Rafie Basmah A, AbuHamdan Omar J, Trengganu Nawal S
Department of General Surgery, Hera General Hospital, Makkah, Saudi Arabia
Department of General Surgery, Hera General Hospital, Makkah, Saudi Arabia.
J Surg Case Rep. 2013 May 9;2013(5):rjt032. doi: 10.1093/jscr/rjt032.
Despite near-universal implementation of protocols for surgical sponges, instruments and needles, incidents of retained surgical foreign bodies (RSFB) continue to be a significant patient safety challenge. We report a case of a 29-year-old woman who presented with small intestinal obstruction caused by complete intraluminal migration of a retained surgical sponge into the intestine 9 months after cesarean section. The diagnosis was confirmed by plain abdominal radiograph. The patient underwent exploratory laparotomy, sponge removal and became completely asymptomatic. Although safety standards for hospital employees have been developed during the past decades, no detection system to date has been evaluated as a replacement for traditional manual counting protocols and procedures. The best approach is the prevention of this condition, which can be achieved by implementation of standardized institutional regulations and strict adherence to them. Perhaps, with increasing use of the new technologies as adjunct to the counting, the incidence of RSFB will fall dramatically.
尽管手术中对纱布、器械和缝针的清点规程几乎已普遍实施，但手术中异物残留（RSFB）事件仍是重大的患者安全挑战。我们报告一例29岁女性病例，该患者在剖宫产术后9个月因一块残留手术纱布完全迁移至肠腔内导致小肠梗阻。腹部平片确诊了该诊断。患者接受了剖腹探查术、取出纱布，术后完全无症状。尽管在过去几十年间已制定了针对医院工作人员的安全标准，但迄今尚无检测系统被评估可替代传统的人工清点规程和程序。最佳方法是预防这种情况的发生，这可通过实施标准化的机构规定并严格遵守来实现。或许，随着新技术越来越多地作为清点辅助手段使用，手术中异物残留的发生率将大幅下降。
