Subfascial‐located contraceptive devices requiring surgical removal

Abstract

Background Subdermal etonogestrel implants are highly effective contraceptive methods. Despite standardization of insertion technique by the manufacturer, some implants are inadvertently placed too deeply within or below the plane of the biceps brachii fascia. Placement of these implants in a deep tissue plane results in more difficult removal, which is not always possible in the office setting. In rare cases, surgical removal by an upper extremity surgeon is warranted. Case presentation Here we present 6 cases of etonogestrel implants located in a subfascial plane requiring removal by an upper extremity surgeon. Implants were all localized with plain radiography and ultrasound prior to surgical removal. All cases had implants located in the subfascial plane and one was identified intramuscularly. The average age was 28 years (19–33) and BMI was 24.0 kg/m^2 (19.1–36.5), with the most common reason for removal being irregular bleeding. The majority of cases (5/6) were performed under monitored anesthesia care with local anesthetic and one case utilized regional anesthesia. All implants were surgically removed without complication. Conclusions Insertion of etonogestrel contraceptive implants deep to the biceps brachii fascia is a rare, but dangerous complication. Removal of these implants is not always successful in the office setting and referral to an upper extremity surgeon is necessary to avoid damage to delicate neurovascular structures for safe removal.

Localization and removal of nonpalpable contraceptive implants: Experience from a teaching hospital in Ethiopia: A case series

“…24,27 Once a nonpalpable implant is localized, several removal techniques have previously been described. [19][20][21][22] The use of a modified vasectomy clamp with a 2. c For Jadelle: request imaging to be set at 50-55 kV and 4-5 mA with an exposure time of 0.03 seconds. at removal.…”

“…Once a nonpalpable implant is localized, several removal techniques have previously been described 19–22 . The use of a modified vasectomy clamp with a 2.2 mm ring diameter has gained more popularity.…”

“…Studies report difficulty in localizing nonpalpable implants and complications from iatrogenic neurovascular injury during removal attempts. 17,18 Different strategies can be instituted to localize and remove nonpalpable implants, including intraoperative fluoroscopy or referral to an orthopedic surgeon 19 or peripheral nerve surgeon. 20 Ultrasound localization followed by removal using a modified vasectomy clamp, 21 or removal under continuous ultrasound guidance 22 are other approaches.…”

Median nerve neuropathy resulting from blind removal attempts of etonogestrel contraceptive implant: A case report

“…Blind removal of the rod without imaging guidance is associated with adverse outcomes [11,12]. Several techniques for the removal of deeply placed or impalpable implants have been reported, all of which require the precise location of the implant to be identi ed using imaging [7,[13][14][15].…”

“…Complications of implant insertion and removal occur infrequently [2]. Case reports and case series have addressed the complications associated with insertion and removal procedures [3][4][5][6][7]. This case report will support healthcare providers regarding specialist referral if there are any di culties/complications related to implant removal, such as impalpable contraceptive implants, abnormal sensation, or persistent pain at the implantation site, as removal-related complications are often anticipated with the aforementioned conditions [2,8].…”