To the Editor:
With improvements in technology and techniques, both surgery and anesthesia are getting better. However, these novel devices may also pose new problems, to the extent of causing morbidity and mortality.
A total laryngectomy was being performed in an adult patient for carcinoma of the larynx. Late in the surgery, bilateral neck skin incision wounds were closed with skin staplers (Proximate Plus MD 35W). During final fashioning of the end-tracheostoma, the armored tube was intermittently removed from the trachea (intermittent apnea) and sutures inserted in the end-stoma. The tracheal lumen was wide and revealed carina from the head to the end.
The vigilant anesthesiologist noticed something deep down in the tracheal lumen while looking at the surgical field and informed the surgeon. On closer examination, it turned out to be the unexpected—a skin-staple! Probably, one of the staples dislodged due to unsatisfactory skin-hold and found its way down the trachea through the end-tracheostoma. This could happen if the staple lying somewhere on the drapes is inadvertently picked up with a gauze piece used for mopping and drops into the trachea when wide open.
However, the surgeon easily managed to remove the staple immediately with a long artery forceps under direct vision. Careful inspection revealed no obvious tracheal mucosal injury. It was fortunate to be noticed before the armored tube was reinserted. Intermittent positive pressure ventilation, blood trickle, and tracheal suction could have caused such a foreign body to be pushed further down the trachea/bronchus. Being a sharp, pointed nonvegetative foreign body, these pins can cause severe airway injuries and consequences (1).
I am raising this alert because it is a preventable, iatrogenic danger and suggest:
- Careful collection of the removed staples away from the surgical field and subsequent safe disposal into ”sharps-disposal” devices.
- Sticking to the good, old habit of keeping a vigilant watch on the surgical field and the patient under anaesthesia (rather than relaxing away in the high-tech, sophisticated anesthesia environment).
- Being aware of such a possibility when some airway complication occurs in a similar situation.
I hope this warning letter may help prevent any such complication in future.
Prasad V. Akole, DNB (Anaesthesiology)
1. Finkelstein DM, Noyek AM, Friedberg J, Goldberg M. Inhalation of a safety pin by a laryngectomized patient: a case report. J Otolaryngol 1989; 18: 189–92.