Gabin Yun MD Ella A Kazerooni MD MS Elizabeth M Lee MD Palmi N Shah MD Michael Deeb MD Prachi P Agarwal MBBS Author affiliations Department of Radiology University of Michigan GY EAK EML PPA ID: 932149
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Slide1
Retained Surgical Items at Chest Imaging
Gabin Yun, MD
Ella A.
Kazerooni
, MD, MS
Elizabeth M. Lee, MD
Palmi
N. Shah, MD
Michael
Deeb
, MD
Prachi P. Agarwal, MBBS
Slide2Author affiliations:
Department of Radiology, University of Michigan (G.Y., E.A.K., E.M.L., P.P.A.)
Department of Radiology, Rush University Medical Center (P.N.S.)
Department of Cardiac Surgery, University of Michigan (M.D.)
Corresponding author:
Gabin Yun, MD (
e-mail:
yung2@upmc.edu)
Recipient of Cum Laude award for an education exhibit at the 2019 RSNA Annual Meeting.
Disclosures of Conflicts of interest:
P.P.A.
Activities related to the present article:
disclosed no relevant relationships.
Activities not related to the present article:
institution received grants from
Spiromics
and
MyoKardia
.
Other activities:
disclosed no relevant relationships.
Slide3IntroductionThe current estimate for retained surgical items (RSIs) is 1.32 events per 10 000 procedures, but this number may be underestimated because of confidentiality and reluctance of involved health care providers to disclose the errors.
1
Defined as a reportable “never event” by the National Quality Forum.
Despite preventative measures, RSIs still occur.
Frontal radiograph shows a retained laparotomy sponge (arrow) that was found to be partially incorporated in the small bowel with granulation tissue.
Slide4Learning ObjectivesAfter completion of this online presentation, participants will be able to:Recognize the radiologic appearance of commonly used surgical items and devices with a focus on thoracic RSIs.
Develop strategies to reduce RSIs and ensure timely depiction.
Understand the clinical and medical-legal implications of RSIs.
Target audience: radiology residents, fellows, and faculty.
Slide5The most common type of RSI is a
sponge.
2
Types of RSIs
Types of RSIs
Sponge
*Others: portion of vascular stent, shunt, device marker, bulldog clamp, aneurysm clip, drill bit, or pedicle marker.
Slide6Location of Unintentionally Retained Sponges
Retained surgical items can occur anywhere but are
most commonly
reported in the
abdominal and pelvic cavity.
3
There is a paucity of literature describing RSIs in the thorax and relevant to cardiothoracic radiology.
We hope to increase awareness to enable early depiction of RSIs in the thorax.
Slide7Type
2016
2017
2018
2Q 2019
Unintended
RSI
126
124
131
60
Fall
102
120
123
25
Wrong-site surgery
121
104
105
0Suicide9093510
Clinical and Medical-Legal Implications
Unintended RSIs were identified as
the most frequently reported sentinel events from 2016 to the second quarter of 2019.Medical negligence is easily proven in these cases under the doctrine of res ipsa loquitur (the thing speaks for itself). The estimated cost for an RSI is $166 000–$600 000 per procedure.
Source.—Reference 4.
Slide8Depiction of RSITiming for RSI depiction is variable, ranging from a few hours to several years after the surgery.
Evaluation of RSIs at intraoperative imaging is a time-sensitive matter.
It is important to provide timely interpretation and communicate with the surgical team directly and immediately.
Delayed communication can lead to delays in wound closure and prolonged anesthesia time. Also, prompt radiologic recognition and rapid communication of an RSI is essential to prevent the possibility of a closed surgical wound at the time of communication, which would necessitate reopening the wound and a further increase in anesthesia time.
Slide9Two types of foreign body reactions can occur.Inflammatory reaction leading to abscess, fistulization
, visceral perforation, and bowel obstruction.
Aseptic fibrinous response
leading to granuloma formation followed by calcification and decomposition. This can be clinically silent over months to years and can form a pseudotumor.
