Retained retractor

Case contributed by Dr Prashant Mudgal

Presentation

Post operative case obviously not from our institution ;) . exploratory laparotomy was done.

Patient Data

Age: 57 year
Gender: Female
Modality: X-ray

A retained malleable surgical retractor is visualized in the abdomen and pelvis.

Case Discussion

Retained surgical items (RSIs) are an extreme and obvious example of a medical negligence. Medicolegally, these cases are described by the doctrine of "res ipsa loquitur" which is Latin for "the thing speaks for itself." This means that a breach in duty or care can be inferred directly from the very nature of the event without knowing the circumstances, intent, or actions of the defendant. Unintentionally leaving a surgical instrument or item within a patient is simply "no defense to surgeon".

Take home message 

  • RSI is a profound surgical negligence.
  • RSI increase post-operative mortality and morbidity.
  • count and recount your surgical instruments before and after application its the "simplest" technique to avoid RSI incidences.
  • there is no harm in taking a post operative portable x ray. 
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Case Information

rID: 27223
Case created: 23rd Jan 2014
Last edited: 10th Dec 2015
Tags: pm, iatrogenic
Inclusion in quiz mode: Included

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