A 75-year-old man with a past medical history of end-stage renal disease (on hemodialysis), hypertension, and diabetes was found to have obstructive, multi-vessel coronary artery disease. The patient was referred for bypass surgery and mitral valve repair. He underwent successful surgery and was discharged to a rehabilitation facility where he recuperated at the expected rate.
The patient continued to attend hemodialysis and clinic visits without fail. Eight months later, he was admitted to the hospital with shaking chills and confusion and found to have an empyema (i.e., collection of pus) on the left side of his chest. He underwent thoracic surgery where the trapped lung was freed from its adhesions and a 12-cm red-rubber snare was recovered—a surgical instrument from the prior surgery. The patient recovered to his baseline level of functioning after a 10-day intensive care unit (ICU) course followed by treatment in a rehabilitation facility.
On subsequent investigation, hospital staff members were puzzled by the failure to detect the object. The patient underwent three-times weekly dialysis sessions, at least eight clinic visits with multiple physicians, and had no symptoms until his dramatic presentation many months later. He also had seven chest radiographs postoperatively in which the device was not detected.
1. Legal Dictionary. Law.com. [Available at]
2. Gonzalez-Ojeda A, Rodriguez-Alcantar DA, Arenas-Marquez H, et. al. Retained foreign bodies following intra-abdominal surgery. Hepatogastroenterology. 1999;46:808-812. [go to PubMed]
3. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348:229-235. [go to PubMed]
4. Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps C. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg. 2008;207:80-87. [go to PubMed]
5. Rappaport W, Haynes K. The retained sponge following intra-abdominal surgery. A continuing problem. Arch Surg. 1990;125:405-407. [go to PubMed]
6. Lincourt AE, Harrell A, Cristiano J, Sechrist C, Kercher K, Henifort BT. Retained foreign bodies after surgery. J Surg Res. 2007;138:170-174. [go to PubMed]
7. Hyslop JW, Maull KI. Natural history of the retained surgical sponge. South Med J. 1982;75:657-660. [go to PubMed]
8. Russo CA, Elixhauser A, Steiner C, Wier L. Hospital-Based Ambulatory Surgery, 2007. HCUP Statistical Brief #86. Rockville, MD: Agency for Healthcare Research and Quality; February 2010. [Available at]
9. Yildirim S, Tarim A, Nursal TZ, et al. Retained surgical sponge (gossypiboma) after intraabdominal or retroperitoneal surgery: 14 cases treated at a single center. Langenbecks Arch Surg. 2006;391:390-395. [go to PubMed]
10. Falleti J, Somma A, Baldassarre F, Accurso A, D'Ettorre A, Insabato L. Unexpected autoptic finding in a sudden death: gossypiboma. Forensic Sci Int. 2010;199:e23-e26. [go to PubMed]
11. Taylor FH, Zollinger RW 2nd, Edgerton TA, Harr CD, Shenoy VB. Intrapulmonary foreign body: sponge retained for 43 years. J Thorac Imaging. 1994;9:56-59. [go to PubMed]
12. Szentmariay IF, Laszik A, Sotonyi P. Sudden suffocation by surgical sponge retained after a 23-year old thoracic surgery. Am J Forensic Med Pathol. 2004;25:324-326. [go to PubMed]
13. Wan W, Le T, Riskin L, Macario A. Improving safety in the operating room: systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol. 2009;22:207-214. [go to PubMed]
14. Goldberg JL, Feldman DL. Implementing AORN recommended practices for prevention of retained surgical items. AORN J. 2012;95:205-216. [go to PubMed]
15. Greenberg CC, Regenbogen SE, Lipsitz SR, Diaz-Flores R, Gawande AA. The frequency and significance of discrepancies in the surgical count. Ann Surg. 2008;248:337-341. [go to PubMed]
16. Kaiser CW, Friedman S, Spurling KP, Slowick T, Kaiser HA. The retained surgical sponge. Ann Surg. 1996;224:79-84. [go to PubMed]
17. Cima RR, Kollengode A, Clark J, et al. Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 months. Jt Comm J Qual Patient Saf. 2011;37:51-58. [go to PubMed]
18. Macario A, Morris D, Morris S. Initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology. Arch Surg. 2006;141:659-662. [go to PubMed]
19. Rupp CC, Kagarise MJ, Nelson SM, et al. Effectiveness of a radiofrequency detection system as an adjunct to manual counting protocols for tracking surgical sponges: a prospective trial of 2,285 patients. J Am Coll Surg. 2012;215:524-233. [go to PubMed]
20. Baltimore, MD: Department of Health & Human Services, Centers for Medicare & Medicaid Services; July 2008. SMDL #08-004. [Available at]
21. Cima RR, Kollengode A, Storsveen AS, et al. A multidisciplinary team approach to retained foreign objects. Jt Comm J Qual Patient Saf. 2009;35:123-132. [go to PubMed]