVE

To describe an early small bowel obstruction after robotic-assisted laparoscopic myomectomy with the Davinci system.

DESIGN

Case report.

SETTING

Academic medical center.

PATIENT(S)

Two days after a robotic-assisted laparoscopic myomectomy, a 35-year-old nulligravid African-American woman developed a small bowel obstruction due to retained myoma fragments that had implanted on and subsequently kinked loops of the small bowel.

INTERVENTION(S)

The patient was managed conservatively for 4 days with bowel rest and IV hydration. Due to worsening clinical symptoms and supportive radiologic findings, exploratory laparotomy was performed to lyse adhesions and remove the implanted myoma pieces.

MAIN OUTCOME MEASURE(S)

Clinical resolution of small bowel obstruction symptoms.

RESULT(S)

No bowel resection was needed for this patient.

CONCLUSION(S)

Prompt recognition and operative treatment of the small bowel obstruction prevented the need for intestinal resection. To reduce the risk of ectopic implantation of myoma fragments, meticulous care should be taken to remove all remnants of morcellated tissue. Immediate postoperative complications, such as bowel obstruction, and long-term complications related to recurrent myomas may then be avoided.

Laparoscopic myomectomy: do size, number, and location of the myomas form limiting factors for laparoscopic myomectomy?

STUDY OBJECTIVE

To assess whether it is possible for an experienced laparoscopic surgeon to perform efficient laparoscopic myomectomy regardless of the size, number, and location of the myomas.

DESIGN

Prospective observational study (Canadian Task Force classification II-1).

SETTING

Tertiary endoscopy center.

PATIENTS

A total of 505 healthy nonpregnant women with symptomatic myomas underwent laparoscopic myomectomy at our center. No exclusion criteria were based on the size, number, or location of myomas.

INTERVENTIONS

Laparoscopic myomectomy and modifications of the technique: enucleation of the myoma by morcellation while it is still attached to the uterus with and without earlier devascularization.

MEASUREMENTS AND MAIN RESULTS

In all, 912 myomas were removed in these 505 patients laparoscopically. The mean number of myomas removed was 1.85 +/- 5.706 (95% CI 1.72-1.98). In all, 184 (36.4%) patients had multiple myomectomy. The mean size of the myomas removed was 5.86 +/- 3.300 cm in largest diameter (95% CI 5.56-6.16 cm). The mean weight of the myomas removed was 227.74 +/- 325.801 g (95% CI 198.03-257.45 g) and median was 100 g. The median operating time was 60 minutes (range 30-270 minutes). The median blood loss was 90 mL (range 40-2000 mL). Three comparisons were performed on the basis of size of the myomas (<10 cm and >or=10 cm in largest diameter), number of myomas removed (<or=4 and >or=5 myomas), and the technique (enucleation of the myomas by morcellation while the myoma is still attached to the uterus and the conventional technique). In all these comparisons, although the mean blood loss, duration of surgery, and hospital stay were greater in the groups in which larger myomas or more myomas were removed or the modified technique was performed as compared with their corresponding study group, the weight and size of removed myomas were also proportionately larger in these groups. Two patients were given the diagnosis of leiomyosarcoma in their histopathology and 1 patient developed a diaphragmatic parasitic myoma followed by a leiomyoma of the sigmoid colon. Six patients underwent laparoscopic hysterectomy 4 to 6 years after the surgery for recurrent myomas. One conversion to laparotomy occurred and 1 patient underwent open subtotal hysterectomy for dilutional coagulopathy.

CONCLUSION

Laparoscopic myomectomy can be performed by experienced surgeons regardless of the size, number, or location of the myomas.

Chain removal of myomata by colpotomy

Multiple myomectomy was performed in 67 women between June 1996 and July 1998. In almost every case, myomas were sutured one to another with a single stitch of 1 silk, forming a chain, and taken out through the vaginal cul-de-sac. We believe this method reduces the risk of losing myomas inside the peritoneal cavity and shortens operating time. (J Am Assoc Gynecol Laparosc 6(3):337-338, 1999)

Retained myoma after laparoscopic supracervical hysterectomy with morcellation

Laparoscopic myomectomy and, more recently, laparoscopic supracervical hysterectomy are practical alternatives to traditional surgical management of uterine fibroids. With the advent of mechanical morcellation these procedures are now much more feasible. A 6-cm fibroid was lost at the time of laparoscopic-assisted supracervical hysterectomy and caused persistent, severe abdominal pain over the next 3 weeks. The fibroid was lodged in the region of the liver and gallbladder and required removal by laparotomy. Although retention of fibroids after operative laparoscopy has been reported, it has not been associated with complications. Technical alternatives at the time of operative laparoscopy involving morcellation should be considered to prevent this event.