|Year : 2018 | Volume
| Issue : 3 | Page : 139-142
A rare case report of long-standing foreign body in the abdomen; forgotten scalpel blade in a multipara
Joel A Adze1, Matthew C Taingson1, Makama G Jerry2, Stephen B Bature1, Durosinlorun M Amina1, Mohammed Caleb1, Abubakar Amina1, Airede Lydia1, Sheyin John3
1 Department of Obstetrics and Gynaecology, College of Health Sciences, Kaduna State University, Kaduna, Kaduna State, Nigeria
2 Department of Surgery, College of Medicine, Kaduna State University, Kaduna, Kaduna State, Nigeria
3 Department of Radiology, College of Medicine, Kaduna State University, Kaduna, Kaduna State, Nigeria
|Date of Web Publication||27-Sep-2019|
Dr. Matthew C Taingson
Department of Obstetrics and Gynaecology, College of Health Sciences, Kaduna State University, Kaduna, Kaduna State
Source of Support: None, Conflict of Interest: None
The unintended retention of foreign objects (URFOs) after invasive procedures can cause morbidity and in some cases mortality. There may be an extended period between occurrence and detection of an URFO. Retained foreign objects are most commonly detected immediately postprocedure by X-ray, during routine follow-up visits, or from the patient's report of pain or discomfort. This is a case report of a 46-year-old lady Para 3+04 alive who presented to the gynecological clinic following an incidental radiological finding of a size 22 scalpel blade while being evaluated for low back pain. She had an exploratory laparotomy and retrieval of the blade. She did well and was discharged home in good condition on postoperative day 7.
Keywords: Incidental, laparotomy, scalpel, unintended retention of foreign body
|How to cite this article:|
Adze JA, Taingson MC, Jerry MG, Bature SB, Amina DM, Caleb M, Amina A, Lydia A, John S. A rare case report of long-standing foreign body in the abdomen; forgotten scalpel blade in a multipara. Arch Int Surg 2018;8:139-42
|How to cite this URL:|
Adze JA, Taingson MC, Jerry MG, Bature SB, Amina DM, Caleb M, Amina A, Lydia A, John S. A rare case report of long-standing foreign body in the abdomen; forgotten scalpel blade in a multipara. Arch Int Surg [serial online] 2018 [cited 2019 Nov 15];8:139-42. Available from: http://www.archintsurg.org/text.asp?2018/8/3/139/268127
| Introduction|| |
Foreign objects can be left behind following a surgical procedure in any part of the body, but most frequently, in the abdominal cavity and thorax, although no body cavity is invulnerable. Sponges are the items most frequently reported as retained, followed by instruments.
Estimates of the incidence of retained foreign objects vary. An estimated 1:1,000 to 1:1,500 intra-abdominal surgeries result in a retained foreign body., In a systematic review, the median incidence estimate for retained surgical items was 1.32 events per 10,000 surgical procedures.
Retained foreign objects undergo two types of foreign body reaction. The first is an aseptic fibrinous response, resulting in formation of a granuloma, which can then undergo calcification and decomposition. This response is usually clinically silent and only incidentally discovered. The second is an inflammatory reaction, resulting in an abscess. In the body's attempt to expel retained foreign objects, fistulization, perforation of viscera, and bowel obstruction have been shown to occur.,,, We report a case of a long-standing foreign body in the abdomen.
| Case Report|| |
Mrs. E.R., a 46-year-old Para 3+0 4 alive, presented to the gynecological clinic of our hospital on 7 March 2017 with a plain abdominal X-ray showing an incidental finding of a surgical blade logged in the left lower quadrant of the abdomen, adjacent to the transverse process of the third lumber vertebra, [Figure 1]a while being evaluated for low back pain. She had occasionally suffered from only lower back pain since her last delivery 6 years ago. She attributed the pain to the spinal anesthesia that she had previously. Prior to this, she had two open surgeries, an appendectomy (in 1997) and ovarian cystectomy (in 1998) in two different private hospitals in Kaduna State, Nigeria. Furthermore, she had three Cesarean sections in 2006, 2008, and 2011 in our hospital when it was still a specialist hospital before it was transformed to its present status of a Teaching Hospital. The indications for the Cesarean sections were prolonged labor with fotal distress, twin pregnancy with leading twin breech, and two previous Cesarean sections, respectively. All these Cesarean deliveries were said to have been done under spinal anesthesia. She had no abdominal pains and had no change in bowel habit.
|Figure 1: (a) Plain abdominal X-ray with blade. (b) Computed tomography scan with blade in the abdomen|
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On examination, she was a young lady with a height of about 1.62 m, weight of 115 kg, and body mass index (BMI) of 44 kg/m 2. She was afebrile (temp. 36.5°C), anicteric, not pale, and no pedal edema. The respiratory rate was 22 cycles/min; chest was clinically clear. Her pulse rate was 80 beats/min, regular and good volume, and blood pressure was 110/70 mmHg.
