Retained surgical sponges: what the practicing clinician should know

Etiology, pathogenesis, and management of angiosarcoma associated with implants and foreign body: Clinical cases and research updates

Angiosarcomas are rare and highly malignant soft tissue sarcomas originating from endothelial cells lining the lymphatic or vascular system. While they predominantly emerge from (sub)cutaneous regions, occurrences have been reported throughout the body. The etiology of angiosarcoma remains elusive in most clinical cases. Nevertheless, several prognosis risk factors play a pivotal role, including chronic lymphedema, therapeutic irradiation, environmental carcinogens, familial syndromes, and the presence of foreign materials like metallic objects and biomedical implants. Despite evidence implicating retained foreign material in angiosarcoma development, understanding its prognosis and pathogenesis remains limited. The pathogenesis of angiosarcoma appears to involve a complex interplay of chronic inflammation, tissue remodeling, and genetic factors that create a conducive microenvironment for malignant transformation. Management of these sarcomas remains challenging due to their infiltrative nature owing to the high chance of metastasis and local recurrence. The primary treatment modalities currently include surgery, radiotherapy, and chemotherapy, but recent advances in targeted immunotherapy and gene therapy hold promise for more effective approaches. This comprehensive review delves into the potential etiological and pathogenic roles of foreign materials, such as metallic objects, biomedical implants, and biomaterials, in the development of angiosarcoma. Further research into the underlying molecular mechanisms could provide valuable insights for tailored management and developing novel targeted therapeutic strategies.

Intra-abdominal foreign body as unexpected discovery mimicking suspicious malignancy

Although rare, postoperatively retained foreign bodies in the abdominal cavity still represent a serious issue for the surgical team as for the patients. Its clinical manifestation is often unspecific and the cases are therefore only irregularly registered. There are several known factors that increase the risk of retention of a foreign body, for example emergency surgeries, unplanned changes in procedure or a high body mass index. In this article, we would like to report the case of a male patient with a foreign body in the right lower quadrant after open appendectomy mimicking a tumor.

Transmural Migration of Gossypiboma with Intraluminal Small-Bowel Obstruction: A Case Report

Patient: Female, 26-year-old

Final Diagnosis: Gossypiboma

Symptoms: Abdominal pain

Medication:—

Clinical Procedure: —

Specialty: Surgery

Radiological features and management of retained needles

The identification of retained needles is essential because of their sharp structure with possible life-threatening complications. However, radiological evaluation could be challenging, especially in case of needles' relatively poor conspicuity and small dimension. This pictorial essay focuses on clinical issues (needle features, retention mechanisms and associated complications) and technical aspects (choice of the best diagnostic modality and technique) that can lead the radiologist to an earlier and proper diagnosis of needle retention in order to provide the best treatment for the patient.

Gossypiboma: A Dramatic Result of Human Error, Case Report and Literature Review

Gossypiboma refers to a retained foreign object that was forgotten in the body cavity during an operation. It is a rare surgical complication that most commonly occurs after intraperitoneal abdominal emergency surgical procedures, but may also occur after virtually any type of operation. Gossypiboma can be confused with neoplastic lesions and abscess. Clinical examination and radiological findings may sometimes mislead the physician. We intend to present our cases, which is thought to be a kidney tumour and bladder cancer but resulted gossypiboma which is a condition that is caused by a forgotten sponge during the operation and it can mimic the cancer. During the operation, the team must work in coordination and be careful. Unnecessary operations in such situation can significantly increase the patient's morbidity.

Evaluation of radiofrequency electronic system in intraoperative monitoring of surgical textiles

Objective

To test performance of SurgiSafe^®, a radiofrequency electronic device to detect surgical textiles during operations as compared to manual counting.

Methods

Surgical sponges with radiofrequency TAGs were placed in the abdominal cavity of a pig submitted to laparotomy, in randomly distributed sites. The TAGs were counted manually and also using SurgiSafe^®. Positive and negative predictive values, sensitivity, specificity and time required for counting were analyzed for both methods.

Results

Through the analysis of 35 surgical cycles, SurgiSafe^® immediately identified all sponges, with specificity, sensitivity, positive and negative predictive values of 100%. Although not statistically significant, the manual count had sensitivity of 99.72% and specificity of 99.90%.

