Forgotten Surgical Tools 'Uncommon but Dangerous'
By DENISE GRADY
Published: January 21, 2003
As soon as they saw her patient's C.T. scan last June, radiologists paged Dr. Anne Dembitzer, an internist at the Veterans Affairs hospital in Palo Alto, Calif.
''They were really shocked,'' Dr. Dembitzer said. ''They said, 'You have to come down here and see what we found.' ''
The patient, a 59-year-old man, had consulted Dr. Dembitzer because of nausea and pain in his abdomen.
''I had no idea I was going to find this,'' Dr. Dembitzer said.
''This'' was a six-inch metal surgical clamp, buried deep in the man's abdomen, partly behind his liver. Doctors at another hospital, not part of the veterans system, had inadvertently left it behind after surgery.
Even more shocking, this was the second clamp to be found inside the same patient. The first one, left after intestinal surgery in 2000, was found about eight months after the operation and removed by the same surgeon who had left it. It caused an infection that made the patient quite ill. The second clamp, according to the patient and his lawyer, was apparently left behind in the same operation as the first, but was somehow overlooked when the first was found. Now the patient would need yet another operation to take out the second clamp.
Asked how instruments could be left inside a patient, Dr. Dembitzer said: ''I have no idea. The surgery was not done at the V.A. I'm not a surgeon and I don't work in the operating room, but from all I know we have a lot of systems in place to make sure everything that goes into the operating room is counted when it goes in and when it comes out. And if there is any question, they will hold a patient there and take an X-ray to make sure.''
Dr. Dembitzer was so struck by the startling image of the clamp that she and a colleague, Dr. Edwin J. Lai, submitted the C.T. scan to The New England Journal of Medicine, which published it last week. The scan accompanied an article by researchers at Brigham and Women's Hospital in Boston, about the reasons that things get left inside people after surgery.
The authors of that article, led by Dr. Atul A. Gawande, a surgeon, say that leaving objects behind is ''an uncommon but dangerous error'' that can lead to severe infections, organ damage and sometimes even death.
In some cases described in other medical journals, surgical sponges (which are actually gauze pads) left in patients became embedded in tissue and were mistaken for tumors. As a result, patients had parts of their intestines removed.
Dr. Gawande and his colleagues estimate that sponges or instruments are left behind at least 1,500 times a year in the United States -- a tiny fraction of the total operations, which exceed 28 million. That works out to about one case a year for a typical large hospital. But, the authors note, the cases ''attract wide, critical press coverage,'' and patients often sue. In Massachusetts cases that the researchers studied, patients won an average of about $53,000.
The critical news reports and lawsuits may help explain why, in the language of medical journals, surgical tools sewn up inside people are not lost, forgotten or left behind; rather, they are ''retained,'' almost as if the patient had chosen to hang onto them.
''It is kind of a euphemism,'' Dr. Gawande said. ''It implies a certain lack of responsibility, or that the instrument did it itself. It is the technical term of art, undoubtedly developed in the malpractice context.''
The profession has coined a word for a left-behind surgical sponge: gossypiboma, from the Latin word gossypium for cotton and the Swahili boma for ''place of concealment.''
Dr. Gawande said he had never lost anything in a patient, but wanted to study lost objects because no one fully understood why or how the problem occurred. Sometimes the mistakes happen even though a surgical team follows all the proper procedures, like counting sponges and instruments before and after surgery and feeling around inside the patient before closing the incision.
Sponges can disappear inside a patient even if they have long strings with rings attached to hang outside the incision and help doctors keep track of them, Dr. Gawande said.
''It's a frustrating and an interesting puzzle,'' he said. ''We did the study in part because no one had taken any topic in surgery or the rest of medicine where there's an error and compared it to cases where there wasn't an error, so you could sort of quantify the risk factors.''
Using records from a malpractice insurer in Massachusetts, the researchers found 54 patients who had instruments or sponges left behind from 1985 to 2001. A majority of cases, 69 percent, involved sponges, and the rest, instruments like clamps, retractors or electrodes. Sponges themselves are difficult to see on X-rays but contain threads or tags made of a material that does show up on the films.
''No major body cavity was spared,'' the researchers wrote, noting that 54 percent of the foreign bodies were left in the abdomen or pelvis, 22 percent in the vagina, 7.4 percent in the chest and 17 percent in other places like the spinal canal, face, brain and extremities.
In a few cases, the forgotten object was found by the first day after surgery, but some were left in for years. The median interval was 21 days.