Two surgical sponges were left in a woman’s abdomen for at least six years, according to a new report in the New England Journal of Medicine.
The unidentified 42-year-old went to a primary care clinic in Japan, saying she had experienced bloating for three years, according to the report, published on Wednesday.
A CT scan of her abdomen showed two masses with strings attached to them. A surgical procedure called a laparotomy confirmed the presence of two gauze sponges that had become attached to the patient’s omentum, a fold of tissue that connects the stomach with other abdominal structures and colon.
The authors concluded that the sponges were probably left after a cesarean section. The woman had had two cesarean sections, one six years earlier and one nine years earlier, but it is unclear which one resulted in the retained items. She did not have any other abdominal or pelvic surgeries, according Dr. Takeshi Kondo, a general medicine physician at Chiba University Hospital and a lead author of the report.
“The patient received two C-sections in the same gynecologic clinic,” Kondo said. “Although she met the surgeon and told him (about) the retained foreign bodies, the surgeon did not admit his mistake on the grounds of lack of clear proof.”
After the removal of the sponges, the patient’s symptoms resolved, and she was discharged five days later.
Many, but not all, Japanese hospitals and clinics perform imaging of the abdomen before closing a surgical wound to ensure that no items are left inside the patient, Kondo said.
Otherwise known as retained surgical items, these objects can cause localised pain, discomfort and bloating. In some cases, they can lead to sepsis or death.
“In two-thirds of these cases, there were serious consequences, whether that’s infection or even death,” said Dr Atul Gawande, a practicing surgeon at Brigham and Women’s Hospital and director of Ariadne Labs in Boston. “In one case, a small sponge was left inside the brain of a patient that we studied, and the patient ended up having an infection and ultimately died.”
The mistakes are considered so egregious that they are often referred to as “never events,” a category of surgical errors that includes operating on the wrong site or on the wrong patient.
“The sponges are part of a process that occurs where there’s verification that not only sponges but all instruments that are used are accounted for at the end of the procedure,” added Dr Ana McKee, executive vice president and chief medical officer of the Joint CommissionMcKee added.
“There’s a known rate of human error, and actually it’s pretty impressive that we have it as low as we do,” he added. “What we found doing research on 60 of these cases is that the team virtually always has followed the protocol correctly, and yet it still occurs.”
Distractions during surgery can serve as one source of human error, Dr McKee said.
“If there’s music going on or side conversations or someone is on the phone, that does not meet the spirit of the Universal Protocol,” she said.
Retained surgical items are much more common after an emergency surgery or an unplanned change in operation, according to Dr Gawande.