Skip to main content
Top
Published in: World Journal of Surgery 7/2011

Open Access 01-07-2011

Retained Surgical Items and Minimally Invasive Surgery

Author: Verna C. Gibbs

Published in: World Journal of Surgery | Issue 7/2011

Login to get access

Abstract

A retained surgical item is a surgical patient safety problem. Early reports have focused on the epidemiology of retained-item cases and the identification of patient risk factors for retention. We now know that retention has very little to do with patient characteristics and everything to do with operating room culture. It is a perception that minimally invasive procedures are safer with regard to the risk of retention. Minimally invasive surgery is still an operation where an incision is made and surgical tools are placed inside of patients, so these cases are not immune to the problem of inadvertent retention. Retained surgical items occur because of problems with multi-stakeholder operating room practices and problems in communication. The prevention of retained surgical items will therefore require practice change, knowledge, and shared information between all perioperative personnel.
Literature
6.
go back to reference Association of Perioperative Registered Nurses (2010) Recommended practices for prevention of retained surgical items. In: Perioperative standards and recommended practices. AORN, Denver, CO. http://www.aorn.org/psrp. Accessed 7 Nov 2010 Association of Perioperative Registered Nurses (2010) Recommended practices for prevention of retained surgical items. In: Perioperative standards and recommended practices. AORN, Denver, CO. http://​www.​aorn.​org/​psrp. Accessed 7 Nov 2010
7.
go back to reference Gibbs VC, Coakley FD, Reines HD (2007) Preventable errors in the operating room: retained foreign bodies after surgery–—part 1. Curr Probl Surg 44:281–337PubMedCrossRef Gibbs VC, Coakley FD, Reines HD (2007) Preventable errors in the operating room: retained foreign bodies after surgery–—part 1. Curr Probl Surg 44:281–337PubMedCrossRef
8.
go back to reference Zantvoord Y, van der Weiden RF, van Hooff MH (2008) Transmural migration of retained surgical sponges: a systematic review. Obstet Gynecol Surv 633:465–471CrossRef Zantvoord Y, van der Weiden RF, van Hooff MH (2008) Transmural migration of retained surgical sponges: a systematic review. Obstet Gynecol Surv 633:465–471CrossRef
9.
go back to reference Stawicki SP, Evans DC, Cipolla J et al (2009) Retained surgical foreign bodies: a comprehensive review of risks and preventive strategies. Scand J Surg 98:8–17PubMed Stawicki SP, Evans DC, Cipolla J et al (2009) Retained surgical foreign bodies: a comprehensive review of risks and preventive strategies. Scand J Surg 98:8–17PubMed
10.
11.
go back to reference Gawande AA, Studdert DM, Orav EJ et al (2003) Risk factors for retained instruments and sponges after surgery. N Engl J Med 348:229–235PubMedCrossRef Gawande AA, Studdert DM, Orav EJ et al (2003) Risk factors for retained instruments and sponges after surgery. N Engl J Med 348:229–235PubMedCrossRef
12.
go back to reference Lincourt AE, Harrell A, Cristiano J et al (2007) Retained foreign bodies after surgery. J Surg Res 138:170–174PubMedCrossRef Lincourt AE, Harrell A, Cristiano J et al (2007) Retained foreign bodies after surgery. J Surg Res 138:170–174PubMedCrossRef
13.
go back to reference Wan W, Le T, Riskin L, Macario A (2009) Improving safety in the operating room: a systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol 22:207–214PubMedCrossRef Wan W, Le T, Riskin L, Macario A (2009) Improving safety in the operating room: a systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol 22:207–214PubMedCrossRef
14.
