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Updated: Jul 31, 2025
Intraoperative Ultrasound in Spinal Surgery
Published on: August 17, 2022
A perioperative overview of a retained surgical swab in spinal surgery: Case report and prevention protocol
Shahnawaz Haleem1, Mohamed Hassan Mahmoud2, Gurvinder Singh Kainth1
1The Royal Orthopaedic Hospital, Birmingham, UK.
Introduction:
Retained wound swabs although classified as a 'never event' and well documented in many surgical specialties are uncommon in spinal surgery. The aim of this article is to highlight the perioperative circumstances of an incident of a retained surgical swab and present a prevention protocol, in an attempt to eliminate its incidence.
Case Report:
The perioperative management of a 53-year-old male undergoing spinal surgery in whom a surgical swab was retained is reported. In addition to existing safety procedures such as the World Health Organization checklist, a Retained Surgical Swab-Prevention Protocol was implemented in our hospital and is presented to eliminate the occurrence of this 'never event' occurring again.
Conclusion:
Retained surgical swabs or instruments are rare in spinal surgery occurring mostly in the lumbar spine, during emergency and prolonged procedures in patients with high body mass index. Maintaining a high index of suspicion and utilising a prevention protocol will prevent further harm to the patient.
