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Retained surgical items (RSIs) can include any surgical equipment (i.e., sponge, instrument, needle) unintentionally left inside a patient after an operation. RSIs result in signicant patient morbidity, possible mortality, and excess healthcare costs. Over time, many strategies have been utilized to prevent the retention of sur­gical items. Traditionally, manual surgical counts and intraoperative plain imaging have served this purpose. More recently, new technologies have emerged, including bar-coded sponges and radio-frequency technology. This chapter focuses on review­ing RSI epidemiology, risk factors, and prevention methods—both standard prac­tices and new technology.

The most common RSI is cotton materials, specically sponges (52–69%), fol­lowed by surgical instruments (3–43%), and needles (9%) [7, 8, 11, 12]. It is not surprising that surgical sponges constitute the majority of RSIs as they are small and commonly used and become camouaged when blood-soaked. Interestingly, nee­dles were found to be a major cause of near misses, but less frequently result in an RSI [8].

7, 11, 13, 14]. In one series, 27.5% of RSI cases involved uncomplicated vaginal

deliveries [14].

RSIs can be discovered immediately or take many years until discovery [11]. Throughout the literature, the average time to discovery of an RSI was 6.9years, ranging from under 3months to over 40years [6]. However, the median time to discovery was 2.2years because of high likelihood complications that occur within the rst 2years after surgery. Abdominal and pelvic locations were associated with signicantly longer intervals to retained item identication and removal [13].

Some RSIs are discovered incidentally during the postoperative period, while others are discovered due to clinical signs and symptoms, and others remain hidden for years [11]. The majority of RSIs are discovered on imaging (67%) followed by self-exam or physical exam (24–30%) [7]. The most common imaging detection methods are CT scans (61%), then radiographs (35–51%), and ultrasound (34%) [7,

brosis, and purulence/abscess. Fibrosis was more common in patients whose RSIs were discovered more than 1week after retention [13].

includes about $14,701 for unreimbursed readmission and reoperation costs [16]. Legal fees vary widely between states and specic cases, with a range of $37,041 to $2,350,000, with an average of $52,581 per case [7, 16]. By understanding the risk factors associated with RSIs and the prevention strategies available, these monetary gures represent potential healthcare cost savings.

Approaches to the prevention of RSI have begun with attempts to dene important risk factors. Identication of key risk factors for RSIs could enable additional screening for the highest risk cases. A meta-analysis of three retrospective, case­control studies of RSI risk factors found seven risk factors to be signicantly associ­ated with increased RSI risk, listed in order of highest to lowest risk [17]:

1. Incorrect surgical count

2. Unexpected intraoperative factors

3. More than one surgical team

Some studies suggest that the presence of surgical trainees reduced the risk of RSI by as much as 70% [11, 12]

For standardization of the process, the Association of periOperative Registered Nurses (AORN) rst published surgical count guidelines in 1976, which have undergone multiple revisions, with the most recent update in 2015 with the “Guideline for Prevention of Retained Surgical Items.” The AORN standard prac­tices recommend counting sponges, sharps, instruments, and miscellaneous items on all procedures with the possibility that a foreign object could be retained. They recommend that all cotton sponges be radiopaque. Counting practices are required to be audible and performed by two individuals, including the circulating nurse. Surgical counts should occur before the procedure for a baseline, when new items are added to the eld, before closure of a cavity within a cavity (e.g., bladder), when wound closure begins, when skin closure begins or at the end of the procedure, at the time of permanent relief of either the RN circulator or the scrub person, and any time a discrepancy is suspected.

While manual surgical counting has remained the mainstay of RSI prevention for decades, many call into question its reliability due to dependence on human consis­tency and accuracy in a complex environment plagued with interruptions, time pres­sures, and multitasking. In retrospective studies, 62–88% of retained surgical items occur in operations for which a nal count was erroneously documented as correct [6–8, 11, 12, 14]. In one study evaluating the value of counting, the observed sensi­tivity of manual surgical counts was 77.27%, specicity was 99%, and positive predictive value was 1.6%, owing to the low incidence of RSIs [19]. The positive likelihood ratio of an incorrect count was 113.3, indicating that cases with incorrect counts were over 100 times more likely to result in an RSI [19]. While these statis­tics point to a higher value of counting then found in the literature, surgical teams should be careful to assume a correct surgical count as protective against a retained surgical item, as it can lead to a false sense of security [8].

Another criticism of manual surgical counting relates to the time it takes to per­form counting activities, which divert the attention of ancillary staff from the activi­ties of the surgeon. A mean of 16.6 counting episodes occur per operation, each requiring an average of 8.6min to perform, consuming up to 14% of operative time [20]. In many institutions, this increased operative time correlates with increased healthcare expenditures.

The majority of count discrepancies involve sponges (45%), followed by instru­ments (34%) and needles (21%). Most (59%) result from misplaced items, which are eventually found in the body, on the surgical eld, or elsewhere in the OR. Alternatively, 38% of discrepancies result from errors in the written record [12]. Cases with personnel change, specically circulating nurse or surgical techni­cian, are three times more likely to have a discrepancy [20].

Recognizing that the majority of count discrepancies represent actual misplaced items, all count discrepancies warrant a thorough search and reconciliation [20]. Despite the inability of manual counts to prevent all RSIs, the role for manual surgi­cal counts still exists because standard counting detects 82% of possible RSIs [21]. If no counting was performed, the incidence of retained surgical sponges might be as high as 67 per 100,000 operations [21].

Guidelines for use of radiographic detection of RSI vary widely between institu­tions. Some hospitals require radiographs in every open surgical case, while others selectively require radiographs in high-risk cases or only in those with discrepant counts. Some hospitals do not have radiography policies at all [7, 8, 22].

The literature suggests that sponges and instruments are much easier to detect on imaging than needles [8]. Overall mean accuracy of intraoperative radiographs for needles is 74% and specicity is 80% for plain radiographs in the detection of retained surgical needles. While the overall reported sensitivity of 69% for needle detection on intraoperative radiographs appears higher than the sensitivity for any RSI detection on intraoperative radiograph, this statistic is misleading because it is highly dependent on needle size. Sensitivity for needles 25mm or more in length was 99% compared to needles of 11–24mm, which was 84%, and needles ≤10mm, which was 29%. For reference, the length of a CTX needle on a 0 suture is 48mm in length, an SH needle on a 3-0 suture is 26mm, and a BV needle on a 6-0 suture is 11mm. Some suggest that radiographs for lost needles smaller than 13mm pose unnecessary radiation risk for little or no gain, as the clinical signicance is debat­able [11, 24].

In one institution that requires high-resolution postoperative survey lm prior to patients being brought to the recovery room, 59% of RSIs were discovered through