No Sponges Left Behind

Avoiding retained surgical items should be a united concern among all members of the operating team. Retained surgical items are a completely preventable event that can result in serious implications for all involved parties including the patient, hospital, and medical care providers.


Although the incidence of retained surgical items is relatively low, estimated to only occur in approximately 1 out of every 5,500 surgeries,1,2the legal compensation costs associated with these incidences can range from $37,041 up to $2,350,000 depending on the severity and harm caused to the patient.1Surgical sponges are the most commonly reported retained surgical item and will be the primary object of discussion in today’s post.1,3


Risk Factors

An increased risk of having a retained surgical item is associated with each of the following conditions:1,4

  • Higher BMI
  • Emergency surgery
  • Unexpected change in the procedure
  • Higher number of procedures performed
  • Longer duration of surgery
  • Operation located in the abdomen, pelvis, or thoracic cavity



Retained sponges are typically identified quickly following a procedure.3Prompt detection most commonly occurs during routine follow-up visits through post-op x-rays, an irregular inflammatory response, or the patient’s subjective report of pain and discomfort.4,5Some hospital organizations have implemented routine x-ray screening for patients undergoing surgery in a body cavity prior to transporting the patient to the recovery room. The aim of this directive is to ensure incorrect surgical counts have not occurred causing a sponge to be unintentionally retained in the patient’s body. These earlier detection methods have been shown to decrease the incidence of retained surgical items thus improving patient outcomes.1


Althoughthe health consequences resulting from a retained surgical sponge can develop immediately following the operation, in some instances it can take months or even years for signs and symptoms to manifest.1,3Determining if a retained sponge is present can be especially difficult as the time since surgery increases, because patient complaints are often non-specific when a retained surgical item is the culprit. A patient report of unusual pain in the general area the operation took place, frequent infections following surgery, or a palpable mass could suggest the presence of a retained surgical body.3If a retained surgical sponge is believed to be present months or years following surgery, a CT scan is important to perform in order to establish a definitive diagnosis.1,3


Consequences of Retained Sponges 

Numerous complications can develop from a retained sponge. Regardless of whether or not the retained item is found immediately after surgery or years later, treatment for a retained sponge involves the surgical removal of the item once found. Even if the person is asymptomatic surgery to remove the sponge is still warranted.1The surgical removal of a sponge left behind consequently results in either a prolonged hospital stay or a hospital readmission, which significantly increases hospital spending.


In addition to having to undergo an additional operation, the patient may also experience a number of other health complications related to a retained sponge. Death due to a retained surgical item is rare, but has occurred in some instances1,4 The most common health problems related to retained surgical items include:1

  • Infection and sepsis
  • Intra-abdominal abscess
  • Fistula/bowel obstruction
  • Bowel rupture


Careful Counting

Manual counting protocols are the most commonly utilized strategy to prevent retained surgical items, but these methods are prone to human error.4The complex, fast-paced environment of the operating room is thought to contribute considerably to incorrect counts. This type of hectic environment is likely why emergency surgeries and unexpected changes during surgery increases the risk for a retained surgical item.


In fact, studies have found that approximately 80% of the cases related to retained surgical items happened despite the counted number of sponges at the end of surgery being correct.4Researchers have concluded that a breakdown in communication is the most important factor to reduce the incidence of retained surgical items.3 In 2015 The Association of Operating Room Nurses published a “Nothing Left Behind” policy recommending for sponge and surgical instrument counts to be performed visually and audibly 5 times at specific intervals throughout the procedure.6


Discovering that a surgical item has been left in a body is an event that no patient or member of the operating team ever wants to experience. Despite the relatively low prevalence of these occurrences, because retained surgical items are considered a “never event” the legal payout for medical malpractice claims comes at a high cost to hospitals.



  1. Hariharan D, Lobo DN. Retained surgical sponges, needles and instruments. Ann R Coll Surg Engl. 2013;95(2):87–92. doi:10.1308/003588413X13511609957218.
  2. Bilski J. Left-behind needle proves fatal: Lessons learned from the tragedy a final count might have prevented. 2018. Outpatient Surgery, (online) pp.59-66. Available at: Accessed June 17, 2019.
  3. Zejnullahu VA, Bicaj BX, Zejnullahu VA, Hamza AR. Retained Surgical Foreign Bodies after Surgery. Open Access Maced J Med Sci. ;5(1):97–100. doi:10.3889/oamjms.2017.005 Accessed June 17, 2019.

  1. Pyrek KM. Preventing retained surgical items is a team effort. Published March 31, 2017. Accessed June 17, 2019.
  2. Prevention of retained surgical items. Published 2015. Accessed June 17, 2019.