Evidence map›Paper›PMID 41180417›Full record

ArticleCase reports in surgery2025

Delayed Diagnosis of Retained Surgical Blade 12 Years Post-Hysterectomy: A Rare Case Report.

Alfred Kishe, Agathon Avelin Kimario, Ronaldo Paul Lyimo, Nancy Deliko Ngaga, Joel Pilot Mushi, Emmanuel Pastory Marua

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In one paragraph

Article in Case reports in surgery, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.

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1 · What the graph read from it

What it found

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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

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3 · Its place in the literature

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4 · The record

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5 · Who and what money

Authors and funding

6 authors.

Alfred KisheDepartment of Surgery, St. Joseph Council Designated Hospital, Moshi P.O Box 330, Kilimanjaro, Tanzania.ORCID https://orcid.org/0009-0004-1461-6073
Agathon Avelin KimarioDepartment of Surgery, St. Joseph Council Designated Hospital, Moshi P.O Box 330, Kilimanjaro, Tanzania.ORCID https://orcid.org/0000-0002-1674-3066
Ronaldo Paul LyimoDepartment of Surgery, St. Joseph Council Designated Hospital, Moshi P.O Box 330, Kilimanjaro, Tanzania.
Nancy Deliko NgagaDepartment of Surgery, St. Joseph Council Designated Hospital, Moshi P.O Box 330, Kilimanjaro, Tanzania.
Joel Pilot MushiDepartment of Surgery, St. Joseph Council Designated Hospital, Moshi P.O Box 330, Kilimanjaro, Tanzania.
Emmanuel Pastory MaruaDepartment of Surgery, St. Joseph Council Designated Hospital, Moshi P.O Box 330, Kilimanjaro, Tanzania.

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

Introduction: Retained surgical instruments (RSIs) are rare but serious surgical complications. This report presents a unique case of a retained surgical blade identified 12 years post-hysterectomy, highlighting diagnostic challenges and the need for vigilance. Case Presentation: A 60-year-old female presented with chronic abdominal pain for 4 years, initially misdiagnosed as urinary tract infection (UTI) and gastritis. Investigations, including X-ray and computed tomography scan (CT scan), revealed a retained surgical blade. Elective laparotomy was performed, and the rusted blade, encapsulated by the omentum, was removed. Postoperative recovery was uneventful. Discussion: The delayed diagnosis underscores vulnerabilities in surgical safety protocols. Nonspecific symptoms of RSIs often lead to delayed detection. While manual counting is the standard, human error can occur. This case emphasizes the need for advanced technologies and standardized protocols. Underreporting of RSIs obscures true rates, necessitating improved data transparency and systemic learning. Conclusion: This case highlights the importance of multidisciplinary collaboration, technological integration, and institutional accountability to prevent RSIs. Enhanced postoperative surveillance and heightened clinical suspicion are crucial. This will improve patient safety and uphold healthcare credibility. This case underscores the need for long-term postoperative vigilance, even in the absence of immediate symptoms.

Indexed as

case reportdelayed diagnosishysterectomy complicationretained surgical instrumentsurgical safety

Identifiers

PMID41180417
PMCPMC12575016

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