Description of Event or Problem · 1
THE PATIENT WAS ADMITTED FOR A RECTAL MASS AND TAKEN TO SURGERY FOR A SIGMOIDOSCOPY, LAPAROTOMY, AND LOWER ANTERIOR RESECTION OF THE RECTUM WITH END-TO-END ANATOMOSIS. MULTIPLE REMOVAL METHODS (SIX HOURS WORTH OF SURGERY) WERE ATTEMPTED INCLUDING ENDOSCOPICALLY, BUT THE MASS WAS LEFT TO BE UNRESECTABLE FOR THE ATTEMPTED APPROACHES. SO, AN OPEN INCISION WAS MADE THROUGH THE ABDOMEN AND THE MASS WAS REMOVED FROM THE RECTUM. A 10-FLAT DRAIN WAS PLACED IN THE PELVIS AND THE ABDOMEN WAS CLOSED. SUBFASCIAL CATHETERS WERE PLACED THROUGH THE SKIN FOR INFUSION OF LIDOCAINE POSTOPERATIVELY. ALL NEEDLE AND SPONGE COUNTS WERE CORRECT AT COMPLETION OF THE PROCEDURE. PATIENT DISCHARGED HOME A WEEK LATER WITH WOUNDS HEALING WELL AND SPONTANEOUS RETURN OF BOWEL FUNCTION. THREE WEEKS LATER THE PATIENT ARRIVED AT THE PHYSICIAN'S OFFICE COMPLAINING OF BURNING AND RIGHT-SIDE ABDOMINAL PAIN. DRAINAGE NOTED FROM THE UPPER PORTION OF INCISION. CT SCAN WAS PERFORMED IN OFFICE AND REVEALED A SEGMENT OF TUBING NOTED STARTED AT THE RECTUM SHEATH AND ALSO IN THE SUBCUTANEOUS FAT. THE PATIENT WAS TAKEN BACK TO SURGERY WITH THE SAME SURGEON FOR THE REMOVAL OF A RETAINED FOREIGN BODY IN THE ABDOMINAL WALL AND PLACEMENT OF A WOUND VAC TO BOTH THE FOREIGN BODY REMOVAL SITE AND THE UPPER INFECTED INCISION. THE FOREIGN BODY THAT WAS REMOVED FROM THE PATIENT WAS THE SHEATH USED WITH THE BLUNT TUNNELER FOR PLACEMENT OF THE ON-Q PAIN SYSTEM. MANUFACTURER STATED THAT THIS HAS NEVER HAPPENED BEFORE. SUGGESTED THAT THEY THINK ABOUT PUTTING A COLORED MARKING ON THE END OF THE INTRODUCTION SHEATH SO THAT THE SURGEON COULD DETERMINE THE INTACTNESS OF THE SHEATH UPON REMOVAL. THEY SAID THAT THIS WOULD TAKE YEARS AND SINCE THEY HADN'T HEARD ABOUT IT BEFORE AS BEING AN ISSUE THAT THEY WOULD PROBABLY NOT MOVE ON THIS RIGHT AWAY.