Avoidable Complication of Defibrillator Implantation: Retained Operative Sponge

This PA and Lateral CXR was taken the day after an uneventful defibrillator implantation. I have saved these images for close to a decade as I never wanted to forget this is always a possibility. In full disclosure, this was not a procedure I performed.

This was an eye opening case of an operative sponge left in the pocket. As I recall, the patient was very gracious and sponge was extracted uneventfully the following day. Years later a practice partner of mine called me about an interesting case he was doing on a generator change in a can that went ERI at 8 years. He found an oddly healing pocket and ultimately dissected this sponge (see following picture) out from the pocket. Amazing that the pocket healed at all though clearly the pocket was very abnormal.

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