A novel laparoscopic magnet-assisted technique for extracting a retained needle after repair of PEG-related gastrocolic perforation in a neurologically impaired adolescent: a case report

A novel laparoscopic magnet-assisted technique for extracting a retained needle after repair of PEG-related gastrocolic perforation in a neurologically impaired adolescent: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A novel laparoscopic magnet-assisted technique for extracting a retained needle after repair of PEG-related gastrocolic perforation in a neurologically impaired adolescent: a case report Jonas Povilavičius¹, Kamilė Bagdonaitė¹, Arūnas Strumila¹, Rūta Bernatavičienė¹, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8235487/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Percutaneous endoscopic gastrostomy (PEG) is widely used to provide long-term enteral nutrition in neurologically impaired children. Although generally safe, PEG placement may rarely result in major complications such as visceral perforation or retained surgical items. Loss of a laparoscopic needle is an uncommon but potentially serious event due to its risk of migration and the technical challenge of retrieval. Case Presentation: A 14-year-old boy with Dandy–Walker malformation, cerebral palsy, refractory epilepsy, and dysphagia underwent PEG insertion. Two weeks later, he presented with peritonitis. Emergency laparoscopy revealed a perforation of the transverse colon and additional posterior colonic and anterior gastric perforations secondary to gastrocolic interposition during PEG placement. All defects were repaired laparoscopically. During extraction of the suturing needle through a trocar, the needle fractured and was lost within the peritoneal cavity. Postoperative radiography confirmed the retained metallic fragment. A second laparoscopy successfully retrieved the needle using a simple magnet-assisted technique in which small sterile magnets were enclosed in a glove finger and introduced through a trocar. The postoperative course was complicated by mechanical ileus requiring further laparoscopic interventions. Conclusion This case illustrates two rare but significant complications after PEG placement—gastrocolic perforation and intra-abdominal loss of a laparoscopic needle—and demonstrates a practical magnet-assisted method for retrieval. Strict adherence to instrument-count protocols and early imaging when needle loss is suspected are essential to reducing morbidity in this vulnerable patient population. Percutaneous endoscopic gastrostomy retained surgical needle Laparoscopy gastrocolic perforation magnet – assisted technique pediatric surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Highlights Rare PEG complication with gastrocolic perforation in a pediatric patient. Retained laparoscopic suturing needle identified and retrieved early. Highlights surgical safety in complex neurologically impaired children. Emphasizes structured algorithms for lost-needle management. Supports WHO checklist use and multidisciplinary postoperative care. Introduction Percutaneous endoscopic gastrostomy (PEG) provides an effective method of long-term enteral nutrition for patients with neurological impairment and dysphagia [ 1 , 2 ]. While complication rates are low, major adverse events such as visceral perforation, peritonitis, or retained surgical items can be life-threatening [ 3 , 4 , 5 ]. Retained surgical instruments, including needles, are classified as “never events”, reflecting their preventable nature [ 6 ]. In laparoscopic surgery, limited tactile feedback and the small size of instruments can increase risk [ 7 , 8 ]. Case Presentation A 14-year-old boy with Dandy–Walker malformation, hydrocephalus, cerebral palsy, refractory generalized epilepsy, and dysphagia underwent PEG placement for enteral nutrition. The initial procedure was uneventful. Two weeks after PEG insertion, he presented with fever, abdominal distension, and generalized peritonism. Clinical examination, ultrasound, plain abdominal radiography, CT of abdominal cavity and laboratory findings confirmed peritonitis with free intraperitoneal air. Emergency diagnostic laparoscopy revealed a perforation of the anterior wall of the transverse colon, which was sutured with single-layer interrupted stitches. Further inspection showed the posterior wall of the transverse colon adherent to the anterior wall of the stomach; after gentle separation, additional perforations of both organs were closed with single-layer sutures. During extraction of the suturing needle through the trocar, the needle tip fractured and disappeared into the peritoneal cavity. Despite thorough intraoperative search, it could not be located. Postoperative X-ray confirmed a retained metallic foreign body (Fig. 1 ). A second laparoscopy was performed the following day, and the needle was visualized and retrieved safely by the novel laparoscopic technique. A