Identifying lost surgical needles using radiographic techniques

AORN Journal,  July, 2003  by Michael D. Macilquham,  Robin G. Riley,  Peter Grossberg

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Despite guidelines to improve practice, the occurrence of retained items after surgery remains problematic. Perioperative nurses perform surgical counts of items to be used during a procedure before surgery begins and at specified times during and at the end of surgery to ensure that items are not left in a patient unintentionally. Up to four counts can be undertaken for specific procedures. (1,2) The Australian College of Operating Room Nurses (ACORN) has recommendations regarding the types of items to be counted, including x-ray detectable packs, gauze, and needles. They recognize, however, that "individual organizations ... adopt appropriate risk management strategies to ensure optimal outcomes for the patient." (2 (pA3))

Although not easy to find, there is some literature on foreign bodies retained after surgery. Most articles are published in the form of case studies in medical imaging journals. Very few published papers present summaries of large case study data. On the whole, accurate data on the incidence of retained items is difficult to obtain, likely because the publishing of such data is influenced by the confidentiality requirements of insurance and damage claims.

THE LITERATURE

One group of researchers reported on 24 cases of retained items after abdominal surgery in one institution during a 10-year period. (3) Eight patients were symptomatic. The time between surgery and symptom development ranged from six days to eight months, with the exception of one patient who had undergone surgery 10 years previously. In 15 of these cases, diagnosis was established by plain abdominal x-ray, ultrasound, or computed tomography. The mortality rate was almost 10%.

Case records from an insurance company were reviewed by another group of researchers, who identified 40 cases of retained surgical items during a seven-year period, 11 of which involved uncomplicated vaginal deliveries and 29 of which were surgical procedures. (4) Most of the cases (n = 22, 55%) involved abdominal surgery. An inaccurate count was observed in 22 of the 29 (76%) surgical procedures, and on three occasions, no count was performed. False-negative x-rays were identified as a factor contributing to incorrect diagnosis, as were poor quality films, multiple radiographic opacities, and the radiologist's apparent lack of awareness of surgical team members' concern.

In Australia, reports of retained surgical items are isolated, although precedence has been established in common law. (5) In one of the very few reports in the literature, data from the Medical Defence Union revealed 15 cases of retained surgical items that occurred during a four-year period. (6) Moves to rectify this lack of information are being addressed by the Australian government, which now requires mandatory reporting of retained instruments and other materials after surgery. (7)

Only one published paper was identified that considered the detection of retained needles after surgery. (8) Although it lacked the rigors of blinding and independent assessment and was conducted under artificial conditions, the researcher was able to identify needles on sutures as small as 8/0. Previously, OR myth purported that sutures smaller than 5/0 could not be detected via x-ray; however, 5/0 relates to the size of the suture and not the size of the needle.

The literature from different countries fails to detail adequately at what point an x-ray is superfluous for detecting lost needles. For instance, in Australia, ACORN guidelines state than in the event of a missing item, an "x-ray is performed (unless contraindicated by the condition of the patient)," but they fail to discuss what should be done in the case of small suture needles. (2 (pA3)) In the United States, the literature also indicates a blanket policy approach. (9,10) In the United Kingdom, when items (eg, microneedles) cannot be detected with an x-ray, it is recorded on the intraoperative record. (11) It remains unclear, however, exactly what size needle cannot be detected with an x-ray. Clearly, more rigorous research in this area is needed to influence policy development for individual institutions and the profession as a whole to save patients from unnecessary radiation exposure.

PURPOSE

The purpose of this project was to identify the minimum needle size that can be identified using a variety of commonly used radiographic techniques. Comparison between identification rates achieved with each radiographic technique then would allow determination of the optimum radiographic technique for finding lost surgical needles.

THE PROJECT

Twelve commonly used surgical needles of varying size and type, with suture sizes varying from #1 to 9/0, were placed behind an acrylic Alderson tissue-compensating anthropomorphic radiographic phantom (Table 1). The Alderson phantom weighs approximately 80 kg and is used to simulate radiographic densities and exposures of a patient of the same weight. This type of phantom commonly is used by radiological technology students to practice radiographic positioning. The phantom and needles then were radiographed using routine radiology departmental chest exposures to determine the radiopacity of surgical needles on a simulated patient. This resulted in a standard reference image that displayed all 12 needles on the radiographic phantom (Figure 1).