Most surgical patients don't know that before their operation begins, a laborious process called an instrument count is down. This procedure includes counting each piece of sterile equipment that will be used during the procedure. The count must be done by a registered nurse and the sterile nurse or scrub nurse. (In some jurisdictions, a scrub nurse can be unlicensed personnel called a scrub technician.)

As each tray of instruments is opened unto the sterile field, the two nurses will compare the contents with a paper sheet which comes with the tray. Each and every piece within the tray will be counted.

All sterile supplies are counted. This includes sponges, which are usually wrapped together in groups of five or ten. Sponges can be large gauze bundles, or 4”X 8” rectangles of gauze. Also, small gauze pieces which are bound together into a peanut shape and called peanuts are counted. Larger balls of cotton stuffed gauze pillows are counted. Sutures are counted and divided by types. Needles without sutures, or free needles, are counted separately. All of these supplies are possible foreign objects that can be left behind in a body cavity.

There is a debate about which surgeries are at risk for lost objects. In most states, the standard is to count instruments, sponges and sutures when a body cavity is opened. A cavity would be the head, abdomen or chest. There is also a risk for left behind sponges in some gynecological surgery where instruments are inserted into the uterus. So sponges and needles are counted for those surgeries.

Major, but minimally invasive surgeries, such as laparoscopic gastric bypass, laparoscopic nissen fundalpication, laparoscopic nephrectomy, or laparoscopic assisted vaginal hysterectomy are surgeries in which multiple, small puncture wounds are made in which specially designed sheaths are inserted and then the scope and instruments access the cavity through the sheaths. Except for thoracic endoscopic surgeries, utilizing a scope requires the body cavity to be expanded in some way. Laparoscopic surgeries use carbon dioxide gas, arthroscopic, genitourinary and gynecological surgeries use fluid. The sheaths prevent the

gases or fluids from escaping from the cavity.

Technically, it is hard to imagine how anything could be left behind in a surgery done with a scope. However, small screws, jaws to graspers, and parts of staple guns have all been left behind in patients, require additional surgeries and time and money lost. Ultimately it is the responsibility of the surgeon to know if the instrument he pulls out of a patient is complete, but part of the team mentality is that the nurses must also know the construction of an instrument so that if something is missing, it can be accounted for.

An example of this is something that I experienced; I was scrubbed on a back surgery and one of the bone instruments I gave the doctor was missing a screw. It didn't affect it's operation, but I didn't know if it was missing before I gave it to the doctor or not. It required an xray during the surgery to see if the screw was somewhere within the patient's back incision. It was not.

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