sterile glove finger was cut off, then sterile magnets were inserted into it and secured with ligature suture (Fig. 2 , 3). Using a laparoscopic instrument, the ligature was grasped and the sealed magnets inserted through the 10mm trocar into the abdominal cavity (Fig. 4 ). The metallic foreign body was attracted to the magnet, and it was carefully extracted from the abdomen (Fig. 5 ). The patient’s early postoperative course was stable, but he later developed mechanical ileus, necessitating two additional surgeries. Enteral nutrition continued via a feeding tube. After 20 days in the ICU, he was transferred to palliative care for ongoing management. Discussion PEG insertion is a well-established method of nutritional support in neurologically impaired children [ 9 ]. Major complications such as visceral perforation occur in fewer than 1% of cases [ 3 , 5 , 10 ]. Gastrocolic fistula or perforation usually results from interposition of the colon between the abdominal wall and stomach at the time of PEG placement [ 4 ]. In our patient, anatomical distortion associated with cerebral palsy and previous neurological abnormalities likely contributed to this complication. A retained laparoscopic needle represents an uncommon but serious event. The estimated incidence of intra-abdominal needle loss during laparoscopic procedures is approximately 1 in 9,000 operations [ 11 ]. While most retained surgical items involve sponges, retained metallic sharps are less common but may pose a greater risk due to their potential for migration and chronic inflammation [ 9 ]. The mechanism of needle loss in this case—fracture during withdrawal through a trocar—is consistent with previously described reports of instrument or needle breakage during minimally invasive procedures [ 12 ]. Brahmbhatt et al. reported a similar case of intra-abdominal instrument-tip breakage requiring fluoroscopic retrieval [ 12 ]. Migration of small metallic fragments has been documented, emphasizing the importance of prompt detection and removal [ 1 , 6 , 13 ]. Imaging and intraoperative management protocols are critical once a count discrepancy is identified. Ergin et al. proposed a structured algorithm recommending immediate search, magnetic retrieval tools, intraoperative radiography, and, if necessary, postoperative imaging [ 11 ]. Gulack et al. subsequently developed a pediatric-specific algorithm standardizing management of lost suture needles, highlighting that early recognition and imaging can minimize morbidity [ 14 ]. Prevention remains the cornerstone of patient safety. The WHO surgical safety checklist mandates instrument and needle counts at each critical stage of surgery [ 6 ]. However, even with proper protocols, human and system errors can occur. A systematic review by Weprin et al. [ 9 ] found that communication breakdown, multitasking in complex environments, and lack of technology (e.g., RFID/barcoding) were major contributors to retained surgical sharps. In our case, early postoperative imaging confirmed the presence of the retained needle, enabling timely laparoscopic retrieval and avoiding open exploration. The subsequent development of mechanical ileus likely reflected postoperative adhesions following multiple interventions rather than sequelae of the retained foreign body itself. Conclusion This case illustrates two rare complications—gastrocolic perforation and intra-abdominal loss of a laparoscopic needle—and demonstrates a simple magnet-assisted technique for retrieval. Strict adherence to instrument-count protocols and careful trocar manipulation are essential. Abbreviations PEG - Percutaneous Endoscopic Gastrostomy CT - Computed tomography ICU – Intensive care unit WHO – World Health Organization RFID - Radio-frequency identification Declarations Ethics approval and consent to participate: We consulted Vilnius Biomedical Research Office about Ethics approval. We got the consent to perform our research only by getting written informed patient consent. Consent for publication: Written informed consent for publication was obtained from the patient’s legal guardian. The authors affirm that written informed consent was obtained from the legal guardian of the patient described in this case report. The guardian reviewed the manuscript, including all clinical details and accompanying images, and provided consent for publication in a scientific journal. The guardian understands that: all efforts will be made to protect the patient’s privacy and anonymity; identifying information will not be published; complete anonymity cannot be guaranteed. The authors confirm that a signed copy of the consent form is retained by the corresponding author and is available for review by the journal’s editorial office upon request. Availability of data and materials: Data sharing is not applicable to this article to this article as no datasets were generated or analysed during the current study. Competing