Cases & Commentaries

Did We Forget Something?

Commentary By Verna C. Gibbs, MD

The Case

A 76-year-old-man underwent right aorto-iliac
aneurysm repair. He developed postoperative fever, initially
attributed to ventilator-associated pneumonia. However, the fever
persisted and no definite source was identified. He received
multiple courses of broad-spectrum antibiotics over a 2-month

Several months after discharge, he presented to
another institution with recurrent fever, neurologic deficits, and
renal failure. He was diagnosed as having endocarditis with
Candida albicans on the basis of echocardiography and blood
culture results. Despite amphotericin and valve surgery, he died a
few weeks after this admission.

Autopsy revealed a surgical sponge in the abdomen
around the previous aorto-iliac repair. An abdominal computed
tomographic (CT) scan during the previous hospitalization had shown
a metallic clip in the area of the graft, but no other
abnormalities. The patient had not had any other surgeries.

The Commentary

This patient died of a nosocomial candida
infection months after an aorto-iliac aneurysm repair. The aneurysm
likely was repaired with a prosthetic bypass graft placed during
laparotomy. This graft may have become infected and, in addition to
the intravascular catheters and antibiotics, could have contributed
to the development of an overwhelming fungal infection complicated
by endocarditis. Of course, we cannot ignore the possibility that
the retained surgical sponge discovered at autopsy contributed to
the patient’s infection and eventual demise.

The technical term for "retained sponge" is
gossypiboma (from the Latin gossypium, for cotton and
the Swahili boma, for place of concealment), but discussions
of this issue generally include all types of retained
paraphernalia, including surgical instruments, needles, knife
blades, electrosurgical adapters, and safety pins. A recent
national profile of patient safety indicators in US hospitals
between 1995 and 2000 reported a steady decrease in the incidence
of foreign bodies left during procedures.(1) However, the true scope of this problem is unknown.
Another recent study from a malpractice database in Massachusetts
identified 54 patients with retained foreign bodies (roughly
two-thirds sponges and one-third instruments).(6) This number corresponds to a statewide event rate of 1
in 9,000 to 1 in 19,000 hospital-based surgical procedures. This
estimate implies that a typical large hospital produces at least
one case of a retained sponge or instrument each year.

A surgical sponge inadvertently left in the
abdominal cavity usually produces one of two responses. It can
induce an early foreign body response with an active inflammatory
component, whereby the body attempts to extrude the material. This
may lead to the development of fistulas. Alternatively, the sponge
can induce a fibrinous response that is more indolent, whereby the
body creates adhesions and encapsulates the sponge. Patients with
this response are at risk for pseudotumors and subsequent symptoms
related to obstruction or presence of a space-occupying
Retained sponges have been discovered days, months, and even years
after the original operation.(4,5)
Even retained surgical instruments have remained undetected for
surprising periods of time (though not necessarily without causing
symptoms). In late 2002, a Canadian woman set off an airport metal
detector and wand, which consistently sounded when placed near her
abdomen. She had experienced abdominal pain since surgery 4 months
earlier. Several days later, a plain x-ray of the abdomen revealed
a 12-inch long, 2-inch wide surgical retractor. Regardless of how
retained sponges or surgical instruments are discovered, when
recognized they must be removed.(6)

Surgical teams have used sponge, sharp, and
instrument counts as protection against this problem for decades.
Four separate counts have been recommended: the first when the
instruments are set up or sponges unpackaged, a second before
surgery begins, a third as closure begins, and the final count
performed during subcuticular or skin closure. The purpose of such
protocols is that discrepancies at any stage are pursued with
repeat counts and, if the discrepancy persists, steps are taken to
locate any unaccounted for items. While the practice of sponge
counts is a time-honored, simple preventive measure, it is heavily
dependent on human performance practices and is thus subject to
human error.(7)
Anyone who has ever had to recount a pile of coins will recognize
the potential problem with this approach. If the "double-check"
doesn’t produce the expected number, but a recount does, one
simply stops there—ignoring the possibility that the previous
discrepancy was correct and that the recount was in error.

