Unintended Retained Surgical Items: A Systematic Review of 743 Cases

Abstract Background Despite efforts to count and verify surgical items before skin closure, retained surgical items (RSIs) continue to be reported in hospital settings. This study systematically analyzed both the impact and characteristics of RSI on patients by reviewing relevant studies published since 2000. Methods MEDLINE, EMBASE, and CINAHL databases were searched. Case reports or case studies reporting items unintentionally left inside the patient’s body during invasive procedures were included. Two reviewers independently extracted data and assessed study quality using the Joanna Briggs Institute’s Critical Appraisal Checklist for Case Reports. Results Data from 634 studies included 743 RSI cases across 78 countries. Incidence was higher in women aged 20–49 than in men. RSI occurred across all age groups and surgical sites, with cesarean section, cholecystectomy, hysterectomy, coronary bypass, and appendectomy accounting for 34.6% of cases. The time to discovery of RSI was 24.3 months (median), with 22.6% of cases taking over 10 years. Most patients (60.0% except not reported) initially presented to another hospital, with pain (54.9%) as the primary complaint; symptom duration was 4.1 months (median). Computed tomography was the most frequently used diagnostic method (40.3%), and RSI was confirmed prior to re-surgery in only 24.9% of patients. Surgical intervention was performed in 90.8% of cases, although some patients either declined surgery or did not receive treatment. Most types of RSI (92.0%) involved surgical items subjected to counting. While 56.3% of patients recovered well, 2.6% died. The hospital stay after surgery was 5 days (median). Conclusion RSI is a socially unacceptable never event, but it continues to occur worldwide. The symptoms are often common and nonspecific, making diagnosis difficult without clear information about prior surgeries. This review highlights the ongoing problem of RSIs and emphasizes that preventing them requires multiple technical measures and a strong culture of surgical safety.