Endoscopic removal of a retained surgical sponge in a young Syrian refugee after Caesarean section: a case report with discussion of cultural and political consequences
© The Author(s). 2016
Received: 20 July 2016
Accepted: 13 October 2016
Published: 26 October 2016
Inadvertently retained sponges and instruments still constitute a major but preventable complication in surgery. Given the high geographic mobility of patients, the fluctuation of physician-patient contact, and communication problems due to language barriers, the conscientious use of structured safety protocols in clinical routine is an essential aspect of quality in health care.
We report the case of a 24-year-old refugee from Syria who presented at our gynecological outpatient department with a tumor in the lower abdomen, suspected to be a lump in the ovary or the uterus. Language barriers hindered exact recording of the patient’s medical history. We knew she had undergone three Caesarean sections several years ago. The diagnostic laparoscopy unexpectedly revealed a tumor suspected to be a retained surgical sponge. The lesion was removed completely and the patient discharged from the clinic five days later.
In ambiguous cases, the diagnostic and therapeutic potential of minimally invasive surgery ensures safe and effective treatment of the patient, a short hospital stay, and low rates of complications. Especially in cases of language and/or cultural barriers, structured safety protocols should be a part of clinical routine in order to prevent unnecessary complications.
Symptoms and differential diagnosis of inadvertently retained sponges and instruments
Clinical appearance of inadvertently retained sponges and instruments
Infection at the surgical site with fever, pain and sepsis
Wound infection of other origin, pneumonia, infection of the catheter, urinary tract infection
Acute pain, becoming more extensive, often accompanied by fever and infection
Wound pain, postoperative hemorrhage
Chronic pain persisting after the intervention without any other correlate
Adhesions, nerve damage
Unspecific tumor mass around the surgical site
Coagulum, tumor of other origin, adhesions
Fistulization with suspected material of no natural origin
Fistulization because of disturbed wound healing, infection, or fistulization due to other causes
Obstruction because of fistulization or swelling of the retained object
Tumor of other origin, adhesions
Gastrointestinal, vaginal, or urinary hemorrhage because of fistulization
Prevention of retained surgical sponges and instruments is a crucial step in quality and safety management. Prevention strategies include standardized counting protocols, radiographic screening, counting devices and detection devices. Sponges or instruments tend to be left behind despite the fact that counting protocols are a part of nearly all surgical procedures. In as many as 88 % of cases of retained foreign surgical objects, the sponge and instrument count was reported to be correct [1, 7–9].
We report the case of a 24-year-old refugee from an Arabian country who presented at our gynecological outpatient department with a tumor in the lower abdomen that looked like a retained surgical sponge on explorative laparoscopy. We discuss prevention strategies for such incidents, especially in current times of geographic mobility, fluctuation of physician-patient contact, and growing communication problems due to language barriers, given the large numbers of refugees and immigrants in Western countries.
A 24-year-old woman presented at our gynecological outpatient department with a tumor in the lower abdomen, suspected to be a lump in the ovary or the uterus. The tumor was discovered by her gynecologist at a routine transvaginal ultrasound investigation. The woman was a refugee from Syria. Communication was hindered by language differences and our inability to obtain an adequate translator.
Her medical history included pain, fever, weight loss, and menstrual disorders. She had undergone three Caesarean sections, the last of which had been performed two years ago in a European country. Further details of her medical history were not known.
The patient was given preventive intravenous antibiotic treatment with cefuroxim and metronidazol postoperatively for five days, based on the likelihood of infection of the surgical sponge. After completion of antibiotic treatment she was discharged from the hospital on the sixth day, with no symptoms or restrictions.
Inadvertently retained sponges and instruments constitute a rare medical complication. When it does happen, the event may cause severe harm to the patient as well as professional and medico-legal consequences for the physician and the hospital . In a current study up to 43 % of surgeons reported that they had already left foreign bodies in a patient after a surgical procedure and 73 % asserted the removal of one or more foreign bodies. For the patient it may result in morbidity, acute or chronic pain, infection, misdiagnosis, and several subsequent operations . Often forgotten and underrated are the psychological, emotional, and financial problems for the patient. Consequences for the physician or the hospital include the costs of subsequent treatment, compensation, legal proceedings, a negative public image, and loss of confidence on the part of patients.
Prevention strategies should be used in any medical intervention in order to avoid these grave consequences. This includes structured counting protocols, radiographic screening, counting devices, and detection devices .
Structured counting protocols are the easiest means of preventing retention of a foreign body and should be a part of any medical intervention. A standardized counting protocol should include an initial count before the start of the procedure, a count before closure of a cavity within a cavity, a count when wound closure starts, and a final count at the end of the procedure . Nevertheless, since counting is done by individuals, human error is possible. This is the reason why inadvertently retained sponges or instruments are found in as many as 88 % of operations in which the sponge and instrument count was declared to be correct . Reliable prevention and detection procedures are needed to avoid such human error, especially in operations involving a high risk for a retained sponge or instrument. These high risk situations include emergency surgeries, unexpected changes in surgical procedures or personnel, and patients with a high body mass index .
