Gossypiboma, textiloma or more broadly Retained Foreign Object (RFO) is the technical term for a surgical complications resulting from foreign materials, such as a surgical sponge, accidentally left inside a patient's body

3.  Gossypiboma, textiloma or more broadly Retained
Foreign Object (RFO) is the technical term for a 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(“cotton wool, cotton”) and the suffix -
oma, meaning a tumor or growth.

4.  "Textiloma" is derived from textile (surgical sponges have
historically been made of cloth), and is used in place of
gossypiboma due to the increasing use of synthetic
materials in place of cotton

5. Incidence
 The actual incidence is difficult to determine, possibly due
to a reluctance to report occurrences arising from fear of
legal repercussions, but retained surgical sponges is
reported to occur once in every 3000 to 5000 abdominal
operations and are most frequently discovered in the
abdomen.
 The incidence of retained foreign bodies following surgery
has a reported rate of 0.01% to 0.001%, of which
gossypibomas make up 80% of cases

6. Risk Factors
Human
Communication failure:
• Cross cultural: surgeon to
nurse
• Gender related: male to female
• Hierarchial: captain to crew,
surgeon to OT team
Level of education
Training
Experience
Environment
Noise
Distractions
Conversations
Traffic in and out of
operating room
Unplanned change in surgery

7. Items Retained
 Surgical instruments
 Surgical sponges
 Towels
 Suture needles
 Accessory items

8. Location of gossypiboma
Frequent sites of gossypiboma formation include:
 Thoracic cavity
 pleural cavity
 pericardial cavity
 Abdominal cavity
 Pelvic cavity

9. Pathophysiology
 Surgical sponges are made of cotton, an inert
material that does not stimulate any specific
biochemical reaction except adhesion and granuloma
formation.
 Two major types of reaction occur in response to
retained surgical foreign bodies.

10.  The first type is an exudative, acute inflammatory
reaction, with the formation of an abscess in close
proximity to the retained sponge. This usually occurs
in the early postoperative period and may involve
secondary bacterial contamination
 The second reaction is an aseptic fibrinous response,
resulting in tissue adhesions and encapsulation and
eventually foreign body granuloma.

11. Presentation
 variable.
 In some cases, a retained surgical sponge(RSS) may be
discovered by accident during a radiographic examination
or during an unrelated surgical procedure.
 a mass or abdominal pain or, more commonly, as an
incidental finding on a routine postoperative radiograph.
 Sponges initially placed in the chest or abdomen can
erode through the skin or into the GI tract, creating a
fistula or an intestinal obstruction, appear in a bowel
movement, or cause hematuria

12.  The most common symptoms of RSS are
 Pain
 palpable mass
 vomiting
 weight loss
 diarrhea
 abdominal distention
 tenesmus.

13. Complications
 The main complications of RSS are:
 Abscess development
 Adhesion
 Obstruction
 Fistula
 Peritonitis
 Erosion of urinary or GI tissues
 Migration of the sponge into the lumen of GI system.

14. Workup
 Imaging modalities
 Because RSS symptoms are usually nonspecific and may
appear years after surgery, the diagnosis usually comes
from imaging studies and a high index of suspicion.
 In advanced countries , surgical gauze is manufactured with
radiopaque threads that are easily identified on
radiographs, but this is not the case in all countries.

15. Plain Radiograph
 If the sponge contains a
radiopaque marker, the
diagnosis can be made easily
by plain radiograph
 The most impressive imaging
finding are the curved or
banded radiopaque lines on
plain radiograph

16. Ultrasound
 May appear as a well-
defined mass containing
wavy, bright, internal
echogenic structure with a
hypoechoic rim and a
strong posterior shadow.

17. CT Scan
 Spongiform appearance
with gas bubbles.
 Low-density mass with a
thin enhancing capsule.
 Calcifications deposited
along the network
architecture of a surgical
sponge.

18.  Differentiation from
abscess and hematoma
may be difficult to discern
on CT scan.
 The use of a 3-
dimensional CT scan gives
a clearer, less ambiguous
depiction of the object

19. MRI
 MRI usually shows a well-
defined mass with a
fibrous capsule that
exhibits :
 low signal intensity on T1-
weighted images
 high signal intensity on
T2-weighted images.

20. Management of Clinical Consequences
 Depends on its location.
 Patients should be offered removal of the Retained
Surgical Sponge after it is recognized.
 In cases where the patient is asymptomatic and the
sponge is detected by chance, surgical removal should be
recommended after the patient has been informed about
the possible complications of the retained sponge.

21.  RSSs are usually removed by open surgery
 In selected cases, minimally invasive techniques
(endoscopy and laparoscopy) may be used.
 Endoscopy may be useful when the RSS has migrated
within the lumen of a hollow organ accessible by
endoscopy (such as the stomach).
 Laparoscopy for RSS is rarely performed, since the RSS is
usually large and hard and has caused extensive
adhesions or intensive granuloma formation

22. Prevention
 Preventing Retained Surgical Sponge is far more
important than cure.
 To prevent gossypiboma, sponges are counted by hand
before and after surgeries. This method was codified into
recommended guidelines in the 1970s by the Association
of periOperative Registered Nurses (AORN).
 Other guidelines have been promoted by the American
College of Surgeons and The Joint Commission for
prevention of Retained Surgical Instruments.

