Retained fragmented Raytec gauze eluding an alleged correct postoperative count following cardiothoracic surgery: case report of a rare "never event".

INTRODUCTION

Retained surgical items are rare yet serious complications that may occur despite correct instrument and sponge counts. Surgical sponges remain the most frequently retained items, with gauze marker strand retention being an uncommon mechanism.

CASE PRESENTATION: A 69-year-old male with severe mitral regurgitation and triple-vessel coronary artery disease underwent mitral valve replacement with coronary artery bypass grafting. All surgical counts were verified as correct at the conclusion of surgery. Postoperative chest radiography, however, revealed two linear radio-opaque foreign bodies near the left lower sternum. Mediastinal re-exploration identified two radio-opaque strands, measuring 3.0 cm and 2.0 cm, attached to the left lower chest wall near the internal mammary artery stump. These were confirmed to be detached marker strands from Raytec gauzes. The patient's recovery was uneventful and he was discharged well.

CONCLUSION

This case illustrates that retained gauze fragments can occur despite correct counts due to fragmentation of radiopaque markers. Surgeons and operating room nurses should inspect gauzes for integrity, maintain vigilance when manipulating sponges in confined operative fields, and consider adjunct technologies such as radiofrequency or barcode tracking. In high-risk surgeries, postoperative imaging may be warranted even with accurate counts to ensure patient safety.