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|Year : 2014 | Volume
| Issue : 3 | Page : 324-326
Needle in a haystack: Intraoperative breakage of pediatric minimal access surgery instruments
SV Parelkar, BV Sanghvi, SR Shetty, H Athawale, SN Oak
Department of Pediatric Surgery, King Edward Memorial Hospital, Mumbai, Maharashtra, India
|Date of Submission||26-Feb-2014|
|Date of Decision||29-Mar-2014|
|Date of Acceptance||05-May-2014|
|Date of Web Publication||14-Aug-2014|
Dr. S V Parelkar
Department of Pediatric Surgery, King Edward Memorial Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
The search for tiny bits of broken pediatric minimal access surgery (MAS) instruments in an operative field is akin to the search for a needle in a haystack. With the extension of MAS to the pediatric age group, instruments are becoming smaller and equitably more prone to breakage. When breakages occur, retrieval, especially in the pediatric abdominal cavity, can be challenging. Inability to do so would affect patient safety and also lead to a web of medico legal and ethical issues. We present two cases of intraoperative breakage: An eyeless 3-0 polyamide suture needle and a 2-mm grasper blade both of which were successfully retrieved and fortuitously escaped becoming retained surgical items.
Keywords: Broken, eyeless needle, grasper blade, MAS, pediatric, retrieval RSI
|How to cite this article:|
Parelkar S V, Sanghvi B V, Shetty S R, Athawale H, Oak S N. Needle in a haystack: Intraoperative breakage of pediatric minimal access surgery instruments. J Postgrad Med 2014;60:324-6
|How to cite this URL:|
Parelkar S V, Sanghvi B V, Shetty S R, Athawale H, Oak S N. Needle in a haystack: Intraoperative breakage of pediatric minimal access surgery instruments. J Postgrad Med [serial online] 2014 [cited 2020 Feb 27];60:324-6. Available from: http://www.jpgmonline.com/text.asp?2014/60/3/324/138823
| :: Introduction|| |
The adage needle in a haystack is still very relevant. The high-tech laparoscopic operative field presented an unusual "haystack." Breakage of instruments during laparoscopic procedures is uncommon, but their retrieval and localization in the pediatric age group can be challenging. Of over 1220 pediatric MAS over 8 years, we had two cases of breakage and we present both cases in this paper.
| :: Case Reports|| |
A laparoscopic left hernia repair was performed on a 5-year-old boy. Using a 5-mm port and a 5-mm, 30-degree telescope, 23-mm instruments were inserted directly in both the iliac fossae. For the closure of the purse string, with intracorporeal knots, a 3-0 polyamide suture with 16-mm 3/8th reverse cutting needle was used. During knotting the distal two thirds of the eyeless needle was noted to be missing. No "snap" had been perceived during the procedure. No unusual shearing force had been used. The site of breakage at the junction of the distal two-thirds and proximal one-third was the site where the needle was grasped for optimal maneuverability. An extensive search of the abdominal cavity proved futile. Intraoperative X-rays revealed a faint outline of a metallic object in the left hypochondrium [dotted circle [Figure 1]. A careful reinspection revealed the broken bit on the surface of the left lobe of liver, close to the pericardium. The needle was retrieved and the repair completed [Figure 2]. Operative time was increased by 70 minutes, besides the additional radiation. The hospital authorities were notified and a formal complaint was made to the manufacturer.