Interests: The authors declare no conflict of interest related to this case report. No external funding was received for the preparation, writing, or submission of this manuscript. Funding: The authors declare that no funding was received for the preparation, writing, or publication of this case report. Authors’ Contributions Conceptualisation: J. Povilavičius, K. Bagdonaitė, A. Dulskas, , G. Pikturnaitė, R. Bernatavičienė, A. Strumila Methodology and data curation: J. Povilavičius, K. Bagdonaitė, A. Dulskas, Surgery and clinical supervision: J. Povilavičius Writing – original draft: J. Povilavičius, K. Bagdonaitė, A. Dulskas Writing – review and editing: A. Dulskas, A. Strumila, J. Povilavičius, K. Bagdonaitė All authors approved the final manuscript and agree to be accountable for all aspects of the work, ensuring the accuracy and integrity of the content. Learning Points • PEG insertion in neurologically impaired children with dysphagia carries a small but significant risk of visceral perforation, requiring a high index of suspicion for early diagnosis. • Strict adherence to surgical counting protocols and verification steps is essential to prevent retained instrument incidents, even during minimally invasive procedures. • Prompt recognition and timely laparoscopic management of retained foreign bodies can minimize morbidity and prevent the need for open re-exploration. Statement of Novelty / Importance This case report describes a unique sequence of postoperative complications following percutaneous endoscopic gastrostomy (PEG) in a neurologically impaired child, including concurrent gastrocolic perforation and a retained laparoscopic suturing needle. While PEG-related visceral perforation is rare, the additional occurrence of intra-abdominal needle loss during laparoscopic repair has not been previously reported in this clinical context. The case highlights key technical pitfalls during minimally invasive re-intervention, reinforces the importance of strict intraoperative instrument accountability, and supports the implementation of structured algorithms for managing lost needles in pediatric laparoscopic surgery. Clinical trial number: not applicable. References Homan M, et al. Percutaneous Endoscopic Gastrostomy in Children: An Update to the ESPGHAN Position Paper. J Pediatr Gastroenterol Nutr. 2021;73(3):415-426. Takalo M, et al. Complications after pediatric percutaneous endoscopic gastrostomy: comparison of the push and pull technique. World J Pediatr Surg. 2024;7(1):e000687. Tazi K, et al. Complications of Percutaneous and Surgical Gastrostomy Placements in Children: A Single-centre Series. JPGN Rep. 2023;4(2):e316. Bell N, Rabe E, Kufeji D. Gastrocolocutaneous fistula: a rare complication of percutaneous endoscopic gastrostomy—case report. J Transl Gastroenterol. 2024;2(1):e00007. ESPGHAN. Percutaneous Endoscopic Gastrostomy in Children (Guideline PDF). J Pediatr Gastroenterol Nutr. 2021;73(3):415-426. World Health Organization. WHO Surgical Safety Checklist (2008; updated 2024). Available at: https://www.who.int/patientsafety/safesurgery. Hirose R, et al. Intraoperative breakage of a laparoscopic needle holder confirmed by routine postoperative abdominal X-ray: case report and literature review. J Case Rep Images Obstet Gynecol. 2023;9(1):17-20. Aykanat IC, et al. Entrapped surgical needle in the valveless AirSeal trocar: a case report. Int J Surg Case Rep. 2024;114:109035. Weprin S, et al. Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review. Patient Saf Surg. 2021;15(1):37. Bawazir OA. Percutaneous endoscopic gastrostomy in children < 10 kg: safety and outcomes. Saudi J Gastroenterol. 2020;26(2):78-83. Ergin A, et al. Management of Needle Loss in Laparoscopic Operations. Eurasian J Med Invest. 2019;3(1):78-82. Brahmbhatt S, et al. Intra-abdominal Breakage of Laparoscopic Needle Holder Tip and Its Retrieval Under Fluoroscopic Guidance. J Minim Access Surg. 2021;17(4):572-575. Al Jaafari F. An unusual place to find a lost needle in laparoscopic surgery. Ann R Coll Surg Engl. 2014;96(4):e9-e11. Gulack BC, et al. The Lost Suture Needle: An Algorithm to Standardize Management. J Pediatr Surg. 2021;56(12):2456-2461. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 12 Dec, 2025 Reviewers agreed at journal 10 Dec, 2025 Reviewers invited by journal 03 Dec, 2025 Editor assigned by journal 03 Dec, 2025 Editor invited by journal 02 Dec, 2025 Submission checks completed at journal 02 Dec, 2025 First submitted to journal 02 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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1","display":"","copyAsset":false,"role":"figure","size":483879,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative abdominal radiograph demonstrating retained metallic needle\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8235487/v1/8615c2629af55653e3c918c1.png"},{"id":97675025,"identity":"6485f12b-b66d-459d-8eec-1697e0a4617b","added_by":"auto","created_at":"2025-12-08 