|Year : 2014 | Volume
| Issue : 4 | Page : 489-491
Gossypiboma in the urinary bladder: Time to make new surgical guidelines
Nitin Joshi1, Rajay Kumar2, Vishal Yadav2
1 Department of Urosurgery, MGM Medical College, Navi Mumbai, Maharashtra, India
2 Department of Surgery, MGM Medical College, Navi Mumbai, Maharashtra, India
|Date of Web Publication||25-Jun-2014|
302, Dhavalgiri, Plot No. 11, Sector 11, South Kartik Marg, New Panvel (E), Raigad - 410 206, Maharashtra
Source of Support: None, Conflict of Interest: None
The actual incidence of gossypiboma is difficult to determine possibly due to reluctance to report occurrence arising from fear of legal repercussion, but retained surgical sponge is reported to occur one in every 3000-5000 abdominal operations and is most frequently discovered in abdomen. Here, we report a case of 69-year-old male patient who suffered from severe irritative voiding symptoms with abdominal wall fistula at the incision site due to accidently left surgical sponge in bladder following suprapubic cystolithotomy surgery for bladder stone at some other hospital.
Keywords: Foreign bodies, gossypiboma, surgical sponge, urinary bladder
|How to cite this article:|
Joshi N, Kumar R, Yadav V. Gossypiboma in the urinary bladder: Time to make new surgical guidelines. Med J DY Patil Univ 2014;7:489-91
| Introduction|| |
With fast developing communication technologies, mobile phones have entered in our operation theater. Surgeons do attend calls while operating, which is dangerous. Owing to distractions, it is very likely to lead major surgical blunders like accidently leaving behind foreign bodies in the abdominal cavity causing life-threatening complications and unpleasant medico-legal consequences. Gossypiboma is the technical term for surgical complications resulting from foreign materials, such as a surgical sponge, accidentally left inside a patient's body. The term "gossypiboma" is derived from the Latin word gossypium meaning cotton wool and the Swahili boma, place of concealment and describes a mass within a patient's body comprising of cotton matrix surrounded by a foreign body granuloma. 
| Case Report|| |
A 69-year-old male patient with a history of obstructive and irritative voiding symptoms, diagnosed to have a bladder calculus for which he underwent suprapubic cystolithotomy in some other hospital. However, post-operatively his complain of irritative voiding symptoms deteriorated. Post-operatively, patient started passing turbid hazy urine periurethrally and developed a small fistula at the incision site, discharging pus from it. For the same, patient received multiple antibiotics from local doctors with no improvement. Patient presented to us 9 months following surgery. On per abdominal examination, there was a pfannenstiel incision with a small fistula at left extreme end of incision discharging pus from it. On per rectal examination, there was Grade-1 enlargement of the prostrate. The provisional diagnosis of bladder outlet obstruction secondary to benign prostatic hypertrophy was made. To relive bladder outlet obstruction per urethral catheterization was attempted. On per urethral catheterization, purulent urine was drained, which was collected for routine microscopy and culture. Immediately after draining purulent urine an unusual problem was encountered. There was extreme difficulty in inflation of Foley's balloon in the urinary bladder. On inflation of balloon, patient experienced severe agonizing pain so much so that the catheter had to be removed. Routine hematological investigations were within the normal limits. Urine routine microscopy showed few pus cells with no growth on culture. Ultrasonography of the abdomen of our institute revealed a large 10 cm × 7 cm × 6 cm echogenic mass in the bladder with irregular thickened bladder wall. The initial cystogram phase of intravenous pyelogram showed an ill-defined radiolucency with gas bubble within it [Figure 1]. Although delayed film of cystogram revealed the network of gauze sponge as a separate entity due to sippage of contrast within the cotton material [Figure 2].
|Figure 1: The initial cystogram phase of intravenous pyelogram showed an ill-defined radiolucency with gas bubble within it|
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|Figure 2: Delayed film of cystogram revealed network of gauze sponge as a separate entity due to sippage of contrast within the cotton material|
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Patient was subjected to diagnostic cystoscopy, which showed evidence of inflamed posterior urethra with gross inflammation of entire bladder. The bladder was filled with large whitish mass almost occupying the entire bladder. With rigid biopsy forcep, attempt was made to get a biopsy of the mass, but mass could not be biopsied. As patient was extremely poor computed tomography scan of the abdomen was not performed. Early rapid progression of a disease with fistula formation after surgical intervention is actually considered to be a distinct feature of a retained foreign body.  Keeping this in mind, patient was subjected to exploratory laparotomy. On exploration, there was evidence of grossly inflamed bladder and gross adhesions between inflamed bladder and peritoneum. On cystostomy, it was found that there was a surgical mop in the bladder showing phosphatic encrustation and it was badly stuck. Mop was separated from bladder wall and was delivered out. Cystostomy was closed in layers in standard fashion after achieving hemostasis, per urethral and suprapubic Foley's catheters and retrupubic drain was placed. Post-operatively, patient was put on routine antibiotics for 7 days. Perurethral catheter was removed on the 7 th post-operative day and suprapubic catheter was removed on the 10 th day. Post-operatively, fistula got closed and patient became totally asymptomatic.
| Discussion|| |
A foreign body left behind in abdomen during an operation is a severe medico-legal issue. It can be very dangerous and give rise to varied clinical presentation and hence difficult to diagnose clinically. Surgeon's high index of suspicion is essential to make a timely diagnosis. Retained sponge is most frequently observed in patient with emergency operations, obesity, unplanned changes in operative procedure and laparoscopic surgeries.  Gossypiboma may present at any time, from immediately post-operatively to several decades after initial surgery.  Gossypiboma are most frequently diagnosed in the intra-abdominal cavity. However, they can also be found in the chest, extremities, central nervous system and breast. Items such as cotton or gauze pads when mistakenly left behind during surgery can cause foreign body reaction. Some gossypiboma cause infection or abscess formation in the early stage, whereas other remain clinically silent for many years. Gossypiboma cause two types of response in body; exudative and aseptic fibrous. The later can have adhesions, encapsulations and eventually granuloma formation. However, former usually occurs in early post-operative period and may involve secondary bacterial contaminations, which result in various fistulas.  Gossypiboma can present as pseudotumoral, occlusive or septic syndrome. The diagnosis of gossypiboma may be difficult because it may mimic a benign or malignant tissue tumor and so can lead to erroneous biopsy attempts. To prevent gossypiboma, sponges are counted by hand before and after surgeries. This method was codified into recommended guidelines in the 1970's by the association of perioperative registered nurses.
Mobile phones have become an inseparable companion of mankind world-wide. However, there are no guidelines for its use by doctors in operation theatre. At present in majority hospitals there is no restriction on the use of mobile. However, in era of increasing numbers of complex surgeries it is the need of time to set new guidelines in operation theater as well as by the surgeon for his own and his patient's safety by restricting the use of mobile phone.
| References|| |
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[Figure 1], [Figure 2]