go back to reference McIntyre LK, Jurkovich GJ, Gunn MD, Maier RV (2010) Gossypiboma: tales of lost sponges and lessons learned. Arch Surg 145:770–775PubMedCrossRef McIntyre LK, Jurkovich GJ, Gunn MD, Maier RV (2010) Gossypiboma: tales of lost sponges and lessons learned. Arch Surg 145:770–775PubMedCrossRef
15.
go back to reference Cima RR, Kollengode A, Storsveen AA et al (2009) A multidisciplinary team approach to retained foreign objects. Jt Comm J Qual Patient Saf 35:123–132PubMed Cima RR, Kollengode A, Storsveen AA et al (2009) A multidisciplinary team approach to retained foreign objects. Jt Comm J Qual Patient Saf 35:123–132PubMed
16.
go back to reference Haynes AB, Weiser TG, Berry WR, Lipsitz SR et al (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360:491–499PubMedCrossRef Haynes AB, Weiser TG, Berry WR, Lipsitz SR et al (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360:491–499PubMedCrossRef
18.
go back to reference Huntington TR, Klomp GR (1995) Retained staples as a cause of mechanical small-bowel obstruction. Surg Endosc 9:353–354PubMedCrossRef Huntington TR, Klomp GR (1995) Retained staples as a cause of mechanical small-bowel obstruction. Surg Endosc 9:353–354PubMedCrossRef
19.
go back to reference Mendez LE, Medina C (1997) Late complication of laparoscopic salpingoophorectomy: retained foreign body presenting as an acute abdomen. JSLS 1:79–81PubMed Mendez LE, Medina C (1997) Late complication of laparoscopic salpingoophorectomy: retained foreign body presenting as an acute abdomen. JSLS 1:79–81PubMed
20.
go back to reference Soyer P, Valleur P (2008) Retained surgical needle after laparoscopic sacrocolporectopexy. Clin Radiol 63:688–690PubMedCrossRef Soyer P, Valleur P (2008) Retained surgical needle after laparoscopic sacrocolporectopexy. Clin Radiol 63:688–690PubMedCrossRef
21.
go back to reference Cima RR, Kollengode A, Garnatz J et al (2008) Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg 207:80–87PubMedCrossRef Cima RR, Kollengode A, Garnatz J et al (2008) Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg 207:80–87PubMedCrossRef
22.
go back to reference Kiernan F, Joyce M, Byrnes CK et al (2008) Gossypiboma: a case report and review of the literature. Ir J Med Sci 177:389–391PubMedCrossRef Kiernan F, Joyce M, Byrnes CK et al (2008) Gossypiboma: a case report and review of the literature. Ir J Med Sci 177:389–391PubMedCrossRef
23.
go back to reference Riley R, Manias E, Polglase A (2006) Governing the surgical count through communication interactions: implications for patient safety. Qual Saf Health Care 15:369–374PubMedCrossRef Riley R, Manias E, Polglase A (2006) Governing the surgical count through communication interactions: implications for patient safety. Qual Saf Health Care 15:369–374PubMedCrossRef
24.
go back to reference Greenberg CC, Regenbogen SE, Lipsitz SR et al (2008) The frequency and significance of discrepancies in the surgical count. Ann Surg 248:337–341PubMedCrossRef Greenberg CC, Regenbogen SE, Lipsitz SR et al (2008) The frequency and significance of discrepancies in the surgical count. Ann Surg 248:337–341PubMedCrossRef
25.
go back to reference Jackson S, Brady S (2008) Counting difficulties: retained instruments, sponges and needles. AORN J 87:315–321PubMedCrossRef Jackson S, Brady S (2008) Counting difficulties: retained instruments, sponges and needles. AORN J 87:315–321PubMedCrossRef
26.
go back to reference Rowlands A, Steeves R (2010) Incorrect surgical counts: a qualitative analysis. AORN J 92:410–419PubMedCrossRef Rowlands A, Steeves R (2010) Incorrect surgical counts: a qualitative analysis. AORN J 92:410–419PubMedCrossRef
27.
go back to reference Gibbs VC (2005) Patient safety practices in the operating room: correct site surgery and nothing left behind. Surg Clin North Am 85:1307–1319PubMedCrossRef Gibbs VC (2005) Patient safety practices in the operating room: correct site surgery and nothing left behind. Surg Clin North Am 85:1307–1319PubMedCrossRef
28.