What can be done to prevent this problem?
Incorrect counts and incorrect "correct" counts should trigger an
adjunctive procedure, such as a portable intraoperative radiograph
to detect the presence of the "miscounted" object.(8) However, these additional methods are not universally
applied, nor are they failure proof. All laparotomy pads and
surgical sponges commercially manufactured in the US have a
radio-opaque tail or stripe sewn into the sponge. Sponges placed on
the operative field when the operative site is open, and especially
those inserted into the thoracic or abdominal cavity, should be
radiographically detectable. In the present case, a CT scan was
obtained at the time of the initial hospitalization, but the
foreign body was not detected.(9,10)
The fact that the sponge was not detected may mean one of two
things: either the radiologists "missed" the sponge (although the
radio-opaque markers used in modern sponges are generally quite
obvious [Figure 1 and Figure 2]); or a non-detectable sponge was used at the
time of the operation.

Was this patient at high risk for retention of a
foreign body after his operation? We have no information about
whether sponge counts were performed in this case. A recent
retrospective case-control study of medical records associated with
claims filed between 1985 and 2001 with a large malpractice insurer
in Massachusetts found that patients with retained foreign bodies
were more likely to have had emergency surgery, an unexpected
change in surgical procedure, or a higher mean body-mass index, and
were less likely to have had sponge counts performed at the time of
the operation.(2) In
this study, failure to perform or complete counts generally
occurred in the setting of emergency procedures. Another claims
study revealed that in 10% of cases where retained sponges were
found, no sponge counts had been performed.(11) It is sobering that so many cases of retained sponges
seem to reflect the failure to perform the main strategy for

Retained sponges and instruments remain a
disturbingly common problem, and current preventive practices fail
due to human-related factors. Surgeons use non-radiographically
detectable sponges, counts are not performed, and when they are
performed and errors occur, backup detection systems are not
systematically employed. Operating room training and team
management skill development may be necessary here (eg, institution
of a "time-out for the count" or mandatory intraoperative x-rays
for miscounts). Changes to surgical practice and behavior also
appear indicated, and new opportunities for technological
applications may emerge. Bar-coding or impregnating sponges with
detectable sensors would be new ways to improve an old practice.
The critical question is not "Was the count correct?" It is "Is
there a sponge or instrument in the patient?" Unfortunately, we
have yet to identify the best way to answer this question.

Verna C. Gibbs,
Department of Surgery
University of California, San Francisco


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4. Crossen HS, Crossen DF. Foreign bodies left in
the abdomen. St. Louis, Missouri: The C.V. Mosby company; 1940.

5. Gonzalez-Ojeda A, Rodriguez-Alcantar DA,
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6. Ibrahim IM. Retained surgical sponge. Surg
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7. Gibbs VC, Auerbach AD. The retained surgical
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Making health care safer: a critical analysis of patient safety
practices. Rockville, MD: Agency for Healthcare Research and
Quality; 2001:255-7. AHRQ publication 01-E058. Evidence
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[ go to
related site

8. Reno D, Lobb J. Recommended practices for
sponge, sharp, and instrument counts. AORN Recommended Practices
Committee. In: 2000 standards, recommended practices and
guidelines: with official AORN statements. 1st ed. Denver,
Colorado: Association of operating room nurses; 2000:213-219.

9. Scott WW, Beall DP, Wheeler PS. The retained
intrapericardial sponge: value of the lateral chest radiograph. Am
J Roentgenol.1998;171:595-597.[ go to PubMed ]

10. Choi BI, Kim SH, Yu ES, Chung HS, Han MC, Kim
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11. Kaiser CW, Friedman S, Spurling KP, Slowick
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12. O´Connor AR, Coakley FV, Meng MV,
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Figure 1. Photograph of a 4 x 4 inch surgical
sponge. The interwoven radio-opaque marker is visible

Reprinted with permission from the American
Journal of Roentgenology. (12)

Figure 2. Intra-operative radiograph performed
because of an incorrect sponge count in a woman undergoing a
urethral suspension (not the present case). The radio-opaque marker
(arrow) of a 4 x 4 inch sponge is visible in the pelvis. The sponge
was removed before closure.

Reprinted with permission from the American
Journal of Roentgenology. (12)