[5845951]
While performing a cancer staging procedure laparoscopically, a piece of omentum was taken and placed in an endocatch bag. It was left inside the patient with the intent of retrieving it later, as it was too large to be delivered through the assist port, and was going to be removed vaginally. The specimen was moved aside while the rest of the procedure was performed. The strings that remain outside the trocar were likely cut accidentally, and retracted into the patient who was then placed in steep trendelenburg and had a robotically assisted hysterectomy. Although the abdomen was irrigated, the specimen was not seen, as it presumably migrated under an organ. Consequently, the omentum specimen was not retrieved as intended at the end of the long case, and this was not discovered until the patient was in the pacu. As a result of this incident, we have implemented changes in our practice to prevent similar events; however, we would recommend that covidien add a radiopaque strip if possible to the endocatch bags as an additional safety measure so that the bags can be detected when the patient is wanded at the end of the procedure before the skin is closed.
Patient Sequence No: 1, Text Type: D, B5