Programs that included educating the perioperative staff members, standardizing count practices, formally reviewing every reported count discrepancy with the nursing team, and reviewing and revising the count policy for prevention of retained surgical items could show a reduction of the number of incorrect counts and count discrepancies by 50 % .
Radiographic screening is a tested additional procedure for such prevention and detection . It should be performed whenever counting is declared incomplete. Routine radiographic screening protocols after surgery have been tested in the clinical setting, and were found to be highly sensitive in detecting retained sponges and instruments. The disadvantages of routine screening include the need for high-resolution survey radiographs, high costs, and radiation exposure . Other strategies such as counting and detection devices have been tested, but not incorporated into clinical routine because of their cost as well as the time and the effort involved. Nevertheless, they are promising methods to enhance patient safety and welfare . Future investigations will show whether these systems can be integrated into clinical routine.
The patient we reported on in this article is a refugee from Syria who had travelled through many countries on her way to Germany. The last Caesarean section was performed in a developed country. We had no information about the operation and the potential complications that could have led to the retained sponge. We performed diagnostic laparoscopy because of a suspected malignancy of the ovary or pseudocystic lesions as a consequence of the preceding Caesarean sections. No further imaging diagnostics were carried out because laparoscopy represents an outstanding diagnostic and therapeutic tool in cases of uncertain gynecological lesions. Nevertheless, other imaging procedures, such as computer tomography or magnetic resonance imaging, can help to diagnose a retained surgical sponge. Especially in this case, complicated by language barrier and an inadequate history, laparoscopy offered a safe, effective treatment with a shorter hospital stay. Given the mobility of patients in current times and the fact that many are lost to follow-up, diagnostic and therapeutic procedures must provide maximum safety and ensure the patient’s welfare to the greatest possible extent.
The authors declare that they received no financial support for the study.
Availability of data and materials
All data generated or analyzed during the study have been included in this published article.
JA wrote the manuscript and assessed the patient’s data. MK contributed significantly to the assessment of the patient’s history and her care. MM performed the histological examination of the material retrieved from the operation. UP contributed to the assessment of the patient’s history and her care. NM contributed significantly in terms of writing the manuscript and discussing the data. IA contributed significantly to writing the manuscript and assessing the patient’s data. All authors read and approved the final manuscript.
The authors declare that they have no competing interests
Consent for publication
Consent was obtained from the patient to publish this case as a report.
Ethics approval and consent to participate
This case report has been performed in accordance with the Declaration of Helsinki. Approval was obtained from the ethics committee of the Christian Albrechts University in Kiel.
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- Regenbogen SE, Greenberg CC, Resch SC, Kollengode A, Cima RR, Zinner MJ, Gawande AA. Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness. Surgery. 2009;145(5):527–35.View ArticlePubMedPubMed CentralGoogle Scholar
- 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):229–35.View ArticlePubMedGoogle Scholar
- Dossett LA, Dittus RS, Speroff T, May AK, Cotton BA. Cost-effectiveness of routine radiographs after emergent open cavity operations. Surgery. 2008;144(2):317–21.View ArticlePubMedGoogle Scholar
- Yildirim T, Parlakgumus A, Yildirim S. Diagnosis and management of retained foreign objects. J Coll Physicians Surg Pak. 2015;25(5):367–71.PubMedGoogle Scholar
- Birolini DV, Rasslan S, Utiyama EM. Unintentionally retained foreign bodies after surgical procedures. Analysis of 4547 cases. Rev Col Bras Cir. 2016;43(1):12–7.View ArticlePubMedGoogle Scholar
- Rappaport W, Haynes K. The retained surgical sponge following intra-abdominal surgery. A continuing problem. Arch Surg. 1990;125(3):405–7.View ArticlePubMedGoogle Scholar
- Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps C. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg. 2008;207(1):80–7.View ArticlePubMedGoogle Scholar
- Lincourt AE, Harrell A, Cristiano J, Sechrist C, Kercher K, Heniford BT. Retained foreign bodies after surgery. J Surg Res. 2007;138(2):170–4.View ArticlePubMedGoogle Scholar
- Kaiser CW, Friedman S, Spurling KP, Slowick T, Kaiser HA. The retained surgical sponge. Ann Surg. 1996;224(1):79–84.View ArticlePubMedPubMed CentralGoogle Scholar
- Alkatout I. Communicative and ethical aspects of physician-patient relationship in extreme situations. Wien Med Wochenschr. 2015;165(23–24):491–8.View ArticlePubMedGoogle Scholar
- Wan W, Le T, Riskin L, Macario A. Improving safety in the operating room: a systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol. 2009;22(2):207–14.View ArticlePubMedGoogle Scholar
- Byron B, Bonnie D, Terri L, Mary JO, Lisa S, Cynthia S, Sharon A, Van W, Amber W. Guidelines for prevention of retained surgical items. In: Guidelines for perioperative Practice. AORN, Inc.; 2015. p. 347–63. http://www.aornstandards.org/site/subscriptions/accessterms.xhtml.
- Norton EK, Martin C, Micheli AJ. Patients count on it: an initiative to reduce incorrect counts and prevent retained surgical items. AORN J. 2012;95(1):109–21.View ArticlePubMedGoogle Scholar