09:45:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":848518,"visible":true,"origin":"","legend":"\u003cp\u003eConstruction of improvised magnetic retrieval device\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8235487/v1/c8f6549d767551a9723fb8af.png"},{"id":97674487,"identity":"5b3cd4a4-10db-4f88-a612-76ca98d4bed4","added_by":"auto","created_at":"2025-12-08 09:43:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":849213,"visible":true,"origin":"","legend":"\u003cp\u003eMagnets enclosed within a glove finger and secured with ligature suture\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8235487/v1/d26367fedad47f2289c0cc54.png"},{"id":97658136,"identity":"44cd597a-a9d3-42ec-85cd-7002c5013937","added_by":"auto","created_at":"2025-12-08 07:30:58","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":933074,"visible":true,"origin":"","legend":"\u003cp\u003eInsertion of magnetic device through 10-mm trocar\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8235487/v1/712b6c18a4760c6325944fad.png"},{"id":97658148,"identity":"cd999953-07dd-473f-a2ff-ec726370728a","added_by":"auto","created_at":"2025-12-08 07:30:58","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":969662,"visible":true,"origin":"","legend":"\u003cp\u003eSuccessful attraction and retrieval of the lost laparoscopic needle\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8235487/v1/65b0d3708adb37cb88cb2e50.png"},{"id":97678794,"identity":"d48ba150-9f69-4c5f-bb16-c0efe285bdb3","added_by":"auto","created_at":"2025-12-08 09:56:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5165014,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8235487/v1/030d5c9a-bbab-404b-82a5-ad987438814f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A novel laparoscopic magnet-assisted technique for extracting a retained needle after repair of PEG-related gastrocolic perforation in a neurologically impaired adolescent: a case report","fulltext":[{"header":"Highlights","content":"\u003cul\u003e\n \u003cli\u003eRare PEG complication with gastrocolic perforation in a pediatric patient.\u003c/li\u003e\n \u003cli\u003eRetained laparoscopic suturing needle identified and retrieved early.\u003c/li\u003e\n \u003cli\u003eHighlights surgical safety in complex neurologically impaired children.\u003c/li\u003e\n \u003cli\u003eEmphasizes structured algorithms for lost-needle management.\u003c/li\u003e\n \u003cli\u003eSupports WHO checklist use and multidisciplinary postoperative care.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003ePercutaneous endoscopic gastrostomy (PEG) provides an effective method of long-term enteral nutrition for patients with neurological impairment and dysphagia [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While complication rates are low, major adverse events such as visceral perforation, peritonitis, or retained surgical items can be life-threatening [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Retained surgical instruments, including needles, are classified as \u0026ldquo;never events\u0026rdquo;, reflecting their preventable nature [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In laparoscopic surgery, limited tactile feedback and the small size of instruments can increase risk [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 14-year-old boy with Dandy\u0026ndash;Walker malformation, hydrocephalus, cerebral palsy, refractory generalized epilepsy, and dysphagia underwent PEG placement for enteral nutrition. The initial procedure was uneventful.\u003c/p\u003e\u003cp\u003eTwo weeks after PEG insertion, he presented with fever, abdominal distension, and generalized peritonism. Clinical examination, ultrasound, plain abdominal radiography, CT of abdominal cavity and laboratory findings confirmed peritonitis with free intraperitoneal air. Emergency diagnostic laparoscopy revealed a perforation of the anterior wall of the transverse colon, which was sutured with single-layer interrupted stitches. Further inspection showed the posterior wall of the transverse colon adherent to the anterior wall of the stomach; after gentle separation, additional perforations of both organs were closed with single-layer sutures.\u003c/p\u003e\u003cp\u003eDuring extraction of the suturing needle through the trocar, the needle tip fractured and disappeared into the peritoneal cavity. Despite thorough intraoperative search, it could not be located. Postoperative X-ray confirmed a retained metallic foreign body (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A second laparoscopy was performed the following day, and the needle was visualized and retrieved safely by the novel laparoscopic technique. A sterile glove finger was cut off, then sterile magnets were inserted into it and secured with ligature suture (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, 3). Using a laparoscopic instrument, the ligature was grasped and the sealed magnets inserted through the 10mm trocar into the abdominal cavity (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The metallic foreign body was attracted to the magnet, and it was carefully extracted from the abdomen (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe patient\u0026rsquo;s early postoperative course was stable, but he later developed mechanical ileus, necessitating two additional surgeries. Enteral nutrition continued via a feeding tube. After 20 days in the ICU, he was transferred to palliative care for ongoing management.