Pulsatile lavage irrigator tip, a rare radiolucent retained foreign body in the pelvis: a case report
© Connelly and Archdeacon; licensee BioMed Central Ltd. 2011
Received: 23 May 2011
Accepted: 28 May 2011
Published: 28 May 2011
Retained foreign bodies after surgery have the potential to cause serious medical complications for patients and bring fourth serious medico-legal consequences for surgeons and hospitals. Standard operating room protocols have been adopted to reduce the occurrence of the most common retained foreign bodies. Despite these precautions, radiolucent objects and uncounted components/pieces of instruments are at risk to be retained in the surgical wound. We report the unusual case of a retained plastic pulsatile lavage irrigator tip in the surgical wound during acetabulum fracture fixation, which was subsequently identified on routine postoperative computed tomography. Revision surgery was required in order to remove the retained object, and the patient had no further complications.
Keywordsretained foreign body radiolucent pulsatile lavage surgical complication patient safety
Retained foreign bodies are rare but serious events in patient safety. There is abundant surgical literature regarding the most common retained foreign bodies: surgical gauze, sponges and metallic instruments [1–4]. As a precaution, preoperative and postoperative instrument, sponge and needle counts are standard procedure in the operating suite. Additionally, metallic threading in surgical sponges and routine intraoperative and postoperative imaging are safeguards to prevent retained objects in the surgical wound. However, pieces of instruments that break-off or come apart unnoticed are at risk to be retained in the wound. Furthermore, retained radiolucent objects are not detectable on plain radiographs and may escape detection if patients do not become symptomatic or if advanced imaging is not obtained. We report a case involving a retained pulsatile lavage irrigator tip in the surgical wound after acetabulum fracture fixation.
A sixty-four year old man was transferred to our trauma center from an outside hospital after sustaining a left acetabulum fracture in a fall on ice. The patient was stable on admission and complained of severe left hip pain, without loss or change in sensation. Examination revealed no gross hip deformity; however, left hip pain was elicited on log roll. A neurovascular exam revealed no deficits preoperatively. No other injuries were detected.
Radiographs and preoperative computed tomography (CT) scan demonstrated a left anterior column, posterior hemitransverse acetabulum fracture , OTA 62-B3.2  and an ipsilateral nondisplaced inferior pubic ramus fracture. The patient was placed in balanced skeletal traction in the emergency room. The risks and benefits of surgery, as well as alternative treatments, were discussed with the patient and consent for surgery was obtained. The patient was evaluated by the medicine team and cleared preoperatively.
Non-textile radiolucent retained foreign bodies after surgery have been rarely reported in the literature . Unintentional retained foreign bodies after surgery have the potential to cause serious medical complications for patients and bring fourth serious medico-legal consequences for surgeons and hospitals [1, 3, 4] and are considered "never events" by the National Quality Forum (NQF) and Centers for Medicare and Medicaid Services (CMS) [8, 9]. While strict enforcement of operating room safeguards minimizes the risk of medical errors, the inherent risks of surgery, including the placement of foreign material inside the body, prevents complete elimination of this possibility. It is thought that approximately 1,500 cases of unintentional retained foreign bodies occur in the United States each year [1, 2, 4].
Although the majority of iatrogenic retained foreign bodies are detected soon after surgery [1, 4] others are not detected until many years later . Radiolucent foreign bodies are a particular challenge for detection and require a high index of suspicion. Prevention through instrument inspection and accounting for all radiolucent components used in surgery are the best safeguards to avoid these errors.
Unintentional retained foreign objects after surgery may be asymptomatic or lead to complications including pain, infection, or abscess formation. Occasionally foreign body migration has been noted to result in substantial morbidity [10, 11] and even death . Fortunately, the foreign body in this case was removed without further complication.
While we hope that eliminating this practice of instrument modification will prevent any similar events in the future, we have also instituted several other preventive measures. Because the tip was not a recognized risk for dislodgement and becoming a separate piece, it was not individualized as part of the operative count. Therefore, the second identified root cause issue regards adding lavage nozzle tips to the operative count as an early warning. Additionally, thorough wound inspections will be completed with an increased awareness for the risk of retained instrument components/pieces and nozzle tip dislodgement.
