Gossypiboma case

1. GOSSYPIBOMA

2. • 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. It has been reported to occur following surgical procedures such as abdominal, thoracic,
cardiovascular, orthopedic, neurosurgical, urological, and even in an ileal conduit. 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. 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.
• 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. 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.
• 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. Newer technologies like radiofrequency chip
identification by bar code scanner are being developed that will hopefully decrease the incidence of
such event.
• Ultrasound of retained surgical sponges is diagnostic.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. 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.

3. • 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 and also in differential diagnosis of acute abdomen.
• 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. 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. Though,
counting of sponges and instruments was not a significant predictor in the
multivariate model. 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. 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.
• 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.