Retained Vaginal Foreign Body in Minimally Invasive Gynecological Surgeries

ABSTRACTBackground: Retention of a surgical object in a patient’s body is a preventable human error that is rare but can cause serious clinical complications, lead to malpractice lawsuits, and be a devastating event both for the patient and the care provider. Although the incidence of retained foreign bodies in the abdomen tends to decrease with the rise in minimally invasive surgery, a retained surgical object in the vagina is a possible adverse outcome of which the surgical team should be aware.

Cases: We describe 2 cases of minimally invasive surgeries that were complicated by a retained surgical object in the vagina and occurred within 2 consecutive years at the same institution. The first case describes a retained Asepto bulb (Xodus Medical, New Kensington, Pennsylvania) after a robot-assisted total laparoscopic hysterectomy, and the second describes a retained surgical sponge after a laparoscopic ovarian cystectomy. Both patients did well after removal of the foreign body, without major complications.

Conclusion: The counting system and radiographic screening for high-risk cases are not reliable methods to prevent retained foreign objects. Communication is always important, and standardization of the language in the operating room is essential. The surgical team should be aware of a retained foreign body as a possible adverse outcome, and specific steps should be taken to ensure that all objects are removed from the patient at the completion of the surgery.

Key Words: Retained foreign bodies, Minimally invasive surgical procedures, Surgical error

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