Intraluminal migration of retained surgical sponge as a cause of intestinal obstruction

Despite near-universal implementation of protocols for surgical sponges, instruments and needles, incidents of retained surgical foreign bodies (RSFB) continue to be a significant patient safety challenge. We report a case of a 29-year-old woman who presented with small intestinal obstruction caused by complete intraluminal migration of a retained surgical sponge into the intestine 9 months after cesarean section. The diagnosis was confirmed by plain abdominal radiograph. The patient underwent exploratory laparotomy, sponge removal and became completely asymptomatic. Although safety standards for hospital employees have been developed during the past decades, no detection system to date has been evaluated as a replacement for traditional manual counting protocols and procedures. The best approach is the prevention of this condition, which can be achieved by implementation of standardized institutional regulations and strict adherence to them. Perhaps, with increasing use of the new technologies as adjunct to the counting, the incidence of RSFB will fall dramatically.