go back to reference Whang G, Mogel GT, Tsai J, Palmer SL (2009) Left behind:unintentionally retained surgically placed foreign bodies and how to reduce their incidence—pictorial review. AJR Am J Roentgenol 193:S79–S89PubMedCrossRef Whang G, Mogel GT, Tsai J, Palmer SL (2009) Left behind:unintentionally retained surgically placed foreign bodies and how to reduce their incidence—pictorial review. AJR Am J Roentgenol 193:S79–S89PubMedCrossRef
29.
go back to reference O’Connor AR, Coakley FV, Meng MV, Eberhardt S (2003) Imaging of retained surgical sponges in the abdomen and pelvis. AJR Am J Roentgenol 180:481–489PubMed O’Connor AR, Coakley FV, Meng MV, Eberhardt S (2003) Imaging of retained surgical sponges in the abdomen and pelvis. AJR Am J Roentgenol 180:481–489PubMed
30.
go back to reference Edel EM (2010) Increasing patient safety and surgical team communication by using a count/time out board. AORN J 92:420–424PubMedCrossRef Edel EM (2010) Increasing patient safety and surgical team communication by using a count/time out board. AORN J 92:420–424PubMedCrossRef
31.
go back to reference Kleinpeter SJ, Kline RC, Finan MA (1997) Retained surgical needle in the perineum. Report of a case with a novel method of search and rescue. J Reprod Med 42:303–305PubMed Kleinpeter SJ, Kline RC, Finan MA (1997) Retained surgical needle in the perineum. Report of a case with a novel method of search and rescue. J Reprod Med 42:303–305PubMed
32.
go back to reference Ozgun MT, Batukan C, Basbug M, Atakul T (2008) Management of a broken needle: retained in the first caesarean section, removed during the second abdominal delivery. J Obstet Gynaecol 28:653–655PubMedCrossRef Ozgun MT, Batukan C, Basbug M, Atakul T (2008) Management of a broken needle: retained in the first caesarean section, removed during the second abdominal delivery. J Obstet Gynaecol 28:653–655PubMedCrossRef
33.
go back to reference Karahasanoglu T, Unal E, Memisoglu K et al (2004) Laparoscopic removal of a retained surgical instrument. J Laparoendosc Adv Surg Tech 14:241–243 Karahasanoglu T, Unal E, Memisoglu K et al (2004) Laparoscopic removal of a retained surgical instrument. J Laparoendosc Adv Surg Tech 14:241–243
34.
go back to reference Rodrigues D, Perez NE, Hammer PM, Webber JD (2006) Laparoscopic removal of a retained intra-abdominal ribbon malleable retractor after 14 years. J Laparoendosc Adv Surg Tech 16:369–371CrossRef Rodrigues D, Perez NE, Hammer PM, Webber JD (2006) Laparoscopic removal of a retained intra-abdominal ribbon malleable retractor after 14 years. J Laparoendosc Adv Surg Tech 16:369–371CrossRef
35.
go back to reference Singh R, Mathur RK, Patidar S, Tapkire R (2004) Gossypiboma: its laparoscopic diagnosis and removal. Surg Laparosc Endosc Percutan Tech 14:304–305PubMedCrossRef Singh R, Mathur RK, Patidar S, Tapkire R (2004) Gossypiboma: its laparoscopic diagnosis and removal. Surg Laparosc Endosc Percutan Tech 14:304–305PubMedCrossRef
36.
go back to reference Ibrahim IM (1995) Retained surgical sponge. Surg Endosc 9:709–710PubMed Ibrahim IM (1995) Retained surgical sponge. Surg Endosc 9:709–710PubMed
37.
go back to reference Yuen PM, Rogers MS, Chang AM (1994) Laparoscopic removal of retained surgical gauze after vaginal hysterectomy. Eur J Obstet Gynecol Reprod Biol 57:209–210PubMedCrossRef Yuen PM, Rogers MS, Chang AM (1994) Laparoscopic removal of retained surgical gauze after vaginal hysterectomy. Eur J Obstet Gynecol Reprod Biol 57:209–210PubMedCrossRef
38.
go back to reference Childers JM, Caplinger P (1993) Laparoscopic retrieval of a retained surgical sponge: a case report. Surg Laparosc Endosc 3:135–138PubMed Childers JM, Caplinger P (1993) Laparoscopic retrieval of a retained surgical sponge: a case report. Surg Laparosc Endosc 3:135–138PubMed
39.
