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Retained surgical sponges in veterinary medicine | VETgirl Veterinary Continuing Education Podcasts

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In today’s VETgirl online veterinary CE podcast, we discuss the dreaded retained surgical sponge left in the body cavity of a veterinary patient. After all, we’ve all done it or seen it, right? When in a rush to get to work, to finish paperwork, or to get home to our families and pets, “slowing down” is not a welcomed notion in our veterinary lives. But perhaps we need to make a conscious effort to do just that. Maybe your client showed up late for an appointment, or maybe your already booked day just got rocked by the emergency GDV that came through your doors, but we all know that when we rush, our attention to detail is compromised…and then, we can potentially overlook important things… like details such as how many sponges did we use during that spay or emergency surgery?!

Gossypiboma is the scientific term for a gauze or surgical sponge that is accidentally left inside a patient from a surgical procedure. The true incidence of leaving surgical sponges in veterinary patients is unknown, perhaps from underreporting or due to long asymptomatic periods following surgery. In human medicine, this occurs from a multitude of reasons – most are related to untrained staff or staffing shortages, prolonged surgery or patient instability during procedures. So, Rodriguez et al out of the United Kingdom wanted to evaluate this in a study called Evaluation of factors associated with retained surgical sponges in veterinary patients: a survey of veterinary practitioners, which aimed to identify what factors lead to veterinary gossypibomas. The authors conducted a study among 322 veterinary practitioners at a veterinary conference, and included small animal exclusive, mixed animal, large animal, and equine exclusive hospitals. The authors wanted to review the factors that can contribute to such a mistake.

Only 64 people responded to the survey (19% total). Twenty-nine survey responders were small animal practitioners, 26 were mixed animal practitioners, five were large animal practitioners, three were equine practitioners, and one worked at a university teaching hospital. Survey questions were broken down into four sections. The first section covered types of surgery (such as soft tissue versus orthopedic), caseload, how the hospitals scheduled for their surgeries (do they have designated surgery time slots in their schedules or are they performing surgeries between other procedures or after-hours?), and staffing allotment for surgical procedures (how many staff members in addition to the surgeon?). The second category of questions focused on surgical packs: who prepares them, are radiopaque sponges used, and how many sponges are used. The third category of questions assessed sponge surveillance (e.g., who was responsible for counting the sponges before surgery and/or after surgery). The last category of questions investigated the incidence and factors surrounding recorded gossypibomas including location of retained sponge, the surgical procedure performed, and how long it took after surgery to recognize the retained sponge.

Only 17 of the 64 (26.6%) respondents had involvement in cases of retained surgical sponges. Most of them involved dogs, but there were individual cases of one cat, two horses, and one donkey. Most of the small animal cases occurred during ovariohysterectomy (64.3%). Other surgeries implicated included crytorchidectomy, inguinal herniorrhaphy, unspecified abdominal surgery, and pyometra. One of the 14 small animal cases had identified the retained sponge on post-operative radiographs following a thoracic tumor resection, but most others were identified much later. Although the outcome was good for most cases following surgical revision for sponge removal, two cases died (one during and one after surgical revision) and one was euthanized on the table during revision surgery due to the finding of septic peritonitis as a complication of the retained surgical sponge.

When looking at what factors contributed to the retained surgical sponges, it was found that 12 of the 17 (70%) cases were non-scheduled surgeries. We are left to assume from this information that rushing, as in emergent surgeries and non-scheduled elective surgeries, is a big contributing factor. Other factors include having only two people in the surgery suite (the surgeon plus one other) as was found in 15 of the 17 cases. Non-radiopaque sponges were used in 15 of the 17 cases (88%), but it’s unknown if using radiopaque sponges would have improved early identification since most surgeries in this study did not require immediate post-operative radiographs. Understandably, post-operative radiographs are not economically feasible for every abdominal surgery, but the use of radiopaque sponges has lead to their incidental identification in asymptomatic patients, and can be helpful if there is ever any question on sponge count. Ideally, the sponges should be counted at the beginning of surgery and then immediately prior to closure to identify if any are missing prior to completion of surgery. But we understand that mistakes and oversights happen. So VETgirl’s recommendation? Take precautions and use radiopaque surgical sponges; after all, it would be best for the patient’s overall medical plan. And the last big factor reviewed was sponge surveillance – this article found that 14 of the 17 (82%) cases did not have sponge counts recorded. Sadly, in four cases where sponge count was recorded, a sponge was still left behind in the patient, suggesting that other factors are at play such as having too few staff involved in the surgery and poor time management.

There are a couple limitations to this study that are worth mentioning. First, there was a relatively low response rate to the survey (19%). Second, since this survey was distributed at a conference, there’s a chance that multiple people involved in the same case reported individually to this survey. Thus, the true incidence of veterinary gossypiboma may in fact be smaller than was reported here, and contributing factors may have been duplicated by multiple team members.

So, what do we take from this VETgirl podcast? The overall incidence of retained surgical sponges seems to be low, but a large, multi-institutional study would be needed to create a more reflective incident rate. Rushing in surgery, from various causes, having only two staff per surgery, and lack of reporting sponge count, are risk factors for retained surgical sponges in our veterinary patients. Abdominal surgeries were the most implicated surgical procedures for retained surgical sponges. To protect yourself and your hospital from the risk of leaving behind a surgical sponge, consider implementing a sponge surveillance procedure for each surgery, including a sponge count before and after the procedure (but prior to patient closure), and recording these numbers in the surgical report or anesthesia report. Also, radiopaque sponges may help with early detection of retained surgical sponges (and they are worth the cost!). Most importantly, it’s likely ideal to slow down just a little and protect your time given to each case. This means that if you have to bump that elective spay that was added to your already booked schedule, it can wait! Not only is it better for your patient to not have the surgeon be in such a rush, it may help improve your own quality of life a little.

References:
Rodriguez FR, Kirby BM, Ryan J. Evaluation of factors associated with retained surgical sponges in veterinary patients: a survey of veterinary practitioners. J Sm Anim Prac 2018;59(9):570-577.

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