Retained surgical items

RSI Fundamentals - The Unwanted Souvenirs

• Definition: Iatrogenic failure to remove all surgical equipment after a procedure. Most common in abdominal/pelvic and thoracic surgeries.
• Common Items:
  • Surgical sponges (gossypiboma) are the most frequent (~70%).
  • Instruments (clamps, retractors), needles, and other small items.
• Major Risk Factors:
  • Emergency surgery or unexpected change in procedure.
  • Prolonged duration, multiple teams.
  • High patient BMI.
  • Inaccurate surgical count.
• Clinical Presentation:
  • Acute: Post-op pain, fever, infection, abscess, bowel obstruction, or sepsis.
  • Chronic: Often asymptomatic for years; may present with vague pain, mass effect, or fistula formation.

⭐ Gossypiboma: A retained surgical sponge, which can elicit two types of foreign body reactions: an aseptic fibrinous response leading to encapsulation and adhesions, or an exudative reaction forming an abscess.

Risk & Presentation - Red Flags & Clues

• Key Risk Factors

  • Emergency surgery or unexpected change in procedure
  • Prolonged duration, high patient BMI, major blood loss
  • Multiple surgical teams or staff turnovers during the case
  • ⚠️ Incorrect or reconciled surgical count

• Clinical Presentation

  • Acute (Early Post-op):
    • Unexplained fever, sepsis, abscess formation
    • Wound infection, fistula, or intestinal obstruction
  • Chronic (Months to Years):
    • Often asymptomatic; may be an incidental finding
    • Vague abdominal pain, palpable mass (gossypiboma/textiloma)
    • Can mimic a soft tissue tumor on imaging

⭐ The most commonly retained item is a surgical sponge. Sponges without a radiopaque marker can be missed on X-ray, often appearing as a non-specific soft tissue mass with or without calcification.

Diagnosis & Management - Find and Extract

• Initial Step: Maintain a high index of suspicion in any post-op patient with unexplained pain, fever, or delayed recovery.

• Imaging: The primary diagnostic tool.

  • Plain X-ray (AP & Lateral): First-line for radiopaque objects (instruments, needles, sponges with radiopaque markers).
  • CT Scan: Gold standard. Highest sensitivity and specificity. Can identify non-radiopaque items (e.g., gossypiboma) and evaluate for complications like abscesses or fistulas.
  • Ultrasound: May show a well-defined mass with strong posterior acoustic shadowing.

• Management Algorithm: Prompt removal is mandatory.

⭐ Gossypiboma: A retained surgical sponge, which can create a foreign body granuloma. On CT, it may present as a spongiform mass with gas bubbles, mimicking an abscess or tumor.

High-Yield Points - ⚡ Biggest Takeaways

• The most common retained surgical item is a surgical sponge (gossypiboma).
• Key risk factors include emergency surgery, high BMI, unplanned procedural changes, and multiple surgical teams.
• Presentation varies from asymptomatic for years to acute pain, infection, or obstruction.
• X-ray is the initial imaging to find the radiopaque marker; CT scan is most sensitive.
• Definitive management is surgical removal of the retained body.
• Prevention relies on strict counting protocols and technologies like RFID.