Gossypiboma is the medical term describing the condition ...



Abstract

Gossypiboma refers to a condition of retained surgical sponges. Although gossypiboma occurs rarely, the rates are increasing every year. The smaller sponges tend to be lost more frequently than the larger lap sponges obviously because of their smaller size. Several factors including team fatigue and hurried or poor counts contribute to the onset of gossypiboma. Thus the goal of this project was to design a device that would accurately keep count of all laparotomy sponges used during the surgeries. The device consists of a color-coded system that enables the nurses to accurately distinguish and keep count of the sponges and thus reduce if not inhibit the condition of gossypiboma.

Introduction

Gossypiboma is the medical term describing the condition when surgical sponges are retained within the patient’s body. Surgical sponges are most likely retained in patients who have previously received an abdominal laparotomy or vaginal surgery. During surgery, each member of the operating team has a part in keeping count of all lap sponges provided, however it is the final responsibility of the scrub nurse and the circulating nurse to keep accurate count of all sponges used. Thus, if the sponges are not accurately accounted for, the situation could result in gossypiboma. From 1985 to 1998, the incidence of objects being left in patients has occurred at a steady rate of more than 40 per year. 601 of those cases have involved hospitals, surgical clinics, and TDC-insured physicians.(1,4,5) Most of the incidents involve the 4x4 laparotomy sponge. Although this rate is not yet threatening to the hospitals, the numbers are steadily increasing every year.

The recommended count that in is use today by most hospitals consists of four separate counts: 1) when the sponges are unpacked, 2) before the surgery begins, 3) as the closing of the surgery begins, and 4) during the closure. The nurses count the larger size sponges by fives and the smaller sponges by tens. The surgical sponges are made of gauze material and are used to soak and wipe up the blood and other bodily fluids during the surgical procedure.(2,8) The laparotomy sponges come in several different sizes and the larger the dimensions, the thicker the sponge. The most commonly used sizes are 4x4, 4x8, 12x12, and 18x18 inches. Obviously the 4x4 inch sponges are most likely to be retained because of their small dimension. In recent years, radiopaque materials have been placed in sponges to enable them to be detected by x-ray.3 Factors that lead to gossypiboma include hurried counts, sponges sticking together, team fatigue, and fewer counts than recommended. Many times during surgeries, the blood and fluids from the patient’s body may cause the lap sponges to stick together. An inexperienced nurse would not be very keen on realizing that two sponges are stuck together and pulling them apart to get a correct count. Thus the two sponges will be counted as one and the risk of having a retained sponge increases. Team fatigue would also be a problem if a team has been in surgery for several hours and doesn’t have the energy or the desire to accurately count the sponges. Also, during a speedy surgery where it may be detrimental to the patient if too much time is taken trying to keep count of the sponges, the nurse may risk assuming that everything is accounted for and thus again increases the risk of gossypiboma.

Many people have gone for several years without any difficulty or knowledge of having a laparotomy sponge retained within their body. Conversely, others have developed several complications that seriously affect their health. The complications include inflammatory reaction, obstruction, abscess formation, abdominal pain, tumors, hernias, nausea, vomiting, and fibrinous responses. Once a patient complains of such symptoms after a surgery, the doctor could have them x-rayed and the x-ray detectable band attached to the sponge can verify if indeed a sponge has been retained. The problem with retained sponges is both problematic for the patient and also for the hospitals. Not only does the patient suffer from the troubles caused by the lost sponge, but they must also have another surgery just to remove the sponge. This could cause the hospitals thousands of dollars in lawsuits. The verdicts of such cases have resulted in patients receiving as little as $50,000 to as much as 500,000.(6,7,9) The goal of this project was to create a device that would keep an accurate count of surgical sponges so that surgeons will not leave the sponges inside of the patients' bodies. The numbers of sponges used during surgeries range from lower than four to as much as 100 in excessive cases. Obviously the larger counts make the device necessary. The number of operations per year that mainly involve lap sponges is approximately 29,328,00. One can only imagine how many lap sponges can get lost and retained going by these numbers. Thus it was crucial that a device be made that would reduce if not prevent the chances of patients leaving the hospital with laparotomy sponges retained in their abdomen.

