Delayed Diagnosis of Retained Surgical Blade 12 Years Post-Hysterectomy: A Rare Case Report

TL;DR

A rare case of a surgical blade left inside a patient for 12 years is reported, highlighting the need for better detection and safety protocols.

Contribution

A unique case report of a retained surgical blade diagnosed 12 years post-surgery, emphasizing diagnostic and systemic challenges.

Findings

Chronic abdominal pain led to the discovery of a retained surgical blade 12 years after a hysterectomy.

Nonspecific symptoms and reliance on manual counting contribute to delayed detection of RSIs.

Improved technologies and standardized protocols are needed to prevent such occurrences.

Abstract

Retained surgical instruments (RSIs) are rare but serious surgical complications. This report presents a unique case of a retained surgical blade identified 12 years post-hysterectomy, highlighting diagnostic challenges and the need for vigilance.

A 60-year-old female presented with chronic abdominal pain for 4 years, initially misdiagnosed as urinary tract infection (UTI) and gastritis. Investigations, including X-ray and computed tomography scan (CT scan), revealed a retained surgical blade. Elective laparotomy was performed, and the rusted blade, encapsulated by the omentum, was removed. Postoperative recovery was uneventful.

The delayed diagnosis underscores vulnerabilities in surgical safety protocols. Nonspecific symptoms of RSIs often lead to delayed detection. While manual counting is the standard, human error can occur. This case emphasizes the need for advanced technologies and standardized protocols. Underreporting of RSIs obscures true rates, necessitating improved data transparency and systemic learning.

This case highlights the importance of multidisciplinary collaboration, technological integration, and institutional accountability to prevent RSIs. Enhanced postoperative surveillance and heightened clinical suspicion are crucial. This will improve patient safety and uphold healthcare credibility. This case underscores the need for long-term postoperative vigilance, even in the absence of immediate symptoms.

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