Don't forget the sponge

Sponges - they help us visualize, tissues and structures, help with hemostasis, help us retract tissue, and can be incredibly useful in dissection and other surgical procedure. But when coated in blood they can be incognito. They blend in with their surroundings, and they can be tucked under tissue or instruments out of sight. The dreaded situation of leaving a surgical sponge behind - meaning forgotten in a patient’s body -  is something anyone who does surgery wants to avoid. Despite that it is still a situation that has befallen even the best surgeons. 

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What can happen when a surgical sponge is left behind? When an incision is sewn up with a surgical sponge still inside, it can result in serious infections and other potentially debilitating complications, which in the most severe cases can even lead to death.

Models to determine the carcinogenic properties of surgically implanted sterile foreign material have been developed in animals. The surface of the implanted foreign material is soon covered with plasma proteins and surrounded by neutrophils, lymphocytes, and monocytes. The monocytes differentiate into macrophages and form multinucleated giant cells, making up most of the cells surrounding the foreign material. Eventually a fibrous connective tissue capsule forms around the foreign material to create a microenvironment for the proliferation of abnormal mesenchymal stem cells, making this microenvironment possibly the most important determinant of transformation into a neoplastic process. The generation of free radicals3 and mutation of normal cells appear to play a role in the perpetuation of chronic inflammation and the eventual development of tumors and is described in detail elsewhere.

Risk factors: 

1. Emergency surgery - when there is profuse hemorrhage during an emergency surgery, there is a tendency to use many sponges and pads. This increases the likelihood of some being forgotten if the surgeon and the scrub nurses are not vigilant. ]

2. Fatigue - late night surgeries, more surgeries than you’re comfortable with (Fatigue)

3. Unexpected complication

4. Unplanned procedure

5. Distractions in the operating galler

6. Break in normal sequence of procedure 

7. Large patients  (Patient Obesity) 

8. Poor communication between the technical staff and surgeons - 

9. Staff changes 

Solutions: 

1. Keep sponges a certain distance from the incision 

2. Communicate with team member  Ask you team member to help you remember. ‘I placed a sponge next to the liver. Please record that on a post it note to help us remember 

3. Pre-count sponges - and have that verified with your scrub nurse. If you’re not scrubbing in with an assistant for that procedure then perform a scrub count twice 

4. Keep sponges in a centralized location 

5. Use laparotomy sponges if possible; keep Radiopaque sponges to a minimum 

6.              Post op sponge count 

7.              Radiographs - A radiograph is helpful if you are using a radiopaque gauze but keep in mind that if you left one behind then that means you have to bring your patient back to the operating room which is not good for a variety of reasons

8.              Swabs should only be used intra-abdominally if they are “mounted on a stick” (Cotton tipped applications) 

9.              Newer technologies for gauze tracing include electronic article surveillance systems which uses tagged surgical sponge that can be detected electronically, in which barcodes are applied to all sponges and detectable with bar code scanners. However, these new technologies are not yet in general use. 

10.           There are likely more solutions -- I encourage you to share your solutions down below because Knowledge is power and Information is liberating.