Using a case-based approach, we highlight imaging features of various thoracic RSIs, potential contributors to a missed diagnosis, and strategies to improve performance.
Risks of RSI
Slide10Case: 77-year-old patient after mitral valve replacement.
A normal sponge and instrument count was recorded. Is there a retained surgical item?
Frontal radiograph.
Slide11Case: 77-year-old patient after mitral valve replacement.
Note the radiopaque marker (arrow) of a retained sponge. Although the sponge and instrument count was correct, this imaging finding was identified and communicated to the clinical service.
The retained sponge was removed the following day.
Strategy:
Retained surgical items should be considered postoperatively, even with a correct sponge count.
Slide12Sponge Counts and RSI
Sponge Counts and RSI
Incorrect counts are frequent and occur in one out of eight surgical cases.
5
However, only one out of 70 cases with discrepant counts has an RSI.
6
88% of RSIs occur with a correct sponge and instrument count.7
Slide13Is there a retained surgical item?
In the original read, the finding was noticed but a sponge was considered unlikely
as it did not match the radiograph of a similar sponge that was obtained at the same time.
A retained sponge was demonstrated
3 days later on a two-view radiograph.
Frontal plain radiograph obtained intraoperatively.
Plain radiograph of a sponge obtained at the same time for comparison.
Case: Incorrect sponge count in a
59-year-old man after coronary artery bypass.
Slide14Frontal plain radiograph obtained intraoperatively shows a retained sponge (arrow).
Plain radiograph of a sponge taken at the same time for comparison
Case: Incorrect sponge count in a
59-year-old man after coronary artery bypass.
Strategies:
Be aware that a sponge can look different from the laid-out configuration on a table once it is soaked and rolled inside the body.
Direct one-on-one communication with the surgical team is important to share one’s uncertainty in equivocal cases.
Contributors to missed diagnosis:
The configuration of a sponge marker can look different when rolled up in a patient’s body.
Retained sponge is a rare event. Omission bias for equivocal findings can play a role given the significant downstream implications.
Slide15Post-operative CXR
Pre-operative CXR
What is your impression?
Case: 40-year-old man after thoracoscopic right upper lobectomy.
Frontal radiograph obtained postoperatively.
Frontal radiograph obtained preoperatively.
An abnormal sponge count was recorded.
Where is the retained surgical item?
Slide16Radiograph was reported as right chest tube insertion with pneumothorax; otherwise expected post operative findings.
Magnified View
The original report said: right chest tube in place with small apical pneumothorax and expected postoperative findings.
Contributors to missed diagnosis:
The indication of the imaging study did not call for a missing sponge.
Overlying sternotomy wires in the field may make it difficult to identify.
Unfamiliarity with the appearance of a tonsil sponge, which is frequently used for hemostasis during video-assisted thoracoscopic surgery.
Frontal radiograph obtained postoperatively.
Frontal radiograph obtained preoperatively.
Note the tonsil sponge (circle) in the radiograph obtained postoperatively.
Slide17Laparotomy Sponge
Surgical Sponge
Radiographs show dry and flat sponges.
Radiographs show wet and folded sponges.
Strung Sponge
Tonsil Sponge
Peanut Sponge
Images courtesy of
Ryan Walsh, MD, University of Vermont, Burlington, Vermont.
Strategy: Increase familiarity with commonly used surgical sponges.
A gallery of radiographs of surgical items can be created and uploaded on the picture archiving and communication system (PACS) for quick reference during interpretation.
Slide18Case: After bilateral breast reconstruction.Strategy:
It is critically important to include the entire anatomy. Although the sponge (arrow) is visible on the first radiograph, it is at the edge of the image and becomes more apparent on the repeat radiograph that is centered at the region of interest.
Frontal plain radiograph obtained intraoperatively.
Repeat frontal radiograph obtained intraoperatively that is centered at right lower hemithorax.
Where is the retained surgical item?
Slide19Case: 4-year-old girl following atrial septal defect repair.
