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OJHAS Vol. 6, Issue 3: (2007
Jul-Sep) |
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Missing needle during episiotomy repair |
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Joydeb Roychowdhury,
Associate
Professor, Dept. Of
Gynaecology & Obstetrics, NRS
Medical College, 138, AJC Bose
Road, Kolkata-70014, West
Bengal
Balaram
Samanta,
Associate
Professor, Chittaranjan
Sevasadan, Kolkata. |
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Address For Correspondence |
Associate
Professor,
Dept. Of
Gynaecology & Obstetrics,
NRS
Medical College,
138, AJC Bose
Road,
Kolkata-70014, West
Bengal
E-mail:
rcjoydeb@gmail.com |
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Roychowdhury J, Samanta B. Missing needle during episiotomy repair.
Online J Health Allied Scs. 2007;3:4 |
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Submitted Jun 26, 2007; Accepted Dec
17, 2007; Published Jan 24, 2008 |
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| Abstract: |
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Breakage and
missing of the episiotomy needle is not uncommon occurrence at the hands of the
junior doctors. Retrieving it from deeper tissue planes following its migration
can be a challenging task.
Key Words:
Episiotomy, needle,
migration |
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In
the UK alone, approximately 1,000 women per day will require perineal
repair following vaginal birth.(1) Pain associated with perineal trauma can be very distressing for the
new mother and may interfere with her ability to breast feed and cope
with the daily tasks of motherhood. It also appears to have a clear
causal association with sexual dysfunction and ultimately may affect
the woman’s relationship with her partner. Episiotomy
needle missing after it breaks during repair is quite a common
experience amongst the junior doctors and trainees. This sometimes
results in serious morbidity to the patient. Recovering the missing
needle becomes a real problem as the needle migrates to a distant
place through tissue planes. Hosli has reported one case of lost needle during
episiotomy detected after 20 years and removed.(2)
The patient was
admitted at NRS Medical College, Kolkata on 6.11.2006 with a
history of a missing needle during episiotomy repair following
childbirth on 17.10.2006 at Chittaranjan Sevasadan Hospital, Kolkata.
She was P 1+0,
married for 1½ years. She delivered a female baby by forceps
at 4am on 17th October, 2006. During episiotomy repair, a needle was broken and
embedded in the perineum which could not be traced after 2 hours try.
On the very next day, the consultants detected the presence of the
needle on X ray and ultrasonography. They searched for the needle again under
general anesthesia but could not trace it. The patient was referred
to our college after 3 weeks with all reports and case sheet. On
examination, the patient was symptomless but looked pale, exhausted
and apprehensive. The episiotomy wound was bleeding, edematous and on
naked examination, no needle could be seen or felt through the
tissues. The repeat X ray identified the presence of the needle. The
investigations showed her hemoglobin at 7gm% and she was transfused 3 units
of blood. On comparison between the films, it appeared that the
needle had been displaced into a different place. The operation was
arranged under fluoroscopic guidance along with a general
surgeon on 15.11.2006. The patient and her relatives were sympathetically counseled
because of the prolonged suffering and explained why it was difficult
to trace the needle because of its possible migration through the fascial layers.
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X-ray film showing the missing needle |
During the operation,
the episiotomy wound was extended further upwards and deeper to trace
the possible site of its migration. The ischiorectal fossa was also
opened to look for the needle. On per rectal examination, needle could not be
palpated for its possible attachment to the rectal wall. Under
fluoroscopy, the needle appeared at much higher and anterior
position. One artery forceps was pushed through the anterior vaginal
wall along the paraurethral region and the needle could be felt and
grasped by the forceps under fluoroscopy as high as behind the
symphysis pubis. The tissue was incised over the forceps and the
needle was exposed and removed from the area behind the symphysis
pubis through the anterior vaginal wall. It was a round-body needle
with 3/4th curve broken from its eye. The needle which was supposed to be in
the area along the posterior vaginal wall migrated through the subvaginal
tissue anteriorly behind the symphysis pubis. The posterior vaginal
wound was repaired. The operation lasted for more than an hour. The
patient was transfused 2 units of blood and kept for 7 days in the
postoperative period under antibiotic cover. The wound healed well
and the patient was discharged on 22.11.2006.
The missing broken
needle during episiotomy repair is possible particularly in the hands
of the house-surgeons and could be retrieved immediately in most of
the occasions. But sometimes the problem of retrieving this foreign
body becomes a real challenge as was in this case. Therefore one
should be very careful during repair, particularly when working in a
deeper and higher plane to avoid this harassment which is also
difficult for the patient’s relatives to accept and can easily
become a legal issue.
- Kettle C, Fenner DE. Repair of
episiotomy, first and second degree tears. In Perineal and anal sphincter trauma,
Diagnosis & clinical management. 2007 Springer London. p20-32
- Hosli, Tercanli S,
Holzgreve W. Complications of lost needle after suture of vaginal
tear following delivery. Archives of Gynecology and
Obstetrics 2000;264:3
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