Retained Surgical Items in Korea: A Systematic Review

Park, Seong-Hi; Kim, So-Young; Kim, Eun Young

doi:2025.31.1.75

Qual Improv Health Care > Volume 31(1); 2025 > Article

Review

Quality Improvement in Health Care 2025;31(1): 75-87.
DOI: https://doi.org/10.14371/QIH.2025.31.1.75 Published online June 30, 2025.

국내 연구에서 보고된 수술 후 잔존 이물질 사례: 체계적 문헌고찰

박성희¹, 김소영², 김은영³

¹순천향대학교 간호학과
²순천향대학교 식품영양학과
³순천향대학교 작업치료학과

Retained Surgical Items in Korea: A Systematic Review

Seong-Hi Park¹, So-Young Kim², Eun Young Kim³

¹Professor, School of Nursing, Soonchunhyang University, Asan, Republic of Korea
²Associate Professor, Department of Food Science and Nutrition, Soonchunhyang University, Asan, Republic of Korea
³Associate Professor, Department of Occupational Therapy, Soonchunhyang University, Asan, Republic of Korea

Correspondence Seong-Hi Park ,Tel: +82-41-530-4854, Fax: +82-41-570-2498, Email: shpark2015@sch.ac.kr

Received: April 27, 2025 Revised: June 5, 2025 Accepted: June 9, 2025

Abstract

Purpose
Retained surgical items (RSIs), such as gauze, sponges, instruments, or devices inadvertently left in the body after surgery remain a preventable medical error despite advancements in surgical techniques and safety protocols. This review systematically analyzes the status of residual surgical foreign bodies reported in Korea.
Methods
A comprehensive search was conducted in Koreamed, ScienceON, Medline, Embase, and Korean academic society journals using keywords such as “cottonoid,” “gossypiboma,” “textiloma,” “retained surgical item,” “instruments,” “needle,” “sponge,” “swab,” “retained foreign body,” and “object.” The internal validity of case reports was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Case Reports.
Results
A total of 66 RSI cases were identified across 55 studies. Female patients accounted for 54.5% of the study population, with a median age of 52.5 years. Pain was the most common symptom (39.4%), followed by palpable masses (19.7%) and discomfort (19.7%). The median time to detection was 4.5 years; 31.8% were discovered within one year, and 37.9% were detected after 10 years. Gauze was the most frequently retained item (56.1%), followed by sponges/towels (19.7%); catheter fragments (9.1%); and drains, tubes, and sutures (4.5% each). Most patients (84.8%) were treated surgically, with endoscopic procedures accounting for 13.6%.
Conclusion
RSIs continue to be an undesirable surgical complication, underscoring the ongoing need for comprehensive and multifaceted prevention strategies. Because RSIs cannot be prevented solely through surgical counting systems, effective prevention requires multidisciplinary collaboration among surgeons, anesthesiologists, and nurses. Future research on RSI prevention strategies could play a crucial role in enhancing patient safety in hospitals.

Key words Foreign bodies, Patient safety, Systematic review