Laparoscopic surgeries comprise an increasingly higher proportion of all surgeries. Laparoscopic instruments are designed to enable minimally invasive and accurate procedures. Since these instruments contain many small parts, there is a risk of overlooking instrument fragments that break and are retained in the abdominal cavity. Intraperitoneal retention of foreign bodies—including small instrument pieces—may cause intra-abdominal abscesses and intestinal fistulas [1]. It is therefore critically important to detect this material before finishing surgery. We report a case with intraoperative breakage of a laparoscopic needle holder confirmed by a routine postoperative abdominal X-ray taken before awakening from anesthesia. We additionally review published literature regarding laparoscopic instrument breakage during surgery.

A 58-year-old woman (Gravida 1, Para 0) with an unremarkable past medical history was diagnosed with stage IB1 cervical adenocarcinoma. She was presented with treatment options, including abdominal radical hysterectomy, laparoscopic radical hysterectomy, and concurrent chemoradiotherapy. After thorough discussion, she elected laparoscopic radical hysterectomy with transvaginal vaginal cuff closure and pelvic lymphadenectomy. Surgery was completed without major complications; however, an abdominal X-ray, taken before the patient awoke from anesthesia as a routine postoperative examination, showed a radio-opaque shadow of approximately 3 mm (Figure 1A). The surgical instruments were checked, at which time we realized the tissue-pad of the laparoscopic needle holder tip was broken (Figure 1B). Since laparoscopically detection of such a small foreign body in the abdominal cavity is challenging, we used a fluoroscopy in the operating room. After locating the broken part of the tissue-pad buried in the perivesical fatty tissue, it was successfully removed using laparoscopy with fluoroscopic guidance (Figure 1C). Although removing the fragment prolonged the operative time by about 30 minutes, no further complications occurred.

This was a rare case with intraoperative breakage of a laparoscopic needle holder confirmed by a routine postoperative abdominal X-ray. To discuss this rare condition, we reviewed the literature regarding laparoscopic instrument breakage using a PubMed database search conducted on June 6, 2022. The search strategy used the keywords: “break,” “broken,” “breakage,” “laparoscopic surgery,” and “robotic surgery” in various combinations. Although there were no restrictions on published dates, we excluded articles written in languages other than English. We identified nine published studies, including 13 cases that described intraoperative breakage of laparoscopic instruments; these studies are summarized in Table 1.

The reported instrument breakage sites were jaws of needle holder or grasper in 5 cases [1],[2],[3],[4], forceps tips in 2 cases [5], monopolar tips in 2 cases [5],[6], and tips of other devices in 4 cases [7],[8],[9]. In 12/13 cases, the instrument breakage was noticed during surgery as it was either obvious or impaired function [1],[2],[3],[4],[5],[7],[8],[9]. In the remaining case reported by Fukui et al., a retained foreign body was found incidentally on an abdominal X-ray taken 7 years after laparoscopic-assisted myomectomy [6]. In this case, the foreign body, the monopolar electrode tip of about 30 mm, was retained subcutaneously rather than intraperitoneally [6]. A postoperative abdominal X-ray was not performed and, despite its relatively large size, the breakage of electrode tip was not detected perioperatively [6]. In our case, the detached foreign body was extremely small at approximately 3 mm and did not significantly affect needle holder function. Therefore, the damaged equipment and retained foreign body remained unnoticed until the postoperative X-ray was taken. The surgical video was reviewed very slowly and confirmed that the tissue-pad broke when a needle was grasped by the laparoscopic needle holder. This moment of breakage was overlooked at normal playback speeds.

Our literature review demonstrates that there have been no reports of damage to a tissue-pad of the laparoscopic needle holder. In most laparoscopic needle holders, the tissue-pad is made of magnetic tungsten. Therefore, if its retention is overlooked, organ injury may be caused when the patient undergoes magnetic resonance imaging (MRI) at a later time.

As minimally invasive procedures like laparoscopic or robotic surgeries use instruments that contain small parts, compared to conventional open surgery, there is increased risk of missing a fragment and retention of foreign bodies in the abdominal cavity. Intraperitoneal retention of surgical instrument fragments can lead to serious complications such as intra-abdominal abscesses and intestinal fistulas [6],[10]. Such complications may develop into serious legal problems between medical institutions and patients, regardless of whether the patient is symptomatic or not [1],[10]. Therefore, to prevent such complications, we routinely perform postoperative abdominal X-rays before awakening the patient from anesthesia whether during open, laparoscopic, or robot-assisted surgery. We believe an abdominal X-ray as a routine postoperative examination is valuable to detect such extremely small foreign bodies and avoid serious complications following laparoscopic surgery. However, because retained surgical foreign bodies occur in approximately 0.1% of abdominal surgeries and are extremely uncommon, further research is needed to conclude the value of routine use of postoperative abdominal X-rays.

Our findings in this case and literature review suggest that postoperative abdominal X-ray may help detect intraperitoneal retention of foreign bodies and avoid serious complications following laparoscopic surgery.