Where is the retained surgical item?
Frontal radiograph.
Lateral radiograph.
Slide20Bilateral chest tubes with right apical pneumothorax and expected postsurgical changes from atrial septal defect repair. A
left atrial retained surgical needle
(arrow) was diagnosed 4 days later at follow-up.
Contributors to missed diagnosis:
The indication for the imaging study did not call for a missing needle.
Failure to perceive the abnormality.
Strategies:
Interpret the imaging study without first reviewing the indication to avoid framing bias.
Case: 4-year-old girl following atrial septal defect repair.
Did you notice the finding indicated by the arrow?
Where is it located?
Slide21Case:49-year-old woman following bilateral lung transplant.
Where is the retained surgical item?
Frontal chest radiograph.
Slide22Case:49-year-old woman following bilateral lung transplant.
Can you find the RSI with this additional image?
Frontal chest radiograph.
Frontal abdominal radiograph.
Slide23Magnified view
A
needle
was identified on the abdominal image (arrows) despite a lack of provided clinical history.
The patient returned to the operating room for removal.
Initial radiograph described effusions and pulmonary edema. The
needle
is difficult to visualize even in retrospect.
Slide24Contributors to missed diagnosis:
Underpenetration
of the initial examination makes prospective identification difficult.
Electrocardiography leads and drain tubes can be distracting.
Strategies:
Accounting for all nonbiologic items.
Avoiding biased interpretation due to provided clinical indication.
Slide25Here is a companion case: 69-year-old man following esophagectomy for esophageal cancer.
Frontal radiograph obtained on postoperative day 1.
Frontal radiograph obtained on postoperative day 5.
Where is the retained surgical item?
Slide26The needle was subsequently removed during reoperation for empyema.
Retained surgical needle in the minor fissure (arrow) was detected
on follow-up CT images obtained 5 days later.
Frontal radiograph obtained on postoperative day 5.
Frontal radiograph obtained on postoperative day 1.
These radiographs were reported as
expected postoperative findings.
Axial CT image.
Coronal CT image.
Slide27Contributors to missed diagnosis:
On the radiograph obtained on postoperative day 1, various factors could contribute. The clinical indication was to assess the placement of the PICC (peripherally inserted central catheter) line, which can lead the radiologist to focus on the task at hand. Also, multiple lines and tubes can be distracting.
The alignment of the needle with the minor fissure makes it difficult to identify on the radiograph obtained on postoperative day 5.
Postoperative day 5
Postoperative day 1
Strategies:
Comparison with prior radiographs (in this case, the radiograph obtained on day 5 compared with that from day 1) can help in the detection and confirmation of its presence.
Masking the study indication before interpretation can prevent framing bias.
Slide28Where is the retained surgical item?
This plain radiograph was requested to identify RSI following incorrect instrument count.
Case: 74-year-old patient after emergent coronary artery bypass graft.
This plain radiograph was requested to depict an RSI after an incorrect instrument count.
Frontal radiograph.
Slide29Case: 74-year-old patient after emergent coronary artery bypass graft.
The finding of a curved needle (arrow) was communicated to the surgeon, and the retained needle was removed immediately.
Strategies:
Knowing the details of a missing RSI is important for interpretation.
Emergency surgeries have a high risk of RSI.
Slide30High BMI of patient
Emergency surgery and unexpected intraoperative events
Risk Factors for RSI
Procedure duration
Slide31Case: Tachycardia and hypoxia.
Axial CT images of the pelvis that were obtained for deep vein thrombosis assessment.
What retained surgical item is seen?
Frontal (a) and lateral (b) view CT scout images obtained from a pulmonary embolism and deep vein thrombosis assessment.
a.
b.
Slide32Case: Tachycardia and hypoxia.
The CT scout images (left) show
two metallic densities
:
A
clamp
(arrow) on the lateral view can be confirmed to be external to the patient.
A
retractor
(
) projects over the patient on both views, suggesting this is in the patient.
