• Shafquat Zaman, Robert Clarke, and Andrew Schofield.
• Heart of England NHS Foundation Trust, Bordesley Green, Birmingham, UK.
• JSLS. 2015 Apr 1; 19 (2).

BackgroundIncreasing awareness around patient safety and efforts to reduce medical errors has become a priority in the modern health care system. Losing needles during laparoscopic procedures is an uncommon occurrence; however, it poses a significant dilemma for the operating surgeon because retrieval can be a major challenge even for highly skilled and experienced operators.ObjectiveThe objective of this paper was to review the current literature and highlight this potentially serious issue and suggest a method of dealing with this uncommon occurrence.MethodsA comprehensive literature search was conducted using several Internet search engines including PubMed, Google Scholar, and ScienceDirect.ConclusionsThe risks associated with retained small foreign bodies remains unknown, and there are few reports and little consensus on how surgeons should manage retained needles or other small foreign bodies during laparoscopic surgery. We propose an algorithm that may be implemented as a standard operating procedure in surgical theatres when a surgeon is faced with such a dilemma.

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