|Figure 1: (Left-half) Intraoperative X-ray. (Right-half) Laparoscopic view showing needle fragment above the left lobe of liver below the diaphragm|
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|Figure 2: (Left-half) Broken fragment with rest of the needle (after retrieval). (Right-half) Broken fragment of laparoscopic needle holder with rest of the instrument (after retrieval)|
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A laparoscopic right inguinal hernia repair was being performed on a two-year-old boy and two-millimeter instruments were used, directly. When taking the purse string suture, the 2-mm grasper blade broke and fell in the left paracolic gutter, in our field of vision. Removal of the broken blade would entail insertion of a new grasper through the anterior abdominal wall, withdrawal with the broken bit, then reinsertion of the grasper for completion of the repair. On hindsight (imprudently), a decision was made to complete the repair and retrieve the broken blade when withdrawing the instrument, after completion of repair. To our disbelief, the "stable and clearly visible" broken bit was no longer visible. A detailed and stressful search in the bowel loops, omentum and inferior paracolic gutter did not reveal the blade, it having migrated to the superior paracolic gutter. The blade-bit was retrieved [Figure 2] and X-rays were avoided this time. The operative time was prolonged by 20 minutes.
| :: Discussion|| |
In both cases the instruments were introduced without trocars. This has been our practice for some time, to reduce incision size further. Theoretically, this exposes the tips of instruments to more force than they would have encountered, if introduced through a cannula. Both the instruments were from a reputable, local manufacturing company. The eyeless suture needle was a freshly opened piece, not designed for reuse anyway. But the grasper had been used multiple times. In neither case, do the operators recall any unusual acrobatics to generate an excessive shearing force. The manufacturing company was formally informed and the required data passed on to their technical department.
As more paediatric surgeons opt for MAS over the open approach, there is an increasing demand for size-appropriate instruments. In MAS, small is big and smaller, sublime. Maneuvering these tiny precision instruments in highly restricted neonatal and infant spaces provides a hotbed of opportunities for "breakage." Though the literature so far reports intraoperative MAS instrument breakage as an uncommon occurrence, it does not exclude under-reporting. There are reports of intraoperative breakages of MAS instruments, however, none becoming an RSI and none in the pediatric age group. With increasing use of MAS, the incidence of breakage and hopefully their reporting is likely to increase.
Smith et al. in 1993 report "pop-off" loss of a needle during laparoscopic hernia repair.  After a futile search of the abdominal cavity, X-rays revealed the lost needle in the cannula. The valve mechanism of the cannula acts as a potential "trap" to catch fragments of instruments as well as specimens, highlighting the importance of checking the cannula before performing radiological tests to locate broken instruments.  Lynch et al. in 2000 describe the management of a broken suture needle in a ligament during a laparoscopic Burch colposuspension. A grasper was placed along the site of the lost needle before X-ray, thus facilitating location of the broken bit.  Katara et al. in 2005 describe breakage of a fascial closure device during a laparoscopic lymph node biopsy. The broken bit was located in the extra-peritoneal fat by using intraoperative fluoroscopy and probing with a hemostat.  Park et al. in 2008 describe breakage of a needle driver in a robotic-assisted prostatectomy.  The broken bit was promptly located and retrieved from the visible operative field.
When dealing with hitherto undescribed, non-textbook scenarios in the operation theatre, surgeons are required to improvise and come up with innovative means of dealing with them. Ostrzenski in 1997 describes a technique of using a radiopaque grid on the skin of the abdominal cavity during fluoroscopy, to facilitate location of the broken instrument.  Kandioler-Eckersberger et al. in 2002 have described an even more innovative approach to broken intraoperative instruments. They designed a 6-cm magnetic tipped probe, attached to a 40-cm semi-flexible Teflon rod. Its use was practically demonstrated in the retrieval of a reusable laparoscopic grasper tip, lost in the bowel loops.  Macilquham et al. in 2003 concluded in their study that a mobile image intensifier was the radiographic technique of choice for locating surgical needles. 
If breakage of an instrument were to result in an RSI, it is so far notifiable only in the USA and UK. RSIs reported are usually miscounted MAS sponges/soaks or mini pads. RSIs specifically refer to inadvertently left behind items and hence exclude staples, sutures and clips deliberately left behind. Breakage of instruments potentially causes an increase in operative time, anesthesia time, exposure to radiation, increased handling of tissues, conversion to open laparotomy and the ambiguous scenario of becoming a legally loaded RSI. 