This is confirmed on the axial CT images.
Slide33These CT images were interpreted as showing no definite pulmonary embolism and were suboptimal to show deep vein thrombosis because of poor contrast enhancement. The
retained
surgical retractor
(
) was not mentioned in the report.
Coronal CT image obtained at follow-up 10 months later depicts the
retained metallic surgical retractor.
Contributors to missed diagnosis:
Rare to see a large retained metallic retractor
Clinical context
Failure to account for all foreign bodies
Strategies:
Have a low threshold for discussion with clinical service in the case of an unexplained foreign body.
Slide34Forceps
Towel clamps
Scalpel blades
Penrose drain
Umbilical tape
Needles
Suture needle
Vascular tie
Luer
lock syringe
Clamp tips: rubber for covering tips of surgical clamps.
Images courtesy of
Ryan Walsh, MD, University of Vermont, Burlington, Vermont.
Increase familiarity with the appearance of commonly used surgical instruments and devices at radiography.
Slide35Case: Wound dehiscence following mitral valve repair.
Where is the RSI?
Sagittal CT image.
.
Axial CT image.
Slide36At repeat sternotomy for foreign body, a small catheter tip of a syringe
used
to deliver hemostatic agent to the sternum was successfully removed.
The original report identified a retrosternal
tube
(arrow) with surrounding rim-enhancing fluid collection.
Strategy:
High index of suspicion after surgery.
Prompt communication with clinical service.
Slide37The boy was adopted from parents residing outside the United States. History of D-looped transposition of the great arteries and valvar pulmonary stenosis after Fontan operation. Cardiac MRI was performed for evaluation of ventricular size and function and Fontan pathway.
Axial reconstruction from MR angiography with gadolinium-based contrast agent (right) shows a posterior peripherally enhancing lesion (arrow) partially included in the field of view. This lesion in the lower right hemithorax showed no central enhancement.
Case:
3-year-old boy after Fontan operation.
Case courtesy of
Maryam
Ghadimi Mahani, MD, University of Michigan, Ann Arbor, Michigan.
Slide38Case:
3-year-old boy after Fontan operation.
Posteroanterior (a) and lateral (b) chest radiographs obtained 3 months earlier show a round opacity over the lower right hemithorax (arrows). This was earlier thought to represent pneumonia. However, the patient had no signs or symptoms of a respiratory infection. Note the lack of any associated radiopaque marker.
Case courtesy of
Maryam
Ghadimi
Mahani
, MD, University of Michigan, Ann Arbor, Michigan.
a.
b.
Slide39Ultrasound
Contrast-enhanced sagittal chest CT
US guided biopsy was performed
Case:
3-year-old boy after Fontan operation.
Sagittal contrast-enhanced chest CT image.
US image.
US-guided biopsy was performed.
Case courtesy of
Maryam
Ghadimi
Mahani
, MD, University of Michigan, Ann Arbor, Michigan.
Follow-up contrast-enhanced CT image and US images are shown. This lesion centered over the right posterior pleural space was thought to be an old
organized hematoma, pleural fluid collection, or neoplasm.
Slide40Case:
3-year-old boy after Fontan operation.
Pearls:
Radiopaque markers may not always be present in a
gossypiboma
.
Photomicrograph under polarized light depicts two multinucleated giant cells with birefringent material inside the cytoplasm (arrows). (Hematoxylin-eosin stain; original magnification, ×200.)
Photomicrographs (left, original magnification, ×40; right, original magnification, ×200) of soft tissue obtained at biopsy show soft tissue with chronic inflammation, histiocytes (some with foamy cytoplasm), and foreign body giant cell reaction or granuloma. (Hematoxylin-eosin stain.)
Diagnosis:
The lesion was surgically removed. In the operating room, a retained surgical sponge in the posterior right chest with thick inflammatory rind was noted.
