Count sponges and instruments

Abdominal surgery involves special anxieties, and one of the worst is the fear that a forceps, sponge, or other foreign body has been left behind in the peritoneum after closure of the abdominal wound. Dr. Neugebauer of Warsaw has published a monograph on this terrible accident which will not reassure us. He classifies 101 cases, so that many operators are laudably candid, whilst necropsies tell terrible tales. In 38 cases the foreign body was only found at the post-mortem examination. In this grim list it is not surprising to find that in 19, or precisely half the cases, the object left behind was a sponge. In 14 cases the foreign body was spontaneously discharged through the anus. This occurrence must imply grave risk to the patient. In 12 cases the body was discharged through an abscess opening through the parietes or into the vagina. In 3 cases the body was missed, searched for and found, just before closure of the abdominal wound. In 7 it was missed just after closure of the wound, the wound was opened and the body removed. There is reason to believe that such an accident is so frequent that to these 10 cases several hundreds might be added. The remaining cases include later operations for removal of foreign bodies, also one in which several years after laparotomy Douglas's pouch was opened through the vagina and the body—a signet ring—removed, and 2 in which the missing body was left in the peritoneum in the hopes that it would be discharged through an abscess. These 3 cases were not treated according to the generally-accepted rules of surgical practice. To calculate the proportion of fatal cases in which the body was detected or came away before a necropsy would be of no value, so different were circumstances in different cases. The operator should remember that sponges seem very deadly, forceps nearly as dangerous, whilst gauze pads more readily tend to come away by the bowel. But the successor failure of secondary operations must depend in part on the severity of the laparotomy itself. Neugebauer notes 2 cases where the abdomen was reopened on a false alarm, nothing having been left behind. Such an occurrence might turn the scale against a severe case. This monograph of Neugebauer's is grave reading, but it must be read. (BMJ 1900;i:1047.)