Abstract

Importance: A part of instrument used to grasp the foreign body may get fractured during its use and its fatal dislodgement may render the treating physician liable. This case being second such in the literature highlights the factors behind such mishap and due precautions to avoid such risk.

Observations: A prong of a strong/ stout crocodile action forceps fractured during attempts to firmly hold a metallic foreign body prior to its extraction. It slipped in the digestive tract as the airway was secured with cuffed endotracheal tube and subsequently was excreted per via naturalis.

Conclusions and relevance: The contributing factors for failure of metallic instrument can be related to its (1) moderate to severe degree of Impaction and (2) quality of metal used in the instrument: Routine inspection of microsurgical instruments for early detection of metal corrosion and fatigue is desirable while strength of forceps may be tested by its firm grasp / indention on a paraffin wax. An international standard be made for all manufacturers to disclose the speculated time of its safe use or else be made liable for such accident.