title: Surgical mystery: where is the missing pituitary rongeur tip?
abstract: METHODS
  Case report.
  
  
  OBJECTIVE
  We report the unusual case of a patient who was referred to our institution after she sustained an intraoperative injury to the common iliac vein during posterior lumbar discectomy at L5-S1 with a pituitary rongeur. There was only minimal bleeding with spontaneous hemostasis and no hemodynamic instability. Subsequently, the referring surgeon noted that the pituitary rongeur tip was missing.
  
  
  BACKGROUND
  Vascular injury during lumbar discectomy is a rare, but potentially devastating complication. Rapid diagnosis and treatment is traditionally targeted toward hemodynamic stabilization and repair of compromised structures.
  
  
  METHODS
  Intraoperative fluoroscopy confirmed the presence of the tip anterior to the L3 vertebral body, indicating a possible intravascular migration of the foreign body. After completion of the surgical procedure, an abdominal computed tomography scan failed to confirm the metallic object within the abdominal cavity. Subsequent imaging studies demonstrated the presence of the rongeur tip in the left ventricle. Transthoracic echocardiogram and cardiac catheterization confirmed the presence of a patent foramen ovale and localized the rongeur tip within the papillary cords of the left ventricle, in close proximity of the mitral valve leaflets.
  
  
  RESULTS
  After failure to retrieve the foreign object during cardiac catheterization, the patient underwent sternotomy, removal of foreign metallic object, and closure of patent foramen ovale.
  
  
  CONCLUSIONS
  Close multidisciplinary collaboration allowed for proper diagnosis and the safe retrieval of the missing rongeur tip from the left ventricle.
authors.affiliation: Department of Neurosurgery, Johns Hopkins University, Baltimore, MD 21287, USA. abydon1@jhmi.edu
authors.forename: Ali
authors.initials: A
authors.lastname: Bydon
authors.forename: Risheng
authors.initials: R
authors.lastname: Xu
authors.forename: John V
authors.initials: JV
authors.lastname: Conte
authors.forename: Ziya L
authors.initials: ZL
authors.lastname: Gokaslan
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Brinker
authors.forename: Timothy F
authors.initials: TF
authors.lastname: Witham
authors.forename: Reza
authors.initials: R
authors.lastname: Yassari
mesh_terms: D017586:Diskectomy / Q000009:adverse effects*; D005260:Female; D005547:Foreign Bodies; D006801:Humans; D007084:Iliac Vein / Q000000981:diagnostic imaging / Q000293:injuries*; D007431:Intraoperative Complications / Q000000981:diagnostic imaging; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery*; D019300:Medical Errors; D008875:Middle Aged; D011859:Radiography; D014652:Vascular Diseases / Q000000981:diagnostic imaging / Q000209:etiology*