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Retained swab after varicocele ligation

01 September 2006

Mr D, a 45-year-old boat builder, was referred to a urology consultant, Mr E, with a history of left-sided scrotal pain. Dr E diagnosed a varicocele, which was subsequently confirmed on ultrasound.

Mr D was counselled regarding surgical ligation of the varicocele and gave his consent to a repair, which Mr E performed. Immediate postoperative progress was recorded as satisfactory.

Six weeks later Mr D visited Dr E complaining of wound pain and discharge. Mr E assessed him and diagnosed a superficial wound infection. He prescribed antibiotics and regular dressing. Mr D sought a further opinion from a consultant general surgeon, Mr T, who performed an x-ray of the inguinal region and found a retained surgical swab from the recently performed procedure.

Mr E consulted the operation record and found that the surgery was duly entered into the log but he was shocked to see that there was no entry in the swab record. Mr T removed the swab from the incision and several months later performed an inguinal hernia repair, since the infection had caused damage to the inguinal canal.

Mr E accepted that his actions were indefensible. However, he felt that the liability should be shared by the hospital.

The hospital agreed to pay 50% of the damages. These were mostly to cover the complication of the hernia repair and the psychological stress. They also covered pain, suffering, nursing care, the impact on Mr D’s domestic, social and leisure pursuits and his inability to perform tasks around the home.

The claim was settled for £80,000 (US$150,000), divided equally between Dr E and the hospital. 

Learning point

  • There is a difference between responsibility and liability. In the operating theatre, and in healthcare generally, it is good practice to work as a team, and take responsibility as a team. This is a key message of corporate governance. However, like the much-used analogy of the captain of the ship, the surgeon is still liable when mistakes are made. However minor the procedure, there should always be a check on swabs and instruments. As the old maxim has it, there is no minor surgery, only minor surgeons.

Further information

The Risk and Quality Management System published by the Association for Perioperative Practice with involvement from MPS, provides a tool to assess risks and improve patient care in the peri-operative environment. On the subject of retained swabs, the audit includes the following criteria:

  • The surgeon is audibly informed of the results of the first swab, instrument and needle check (prior to closure of the first layer or cavity).  
  • The surgeon is audibly informed of the results of the final swab, instrument and needle checks.  
  • The swab, instrument and needle check is recorded in accordance with local policy, which reflects national recommendations.

See www.afpp.org.uk for more details.