Laparoscopic needle fragment removal 2019

Stimulated by Liu et al 2019.[1]

Photo by Idella on Unsplash.
This image is chosen to illustrate the phrase ‘like trying to find a needle in a haystack’, and it reminds me of the difficulties surgeons used to have in finding embedded foreign bodies.

This is a noteworthy case because it is the first report I have seen of a laparoscopic removal of a broken needle fragment. The case is written up by a urological team from Beijing. I guess they became involved because of the location of the needle fragment in the patient’s retroperitoneum.

The patient was a 42-year-old man who had been treated with acupuncture for back pain 2 years previously. There are no details of how the needle came to break, and apparently the patient had no symptoms at the time. Presumably no symptoms related to the needle rather than his back, although this is not clear. The case includes some nice images, including x ray films, abdominal CT and an image taken on finding the needle at laparoscopy (see below) , although for the life of me I cannot see it, hence the cover image for this blog – needle in a haystack.

Figure 1 Preoperative Abdominal X-ray. The broken acupuncture needle was showed by arrow. [1]

The CT images compared with the single abdominal x-ray film beautifully illustrate the problem of finding an object in 3 dimensions, and the importance of two perpendicular views.

Figure 2 Preoperative Abdominal CT. The broken acupuncture needle was showed by arrow. [1]

From the report it seems as though the patient was most inconvenienced by security checks, but I confess to be surprised that such a small metallic fragment would be detected. Anyway, he was up and about 6 hours after surgery and home on the second day we are told.

The size of the needle fragment appears to be nearly 50mm, so presumably the needles used were longer still. I guess that is not a particular surprise considering the geographical region.

Figure 3 Operation diagram by laparoscopy. a, Psoas major muscle; b, descending colon; Arrow, the broken needle in a fibrous stripe. [1]

Broken needles are uncommon. White reports just 2 events in a total of 1.1 million treatments (over 12 prospective surveys),[2] and they were both from the oldest report, published over 30 years ago.[3] Witt et al (2009) report no cases in their prospective survey of 2.2 million treatments in Germany.[4] So this may represent the change from reusable needles to disposable ones around the early 90’s.

In China, however, cases of broken needles persist, and Wu et al document 7 cases raging from 1986 to 2010 in their systematic review of adverse events of acupuncture over the period from 1980 to 2013 in China.[5] The present paper suggests that the problem has not gone away entirely as it appears to have done in the West. This is likely to be a combination of needle quality, the techniques employed and the total number of acupuncture treatments performed in the different geographical regions.

References

1 Liu Z-H, Wang H-D, Xu X, et al. Removal of a broken acupuncture needle in retroperitoneum by laparoscopy: a case report. BMC Surg 2019;19:102. doi:10.1186/s12893-019-0572-y

2 White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med 2004;22:122–33. doi:10.1136/aim.22.3.122

3 Umlauf R. Analysis of the Main Results of the Activity of the Acupuncture Department of Faculty Hospital. Acupunct Med 1988;5:16–8. doi:10.1136/aim.5.2.16

4 Witt CM, Pach D, Brinkhaus B, et al. Safety of Acupuncture: Results of a Prospective Observational Study with 229,230 Patients and Introduction of a Medical Information and Consent Form. Forsch Komplementmed 2009;16:91–7. doi:10.1159/000209315

5 Wu J, Hu Y, Zhu Y, et al. Systematic Review of Adverse Effects: A Further Step towards Modernization of Acupuncture in China. Evidence-Based Complement Altern Med 2015;2015:1–19. doi:10.1155/2015/432467

Declaration of interests MC