Detection of a Missing Surgical Device during Laparoscopic Gynecologic Surgery: Case report

Misplacement and retention of a small surgical device should be avoided because it may result in complications such as infection or injury. Compared to a laparotomy, because of limited visualization during laparoscopic surgery, loss of a small surgical device is more likely and detection is more difficult. A 48-year-old woman underwent a total laparoscopic hysterectomy for cervical adenocarcinoma in situ. During the surgery, we used 5 mm metallic clips for bundling the tapes, which marked the ureters. When we removed the tapes and clips through a 12 mm trocar following removal of the uterus, one of metallic clips was missing. Laparoscopic exploration of the abdominal cavity, a search of the entire operating room, and exploration of the interior of the trocar failed to detect the clip. We then ordered abdominal X-rays while the patient was still under anesthesia; however, the item was not located. Subsequently, an X-ray of the trocar detected the clip buried deep within it. Detection of small devices are difficult during laparoscopic surgery; therefore, we should handle them carefully.