From laparoscopy to laparotomy: Patient safety lessons from an unretrieved endobag incident

Endobags are commonly used in laparoscopic surgeries for safe specimen retrieval, and complications associated with them are rare. We report a unique case of a 48-year-old woman undergoing laparoscopic ovarian cystectomy for a benign ovarian mass, during which the endobag could not be visualised intraabdominally after its introduction through the main port. Despite thorough intraoperative camera-guided exploration, the endobag remained untraceable, prompting conversion to open surgery. The endobag was ultimately located between the rectus sheath and rectus abdominis muscle, having failed to enter the peritoneal cavity. It was retrieved, and the abdominal wall was closed in layers. The patient had an uneventful recovery. This case highlights a rare but serious intraoperative complication with potential implications for patient safety.