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OJHAS Vol. 8, Issue 2: (2009
Apr-Jun) |
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Missing Broken Needle During
Caesarean Section |
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Chandana Das, Associate Professor,
Gautam Mukherjee, Assistant Professor,
Pati S, Professor
Animesh Naskar, Resident Medical Officer,
Dept of G & O, North Bengal Medical College, Darjeeling,
West Bengal |
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Address For Correspondence |
P 232 C, CIT Road
Scheme VI M, Kolkata
- 700054
West Bengal, India.
E-mail:
dasc54@yahoo.com |
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Das C, Mukherjee G, Pati S, Naskar A. Missing Broken Needle during
Caesarean Section. Online J Health Allied Scs.
2009;8(2):12 |
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Submitted: Jun 10, 2009; Accepted:
Jul 25, 2009 Published: Sep 8, 2009 |
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| Abstract: |
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Breakage of the
needle and missing while repairing the uterine wound during cesarean section is
an uncommon event. Subsequently it was removed under fluoroscopic guidance on
the 7th postoperative day.
Key Words: Broken Needle,
Foreign body, Caesarean section
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Foreign bodies
retained in the peritoneal cavity rarely are documented, owing to medical, legal
and other reasons. Each such incident acquires major importance because it
upsets patients, relatives, surgeons, hospital room staff and the hospital
administrator. They may be symptomatic or remain asymptomatic for months and
years and removed incidentally. The present report concerns one patient with
intra abdominal foreign body (broken surgical needle left behind during cesarean
section) which was retrieved successfully on 7th postoperative
day.
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A 30 years old lady,
para 2+0 was admitted at North Bengal Medical College Hospital (NBMCH)
as a referred case from a peripheral hospital where an Emergency caesarean
Section was done at term two days earlier, indicated as a result of a previous
Caesarean section and severe Pregnancy Induced Hypertension and scar
tenderness. According to the referral paper, while repairing the uterine wound
during cesarean section, the needle
was broken and in spite of thorough search the surgeon could not find it out and
completed the operation and referred her to NBMCH. On admission, her general
condition was very poor with severe anemia, haemoglobin being 6 gm% and blood
pressure 180/100
mm Hg. The relatives were very much anxious and concerned about the retained
needle in the abdomen. Her general condition was improved by transfusing 4 units
of blood. She was put on broad spectrum antibiotics and other supportive
measures including antihypertensive namely Tablet Labetalol. All necessary
investigations were done including a straight X-ray PA and lateral view of lower
abdomen and pelvis which clearly demonstrated the presence of a broken needle in
the abdomen; however its precise location could not be established even by
ultrasonogram.
After proper counseling on the 7th post
operative day, laparotomy was performed. Under fluoroscopic guidance the needle
was located deep inside the myometrium near the left angle of the uterine wound.
Incision was made on the myometrium and it was deepened gradually until an
artery forceps hit the embedded needle and a portion of it became visible which
was then removed. The uterine wound was repaired and the abdomen was closed in
layers. Post operative period was uneventful
and she was discharged home in satisfactory condition on the 10th post
operative day. |
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Fig. I Straight X-Ray of Abdomen and
Pelvis showing a Leftover broken surgical needle. |
Retained foreign
body (RFB) following cesarean section is not common and reported variedly in the
literature. The commonest RFB is the surgical sponge.1 In
spite of all precautions, mistakes do occur resulting in various complications
with considerable suffering for the patients. It may remain asymptomatic for
months and years and removed accidentally.2
Some times diagnosis of RFB is
difficult, and at times it is difficult to retrieve it at laparotomy,3 particularly
for a small object like needle. In our case the diagnosis of RFB was no problem
as the patient was sent with a note of a retained broken needle which could not
be retrieved during cesarean section by the surgeon. This was because of the
poor general condition of the patient which compelled him to close the abdomen
quickly without getting adequate time for thorough search for the needle. Though
the presence of a needle in the pelvis was confirmed by X-ray later on, its
precise location could not be identified easily until the help of peroperative
fluoroscopy (C-Arm ) was taken which showed that the needle was embedded deep in
the myometrium near the left angle of uterine wound. Some times in long
standing cases, RFB are surrounded by gut and fistulas may occur and may even
migrate to other organs like intestine, urinary bladder etc., making retrieval
difficult.4,5 Very rarely a tumour like thing may develop with the FB as nidus,
along with the adherent
gut and omentum and discovered only after resection and removal of the mass at
laparotomy.2 According to some, removal of foreign bodies like needle or small part of surgical items may
cause more harm than the item itself and removal is not recommended.6 But
it is very difficult to translate this recommendation practically. As the patient
as well as the relatives are very much worried about the left over needle
in the abdominal cavity, and also from the medicolegal point of view, removal is
preferred in spite of difficulty.
One should take utmost care to avoid RFB to occur at all. Recently, New
England Journal of Medicine published an article about risk factors of RFBs. Of
the 8 risk factors the authors identified (emergency operation, unexpected
change in operation, more than one surgical team involved, change in nursing
staff during procedure, body mass index (BMI), volume of blood loss, female sex,
and surgical counts) only 3 were found to be statistically significant. The 3
significant risk factors were emergency surgery, unplanned change in the
operation, and BMI.7 Proper
counting of instruments / sponges repeatedly by different members of the team
can prevent RFB to a great extent. New technologies are being developed that
will hopefully decrease the incidence of RFB. An electronic article surveillance
system has been examined which uses a tagged surgical sponge that can be
identified electronically.8 Bar codes can be applied to all
sponges, and with the use of a bar code scanner the sponges can be counted on
the back table. The use of radiofrequency identification systems holds much hope
for application in the area of detection of sponges.6
As surgery is a team work, preventing RFB is also a team work;
every member in
the ream including nurses should make conscious effort in this direction
abiding recommendations, more so in high risk cases, thereby preventing
mortality and morbidity of the patients and averting litigations.
- Mirsharifi
R, Aminian A, Jafarian A, Kalhor M, Dashti H, Ali FAH, Alibakhshi A,
Tahvildary M, Heidari S, Tavakoli F .Retained Foreign Body, Brief Review. Shiraz
E-Medical Journal. 2008;9(4)
- Rodriguez
GR, Mano DL, Rodriguez R et al. Intra-abdominal
Foreign Body 19 Years After a
Cesarean Section. Journal of
Pelvic Medicine & Surgery. 2008;14(6):437-40
- Revesz G, Siddiqi TS, Buchheit WA,
Bonitatibus M. Detection of retained surgical sponges. Radiology. 1983;149:
411-413.
- Gupta NM, Chaudhary A, Nanda V,
Malik AK, Wig JD. Retained surgical sponge after laparotomy: Unusual
presentation. Disease of the colon and rectum. 1985;28:451- 53
- Tomás
Lázaro Rodríguez Collar, Yamel
Gil del Valle, Basily
Valdés Estévez, Víctor
Osvaldo Barquín Carmona, José
Antonio García Monzón. Bladder
lithiasis secondary to intrauterine device migration. Case report. Arch Esp Urol. 2008;61(5):640-3
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Gibbs VC, Coakley
FD, Reines HD. Preventable errors in the operating room: retained foreign bodies
after surgery. Curr Probl Surg. 2007;44:281-337.
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Gawande AA, Studdert
DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and
sponges after surgery. N Engl J Med. 2003;348:229-235.
-
Fabian CE. Electronic tagging
of surgical sponges to prevent their accidental retention. Surgery. 2005;137:298-301.
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