Slide41GossypibomaThe term gossypiboma is derived from
gossypium
(“cotton” in Latin) and
boma
(“place of concealment” in Swahili). Gossypiboma refers to a
pseudomass consisting of a cotton matrix and surrounding reactive change.Imaging appearance can vary. Requires a high index of suspicion.A clue is a radiopaque marker, although this may not always be present (marker can disintegrate, and older sponges may not have markers).
Mottled lucencies may be seen because of air trapped between the fibers.
Axial CT image depicts mottled air
lucencies
and a radiopaque marker (arrow) in an intra-abdominal
gossypiboma
.
Slide42Pitfalls and False-Positives for RSI
While high sensitivity is paramount, it is important to remember that some foreign bodies can mimic RSIs.
Common examples include a broken sternal wire that can mimic a surgical needle and hyperattenuating surgical material that may be confused for RSI.
Frontal radiograph (a) and coronal CT image (b) show broken fragmented sternal wire, which can mimic a surgical needle.
(c) Axial CT image shows a retrosternal, linear, wavy hyperattenuating structure with associated fluid collection. This represents an infected pericardial patch. Correlation with prior operative details can help avoid misinterpretation.
a.
b.
c.
Slide43Once RSIs are soaked and folded inside the body, some change in configuration may occur.
88% of RSIs occur with correct counts.
Communication gaps may exist between surgical teams and radiologists.
RSI may not be suspected clinically.
Challenges Regarding RSIs
Slide44When RSI Is Clinically SuspectedDirect communication between radiology and surgical departments is important.
Be aware of the type and appearance of a missing surgical item, the body cavities involved, and the surgical procedure performed.
Always keep in mind the limitations of intraoperative imaging (low positive predictive value; depicts 67% of RSIs).
Consider postoperative imaging in cases with a index of high suspicion or if counts are not reconciled. If findings remain indeterminate, consider cross-sectional imaging.
Slide45When
When RSI Is
Not
Clinically Suspected
Consider RSI when the symptoms include pain, irritation, a palpable mass, or fever.
Maintain a high index of suspicion when examining all postoperative studies, whether the surgery was recent or distant.
All nonbiologic objects must be accounted for when imaging studies are interpreted.
Slide46Assistive technology for RSI detection
Assistive Technology for RSI Depiction
Bar code sponge
Each sponge has a unique bar code to aid counting and help prevent counting errors.
Radiofrequency tags
Radiofrequency tags are added to sponges to aid depiction.
Radiofrequency identification systems
To aid depiction (if left in patient) and counting.
Although not completely foolproof, assistive technologies can be a supplement to other manual counting procedures and strategies aimed at reducing RSI.
Limitation of intraoperative plain radiography
33% of RSIs are not depicted.
8
Slide47Assistive technology for RSI detection
Collaborative Surgical and Radiological Team Approach
Intraoperative radiography for RSI performed in the following scenarios:
When counts are incorrect.
High-risk procedure for RSI (even with correct counts).
Radiologists should talk directly to the surgical team, and members of both teams should review images simultaneously.
RADIOLOGY
SURGERY
Slide48Based on the Joint Commission’s Sentinel Event database
Common root causes of missed RSIs
Failure in communication
Inadequate or incomplete education of staff
Failure to comply with existing policies and procedures
Problems with hierarchy and intimidation
Others
Ensure appropriate communication between members of surgical team and patient care teams. Institute team briefings and debriefings as a standard part of the surgical procedure.
When ordering radiography to help rule out a retained object, provide a description of the object.
Implement a high-priority alert and a verbal report from the radiologist to the provider if a retained object is identified at radiography.
Source.—Reference 3.
Strategies to reduce RSI
Slide49Based on the Joint Commission’s Sentinel Event database
Common root causes of missed RSIs
Failure in communication
Inadequate or incomplete education of staff
Failure to comply with existing policies and procedures
Problems with hierarchy and intimidation
Others
Allocate resources for education, training, credentialing, audit, and feedback.
Educate about risks and reduction strategies of RSI.
Assess competency of personnel.
Provide team training. (
TeamSTEPPS
or other standard training).
