F Kiernan1, M Joyce, C K Byrnes, H O'Grady, F B V Keane, P Neary. 1. Division of Minimally Invasive Surgery, Department of General and Vascular Surgery, Adelaide and Meath Hospital, Tallaght, Dublin 24, Ireland. fionamaireadkiernan@yahoo.co.uk
Abstract
INTRODUCTION: Post-operative complications in surgery may frequently be unavoidable. However, some complications result from human error, both in the intra-operative and post-operative period. One such complication, which is frequently underreported, is the retained swab, or gossypiboma. CASE REPORT: We report a case from our hospital of a patient who presented with unexplained pyrexia, 4 years post-gynaecological surgery in another institution. A 67-year-old woman from overseas presented to our emergency department with a 2-day-history of pyrexia, collapse and confusion. Following a CT guided biopsy, which was inconclusive, she was scheduled for retroperitoneal biopsy. In theatre, a retained swab was discovered. CONCLUSION: Prevention of gossypiboma is far better than cure. Strict adherence to swab counts, and the avoidance of change of staff during procedures is important in decreasing the incidence. Perhaps, with the increasing use of minimally invasive procedures, the incidence of gossypiboma will fall dramatically.
INTRODUCTION: Post-operative complications in surgery may frequently be unavoidable. However, some complications result from human error, both in the intra-operative and post-operative period. One such complication, which is frequently underreported, is the retained swab, or gossypiboma. CASE REPORT: We report a case from our hospital of a patient who presented with unexplained pyrexia, 4 years post-gynaecological surgery in another institution. A 67-year-old woman from overseas presented to our emergency department with a 2-day-history of pyrexia, collapse and confusion. Following a CT guided biopsy, which was inconclusive, she was scheduled for retroperitoneal biopsy. In theatre, a retained swab was discovered. CONCLUSION: Prevention of gossypiboma is far better than cure. Strict adherence to swab counts, and the avoidance of change of staff during procedures is important in decreasing the incidence. Perhaps, with the increasing use of minimally invasive procedures, the incidence of gossypiboma will fall dramatically.
Authors: Atul A Gawande; David M Studdert; E John Orav; Troyen A Brennan; Michael J Zinner Journal: N Engl J Med Date: 2003-01-16 Impact factor: 91.245