|Year : 2017 | Volume
| Issue : 2 | Page : 81-82
Unusual complication of intercostal chest drainage insertion: Retained surgical blade in liver
Anshuman Darbari1, Devender Singh2, Subramanian Paulvannan3
1 Department of Cardiothoracic and Vascular Surgery (T&E), All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Cardiothoracic Surgery, Kovai Medical Centre and Hospital, Coimbatore, Tamil Nadu, India
3 Department of General and Laparoscopic Surgery, Kovai Medical Centre and Hospital, Coimbatore, Tamil Nadu, India
|Date of Web Publication||4-Jul-2017|
Cardiothoracic and Vascular Surgery (T&E), All India Institute of Medical Sciences (AIIMS), Rishikesh - 249 203, Uttarakhand
Source of Support: None, Conflict of Interest: None
Intercostal chest tube drainage or tube thoracostomy procedure is widely used by the medical, surgical and critical care specialists. Despite being relatively a minor procedure, devastating complications can occur owing to inadequate knowledge of thoracic anatomy, improper training and lack of experience. Iatrogenic or technical complications are however rare, but can often be life-threatening. Here, we are reporting a case of an accidentally retained surgical blade in the right lobe of liver during chest tube insertion for the management of post-traumatic right pneumothorax. To the best of our knowledge, this is the first ever case report of a retained surgical blade in the liver as a complication of tube thoracostomy procedure, which was later successfully removed using laparoscopy.
Keywords: Foreign body, intercostal drainage, pleural drainage, tube thoracostomy
|How to cite this article:|
Darbari A, Singh D, Paulvannan S. Unusual complication of intercostal chest drainage insertion: Retained surgical blade in liver. J Assoc Chest Physicians 2017;5:81-2
|How to cite this URL:|
Darbari A, Singh D, Paulvannan S. Unusual complication of intercostal chest drainage insertion: Retained surgical blade in liver. J Assoc Chest Physicians [serial online] 2017 [cited 2018 Jul 18];5:81-2. Available from: http://www.jacpjournal.org/text.asp?2017/5/2/81/202900
| Case Report|| |
A 29-year-old male patient was admitted with history of road traffic accident and blunt injury over right side of chest. At initial evaluation, his chest X-ray revealed multiple rib fractures and right pneumothorax. Hence, a right sided intercostal drainage (ICD) procedure was planned, but during the procedure, a surgical blade was accidently left inside due to selection of lower space and loose-fitting of blade with knife handle. Digital or instrumental exploration was not attempted considering the sharp nature of the object. After re-assessment, chest tube was inserted one space higher to the prior attempted area by a thoracic surgeon. Chest X-ray postero-anterior (PA) and lateral views showed a radiopaque foreign body (surgical blade) below the right hemi diaphragm [Figure 1]. Computerised tomography (CT) scan of thorax with abdomen showed a linear metallic foreign body approximately 3.8 cm in length in the anterior superior segment of right lobe of the liver. The outer end of the foreign body was seen just outside the liver capsule [Figure 2].
|Figure 1: Chest X-ray postero-anterior (PA) and lateral views showing surgical blade below the right hemi diaphragm with right sided chest tube in situ|
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|Figure 2: CT scan of abdomen showing metallic foreign body (retained surgical blade) in liver|
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General physical examination of the patient was unremarkable and patient was hemodynamically stable. Therfore, after proper evaluation and investigations, the patient was planned for laparoscopic removal of the surgical blade. Under general anesthesia and patient in left lateral position, pneumoperitoneum was created and a 10 mm right subcostal port was inserted for camera. The edge of the surgical blade was seen outside and was adherent to the peritoneum. Through another 10 mm port in the right subcostal region, a grasper was introduced and the surgical blade was removed from the liver. Hameostasis was achieved using a diathermy. Subsequently the wound got closed in layers. After resolution of pneumothorax, chest tube was removed on the 3rd post-operative day and the patient was discharged in stable condition after 1 day with standard conservative advices.
| Discussion|| |
Descriptions of the pleural space drainage procedure date back to the times of Hippocrates. After the Vietnam war, chest tube drainage has become the standard of care for the management of chest trauma patients. Despite various techniques mentioned, the basic anatomical principle for procedure is still the same. Various complications of thoracostomy procedure are reported in literature. Cumulative rates of early and late chest tube complications are approximately 3 and 8–10%, respectively. During thoracostomy, anatomical structures of thoracic and abdominal region can be injured due to technical or iatrogenic faults. The lung is the most commonly injured organ during chest tube placement but liver injury associated with chest tube insertion is vey uncommon.
For the prevention of iatrogenic injuries, it is recommended that all chest tubes should be inserted in the “triangle of safety”. The guidelines also suggest that the placement of a chest drain outside the “triangle of safety” should always be performed or discussed with a senior expert clinician. Guidelines also emphasise on proper training of technique.
Harris et al., in a national survey of chest physicians in the UK recorded their experiences regarding serious complications of this procedure. The survey revealed that 67% of national hospital services (NHS) trusts have experienced major complications. The reported complication rates in various studies are between 6 and 38% with a majority of studies reporting a rate between 20 and 35%. A survey of junior residents for inserting a chest drain revealed that 45% were placed outside the safe triangle area and the most common error (20%) is a choice of insertion too low. In full expiration, the diaphragm dome tend to rise as high as the 4th dorsal intervertebral space on the right and 5th space on the left; therefore, whenever a chest tube is placed too inferiorly, there will be a high probability of diaphragm perforation and intra-abdominal organ damage.
In our case, selection of inferior space with a loose fitting blade in handle might have been responsible for the complication. The complication described here could also have been avoided by using a properly fixed blade or non-detachable scalpel and by incising the only skin by blade. As per guidelines, performance of blunt dissection through the intercostal muscles and digital exploration before tube insertion should also be performed. The similar complication, like this retaining of a surgical blade in pleural space, has been documented previously due to technical fault.
We believe that all physicians performing chest tube insertion should be so vigilant and undergo supervised training. Iatrogenic complications due to equipment failure can only be prevented by strict adherence to procedure protocols and availability of well-prepared equipments. We also hope that this rare and unusual chest tube insertion complication report will serve as a precautionary note for non-adherence to standard protocols and preparations.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]