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Abdominal Re-exploration for a Missing Needle Following Cesarean Delivery: The Power of Suggestion
Abstract Number: SU-53
Abstract Type: Case Report/Case Series
Case Description: A healthy 38-year-old gravida 3, para 1 female presented urgently to the operating room at 3 a.m. for repeat cesarean delivery for nonreassuring fetal status after a prolonged trial of labor. Surgical anesthesia was obtained with a pre-existing epidural catheter. Dissection to the uterus was difficult due to significant adhesions. After delivery of the newborn, the patient required methergine in addition to oxytocin infusion for uterine atony. After closure of fascia, the surgical instrument count was incorrect with one missing curved suture needle. An intra-operative AP X-ray was ordered (Figure). The preliminary report by the radiology resident on call identified a needle to the right of midline at the L1 vertebral body. The patient was re-explored meticulously in search of the suture needle. Upon exploration and exteriorization of the uterus, recurrent atony required a second dose of intramuscular methergine. With brisk, continued blood loss, additional intravenous and arterial access were obtained and the patient was stabilized. Re-exploration did not reveal a needle in the abdomen. A second AP X-ray was obtained to see if the needle was displaced from the original location. This more cephalad view, along with a lateral X-ray confirmed that the object had not moved and was located posterior on the back. The curved suture needle originally identified was, in fact, an epidural catheter taped to the back in a curved fashion. The abdomen was closed and estimated blood loss for the case was 1500mL.
Discussion: The risk of retained instruments after surgery significantly increases in emergency procedures.1 In this case, while there was no actual retained foreign body, the circumstances in which information was presented indicated re-exploration. Misinterpretation of an epidural catheter on X-ray as a retained foreign body after laparotomy has not been described in the literature. Unnecessary surgical re-exploration certainly leads to increased morbidity in patients. Re-exploration in this patient may have been avoided by accurate instrument count or recognition of the epidural catheter in the original X-ray. Furthermore, careful communication between surgeons, anesthesiologists, and radiologists about clinical context, including the presence of indwelling lines, is paramount.
1. Gawande AA et al. Risk factors for retained instruments and sponges after surgery. NEJM. 2003;348:229-235.