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© 2003 European Association of Cardio-Thoracic Surgery
Missing washer of the rib approximator? An easily overlooked foreign bodyDepartment of Cardiothoracic Surgery, Victoria Hospital, Whinny Heys Road, Blackpool FY3 8NZ, UK
* Corresponding author. Tel.: +44-1253-300-000 ext. 308; fax: +44-1253-306-854 Received August 1, 2002; received in revised form November 20, 2002; accepted November 21, 2002
Iatrogenic Foreign bodies especially Gauze swab following surgery are well reported. We report a very unusual case of a loose washer from SELLARS rib approximator, which came out loose in a thoracotomy wound. It was not recognised till reported missing by the central surgical supply department. The foreign body was identified and removed successfully. This case highlights the importance of checking the small connections of the instrument as a routine and especially if an instrument become loose.
Key Words: Iatrogenic foreign body; Rib approximator; Thoracotomy
Iatrogenic foreign bodies especially missing gauze swabs following surgery are well known [1–3]. Incidences of missing gauze swabs have almost vanished with strict swab counts prior to closure of wound. Use of raytec material in the swab help in the localisation and removal of these swabs if missing. However missing small connector of the instruments is never heard of nor reported in the literature to the best of our knowledge and search. We report a case in which washer of the rib approximator was lost in the thoracotomy wound. We discuss the circumstances of this problem happening and suggest preventive measure to avoid this potential medico-legal situation.
Fifty-one-year-old gentleman, a chronic smoker, underwent right postero-lateral thoracotomy for possible right middle and lower lobectomy for histologically proven adenocarcinoma. He has no evidence of mediastinal lymphadenopathy on the CT Scan. Bronchoscopy revealed necrotic tumour occluding the right lower lobe orifice with evidence of compression of right middle lobe as well. The carina and left main bronchus along with right upper lobe bronchus have no evidence of intra luminal malignancy. He had history of successfully treated tuberculosis of the chest wall 8 years previously. He had 6-month anti-tuberculous treatment comprising of triple regimen (Rifinah 600 mg daily, Perazinamide 2 g daily for 6 months) with no clinical or radiological evidence of recurrence of disease. He also had an Abdomino-perineal resection for adeno-carcinoma of rectum with an end colostomy 5 years back with no evidence of recurrence. There was a debate whether he was a primary lung cancer or metastatic colonic tumour, however in either case the resection was felt to be a better option. He underwent right postero lateral thoracotomy through 5th intercostal space. Intra-operatively there were dense adhesions with no plane between the fissure. The tumour was adherent to the upper lobe. The procedure was abandoned, as the patient was not suitable for pneumonectomy, with borderline blood gases. The chest was closed with continuous number 1 vicryl (Ethicon limited-Edinburgh, UK) with the help of SELLARS rib approximator (Fig. 1). After putting the pericostal sutures the rib approximator was removed, one of it blades was noticed to be TOO loose, however it did not warrant any attention. The muscles were closed in layers with number 1 vicryl (Ethicon limited-Edinburgh, UK) sutures. The routine swab, instrument and needles counts were reported normal by the scrub nurse. The patient was transferred to the intensive care unit for recovery.
However in the central surgical supply department, Washer of one of the blades of the SELLARS rib approximator was found to be missing. The chest X-ray in the intensive care unit showed it to be inside the chest (Fig. 2). A lateral chest X-ray for exact localisation of the foreign body is relation to chest wall and pleural cavity was unhelpful.
The patient thoracotomy wound was re explored, however it was difficult to locate the foreign body, a very small washer in the wound. The pleural cavity was explored without any success. Magnetic source was used to catch the foreign body without any luck. Finally the Nut was found to be in between muscle plane and the ribs in the most posterior location partially embedded in the muscles. The foreign body was removed successfully. All the connections of the instruments including the washer and spring were checked and were found to be correct. The patient made an uneventful recovery.
Foreign body in the chest can be broadly classified into three group's, i.e. aspiration, traumatic or accidental and iatrogenic. Aspiration foreign bodies are more commons among all foreign bodies. Among the various reported traumatic foreign body the most common being the bullet. Delayed complication after 17 years has been reported [4]. Majorities of reported iatrogenic thoracic foreign bodies are migratory metals. The guide wire used for pre-operative localisation of non-palpable breast lesion [5], segment of sternal wire puncturing the heart [6], orthopedic fixation pin into the thoracic cavity following fixation of humeral fracture [7], pectus excavatum correction bar into the left ventricle [8,9] are already reported. The gauze swabs and surgical instruments (famous surgeons’ scissors) are well known foreign bodies to be left inside the chest cavity following surgical intervention [1–2]. The clinical and medicolegal implication of this mishap is such that the swab and instruments count is mandatory before and after any surgical intervention, as is the case in our department. For this reason-missing swabs are noticed before closure of the chest. This help in identification of missing foreign body and removal. If we fail to locate missing swab or instrument, our department policy is to perform an on table X-ray to exclude the foreign body being inside before closing the chest and patient transfer from theatre. SELLARS rib approximator has two blades, which are secured, in place with a spring and washer (Fig. 1). Retrospectively, the washer was loose and fell out while removing the instrument after closure of the rib. The instrument and swab count was done and found to be correct. The missing washer was not thought of nor counted. This led to washer being left inside the thoracotomy wound without any body notice of it being missing. The central supply department identified the missing washer. Although the chest X-ray P/A view show the missing washer clearly, contrary to reported beneficial role [10], the lateral chest X-ray was not helpful in differentiating whether the foreign body is inside or outside the pleural cavity. The message from the case is that the whole surgical team especially scrub nurse to be vigilant if the instruments get loose. One should look into the reasons of instrument getting loose, and check all the connectors of the instrument for any missing pieces. This, like gauze swabs, can avoid missing iatrogenic foreign body, unnecessary re-exploration and possible medico-legal problems. doi:10.1016/S1569-9293(02)00114-7
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Abstract
1. Introduction