Furthermore, a higher level of suspicion for radiolucent retained foreign bodies will be considered. Undetectable on intraoperative and immediate postoperative imaging, retained radiolucent objects may not be discovered unless the patient becomes symptomatic or unless advanced imaging is ordered. In this case, the diagnosis was not suspected until a discrepancy was noticed on the routine postoperative CT scan. Thus, the incompatibility of radiolucent foreign bodies with standard early detection methods contributed to delayed detection and a return to the operative suite.
Finally, there should be heightened awareness for potential retained foreign bodies with surgical procedures involving large body cavities (abdomen, pelvis, chest)  or patients with elevated body mass indices (BMI) . This case included both risk factors, a patient with a BMI of 37.5 and large pelvic wound bed.
Although standard operating room counts, wound explorations and careful intraoperative imaging prevent most unintentional retained foreign bodies, radiolucent foreign bodies are a particular challenge for detection and require a high index of suspicion. We present this case to share awareness for potential pulsatile lavage nozzle tip dislodgement and advise that instrument modification may sacrifice connection integrity. We suggest that particular attention should be paid while utilizing instruments or equipment with radiolucent components in surgery and that instrument components should be individually counted items. We reiterate the importance of standard operating room procedures: time-outs, instrument and sponge counts, wound inspection and careful assessment of intraoperative/postoperative imaging.
Radiolucent retained foreign bodies are not easily detected and there is potential for uncounted components to become unintended retained foreign bodies. When using powered lavage systems we advise against equipment modification. We also advocate the addition of the nozzle tip to the countable items list and recommend thorough inspection and palpation of surgical wounds immediately prior to closure.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ: Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003, 348 (3): 229-235. 10.1056/NEJMsa021721.View ArticlePubMedGoogle Scholar
- Schonleben K, Strobel A, Schonleben F, Hoffman A: Retained foreign bodies from the surgical point of view. Chirurg. 2007, 78: 7-12. 10.1007/s00104-006-1271-7.View ArticlePubMedGoogle Scholar
- Stawicki SP, Evans DC, Cipolla J, Seamon MJ, Lukaszczyk JJ, Prosciak MP, Torigian DA, Doraiswamy VA, Yazzie NP, Gunter OL, Steinberg SM: Retained surgical foreign bodies: a comprehensive review of risks and preventive strategies. Scandinavian Journal of Surgery. 2009, 98: 8-17.PubMedGoogle Scholar
- Whang G, Mogel GT, Tsai J, Palmer SL: Left behind: unintentionally retained surgically placed foreign bodies and how to reduce their incidence--pictorial review. Am J Roentgenol. 2009, 193 (Suppl 6): 79-89.View ArticleGoogle Scholar
- Letournel E, Judet R: Fractures of the Acetabulum. 1981, New York: SpringerView ArticleGoogle Scholar
- Orthopaedic Trauma Association: Fracture and dislocation classification compendium. J Orthop Trauma. 2007, 21 (Suppl 10): 64-67.Google Scholar
- Archdeacon MT, Kazemi N, Guy P, Sagi HC: The modified stoppa approach for acetabular fracture. J Am Acad Orthop Surg. 2001, 19: 170-175.Google Scholar
- Milstein A: Ending extra payment for "never events"--stronger incentives for patients' safety. N Engl J Med. 2009, 360: 2388-2390. 10.1056/NEJMp0809125.View ArticlePubMedGoogle Scholar
- Rosenthal MB: Nonpayment for performance? medicare's new reimbursement rule. N Engl J Med. 2007, 357: 1573-1575. 10.1056/NEJMp078184.View ArticlePubMedGoogle Scholar
- Massad M, Slim MS: Intravascular missile embolization in childhood: report of a case, literature review, and recommendations for management. J Pediatr Surg. 1990, 25: 1292-1294. 10.1016/0022-3468(90)90536-I.View ArticlePubMedGoogle Scholar
- Goodsett JR, Pahl AC, Glaspy JN, Schapira MM: Kirschner wire embolization to the heart: an unusual cause of pericardial tamponade. Chest. 1999, 115: 291-293. 10.1378/chest.115.1.291.View ArticlePubMedGoogle Scholar
- Freund E, Nachman R, Gips H, Hiss J: Migration of a Kirschner wire used in the fixation of a subcapital humeral fracture, causing cardiac tamponade: case report and review of literature. Am J Forensic Med Pathol. 2007, 28: 155-156. 10.1097/PAF.0b013e31806195a1.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.