Strategies to reduce RSI
Source.—Reference 3.
Slide50Based on the Joint Commission’s Sentinel Event database
Common root causes of missed RSIs
Failure in communication
Inadequate or incomplete education of staff
Failure to comply with existing policies and procedures
Problems with hierarchy and intimidation
Others
Address disruptive behavior.
Minimize distractions and interruptions.
Audit and provide feedback of compliance with policies and procedures.
Use standardized practices to develop and sustain reliable counting practices.
Add a best-practice alert to notify the proceduralist of required documentation and when radiography is recommended.
Strategies to reduce RSI
Source.—Reference 3.
Slide51Based on the Joint Commission’s Sentinel Event database
Common root causes of missed RSIs
Failure in communication
Inadequate or incomplete education of staff
Failure to comply with existing policies and procedures
Problems with hierarchy and intimidation
Others
Prioritize a culture of safety.
Conduct a proactive risk assessment.
Celebrate successes.
Encourage reporting of near misses.
Strategies to reduce RSI
Source.—Reference 3.
Slide52Failure in communication Inadequate or incomplete education of staff
Failure to comply with existing policies and procedures
Problems with hierarchy and intimidation
Others
Based on the Joint Commission’s Sentinel Event database
Common root causes of missed RSIs
Document verification of removal and integrity of objects.
Report events of retained fragments to the manufacturer.
Collaborate with manufacturers to improve safety of the design of medical devices.
Strategies to reduce RSI
Source.—Reference 3.
Slide53SummaryIdentification of retained surgical items (most commonly sponges) can be difficult despite use of radiopaque markers.
The majority of retained sponges occur in the setting of a correct sponge count, which may also contribute to a delayed diagnosis.
Key strategies to reduce missed RSIs include:
Maintaining a high index of suspicion in patients with a surgical history.
Practicing direct communication with the surgical team.
Accounting for all nonbiologic findings on studies.
Slide54Suggested ReadingsFeldman DL. Prevention of retained surgical items. Mt Sinai J Med 2011;78(6):865–871.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(3):229–235.
Porter KK, Bailey PD, Woods R, Scott WW Jr, Johnson PT. Retained surgical item identification on imaging studies: a training module for radiology residents. Int J CARS 2015;10(11):1803–1809.Whang G, Mogel GT, Tsai J, Palmer SL. Left behind: unintentionally retained surgically placed foreign bodies and how to reduce their incidence—self-assessment module. AJR Am J
Roentgenol 2009;193(6 Suppl):S90–S93.Wolfson KA, Seeger LL, Kadell BM, Eckardt JJ. Imaging of surgical paraphernalia: what belongs in the patient and what does not.
RadioGraphics
2000;20(6):1665–1673.
Slide55ReferencesHempel S, Maggard-Gibbons M, Nguyen DK, et al. Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires: a Systematic Review of Surgical Never Events. JAMA Surg 2015;150(8):796–805.
Cima
R et al. Incidence and Characteristics of Potential and Actual Retained Foreign Object Events in Surgical Patients. J Am Coll Surg 2008;207(1):80–87.
Steelman VM, Shaw C, Shine L, Hardy-Fairbanks AJ. Unintentionally Retained Foreign Objects: a Descriptive Study of 308 Sentinel Events and Contributing Factors.
Jt
Comm J Qual Patient Saf 2019;45(4):249–258.Summary Data of Sentinel Events Reviewed by The Joint Commission. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/summary-2q-2019.pdf. Accessed June 30, 2020.
Greenberg CC, Regenbogen SE, Lipsitz SR, Diaz-Flores R, Gawande AA. The frequency and significance of discrepancies in the surgical count. Ann Surg 2008;248(2):337–341.
Egorova
, N, et al. Managing the prevention of retained surgical instruments: what is the value of counting? Annals of Surgery 2008;247(1):13-18.
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(3):229–235.Steelman VM, et al. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. AORN J 2011;94(2):132-141.