Unhealed wounds revealing retained surgical items and systemic patient safety failures: case series

Introduction: Retained surgical items represent a critical yet preventable failure in surgical safety systems worldwide, reflecting systemic weaknesses that threaten patient outcomes. Persistent postoperative fistulae are a potential clinical marker of such retained foreign bodies, but they are often underrecognized, particularly in resource-limited settings. By reporting this case series, we aim to underscore the diagnostic value of wound fistulae as a sentinel sign of retained surgical items and to highlight the ongoing gaps in surgical safety systems. Case presentation: Two Black African women presented with chronic, non-healing wounds and persistent fistulous drainage following surgery. The first case involved a 46-year-old woman with abdominal pain and wound discharge persisting for five months after hysterectomy. Imaging revealed a retained abdominal pack that had migrated into the bowel, resulting in an ileo-ileal fistula. The second case described a 45-year-old woman with six months of neck wound drainage after thyroidectomy, despite multiple unsuccessful surgical attempts; exploration uncovered retained gauze within a fistulous tract. Both patients underwent surgical removal of the foreign bodies with full symptom resolution. Conclusion: These cases expose the systemic deficiencies in operative safety that permit the occurrence of retained surgical items, leading to severe patient harm and prolonged morbidity. They highlight the urgent need to reinforce surgical safety culture, ensure strict compliance with established checklists, and implement reliable detection protocols. Addressing these systemic gaps is essential to prevent such avoidable complications and improve patient safety outcomes globally.