by Brian Camazine

Although less likely to garner public notoriety, errors relating to the failure to remove surgical instruments at the end of a procedure...are no less egregious than the better known mishaps such as “wrong-site surgery”(1). Although retained foreign bodies are an uncommon event, the true incidence is unknown. ”The foreign body problem is rarely discussed as there is an understandable tendency not to advertise ones errors” (2)

 A retained laparotomy sponge does not appear to be a random event.  A recent study has found that retained foreign bodies are more likely to occur 1) during emergency surgery 2) when there is an unexpected change in surgical procedure 3) in obese patients. The authors concluded that routine intraoperative xrays would be a useful adjunct for detecting retained foreign bodies in these high risk categories of patients (3).

 A different study recommended the following. “Before closure, the surgeon should explore the abdomen to ensure all laparotomy sponges are removed. This is especially important when these [sponges] are placed away from the area where the surgeon has been working: eg., laparotomy pads are placed over the liver during cholecystectomy. Only sponges with radiopaque markers should be used, and quality control should be checked. Sponges should not be used to facilitate closure, but instead large malleables or the rubber “fish” should be used. We believe that two counts after fascial closure should be done to avoid taking into account sponges purposely left in the abdomen during closure. Following shift change, two counts should be performed by the new personnel. Finally, in trauma situations we recommend routine abdominal roentgenograms before closure if feasible” (4)

 The surgeon and the operating room team rely upon the practice of sponge, sharp, and instrument counts as a means to eliminate retained foreign bodies. Use of this simple preventative measure, however,  is not universal. “Legislation does not prescribe how counts should be performed, who should perform them, or that they need to be performed. The law only requires that foreign bodies not be negligently left in patients” (5). The following practices were developed by the AORN Recommended Practices Committee and are effective January 1, 2000.

 “Sponges should be counted on all procedures in which the possibility exists that a sponge could be retained. Sponge counts should be taken:

1. before the procedure to establish a baseline
2. before closure of a cavity
3. before wound closure begins
4. at skin closure or end of procedure
5. at the time of permanent relief of either the scrub person or the circulating nurse” (5).

Although the responsibility for performing sponge counts rests with the operating room nursing service, for practical purposes, the legal responsibility for accurate counts often extends to the surgeon. This can be true even when an intraoperative xray fails to detect a retained sponge (6). In the case Ravi v Williams (536 So2d 1374 [Ala 1988]), the Alabama Supreme Court, on the basis of “Captain of the Ship” Doctrine “...reasoned that the surgeon remains responsible for what he put in the patient’s abdomen, despite the fact that the general custom and practice...is to delegate the task of accounting for sponges to the OR nurses. The fact that the surgeon delegated the task of counting the sponges [to the nurses]...does not relieve the surgeon of the responsibility to remove them in the first place. The surgeon alone has the responsibility for removing all sponges”(7).  The Doctrine of “Captain of the Ship”, placing all responsibility on the surgeon, is not recognized in all jurisdictions (8).

 “The retained surgical sponge represents the bete noire of the healthcare provider because in most jurisdictions, the doctrine of res ipsa loquitor may be applied against the parties deemed responsible for the act. This legal principle essentially holds that the documented presence of such an adverse occurrence represents evidence that substandard and negligent care may be presumed to have taken place” (6). In the case of a retained sponge, the Doctrine of res ipsa loquitor “...raises such strong inference of negligence that the plaintiff does not even need to produce expert testimony to prove that the act falls below the standard of care required by physicians and surgeons. Such a negligent act also imputes liability to the nursing staff on the same res ipsa loquitor theory as that applied to the surgeon”(7). Although the Doctrine of res ipsa loquitor is not always applicable, settlements and trial verdicts suggest that negligence on the part of surgeons and nurses is often assumed (6, 9)

REFERENCES

 1. Making Health Care Safer. A Critical Analysis of Patient Safety Practices. Prepared by University of California at San Francisco (UCSF)-Stanford University Evidence-based Practice Center. Project Director: Robert M. Wachter, MD .Evidence Report/Technology Assessment, No. 43.

 2. The foreign body problem after laparotomy. Jones, A. Am J Surg. 1971 122:785-6.

 3. Risk factors for retained instruments and sponges after surgery. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. N Engl J Med. 2003 Jan 16;348(3):229.

 4. The retained surgical sponge following intra-abdominal surgery. A continuing problem. Rappaport W, Haynes K.  Arch Surg. 1990 Mar;125(3):405-7.

 5. Recommended practices for sponge, sharp, and instrument counts. AORN Recommended Practices Committee. Association of perioperative registered nurses. AORN J 1999; 70:1083-9.

 6.  The retained surgical sponge. Kaiser CW, Friedman S, Spurling KP, Slowick T, Kaiser HA. Ann Surg. 1996 Jul;224(1):79-84.

 7. Nurses' vs surgeons' responsibility for sponge counts. Zuffoletto JM. AORN J. 1993 Jun;57(6):1457-8.

 8. The Doctor’s Chart. Wisconsin Cases of Note “Captain of the ship doctrine not viable; doctor not liable for nurses’ negligence. nalawyers.lawoffice.com/publi- cations_december.htm

 9. The Doctrine of Res Ipsa Loquitur and Article 4590i. Meador, EL

 ABOUT Brian Camazine, M.D.