go back to reference Chin EH, Hazzan D, Herron DM, Salky B (2007) Laparoscopic retrieval of intraabdominal foreign bodies. Surg Endosc 21:1457PubMedCrossRef Chin EH, Hazzan D, Herron DM, Salky B (2007) Laparoscopic retrieval of intraabdominal foreign bodies. Surg Endosc 21:1457PubMedCrossRef
40.
go back to reference Bhansali M, Patankar S, Dobhada S (2006) Laparoscopic management of a retained heavily encrusted ureteral stent. Int J Urol 13:1141–1143PubMedCrossRef Bhansali M, Patankar S, Dobhada S (2006) Laparoscopic management of a retained heavily encrusted ureteral stent. Int J Urol 13:1141–1143PubMedCrossRef
41.
go back to reference Bharathan R, Dexter S, Hanson M (2009) Laparoscopic retrieval of retained Redivac drain fragment. J Obstet Gynaecol 29:263–264PubMedCrossRef Bharathan R, Dexter S, Hanson M (2009) Laparoscopic retrieval of retained Redivac drain fragment. J Obstet Gynaecol 29:263–264PubMedCrossRef
42.
go back to reference Dutta R, Kumar A, Das CJ, Jindal T (2010) Emergency video-assisted thoracoscopic foreign body removal and decortication of lung after chest trauma. Gen Thorac Cardiovasc Surg 58:155–158PubMedCrossRef Dutta R, Kumar A, Das CJ, Jindal T (2010) Emergency video-assisted thoracoscopic foreign body removal and decortication of lung after chest trauma. Gen Thorac Cardiovasc Surg 58:155–158PubMedCrossRef
46.
go back to reference Macario A, Morris D, Morris S (2006) Initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology. Arch Surg 141:659–662PubMedCrossRef Macario A, Morris D, Morris S (2006) Initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology. Arch Surg 141:659–662PubMedCrossRef
47.
go back to reference Greenberg CC, Diaz-Flores R, Lipsitz SR et al (2008) Bar-coding surgical sponges to improve safety: a randomized controlled trial. Ann Surg 247:612–616PubMedCrossRef Greenberg CC, Diaz-Flores R, Lipsitz SR et al (2008) Bar-coding surgical sponges to improve safety: a randomized controlled trial. Ann Surg 247:612–616PubMedCrossRef
48.
go back to reference Cima RR, Kollengode A, Clark J, Pool S et al. (2010) Evaluation and implementation of a bar-coded sponge counting system: impact on retained sponges after one year. Presented at American College of Surgeons Clinical Congress, Washington DC, October 3–7, 2010 Cima RR, Kollengode A, Clark J, Pool S et al. (2010) Evaluation and implementation of a bar-coded sponge counting system: impact on retained sponges after one year. Presented at American College of Surgeons Clinical Congress, Washington DC, October 3–7, 2010
49.
go back to reference Rupp CC, Kim HJ, Kagarise MJ (2010) Effectiveness of radio-frequency surgical detection system to promote patient patient safety during an operative procedure by improving the process by which doctors and nurses track sponges prior to wound closure. Presented at American College of Surgeons Clinical Congress, Washington DC, October 3–7, 2010 Rupp CC, Kim HJ, Kagarise MJ (2010) Effectiveness of radio-frequency surgical detection system to promote patient patient safety during an operative procedure by improving the process by which doctors and nurses track sponges prior to wound closure. Presented at American College of Surgeons Clinical Congress, Washington DC, October 3–7, 2010
50.
go back to reference Lauwers PR, Van Hee RH (2000) Intraperitoneal gossypibomas: the need to count sponges. World J Surg 24:521–527PubMedCrossRef Lauwers PR, Van Hee RH (2000) Intraperitoneal gossypibomas: the need to count sponges. World J Surg 24:521–527PubMedCrossRef
Metadata
Title
Retained Surgical Items and Minimally Invasive Surgery
Author
Verna C. Gibbs
Publication date
01-07-2011
Publisher
Springer-Verlag
Published in
World Journal of Surgery / Issue 7/2011
Print ISSN: 0364-2313
Electronic ISSN: 1432-2323
DOI
https://doi.org/10.1007/s00268-011-1060-4

Other articles of this Issue 7/2011

World Journal of Surgery 7/2011 Go to the issue