Gossypiboma during orthognathic surgery: A case report

Area of Science:

• Medical Devices
• Surgical Complications
• Patient Safety

Background:

• Nasopharyngeal temperature probes are used during orthognathic surgery.
• Dislodgment of these probes or unretrieved device fragments (UDFs) is a rare but serious complication.
• The exact mechanism of probe dislodgment remains unclear.

Observation:

• A case report details a 12-cm temperature probe dislodging after orthognathic surgery.
• The probe was presumed removed post-operatively but was later coughed up by the patient.
• The patient experienced mild throat irritation and coughing prior to retrieval.

Findings:

• This is the first reported case of a missing temperature probe after orthognathic surgery.
• A literature review on UDFs and gossypiboma in surgical cases was conducted.
• Clinical practice modifications were implemented following this event.

Implications:

• Enhanced vigilance by surgical and anesthesia teams during patient extubation is crucial.
• Ensuring complete device removal or maintaining visibility outside the oral/nasal cavity can prevent complications.
• Alternative nasopharyngeal temperature probe insertion routes with covers may be beneficial for orthognathic surgery.