Patient Safety Guideline Failure: two in one

Missed foreign body during operation is unacceptable and a preventable issue. Modern multidisciplinary pre and intra operative patient safety guidelines could prevent most of unintentional errors. Break in these guidelines can make significant morbidity and sometime lethal events for patients and Health personnel team.Although missed foreign body during operation is rare, surgeons must be aware and careful about this possibility in every bizarre post-operative presentation and should keep in mind that missed foreign body is a diagnosis of exclusion .Sponge or surgical gauze is a common type of missed foreign body.Case:A 12-year-old girl was referred from another city to our department due to signs and symptoms of partial intestinal obstruction. She had had the history of appendectomy 2 years before. Abdominal Xray revealed retained gauze in abdominal cavity.Exploratory laparotomy was performed. A textiloma covered by a loop of small intestine and omentum was found as the cause of intestinal obstruction. Resection of the whole textiloma (contained foreign body) with a loop of the small bowl that attached firmly to this conglomerate tissue with surrounding momentum was performed. The continuity of GI tract was established with primaryanastomosis. Exploration of other parts of abdominal cavity was normal and the abdomen was closed after careful correct counting of the towels and four by fours that were used during operation. Abdominal X-ray the day after surgery revealed the presence of a similar object in the abdominal cavity in a different location compared to previous imaging studies. The patient condition was acceptable. Serial imaging studies in next days, showed that this gauze was moving through the distal colon. As we were certain that no sponge remained in abdominal cavity in recent celiotomy and in grossincised pathology of specimen only parts of missed 4×4 was found, we guessed that the remaining part of FB was in the bowel lumen, so we followed the case conservatively. In 5th post-operative day, she passed the remaining part of the gauze with stool. The last imaging of abdomen was free of FB .The next day she was discharged home in a good condition. The final judgment for this event was partialtrans mural migration of FB and partial removal of FB during the exploratory laparotomy. Transmural migration of retained gauze is rare event. The most prevalent site where the gauze migrates transmurally, is ileum, yet migration through colon, duodenum, stomach, and bladder have been reported. In about half of cases, the gauze was passed trans anally, but it may be trapped in the bowel lumen especially in the ileocecal valve and cause GI obstruction. Take home message:Strict following of patient safety guidelines could prevent such a significant morbidity