The Hidden Risks of Intraoperative Radiography: A Closer Look at Surgical Miscounts

A few real-life false negatives in intraoperative radiography recently led me down a rabbit hole of research on surgical miscounts and the use of X-ray. This search led me to a 2015 Journal of the American College of Radiology publication titled “Intraoperative Radiography for Evaluation of Surgical Miscounts,” which provides valuable insights into the accuracy and limitations of this technique.

Method used:

The study, conducted with institutional review board approval, analyzed 183 surgical miscounts across 20,820 operations performed between January 2011 and April 2013, involving 180 patients (97 male, 83 female, median age 55). Per departmental protocol, intraoperative radiographs of the suspected retained items were taken alongside patient imaging. Three board-certified radiologists retrospectively reviewed these images, along with follow-up scans, to reach a consensus. The study also assessed compliance with institutional protocols and recorded patient demographics, surgical documentation, and clinical outcomes.

Alarming 44% false-negative rate on intraoperative radiography

Intraoperative radiography is essential for detecting retained surgical items, but its accuracy is uncertain, particularly for small objects like needles. While large items are easily identified, suture needle detection drops from 90% for larger sizes to below 30% for smaller ones. In this series, intraoperative radiography had a 44% false-negative rate. Poor image quality further reduces sensitivity, especially for vascular suture needles. Despite recommendations to improve its effectiveness, adoption remains limited. Some institutions routinely screen all postoperative patients, with studies showing most retained items occur in cases relying solely on manual counts.

Needle accounts for 65% of surgical miscounts

Among 183 cases of surgical item miscounts, 180 prompted intraoperative radiographic evaluation. Needles were the most commonly overlooked item, accounting for 65% (118 cases), followed by sponges and laparoscopy pads at 9% (17 cases). In total, 14 different types of surgical items were at risk of retention.

High needle count, small needles, and infrequent procedures are main contributors

Cardiac surgeries had the highest rate of surgical item miscounts, accounting for 25% of cases, including coronary artery bypass grafting (18%) and valve surgery (7%). Less common procedures and high needle count cases had higher proportional miscount rates, such as esophagogastrectomies (33%), liver transplants (18%), and Whipple procedures (16%). In contrast, frequently performed surgeries like hysterectomy, laparoscopic cholecystectomy, and appendectomy had the lowest miscount risk.

“Preventable Condition” has legal ramifications

Preventing retained surgical items requires a team effort, involving surgeons, nurses, technologists, and radiologists. As a result, legal responsibility now extends beyond the surgeon to include other perioperative staff, particularly in cases of miscount discrepancies. The Department of Health and Human Services classifies retained items, except in emergencies, as preventable, with legal standards generally presuming negligence when they occur.

In this study, only 9% (17 of 183) of surgical miscounts were successfully resolved. Most cases were identified after intraoperative radiographs were taken, with items found in the operating room or detected through imaging. While intraoperative radiography helped in a few instances, it often led to delays without significantly improving outcomes. More concerning, its potential for false negatives raises questions about its reliability as a standalone tool for preventing retained surgical items.

Reference:

Walter, W., & Amis, S. (2015, August). Intraoperative Radiography for Evaluation of Surgical Miscounts. Journal of the American College of Radiology. https://www.jacr.org/article/S1546-1440(15)00117-9/abstract