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePEG insertion is a well-established method of nutritional support in neurologically impaired children [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Major complications such as visceral perforation occur in fewer than 1% of cases [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Gastrocolic fistula or perforation usually results from interposition of the colon between the abdominal wall and stomach at the time of PEG placement [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In our patient, anatomical distortion associated with cerebral palsy and previous neurological abnormalities likely contributed to this complication.\u003c/p\u003e\u003cp\u003eA retained laparoscopic needle represents an uncommon but serious event. The estimated incidence of intra-abdominal needle loss during laparoscopic procedures is approximately 1 in 9,000 operations [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. While most retained surgical items involve sponges, retained metallic sharps are less common but may pose a greater risk due to their potential for migration and chronic inflammation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe mechanism of needle loss in this case\u0026mdash;fracture during withdrawal through a trocar\u0026mdash;is consistent with previously described reports of instrument or needle breakage during minimally invasive procedures [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Brahmbhatt et al. reported a similar case of intra-abdominal instrument-tip breakage requiring fluoroscopic retrieval [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Migration of small metallic fragments has been documented, emphasizing the importance of prompt detection and removal [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eImaging and intraoperative management protocols are critical once a count discrepancy is identified. Ergin et al. proposed a structured algorithm recommending immediate search, magnetic retrieval tools, intraoperative radiography, and, if necessary, postoperative imaging [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Gulack et al. subsequently developed a pediatric-specific algorithm standardizing management of lost suture needles, highlighting that early recognition and imaging can minimize morbidity [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePrevention remains the cornerstone of patient safety. The WHO surgical safety checklist mandates instrument and needle counts at each critical stage of surgery [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, even with proper protocols, human and system errors can occur. A systematic review by Weprin et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] found that communication breakdown, multitasking in complex environments, and lack of technology (e.g., RFID/barcoding) were major contributors to retained surgical sharps.\u003c/p\u003e\u003cp\u003eIn our case, early postoperative imaging confirmed the presence of the retained needle, enabling timely laparoscopic retrieval and avoiding open exploration. The subsequent development of mechanical ileus likely reflected postoperative adhesions following multiple interventions rather than sequelae of the retained foreign body itself.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case illustrates two rare complications\u0026mdash;gastrocolic perforation and intra-abdominal loss of a laparoscopic needle\u0026mdash;and demonstrates a simple magnet-assisted technique for retrieval. Strict adherence to instrument-count protocols and careful trocar manipulation are essential.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003ePEG\u003c/strong\u003e - \u003cem\u003ePercutaneous Endoscopic Gastrostomy\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eCT\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e\u0026nbsp;-\u0026nbsp;\u003c/em\u003eComputed tomography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eICU\u003c/strong\u003e \u0026ndash; Intensive care unit\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWHO\u003c/strong\u003e \u0026ndash; World Health Organization\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRFID\u003c/strong\u003e - \u003cem\u003eRadio-frequency identification\u003c/em\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe consulted\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/em\u003eVilnius Biomedical Research Office about Ethics approval. We got the consent to perform our research only by getting written informed patient consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from the patient\u0026rsquo;s legal guardian.