In situations of breakage of instruments less than 13 mm, there are additional considerations. These tiny bits show up very poorly on X-rays. In adults, the literature suggests a little expectation of major damage by these tiny RSIs in the abdominal cavity.  Of course, the same tiny size breakage in the small and developing neonatal abdominal cavity begs to be excused comparison and, one suspects, with far more deleterious outcomes.
Worldwide RSIs are regarded as a surgeon's nemesis. Despite the fact that most RSIs occur in "large stakeholder" culture operation theatres, the sole legal responsibility rests with the operating surgeon. Thus, an impeccable record of surgical skills and repute is liable to get reduced to shreds by media and peer-ridicule attributable to these tiny culprits.  In the foreseeable future, the term "sole legal responsibility" is likely to require clarifications. If the surgeon encounters breakage, and despite all efforts, it leads to an RSI, are the manufacturing companies completely absolved of any responsibility? MAS is, after all, a highly evolving field, still in its steepest part of the learning curve.
Certain precautions taken during laparoscopic procedures may help decrease the incidence of RSI in MAS. Broken instruments, if visible, ought to be retrieved without delay. Migration of broken bits following non-gravitational "wick-action" laws of fluid movement may occur. The cannula should be checked for "caught" broken bits. Operative field radio-opaque markers, e.g. instruments or grids during fluoroscopy, may aid in the localization of the broken instrument. In high turnover laparoscopic units, such as ours, it might be prudent to invest in the Kandioler-Eckersberger magnetic-tip probe.  Instruments, especially, those designed for multiple use, should be checked before introducing them into the surgical field. Uniform hospital-based policy and initiative against RSIs- 'Nothing to leave Behind' model recommended by Verna Gibbs, has been adapted and adopted voluntarily by many hospitals across the USA.  It is recommended that the hospital administration invests in high-quality MAS instruments, especially for neonatal and infant age group. All data regarding such instances should be published despite the mortification accompanying it, and reporting and publishing of similar incidents should be encouraged for the sake of global medical betterment and learning.
| :: Acknowledgment|| |
We would like to acknowledge and thank Dr. Renuka S. Parelkar, for her help in modifying and rewriting this article.
| :: References|| |
|1.||Smith BM, Brown RA, Lobe TE. The lost needle: A laparoscopic dilemma. J Laparoendosc Surg 1993;3:425-6. |
|2.||Lynch CM, Powers AK. Management of a broken needle at the time of laparoscopic burch. JSLS 2000;4:275-6. |
|3.||Katara AN, Bhandarkar DS, Shah RS, Udwadia TE. Breakage of fascial closure device during laparoscopic surgery. J Minim Access Surg 2005;1:79-81. |
|4.||Park SY, Cho KS, Lee SW, Soh BH, Rha KH. Intraoperative breakage of needle driver jaw during robotic-assisted laparoscopic radical prostatectomy. Urology 2008;71:168.e5-6. |
|5.||Ostrzenski A. An intraoperative method of localizing a missing piece of a broken laparoscopic instrument. Am J Obstet Gynecol 1997;176:726-7. |
|6.||Kandioler-Eckersberger D, Niederle B, Herbst F, Wenzl E. A magnetic probe to retrieve broken metallic parts of instruments during laparoscopic procedures. Surg Endosc 2002;16:208-9. |
|7.||Macilquham MD, Riley RG, Grossberg P. Identifying lost surgical needles using radiographic techniques. AORN J 2003;78:73-8. |
|8.||Barto W, Yazbek C, Bell S. Finding a lost needle in laparoscopic surgery. Surg Laparosc Endosc Percutan Tech 2011;21:e163-5. |
|9.||Gibbs VC. Retained surgical items and minimally invasive surgery. World J Surg 2011;35:1532-9. |
[Figure 1], [Figure 2]