Abdominal examination revealed a midline scar extending from the umbilicus to the upper border of the pubis symphysis and a grid iron scar. There was no area of tenderness and nil palpable masses felt. A computed tomography scan of her abdomen and pelvis in addition to the plain abdominal x-ray demonstrated the blade as well [Figure 1]b. The patient was further counselled on the findings and the necessity of surgery, which she consented. Under general anesthesia, abdominal cavity was entered via the previous midline incision; findings were those of adhesions in the posterior surface of the previous scar with attachment of the omentum and some part of the bowel. Other intra-abdominal organs were essentially normal. Following extensive exploration, a size 22 surgical blade surrounded by granulation tissue was found lying transversely in the mid-portion of the meso-colon of the transverse colon; fine dissection and retrieval of the blade was done [Figure 2]a,[Figure 2]b,[Figure 2]c, hemostasis secured, and the abdomen closed in layers.
The patient had an uneventful postoperative course. She was discharged home on postoperative day 7; a check abdominal X-ray done revealed normal finding [Figure 3]. Subsequent follow-up visits were normal and back pain had remarkably improved.
An exhaustive effort was put forward to find out previous operative counts, but we could not ascertain correct counts due to the long duration and multiple operations that patient had at multiple centers.
The histopathological report of tissues around the blade (H-1271/17) was as follows:
Macroscopy: Received a yellow fatty tissue that has grayish capsule. It measures 2.5 × 1.5 and weighed 1 g. Cut section shows yellow and grayish surfaces (AE).
Microscopy: Section show fibrocollengnized tissue, a pseudocapsule around lobules of adipocyte in areas, infiltrates of mononuclear cells mainly lymphocytes and histiocytes are noted.
Conclusion: Exploratory laparotomy specimen - chronic nonspecific inflammation.
| Discussion|| |
Foreign bodies inside the body that are forgotten during surgeries occasionally cause symptoms after months and even after years. Our patient had a total of five surgeries spanning 6–20 years prior to presentation; she had only occasional lower back pain.
Sponges are the items most frequently reported as retained, followed by instruments. Cases of scalpel blades retained in the body have been reported., However, both patients were symptomatic necessitating reoperation and retrieval within 7 days of the primary surgery, unlike Mrs. E.R., where the blade was incidentally detected 6 years after the last surgery.
Several risk factors, including emergency surgery, unexpected changes in the operative procedure, high patient-BMI, and breakdowns in communication, are responsible for retained foreign bodies. This patient had three emergency surgeries in 1997, 1998, and 2006, which put her at risk. In addition, the procedures were open surgeries involving the abdominal cavity. Her BMI of 44 kg/m 2 is a reported independent risk factor for retaining foreign objects after surgery  and lastly the noninstitutionalization of instruments count in most private and public hospitals before and after operation contribute to this adverse outcome.
Location of the blade outside the bowel for 6–20 years after surgery is in keeping with published facts that metallic and other medical materials that are left in the abdomen may stay anywhere in the intra-abdominal space and rarely move to the intestine or the colon., This is thought to be so especially when minimal inflammation, accompanied by fibrous adhesions, occurs and restricts movement. In this patient, the surgical blade was in the meso-colon of the transverse colon, neatly covered by fibrous adhesions, thereby minimizing further migration and possible perforation/injury to loops of bowel. We are, therefore, not too surprise that the patient could remain minimally symptomatic for this length of time.
Laparoscopic removal of retained surgical items from abdominal cavity has been published., This approach has the added advantage reduced morbidity and retention of surgical items; however, our hospital did not offer such service at the time the patient was managed.
Various techniques can be used for the detection and identification of retained foreign objects; one of which is plain radiographs for radio-opaque items as in this patient. Ultrasonography also plays a vital role in the detection of gossypiboma. This can be diagnosed by the presence of bright echogenic wavy structures with a mass showing posterior acoustic shadowing that changes in parallel with the direction of the ultrasound beam. Another technique is the use of computed tomography (CT) scan. A surgical sponge will show bubbles on soft tissue masses. The flaw with this technique is that gossypibomas are easily confused with abscesses. In this patient, the plain abdominal X-ray, abdominal ultrasound, and abdominal CT scan done were able to detect clearly the surgical blade and where it was located, which facilitated a purposeful exploration of the abdomen during the operation. Magnetic resonance imaging and scintigraphy are other imaging techniques that could be used. Endoscopy  and handheld wand-scanning devices  have been deployed to detect retained foreign objects, such as surgical gauze sponges.
Meticulous counting of sponges, sharps, and instruments is a major factor in the prevention of this mishap; guidelines for the performance of counting of all sponges and sharps, even though are available, need to be standardized and simplified further for easy application and use. For instance, if a count is incorrect, then a radiography or manual re-exploration is mandatory.
| Conclusion|| |
In conclusion, retained scalpel blade and other material is potentially life threatening. It may cause serious medical problems, disability and subsequent reduction in the quality of life of the victim. It may also cause legal problems between the patient and the doctor. Therefore, extreme care should be taken in the handling of instruments during surgical procedures including proper and double counting at the end to enhance patient safety. Proper communication among the personnel participating in surgery will go a long way in preventing this kind of mishap.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]