\u0026nbsp;The authors affirm that written informed consent was obtained from the legal guardian of the patient described in this case report. The guardian reviewed the manuscript, including all clinical details and accompanying images, and provided consent for publication in a scientific journal.\u003c/p\u003e\n\u003cp\u003eThe guardian understands that:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eall efforts will be made to protect the patient\u0026rsquo;s privacy and anonymity;\u003c/li\u003e\n \u003cli\u003eidentifying information will not be published;\u003c/li\u003e\n \u003cli\u003ecomplete anonymity cannot be guaranteed.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe authors confirm that a signed copy of the consent form is retained by the corresponding author and is available for review by the journal\u0026rsquo;s editorial office upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article to this article as no datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest related to this case report. No external funding was received for the preparation, writing, or submission of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that \u003cstrong\u003eno funding\u003c/strong\u003e was received for the preparation, writing, or publication of this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualisation: J. Povilavičius, K. Bagdonaitė, A. Dulskas, , G. Pikturnaitė, R. Bernatavičienė, A. Strumila\u003cbr\u003e\u0026nbsp;Methodology and data curation: J. Povilavičius, K. Bagdonaitė, A. Dulskas,\u0026nbsp;\u003cbr\u003e\u0026nbsp;Surgery and clinical supervision: J. Povilavičius\u003cbr\u003e\u0026nbsp;Writing \u0026ndash; original draft: J. Povilavičius, K. Bagdonaitė, A. Dulskas\u003cbr\u003e\u0026nbsp;Writing \u0026ndash; review and editing: A. Dulskas, A. Strumila, J. Povilavičius, K. Bagdonaitė\u003cbr\u003e\u0026nbsp;All authors approved the final manuscript and agree to be accountable for all aspects of the work, ensuring the accuracy and integrity of the content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLearning Points\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026bull; PEG insertion in neurologically impaired children with dysphagia carries a small but significant risk of visceral perforation, requiring a high index of suspicion for early diagnosis.\u003c/p\u003e\n\u003cp\u003e\u0026bull; Strict adherence to surgical counting protocols and verification steps is essential to prevent retained instrument incidents, even during minimally invasive procedures.\u003c/p\u003e\n\u003cp\u003e\u0026bull; Prompt recognition and timely laparoscopic management of retained foreign bodies can minimize morbidity and prevent the need for open re-exploration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatement of Novelty / Importance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report describes a unique sequence of postoperative complications following percutaneous endoscopic gastrostomy (PEG) in a neurologically impaired child, including concurrent gastrocolic perforation and a retained laparoscopic suturing needle. While PEG-related visceral perforation is rare, the additional occurrence of intra-abdominal needle loss during laparoscopic repair has not been previously reported in this clinical context. The case highlights key technical pitfalls during minimally invasive re-intervention, reinforces the importance of strict intraoperative instrument accountability, and supports the implementation of structured algorithms for managing lost needles in pediatric laparoscopic surgery.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eClinical trial number: not applicable.\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHoman M, et al. Percutaneous Endoscopic Gastrostomy in Children: An Update to the ESPGHAN Position Paper. J Pediatr Gastroenterol Nutr. 2021;73(3):415-426.\u003c/li\u003e\n\u003cli\u003eTakalo M, et al. Complications after pediatric percutaneous endoscopic gastrostomy: comparison of the push and pull technique. World J Pediatr Surg. 2024;7(1):e000687.\u003c/li\u003e\n\u003cli\u003eTazi K, et al. Complications of Percutaneous and Surgical Gastrostomy Placements in Children: A Single-centre Series. JPGN Rep. 2023;4(2):e316.\u003c/li\u003e\n\u003cli\u003eBell N, Rabe E, Kufeji D. Gastrocolocutaneous fistula: a rare complication of percutaneous endoscopic gastrostomy\u0026mdash;case report. J Transl Gastroenterol. 2024;2(1):e00007.\u003c/li\u003e\n\u003cli\u003eESPGHAN. Percutaneous Endoscopic Gastrostomy in Children (Guideline PDF). J Pediatr Gastroenterol Nutr. 2021;73(3):415-426.