Conclusion

SurgiSafe^® proved to be an effective device to identify surgical sponges in vivo, in real time; and its use as an adjuvant to manual counting is very helpful to increase patient's safety.

Incidence, root cause, and outcomes of unintentionally retained intraabdominal surgical sponges: a retrospective case series from two hospitals in Togo

Background

The term gossypiboma refers to a sponge that has been forgotten in the surgical field. It is the most common retained surgical item, and constitutes a continuing problem for surgical safety. We performed a hospital-based study to examine their incidence, root cause, and outcomes, as an effort toward improving prevention.

Methods

This retrospective study covered 10 years (2006-2015) and included surgically confirmed cases of abdominal gossypibomas occurring after 45,011 abdominal and gynaecological operations in 2 public hospitals in Lome (Togo). Age, diagnosis, initial surgical procedure, evidence of textile count, and data related to the revision procedure were collected for descriptive analysis.

Results

Fifteen cases of gossypibomas (11 women and 4 men) were recorded. The mean age of the patients was 27 (range 21-55) years. Initial procedures were gynaecological in 11 patients and 5 cases involved an emergency surgery. Evidence of sponge counting was found in 6cases. Gossypiboma was an incidental finding in 1 patient. The average time to onset of symptoms after the initial procedure was 2 months. The gossypiboma was removed within 7 days to 4 years after the initial procedure. Postoperative complications included enterocutaneous fistula in 2 patients, incisional hernia in 2 patients, and wound sepsis in 1 patient. Death occurred in 2 patients (13.3%).

Conclusions

Although rare, the incidence of gossypibomas is still unacceptably high and reveals failures regarding patient safety standards. The associated morbidity and mortality are significant, yet can be reduced by an early diagnosis in the immediate postoperative period. A systematic methodical count of sponges is the cornerstone of prevention, and introducing surgical safety protocols, such as the WHO Safe Surgery Saves Lives checklist, can enhance effectiveness. There is a crucial need for safety-focused policies, which may include a never event reporting system, elaboration of prevention strategies, interventions, and evaluation.

Unusual Complication following a Myomectomy: Colic Migration of a Forgotten Abdominal Swab

Surgical sponges are the most common retained foreign bodies following surgery. The morbidity of this condition is illustrated herein with the case of a 36-year-old female patient with a history of myomectomy 5 months before her admission into our unit for enterocutaneous fistula. Although imaging and etiological investigations were made, diagnosis was carried out only by laparotomy. The foreign body found was an abdominal swab that migrated from abdominal cavity to the colon causing several intestinal injuries. The lack of specific clinical signs and the death of the patient raise the necessity of preventing these complications that involve the surgeon liability.

Retained Foreign Body: "Needle in a Haystack"

Retained foreign bodies remain an area of potential patient harm. This case describes a retained needle from distant surgery discovered at the time of the needle count after myomectomy.

Thoracic textilomas: CT findings

OBJECTIVE:

The aim of this study was to analyze chest CT scans of patients with thoracic textiloma.

METHODS:

This was a retrospective study of 16 patients (11 men and 5 women) with surgically confirmed thoracic textiloma. The chest CT scans of those patients were evaluated by two independent observers, and discordant results were resolved by consensus.

RESULTS:

The majority (62.5%) of the textilomas were caused by previous heart surgery. The most common symptoms were chest pain (in 68.75%) and cough (in 56.25%). In all cases, the main tomographic finding was a mass with regular contours and borders that were well-defined or partially defined. Half of the textilomas occurred in the right hemithorax and half occurred in the left. The majority (56.25%) were located in the lower third of the lung. The diameter of the mass was ≤ 10 cm in 10 cases (62.5%) and > 10 cm in the remaining 6 cases (37.5%). Most (81.25%) of the textilomas were heterogeneous in density, with signs of calcification, gas, radiopaque marker, or sponge-like material. Peripheral expansion of the mass was observed in 12 (92.3%) of the 13 patients in whom a contrast agent was used. Intraoperatively, pleural involvement was observed in 14 cases (87.5%) and pericardial involvement was observed in 2 (12.5%).

CONCLUSIONS:

It is important to recognize the main tomographic aspects of thoracic textilomas in order to include this possibility in the differential diagnosis of chest pain and cough in patients with a history of heart or thoracic surgery, thus promoting the early identification and treatment of this postoperative complication.

