Retained Surgical Items: Surgical Tools Left Inside Patients
Every year in the United States, at least 1,500 to 2,000 retained surgical items (RSIs) are discovered in the bodies of postsurgical patients (1). Retained surgical items, also known as retained surgical foreign bodies (RFBs), include instruments, needles, sponges, and other materials used in a prior surgery. RSIs threaten the safety and survival of patients, with around 70% sustaining minor complications and 15% suffering severe harm (2). Surgical instruments, like forceps, can puncture organs and cause immediate damage; more frequently, however, cotton surgical materials, or “sponges,” are left behind, resulting in a gossypiboma that can cause obstruction, infection, sepsis, and death (3). Most commonly occurring in the abdominal, thoracic and pelvic cavities (4), RSIs present a serious threat to patient safety and typically require reoperation to be removed (2-4). However, with the right operating room culture and perioperative procedures, the occurrence of RSIs can be significantly minimized.
The risk factors associated with RSIs fall into two categories: the characteristics of the operation and perioperative procedure errors. First, although little research has been conducted on surgical errors such as RSIs, the current literature suggests positive associations between RSI occurrences and emergency operations, prolonged procedures, and multiple operative teams (1, 2). However, perioperative procedure errors more commonly resulted in RSIs, including incorrect instrument and sponge counts and poor communication (1, 3). In roughly 80% of RSI cases involving sponges — the most common RSI — the sponge count performed at the end of the surgery was erroneously called correct (4, 5). Incomplete body cavity examinations and incorrect instrument counts often stem from communication and cooperation problems between the surgeons and nurses, i.e. failing to work together to rectify an incorrect count or the dismissal of requests to look for missing items (1, 4). Moreover, some studies suggest that the communication errors that result in RSIs originate from the operating room “culture,” or the social ecosystem involving relationships between members of a surgical team (1, 3, 4).
Like other surgical errors, RSI cases are completely preventable. Hospitals around the country that have implemented perioperative and systematic strategies to prevent the retention of any surgical object have significantly decreased RSI cases (6). Using only radiopaque materials — such as gauze pads with x-ray markers — intracorporeally and performing x-rays to identify any missing materials before closing the incision are a vital preventative method that can take place perioperatively (1, 4, 7). Creating a standardized and robust counting system for each type of surgical material, often by using designated dry-erase boards or discrete plastic holders, constitutes one of the most successful preventative techniques (1, 4). Additionally, as some researchers argue that the communication errors that result in RSIs are systematic, changing the “culture” of the operating room is often necessitated (1). Encouraging communication and collaboration between all members of the surgical team remains one of the most important methods needed to reduce the incidence of retained surgical items.
References
1: Gibbs, V. 2011. Retained surgical items and minimally invasive surgery. World Journal of Surgery, vol. 35. DOI: 10.1007/s00268-011-1060-4.
2: Steelman, V., Shaw, C., Shine, L. and Hardy-Fairbanks, A. 2018. Retained surgical sponges: a descriptive study of 319 occurrences and contributing factors from 2012 to 2017. Patient Safety in Surgery, vol. 12. DOI: 10.1186/s13037-018-0166-0.
3: Feldman, D. 2011. Prevention of retained surgical items. Mount Sinai Journal of Medicine, vol. 78. DOI: 10.1002/msj.20299.
4: Gibbs, V., Coakley, F. and Reines, H. Preventable errors in the operating room: retained foreign bodies after surgery — part I. 2007. Current Problems in Surgery, vol 44. DOI: 10.1067/j.cpsurg.2007.03.002.
5: Kaiser, C., Friedman, S., Spurling, K., Slowick, T. and Kaiser, H. 1996. The retained surgical sponge. Annals of Surgery, vol. 224. DOI: 10.1097/00000658-199607000-00012.
6: Weprin, S., Crocerossa, F., Meyer, D., Maddra, K., Valancy, D., Osardu, R., Kang, H., Moore, R., Carbonara, U., Kim, F. and Autorino, R. 2021. Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review. Patient Safety in Surgery, vol. 15. DOI: 10.1186/s13037-021-00297-3.
7: Hariharan, D. and Lobo, D. 2013. Retained surgical sponges, needles and instruments. Annals of the Royal College of Surgeons of England, vol. 95. DOI: 10.1308/003588413X13511609957218.