Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 6  |  Issue : 1  |  Page : 98-101  

Retained surgical sponge: An enigma


Department of General Surgery, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India

Date of Web Publication14-Mar-2013

Correspondence Address:
Gurjit Singh
Department of Surgery, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.108664

Rights and Permissions
  Abstract 

Retained surgical sponge in the body following a surgery is called "gossypiboma". A 27-year-old female who had undergone lower segment cesarean section 4 months earlier was admitted with complaints of pain abdomen with a palpable mass in left iliac fossa. X-ray, ultrasonography, and CT scan findings were suggestive of retained surgical sponge. Surgical sponge was removed following laparotomy. Surgeons must be aware of the risk factors that lead to gossypiboma, and measures should be taken to prevent it. Besides increasing morbidity and possible mortality, it may result in libel suit for compensation.

Keywords: Acute abdomen, gossypiboma, retained sponge


How to cite this article:
Singh G, Dubhashi SP, Jindal N. Retained surgical sponge: An enigma. Med J DY Patil Univ 2013;6:98-101

How to cite this URL:
Singh G, Dubhashi SP, Jindal N. Retained surgical sponge: An enigma. Med J DY Patil Univ [serial online] 2013 [cited 2024 Mar 29];6:98-101. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2013/6/1/98/108664


  Introduction Top


A surgical sponge is the most common type of retained foreign body (RFB). The condition is sometimes called gossypiboma, derived from Latin word gossypium (cotton) and in Swahili language boma (place of concealment). [1] The term "gossypiboma" denotes a mass of cotton that is retained in the body following surgery. Gossypiboma creates a medico-legal problem.


  Case Report Top


A 27-year-old female patient presented with pain abdomen, 3 episodes of post-prandial vomiting, and constipation of 2 days duration. Patient had undergone lower segment cesarean section 4 months earlier. Patient had recurrent attacks of pain abdomen and constipation on and off during past 4 months, during which she had a short febrile course treated with antibiotics. Examination of abdomen revealed a healthy midline infraumbilical scar with a firm, non-tender 6 cms΄ 6 cms mass in the left iliac fossa. Per vaginal examination was unremarkable. X-ray erect abdomen showed multiple air fluid levels in small bowel, USG abdomen examination showed echogenic area with extensive posterior acoustic shadowing, suggestive of surgical sponge. Further evaluation was done to confirm the diagnosis by a CT scan, which revealed a round, well-defined soft-tissue mass with a dense, enhanced wall containing aninternal high-density area with air-bubbles within an abscess cavity, suggesting a retained surgical sponge. At laparotomy, a surgical sponge was removed from within an abscess cavity, which was adherent to bowel wall [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] and [Figure 6]. Postoperative period was uneventful.
Figure 1: Previous LSCS scar

Click here to view
Figure 2: Ultrasonography - Highly echo-refl ective structure with posterior acoustic shadow suggestive of encysted collection

Click here to view
Figure 3: CT scan - Cross-sectional axial image of abdomen reveal soft tissue density round to oval lesion with entrapped air pockets. Hypodense area adjacent to it may suggest encysted collection

Click here to view
Figure 4: Abscess cavity

Click here to view
Figure 5: Retained surgical sponge

Click here to view
Figure 6: Surgical sponge

Click here to view



  Discussion Top


Gossypibomas result from a variety of operative substances. Surgical sponge is the commonest reported postoperative intra-abdominal foreign body and has been widely mentioned in the literature. [2] It has been reported to occur following surgical procedures such as abdominal, thoracic, cardiovascular, orthopedic, neurosurgical, urological, and even in an ileal conduit. [3],[4] Although the real incidence is unknown, it has been reported as 1 in 100 to 3000 for all surgical interventions and 1 in 1000 to 1500 for intra-abdominal operations. [5] Septicemia may be present in the early postoperative period with plain abdominal radiologic investigations revealing a characteristic soft tissue mass containing air bubbles with or without a fistula. [6]

The gossypiboma may remain unnoticed for years till the time that they result in a complication or be incidentally picked up. Common complications are bowel obstruction, perforation, pseudotumour, and granulomatous peritonitis. The low index of suspicion due to the rarity of the condition and the long latency in the manifestation of the symptoms frequently result in misdiagnosis (or even missed diagnosis), leading to inordinate delay in proper management.

Two usual responses lead to the detection of a retained sponge. The first type is an exudative inflammatory reaction with the formation of an abscess and usually leads to early detection and surgical removal. The second type is aseptic with a fibrotic reaction to the cotton material and development of a mass. [7] An unusual response is migration of foreign body, which have been self-introduced or have migrated into intestinal lumen, uterus, vagina, pelvis, rectum or into urinary bladder and urethera. [8]

It can be diagnosed preoperatively in many instances with the help of radiological studies such as plain radiography, ultrasonography (USG), computerized tomography (CT), magnetic resonance imaging (MRI), and gastrointestinal contrast series. [9] Newer technologies like radiofrequency chip identification by bar code scanner are being developed that will hopefully decrease the incidence of such event. [10]

