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PROLONGED RETENTION OF ARTERY FORCEPS IN THE ABDOMEN.
By A. J.Watson, M.B., B.S., F.R.C.S. (Eng.), Asst.Medical Officer, St. Giles' Hospital.
and
J. A. Braxton Hicks, M.D., M.R.C.P., D.P.H., Group Pathologist, Lambeth Group
Laboratory.
A series of 44 instances of surgical instruments accidently left in the abdomen
at surgical operations has been described by Clifford White in 1923. In the majority
of these cases, the instruments were recovered within a few weeks or days after the
operation. He recorded the longest interval as having been nineteen years.
The following two instances of artery forceps left in the peritoneal cavity at
operation are of interest because of the length of time elapsing before they were
discovered and the comparative freedom from serious symptoms of the patients
during that time.
Case reports.
Case 1.—E. T., aged 70 years. Admitted to St. Giles' hospital 16th July, 1934, with
symptoms of subacute intestinal obstruction probably in the small intestine. The patient gave
a history of appendicectomy in September, 1921. From the previous notes it would appear
that the patient had suffered from chronic appendicitis, and the appendix had been removed
through a "Battle" incision. Except for some infection of the wound, convalescence had been
normal, and the patient had left hospital with the wound well healed.
She was re-admitted in December, 1921, with symptoms of subacute obstruction. A mass,
thought to be a gland, was felt in the right iliac fossa at this time. The symptoms subsided and
the lump disappeared without further surgical intervention, and the patient left hospital
apparently quite well.
Her general condition had remained good since that time, except for occasional attacks of
abdominal pain, but she had recently lost a lot of weight, and had developed a cough with
shortness of breath and also a vaginal discharge.
For two weeks prior to admission in 1934 the abdomen had become distended and the
patient had vomited. Her bowels had been opened quite freely.
Clinical examination.—Patient rather wasted. A scar of a "Battle" incision in right lower
abdomen generally distended. Visible coiling in centre of abdomen with active peristalsis—
no tumour felt.
Pelvic examination revealed four inches of closed metal blades protruding through the
posterior fornix of the vagina.
Patient also had signs of myocardial degeneration with cardiac failure, and chronic
bronchitis.
X-ray showed a 5-inch pair of artery forceps lying with the handles in the right iliac fossa,
and the blades running vertically downwards into the pelvis.
Although the general condition of the patient improved while in hospital, the distention and
symptoms of obstruction remained. It was, therefore, decided to attempt to relieve the
obstruction and, if possible, to remove the forceps.
Operation by Mr. R. M. Handfield-Jones, consulting surgeon to St. Giles' hospital, under
gas-oxygen anæsthesia, 24th July, 1934.—On opening the abdomen through a right paramedian
incision, greatly distended small intestine was found. The handles of the forceps could be felt
in the right iliac fossa. A loop of small intestine was adherent to the medial aspect of the
caecum, and one handle was found to be lying in the lumen of this loop. The other handle lay
inside the caecum. There appeared to be a fistulous communication between this loop and the
caecum. There was no obvious point of obstruction.
A small incision was made in the small intestine loop, and one handle was withdrawn from
the bowel, the other handle was removed from the caecum via the fistula between the small bowel
and the cæcum. The blades lay apparently in a mass of adhesions on the side wall of the pelvis,
and were withdrawn easily. The opening in the bowel was sutured and the wound closed. A
small rubber tube was inserted up to the vault of the vagina and along the track of the blades.
The patient stood the operation well, but the distension remained, and she died six days
later apparently from paralytic ileus.
Post-mortem revealed no further information. The adherent loop of small intestine was
about six feet from the duodenojejunal flexure. There had been no leakage from the enterotomy,
and no peritonitis. There was marked degeneration of the heart muscle, and congestion at the
bases of both lungs.
Case 2.—Aged 48 years. Admitted to Westminster hospital in February, 1922, under
Dr. de Souza, to whom we are indebted for permission to publish the clinical notes of the case.
Complaining of loss of strength since the death of her husband 3 months previously. Also
shortness of breath and giddiness.
She gave a history of two operations at another hospital seventeen years previously—one
for ovariotomy, and one for appendicectomy. Since then she had been perfectly well except
for chronic constipation.
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