Methodology and Results

The system structure consists of a trashcan much similar to the containers currently used in hospitals. The unit has wheels attached to minimize tipping over and causing the contents to contaminate the operating room. The trashcan is divided into four different sections in order to collectively hold more than one size of lap sponge. Within each division is also a colored bag that will hold the colored zip lock bags. Bag rings were also attached to device to ensure that the opening of the plastic bags were wide enough to easy collect the zip lock bags. Three bag holders were placed on the device to keep the dividers and the plastic bags in place. In this way, everything is kept sanitary. During surgeries, hospital teams do not normally use more than two to three types of lap sponges on the patients. Thus a four-way divided container should be more than enough for any extra sponge sizes that may be used, or two different divisions can be used to hold one sized sponge. The important thing about each division is that they will be color-coded. As the nurses count the sponges during in their usual counting procedure, instead of them placing the sponges in the trashcan or in another close-by container, they place the sponges in color-coded zip lock bags that correspond to each of the colors of the trashcan divisions. Since the nurses count the smaller sponges by fives and the larger ones by tens, the bags are large enough to accommodate these numbers. Not only does this system speed up the process for keeping count of the sponges, but also the color-coded trashcan and bags help to ensure that each sponge goes into the correct container. In this way, it is easier for the nurses to determine if all sponges are accounted for. If all sponges are not accounted for, the nurses can check each pack and then the patient to make sure that nothing is left inside of the body. After the sponges have all been collected and the counts have been accurately matched, the hospital team and the patient can rest assured that no other surgeries will be performed because of gossypiboma. The nurses can take the same precautions for this machine as they take with any container containing bodily fluids or biohazardous materials. The life cycle of the product would be fairly long, lasting about the same amount of time as any trashcan. Since wheels are attached, the product could have a very long life cycle because the wheels reduce the risk of the trashcan tipping over and becoming damaged. The total cost of the device was a little less than $60. Hospitals should think it a good investment to have a $60 machine that could save them as much as $500,000 in law suits.

Conclusion and Recommendation

The device holds to be very efficient for the nurses who need an accurate method for counting the laparotomy sponges. This product has great potential to be a top of the line market item. It can be sold to hospitals all over the world that need to reduce or possibly eliminate their percentage of gossypiboma cases. The device is easy to use, reasonable, and accurate. It provides a method for keeping all sponges together and accurately accounted for. The speed of the overall counting process also increases. A lost sponge will be found quicker by going through the zip lock bags (which should only include 5 or 10 lap sponges). The color-coded system makes it easy to distinguish different sized lap sponges and thus reduces the chance of leaving the sponges inside of a patient.

References

1. Rappaport W, Haynes K. The retained surgical sponge following intra-abdominal surgery. A continuing problem. Arch Surg 1990 Mar;125(3):405-7 UI:90165740

2. Zbar AP, Agrawal A, Saeed IT, Utidjian MR. Gossypiboma revisited: a case report and review of the literature. J R Coll Surg Edinb 1998 Dec;43(6):417-8 UI:99144605

3. Kaiser CW, Friedman S, Spurling KP, Slowick T, Kaiser HA. The retained surgical

sponge. Ann Surg 1996 Jul;224(1):79-84 UI:96289480

Comment in: Ann Surg 1997 Apr;225(4):442

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Figure 4: Prototype of the device

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Figure 5: Color-coded Zip lock bags

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Figure 3: Retained sponge shown by x-ray detectable band

Figure 1: Larger size sponges with x-ray detectable bands

Figure 2: Smaller sponges with x-ray detectable bands

Figure 6: Total cost of product

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