Radiographic Detectability of Retained Neuropatties in a Cadaver Model

BACKGROUND

Counts are the commonest method used to ensure that all sponges and neuropatties are removed from a surgical site before closure. When the count is not reconciled, plain radiographs of the operative site are taken to determine whether the missing patty has been left in the wound. The purpose of this study was to describe the detectability of commonly used neuropatties in the clinical setting using digital technologies.

METHODS

Neuropatties were implanted into the anterior and posterior cranial fossae and the thoracolumbar extradural space of a mature male cadaver. Four neuropatty sizes were used: 3 × 1 in, 2 × ½ in, ½ × ½ in, and ¼ × ¼ in. Neuropatties, with size and location chosen at random, were placed in the surgical sites and anteroposterior/posterior-anterior and lateral radiographs were taken using standard portable digital radiographic equipment. Six clinicians reviewed the digital images for the presence or absence of neuropatties. The readers were not aware of the number and size of the patties that were included in each image.

RESULTS

The detectability of neuropatties is dependent on the size of the neuropatty's radiopaque marker and the operative site. Neuropatties measuring 2 × ½ in and 3 × 1 in were detected reliably regardless of the operative site. ¼ × ¼ in neuropatties were poorly detected by neurosurgeons and radiologists in all three operative sites. Readers of various experience and background were similar in their ability to detect neuropatties under these conditions.

CONCLUSIONS

Under simulated operating room conditions and using currently available neuropatties and plain radiograph imaging technology, small ¼-in and ½-in neuropatties are poorly visible/detectable on digital images.

[Gossypiboma after abdominal surgery is a challenging clinical problem and a serious medicolegal issue]

INTRODUCTION

The term "gossypiboma" refers to a textile matrix surrounded by foreign body reaction. Gauze and surgical dressings are the most commonly retained materials after laparotomy.

AIM

To evaluate the incidence of abdominal gossypiboma, its causes and the preventive measures to reduce the frequence and morbimortality.

METHOD

Was conducted a literature review in Medline/Pubmed in english. The survey was about the last 10 years, selecting the headings: gossypiboma, textiloma, retained foreign body and abdominal surgery. Thirty articles were considered in this review.

RESULTS

The incidence of gossypiboma is underreported, mostly due to the legal implications of their detection but also because many patients remain asymptomatic. Occur in 1/1000 to 1/1500 of intra-abdominal operations. Clinical presentation is variable, and depends on the location of the foreign body and on the type of inflammatory reaction presented by the host. The recommended course of treatment is excision, which can be accomplished endoscopically, laparoscopically, or via the open route, and seeks to prevent the complications that lead to a high mortality rate. The most important approach is prevention. Preventive measures required include exploration of the abdominal cavity at the end of the procedure, use of textiles with radiopaque markers and a meticulous account of surgical materials.

CONCLUSION

Gossypiboma is a former medical-legal problem, whose incidence is apparently increasing. Therefore needs to be revised to take preventive measures in the operating room.

Retained surgical sponges, needles and instruments

INTRODUCTION

Retained sponges and instruments (RSI) due to surgery are a recognised medical 'never event' and have catastrophic implications for patients, healthcare professionals and medical care providers. The aim of this review was to elucidate the extent of the problem of RSI and to identify preventative strategies.

METHODS

A comprehensive literature search was performed on MEDLINE(®), Embase™, the Science Citation Index and Google™ Scholar for articles published in English between January 2000 and June 2012. Studies outlining the incidence, risk, management and attempts to prevent RSI following surgical intervention were retrieved.

RESULTS

The overall incidence of RSI is low although its incidence is substantially higher in operations performed on open cavities. Sponges are the most commonly retained item when compared with needles and instruments. Clinical presentation is varied, leading to avoidable morbidity, and the error is indefensible medicolegally. Risk factors include emergency operations, operations involving unexpected change in procedure, raised body mass index, and a failure to perform accurate sponge and instrument counts. The existing strategy for prevention is manual counting of sponges and instruments undertaken by surgical personnel. This, however, is fallible. Computer assisted counting of sponges using barcodes and gauze sponges tagged with a radiofrequency identification device aiding manual counting have been trialled recently, with success.

CONCLUSIONS

Vigilance among operating theatre personnel is paramount if RSI is to be prevented. Prospective multicentre trials to assess efficacy of new technologies aiding manual counting should be undertaken if this medical error is to be eliminated completely.