van den Berg Nadia, Corbett Mel, Cleere Eoin, Keogh Ivan
Department of Otolaryngology Head & Neck Surgery, Galway University Hospital, Galway, Ireland.
J Surg Case Rep. 2022 Apr 25;2022(4):rjac181. doi: 10.1093/jscr/rjac181. eCollection 2022 Apr.
Equipment failure can be a cause of morbidity during surgical procedures. We present two cases where a broken surgical instrument, a heart-shaped curved micro-grasper, colloquially termed 'sweetheart' micro-forceps, compromised patient safety during microlaryngoscopy. We discuss the importance of thorough safety protocols and communication between team members to mitigate this risk. Microinstruments used during microlaryngoscopy are at risk of failure or breakage due to their small size. Surgeons must be alert to the risk of equipment failure during surgery as a potential cause of patient morbidity. In our patient, loss of the broken instrument in the respiratory tract could have resulted in iatrogenic aspiration, respiratory infection and would have necessitated rigid bronchoscopy for removal. Instruments and equipment must checked and communicated by the surgical team before and after use to prevent potential patient morbidity.
设备故障可能是手术过程中发病的一个原因。我们呈现两例病例，在这两例中，一把破损的手术器械，即一把心形弯曲微型抓钳，俗称“甜心”微型镊子，在显微喉镜检查过程中危及了患者安全。我们讨论了完善的安全协议以及团队成员之间沟通对于降低这种风险的重要性。显微喉镜检查中使用的微型器械因其尺寸小而有发生故障或破损的风险。外科医生在手术期间必须警惕设备故障这一可能导致患者发病的风险。在我们的患者中，破损器械遗留在呼吸道可能会导致医源性误吸、呼吸道感染，并且将需要进行硬质支气管镜检查来取出。手术团队在使用器械和设备前后必须进行检查并沟通，以防止可能的患者发病情况。