23. History
 Unclear if there were sponge counts prior to 1901
 Sponge counts - 1901
 Needle counts - 1976
 Instrument counts - mid ‘80s
 Accessory items - early ‘90s

24.  Separate counts are recommended:
 Before the procedure to establish a baseline and identify
manufacturing packaging errors (ie, initial count)
 When new items are added to the field
 Change of scrub person or circulator/runner.
 Before closure of a cavity within a cavity (eg, uterus)
 When wound closure begins
 At skin closure or at the end of the procedure when
counted items are no longer in use (ie, final count)

25.  Accurate counting of all surgical sponges during a
procedure is should be the priority of all members of
surgical team.
 Unnecessary activity and distractions should be curtailed
during the counting process to allow the scrub person
and circulator to focus on counting tasks.

26.  The scrub person should maintain awareness of the
location of soft goods (eg, sponges, towels, textiles); and
instruments on the sterile field during the course of the
procedure. It is the scrub person's responsibility to:
 Verify the integrity and completeness of sponges when they
are counted.
 Confirm that instruments or devices that are returned from
the operative site are intact.
 Speak up when a discrepancy exists.

27.  The surgeon(s) and surgical first assistant(s) should be aware
of all soft goods, instruments, and sharps used in the surgical
wound during the course of the procedure.
 The surgeon does not perform the count but should facilitate
the count process by:
 Communicating placement of surgical items in the wound to the
perioperative team for notation (eg, whiteboard).
 Acknowledging awareness of the start of the count process.
 Removing unneeded soft goods and instrumentation from the
surgical field at the initiation of the count process.
 Performing a methodical wound exploration when closing counts
are initiated.
 Accounting for and communicating about surgical items in the
surgical field.
 Notifying the scrub person and circulator about surgical items
returned to the surgical field after the count.

28.  Anesthesia care providers should maintain situational
awareness and engage in safe practices that support the
prevention of Retained Surgical Instruments.
 Situational awareness is the process of recognizing a threat
and taking steps to avoid the threat..
 Anesthesia care providers should not use counted items.
 Anesthesia care providers should verify that throat packs,
bite blocks, and other similar devices are removed from
the oropharynx and communicate to the perioperative
team when these items are inserted and removed.

29. Cost and Legal Ramifications
 Prevention of RSS is of key importance to avoid not only
morbidity and mortality but also medicolegal
consequences.
 The cost of an Retained Surgical Sponge can be
significant, as it may lead to patient harm, increased
hospital stays, and litigation. Damages awarded to
plaintiffs vary markedly according to circumstances,
injury, and the state/country in which the case was tried.
 The psychologic trauma and negative publicity for the
surgical care providers can be significant.

30. Emerging Technologies
 Physically counting surgical items by the OT staff before
and after procedures is the most common policy.
 New technologies are being developed that may increase
the efficiency and accuracy of accounting for surgical
items.
 Barcode and Radiofrequency identification technology
have been incorporated into cotton sponges to help
improve the reliability of counting these products.

31. Radiofrequency identification system
 Detects sponges
 sponge have RF sensors.
 RF sensors Sponge absorbs low frequency radio
waves and return it to the wand to indicate its
presence.

33. .
 Barcodes can be applied to
all sponges, and with the use
of a barcode scanner
 Electronic tagging of surgical
sponges involves a device
that gives off a signal
indicating the presence of an
RSS when it is swept across a
surgical site.

34. Take Home Message
 Preventing an RSS is far more important than cure.
 Multidisciplinary approaches may help to avoid retained
foreign objects.
 New technologies may help to reduce the incidence of
retained foreign objects.
 There should be high index of suspicion of RSS in patients
with past history of surgery.
 RSSs should be included in the differential diagnosis of a
soft-tissue mass detected in a patient with a history of
surgery.

35. Please pay attention when counting
sponges.
Your few seconds can lessen the
undue morbidity and mortality

36. References
 Yildirim S, Tarim A, Nursal TZ, et al. Retained surgical sponge (gossypiboma) after
intraabdominal or retroperitoneal surgery: 14 cases treated at a single
center. Langenbecks Arch Surg. 2006;391:390–395.
 Gawande AA, Studdert DM, Orav EJ, et al. Risk factors for retained instruments and
sponges after surgery. N Eng J Med. 2003;348:229–235.
 Institute of Medicine. To Err is Human: Building a Safer Health System. Washington,
DC: National Academy Press; 2000.
 Greenberg CC, Gawande AA. Retained foreign bodies. Adv Surg. 2008;42:183–191.
 Miller MR, Elixhauser A, Zhan C, Meyer GS. Patient safety indicators: using
administrative data to identify potential patient safety concerns. Health Serv
Res. 2001;36:110–132.
 Gibbs VC, Auerbach AD. The retained surgical sponge. In: Shojania KG, Duncan BW,
McDonald KM, Wachter RM, editors. Making health care safer: a critical analysis of
patient safety practices. Rockville, MD: Agency for Healthcare Research and
Quality; 2001, p. 255–257.
 Gibbs VC, McGrath MH, Russell TR. The prevention of retained foreign bodies after
surgery. Bull Amer Coll Surg.2005;90:12–14; 16.
 Gibbs VC. Patient safety practices in the operating room: correct-site surgery and
nothing left behind. Surg Clin North Am. 2005;85:1307–1319.
 Joint Commission Resources. Foreign objects retained after surgery.
http://www.jcrinc.com/Foreign-Objects-Retained-After-Surgery. Accessed
November 28, 2012