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. WHO Surgical Safety Checklist (2008; updated 2024). Available at: https://www.who.int/patientsafety/safesurgery.\u003c/li\u003e\n\u003cli\u003eHirose R, et al. Intraoperative breakage of a laparoscopic needle holder confirmed by routine postoperative abdominal X-ray: case report and literature review. J Case Rep Images Obstet Gynecol. 2023;9(1):17-20.\u003c/li\u003e\n\u003cli\u003eAykanat IC, et al. Entrapped surgical needle in the valveless AirSeal trocar: a case report. Int J Surg Case Rep. 2024;114:109035.\u003c/li\u003e\n\u003cli\u003eWeprin S, et al. Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review. Patient Saf Surg. 2021;15(1):37.\u003c/li\u003e\n\u003cli\u003eBawazir OA. Percutaneous endoscopic gastrostomy in children \u0026lt; 10 kg: safety and outcomes. Saudi J Gastroenterol. 2020;26(2):78-83.\u003c/li\u003e\n\u003cli\u003eErgin A, et al. Management of Needle Loss in Laparoscopic Operations. Eurasian J Med Invest. 2019;3(1):78-82.\u003c/li\u003e\n\u003cli\u003eBrahmbhatt S, et al. Intra-abdominal Breakage of Laparoscopic Needle Holder Tip and Its Retrieval Under Fluoroscopic Guidance. J Minim Access Surg. 2021;17(4):572-575.\u003c/li\u003e\n\u003cli\u003eAl Jaafari F. An unusual place to find a lost needle in laparoscopic surgery. Ann R Coll Surg Engl. 2014;96(4):e9-e11.\u003c/li\u003e\n\u003cli\u003eGulack BC, et al. The Lost Suture Needle: An Algorithm to Standardize Management. J Pediatr Surg. 2021;56(12):2456-2461.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Percutaneous endoscopic gastrostomy, retained surgical needle, Laparoscopy, gastrocolic perforation, magnet – assisted technique, pediatric surgery","lastPublishedDoi":"10.21203/rs.3.rs-8235487/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8235487/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePercutaneous endoscopic gastrostomy (PEG) is widely used to provide long-term enteral nutrition in neurologically impaired children. Although generally safe, PEG placement may rarely result in major complications such as visceral perforation or retained surgical items. Loss of a laparoscopic needle is an uncommon but potentially serious event due to its risk of migration and the technical challenge of retrieval.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e\u003cp\u003eA 14-year-old boy with Dandy\u0026ndash;Walker malformation, cerebral palsy, refractory epilepsy, and dysphagia underwent PEG insertion. Two weeks later, he presented with peritonitis. Emergency laparoscopy revealed a perforation of the transverse colon and additional posterior colonic and anterior gastric perforations secondary to gastrocolic interposition during PEG placement. All defects were repaired laparoscopically. During extraction of the suturing needle through a trocar, the needle fractured and was lost within the peritoneal cavity. Postoperative radiography confirmed the retained metallic fragment. A second laparoscopy successfully retrieved the needle using a simple magnet-assisted technique in which small sterile magnets were enclosed in a glove finger and introduced through a trocar. The postoperative course was complicated by mechanical ileus requiring further laparoscopic interventions.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThis case illustrates two rare but significant complications after PEG placement\u0026mdash;gastrocolic perforation and intra-abdominal loss of a laparoscopic needle\u0026mdash;and demonstrates a practical magnet-assisted method for retrieval. Strict adherence to instrument-count protocols and early imaging when needle loss is suspected are essential to reducing morbidity in this vulnerable patient population.\u003c/p\u003e","manuscriptTitle":"A novel laparoscopic magnet-assisted technique for extracting a retained needle after repair of PEG-related gastrocolic perforation in a neurologically impaired adolescent: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 07:30:53","doi":"10.21203/rs.3.rs-8235487/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-12T20:10:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204211345031164197687903285011967862949","date":"2025-12-10T17:13:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-03T07:42:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-03T07:38:14+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-02T12:42:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-02T11:18:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-12-02T10:39:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8f0c4432-64cd-47c8-b20e-25069d56fc45","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T07:30:53+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-08 07:30:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8235487","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8235487","identity":"rs-8235487","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}