Introduction
Retained surgical foreign bodies have been a well-described phenomenon in the surgical literature. Such surgical complications specifically in Mohs micrographic surgery (MMS), however, are exceedingly rare.1 Here, we report a case of instrument failure during MMS, where intraoperative breakage of surgical scissors led to a retained foreign body in the scalp.
Case report
A 59-year-old male presented to clinic for MMS of a biopsy-confirmed squamous cell carcinoma, keratoacanthoma-type of the vertex scalp (Fig 1, A). Excision was completed in one stage, yielding a 2.2 × 1.7 cm defect to the depth of subcutaneous tissue with clear margins.
Fig 1.
A, Squamous cell carcinoma keratoacanthoma-type of the vertex scalp. B, Repair after removal of the scissor fragment.
The patient opted for closure of the wound rather than healing with secondary intention, to decrease risks of scarring and alopecia. To accommodate closure, the surgeon undermined the scalp down to the sub-galeal plane. In order to avoid excess tension with linear repair, closure was achieved with a rhombic transposition flap with a single Z-plasty, utilizing 4.0 Monocryl and 4.0 Prolene sutures. This flap was chosen given the surgeon’s past experience with favorable cosmetic outcomes. The patient tolerated the procedure well and the initial postoperative course was uneventful.
After the patient had left the surgical suite, the surgical nurse noticed the tip was missing off the surgical scissors used throughout the procedure (Fig 2). After careful inspection of the surgical field and the floor, the scissor tip was unable to be located.
Fig 2.
A and B, Broken scissor tip, Mueller, and Steven's Tenotomy. Stock number OP5691.
The patient was contacted immediately and asked to return the following day for an explanation of the preceding events. The patient agreed to x-ray imaging of the surgical site, which located the scissor tip along the midline of the surgical wound, just above the galea (Fig 3). Following this discovery, the physician who had performed the surgery had a face-to-face discussion regarding the risks and benefits of removing the scissor tip, and subsequently, the patient opted for removal of the foreign body. An incision was made along the original surgical wound, the flap was elevated, and the scissor tip fragment was located just underneath the flap. The fragment was removed without complications or out-of-pocket cost to the patient (Fig 1, B).
Fig 3.
X-ray image identifying the location of the retained scissor tip along the midline of the surgical wound, at the level of the galea. The arrow in the image is pointing to the retained scissor fragment.
Discussion
Unintentionally retained surgical foreign bodies have been associated with increased morbidity, as well as increased costs and medicolegal consequences. The potential harm caused by such retained foreign bodies varies and is largely related to its location and composition.2 Depending on these factors, foreign bodies can either be removed through surgical intervention or left in situ.
Instruments and devices made of stainless steel (as in the case of surgical scissors) are considered to be relatively inert, and thus, retained foreign bodies of this material are fairly well-tolerated.2 Many have advocated for conservative management of such metallic foreign bodies in soft tissue, citing minimal inflammatory reactivity,2,3 lower risk of infection, and the risk of additional tissue trauma with removal rather than leaving in place.4 Despite the low risks of leaving such asymptomatic foreign bodies in place, surgeons must be aware of certain key safety concerns and long-term complications, including metal allergy, Magnetic Resonance Imaging (MRI) implications, and although rare, foreign body reactions.
Stainless steel is an iron-based metal alloy that contains varying amounts of iron, nickel, chromium, and molybdenum. As the incidence of nickel allergy in the Western population is reported to be as high as 20%,5 surgeons must be aware of the development of potential allergic reactions to the nickel component of such surgical tools. Multiple cases of nickel allergy have previously been reported with the use of surgical devices, such as stainless steel surgical staples and metal clamps; adverse events commonly included pruritic eczematous or urticarial eruptions.5 Such allergies are a risk for bacterial superinfection or can impact wound healing.
MRI compatibility and safety are also of concern with retained metallic foreign bodies. The presence of stainless-steel surgical implants was shown to be associated with a moderate amount of artifact on MRI; this may potentially hinder MRI assessment if the area of interest is in close range to the respective surgical implant.6 Aside from functionality, MRI safety concerns in patients with ferromagnetic materials include the possibility of migration through tissue,7 which may, in turn, cause unintended neurovascular damage. Despite these risks, retained metallic objects are not an absolute contraindication to MRI imaging, which can safely be performed after taking into account the proximity to vital organs, MRI strength, and other safeguards.8
Foreign body reaction to stainless steel implants is rare but has been reported. One case described an 87-year-old patient with an unusual lesion resembling a basal cell carcinoma on the nasal bridge, found to be a foreign body reaction to stainless steel wire 3 decades after implantation.9 Another case reported a 77-year-old patient who developed a foreign body granuloma in the form of a cutaneous nodule with episodic bloody discharge, stemming from a retained stainless steel temporary epicardial pacemaker wire.10 Both aforementioned cases necessitated removal of the foreign body fragments.
With this in mind, individualized discussions with patients must take place, focusing on informed consent and highlighting both the aforementioned long-term risks and benefits of leaving an asymptomatic foreign body in place. Additionally, the surgeon needs to address any contraindications of removal, which may include proximity to vital structures, inability to locate the foreign body, or tolerability of the procedure. With this information, physicians can better guide patients to make appropriate decisions about their care.
Conclusion
In summary, we present a case of intraoperative breakage of surgical scissors leading to a retained foreign body in the scalp, which was subsequently located and removed. We highlight the importance of disclosing the event early, offering imaging to locate the object, and encouraging prompt discussion on both the risks and benefits of removal or preservation of the foreign body. This patient-centered process will facilitate informed clinical decision-making and allow for prompt management of this uncommon and unexpected clinic outcome.
Conflicts of interest
None disclosed.
Footnotes
Funding source: None.
IRB approval status: Not applicable.
Statement of prior publication or submission: Information contained in this manuscript has not been presented, published, or submitted elsewhere.
Consent: Consent for the publication of all patient photographs and medical information was provided by the authors at the time of article submission to the journal stating that all patients gave consent for their photographs and medical information to be published in print and online and with the understanding that this information may be publicly available.
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