Hook, Line, and Sinker: Hook Wire Localization of a Retained Suture Needle in the Perineum

Editor: Despite efforts to minimize the incidence of retained surgical instruments, this complication continues to occur in approximately 1 in 8,000–18,000 of all operations (1). Preoperative localization of breast lesions with a hook wire has become a standard radiologic practice (2). This technique is advantageous because the needle is accurately positioned under imaging guidance, and when deployed, the hook maintains the wire in position until the patient can undergo surgical resection of the suspicious lesion. We describe a case of a retained suture needle in the perineum that was successfully localized using a hook wire (Modified Kopans; Cook, Inc, Bloomington, Indiana) and subsequently retrieved. Institutional review board approval was not required for this single retrospective case report. A 30-year-old woman presented to our institution with pain and purulent discharge from her perineum 6 days following a forceps-assisted vaginal delivery with second-degree perineal laceration. On examination, necrotic tissue was present at the edges of the prior laceration repair site, and purulent material was draining from the wound. She underwent incision, debridement, and packing of the wound, in anticipation of a secondary wound closure. During the secondary wound closure procedure, the tissues were approximated using 3-0 polyglactin 910 (VICRYL RAPIDE; Ethicon, Inc, Somerville, New Jersey) sutures. During performance of the crown stitch portion of wound closure, the tip of the suture needle was visualized in the perineal soft tissues, but it could not to be grasped with pickups or a needle driver. Smooth pickups were used to grasp the suture near the base of the needle. When this area of the suture was grasped, the suture detached from the needle, and the needle remained buried in the perineal soft tissues and was not visible or palpable. Limited intraoperative ultrasound of the wound and the perineal soft tissues did not localize the needle. Extensive wound exploration and dissection were not performed because of the patient’s recent history of perineal abscess. Hook wire localization was performed using a helical computed tomography (CT) scanner (HiSpeed Advantage; General Electric Medical Systems, Milwaukee, Wisconsin). An initial CT scan through the right perineum was obtained so that the entry skin site, depth, and angulation of the hook wire needle could be planned with respect to the retained suture needle (Fig 1). The length of the hook wire was determined by the depth required to reach the retained suture needle from the skin surface plus an additional 1.5 cm to position the stiff portion of the hook wire adjacent to the retained suture needle. Using serial CT scans to confirm location, the hook wire needle was positioned past the retained suture needle, and the hook wire was deployed; additional CT images confirmed final placement (Fig 2). The portion of the hook wire external to the patient was secured to the patient with gauze and tape. In the operating room, a sharp dissection from the edge of the vaginal wall in the direction of the hook wire was performed, and the retained suture needle was located and retrieved along with the hook wire. The perineum