Russell Jones and Walker: Retained Surgical Instruments
I recently spotted this post on the Russell Jones and Walker blog about an individual who had surgery for cancer of the oesophagus (the pipe in your throat that is used to move food from the mouth to the stomach.) The procedure for the carcinoma involves removing the poor person’s oesophagus as well as parts of his stomach. Some very uncomfortable stuff comes next involving pulling whats left of the stomach up to whatevers left of the oesophagus which needs to be reformed.
This is a very intricate operation that requires some very skilled surgeons and is a seriously risky operation – all that was fine, I was able to stomach that, however – due to the large team that was required to perform such an operation, the swabs used during the procedure weren’t counted in properly and a medical swab was left in the abdominal cavity also known as Gossypiboma. As such the cancer-patient had to have his scar re-opened some time later on to remove the swab and continuing to render him unable to do anything. There were two medical teams involved in doing this operation, and thats where the problems arose.
Whether it is a problem with communication between the teams, or an issue with the system used for counting in and out swabs, that sounds like a nightmare thing to have happen, all this extremely skilled surgical work all a success just to have something left behind inside you. I continued my search about this sort of stuff and found that retained surgical instruments is actually horrifically higher than I would have thought. A study reported to the Annals of Surgery in 2008 that tool and sponge count mistakes happen in 12.5% of surgeries!
This case raised an interesting paradox – the admirable efforts of the surgeons carrying out a cutting edge and extraordinarily risky procedure juxtaposed with the basic error of failing to count swabs in and out.
-Iona Millais from RJ&W
Having a high body mass index (BMI) increases your risk of having something left behind in you as well, I guess just because theres more room in you to lose something. The University of California at San Francisco (USCF) have been using a bar-code system for surgeries which enables the nurses to pass the items through a hand scanner, due to having a barcode – this theoretically to remove the human-error possibility from surgeries and stop these really physically and emotionally painful things to happen to people already suffering from something or another. I’ve been unable to find anything more recent for it but according to the USCF in 2008, they’ve managed to go a year without any “unintended retained gauze of sponges” since commencing operation of the system.
The blogs by Russell Jones & Walker always manage to be interesting reads, even though this one made me cringe like none-other.