Ultrasound of retained surgical sponges is diagnostic. [11] Several different features may be seen, as in this case, with brightly echogenic wavy structures present in a cystic mass showing acoustic shadowing posteriorly that changes with direction of the ultrasound beam. Computerized tomographic scanning may show gas trapped between the surgical sponge fibers, calcification of the cavity wall in long standing cases, and contrast enhancement of the rim. [12] All of these features may not be distinguishable from other intra-abdominal abscesses. Generally, magnetic resonance imaging shows a mass with variable signal intensity dependent upon the amount of fluid and protein accumulation. The capsule tends to have low signal intensity on both T1- and T2-weighted images with poor Gadolinium enhancement. [2]

Since most of the symptoms are non-specific, diagnosis is guided by details of previous operation and a high index of suspicion. It should be included in the differential diagnosis of soft tissue masses detected in patients with a history of a prior operation [13] and also in differential diagnosis of acute abdomen. [14]

Out of 8 risk factors viz. emergency operation, unexpected change in operation, more than one surgical team involved, change in nursing staff during procedure, body mass index (BMI), volume of blood loss, female sex, and surgical counts, only 3 were found to be statistically significant by multivariate logistic regression. [5] The 3 significant risk factors were emergency surgery, unplanned change in the operation, and BMI. To avoid such instances, 4 separate counts of sponge, and instruments has been advised: First while setting up the instruments and unpackaging of the sponges, second before surgery commences, third as closure begins, and fourth during the skin closure. [15] Though, counting of sponges and instruments was not a significant predictor in the multivariate model. [5] Preventive measures should include placement of radiologically detectable sponges and towels in the operative field, avoid using small sponges in large cavities, and above all, perform a meticulous examination of the wound before closing any wound. [7] Thus, the incidence can be reduced by strictly following above-mentioned methods as well as emphasizing its importance during surgical training amongst undergraduates, interns, residents, and operation theater staff.


  Conclusion Top


Retained sponges are more likely to occur in an obese patient undergoing emergency surgery. It should be suspected early and preoperatively and diagnosis should be confirmed by imaging studies to avoid any form of aggressive surgical therapy. Amongst the measures to prevent this adverse event, a thorough search of the operative area should be made before fascial closure besides the sponge count by the theater and scrub nurse. Retention of sponge may result in morbidity and at times mortality and is liable to negligence suit.

 
  References Top

1.Rappaport W, Haynes K. The retained surgical sponge following intra - abdominal surgery: A continuing problem. Arch Surg 1990;125:405-7.   Back to cited text no. 1
[PUBMED]    
2.Mochizuki T, TakeharaY, Ichijo K, Nishimura T, Takahashi M, Kaneko M. Case report: MR appearance of a retained surgical sponge. Clin Radiol 1992;46:66-7.   Back to cited text no. 2
    
3.Sheehan RE, Sheppard MN, Hansell DM. Retained intrathoracic surgical swab: CT appearances. J Thorac Imaging 2000;15:61-4.   Back to cited text no. 3
[PUBMED]    
4.Kruglick SM, Nikolaidis P, Casalino DD. Ileal conduit gossypiboma. J Urol 2012;187:686-7.   Back to cited text no. 4
[PUBMED]    
5.Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003;348:229-35.   Back to cited text no. 5
[PUBMED]    
6.Apter S, Hertz M, Rubinstein ZJ, Zissin R. Gossypiboma in the early post-operative period: A diagnostic problem. Clin Radiol 1990;42:128-9.   Back to cited text no. 6
[PUBMED]    
7.Gibbs VC, Coakley FD, Reines HD. Preventable errors in the operating room: Retained foreign bodies after surgery-Part I. Curr Probl Surg 2007;44:281-337.   Back to cited text no. 7
[PUBMED]    
8.Mylarappa P, Srikantaiah HC. Calcified Intravesical Gossy piboma Following Abdominal Hysterectomy: A Case Report. J Clin Diagn Res 2011;5:645-7.   Back to cited text no. 8
    
9.Sahin-Akyar G, Yagci C, Aytac S. Pseudotumor due to surgical sponge: Gossypiboma. Australas Radiol 1997;41:288-91.   Back to cited text no. 9
    
10.Macario A, Morris D, Morris S. Initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology. Arch Surg 2006;141:659-62.   Back to cited text no. 10
[PUBMED]    
11.Sugano S, Suzuki T, linuma M, Mizugami H, Kagesawa M, Ozawa K, et al. Gossypiboma: Diagnosis with ultrasonography. J Clin Ultrasound 1993;21:289-92.   Back to cited text no. 11
    
12.Sheward SE, Williams AGJr, Mettler FAJr, Lacey SR. CT appearance of a surgically retained towel (gossypiboma). J Comput Assist Tomogr 1986;10:343-5.   Back to cited text no. 12
    
13.Moslemi MK, Abedinzadeh M. Retained Intraabdominal Gossypiboma, five years after bilateral orchiopexy. Case Report Med 2010;2010:420357.   Back to cited text no. 13
    
14.Lata I, Kapoor D, Sahu S. Gossypiboma, a rare cause of acute abdomen: A case report and review of literature. Int J Crit Illn Inj Sci 2011;1:157-60.   Back to cited text no. 14
[PUBMED]  Medknow Journal  
15.Abdul Haque M. Quraishi, "Beyond a Gossypiboma," Case Reports in Surgery 2012;2012:263841.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

Top
   
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed7479    
    Printed174    
    Emailed2    
    PDF Downloaded320    
    Comments [Add]    

Recommend this journal