Gossypiboma, a rare but serious surgical complication, refers to the retention of surgical textiles within the body following a procedure. This condition typically results in significant inflammation and acute pain, often necessitating further surgical intervention. We present a case involving a 35-years-old female who developed acute abdominal pain after 7-8 months after a caesarian section. Radiological imaging revealed the presence of a retained foreign body, which was subsequently confirmed and retrieved as large surgical sponges during a follow-up operation. This case underscores the importance of adhering to stringent surgical protocols to prevent gossypiboma, given its potential for high morbidity, mortality, and increased healthcare costs.
Gossypiboma refers to the retention of a textile-cotton mass within the body following a surgical procedure. The earliest documented case dates back to 1884, as reported by Wilson.1 Despite its historical recognition, the prevalence of gossypiboma remains unclear due to the complexities surrounding malpractice claims and medicolegal issues. Estimates suggest that retained surgical sponges or swabs occur in 1 in 100 to 5,000 operations, with gossypiboma being most commonly identified in the abdominal cavity, occurring in 1 in 1,000 to 1,500 abdominal surgeries.2 A systematic review of 254 cases revealed that gossypibomas are predominantly found in the abdomen (56%),
followed by the pelvis (18%) and thoracic cavity (11%).3 Gossypibomas can often be asymptomatic and discovered incidentally years after the initial surgery, though they may present with pain, fever, abdominal tenderness, abscess formation, or infections weeks after the operation.4 The longest documented interval between surgery and diagnosis is 43 years in the thoracic cavity.5 Gossypibomas can elicit a granulomatous reaction and capsular formation, leading to symptomless periods that may result in misdiagnosis as an abscess or tumor. Manzella et al.2 provided an overview of typical imaging features of gossypibomas using plainradiography, ultrasonography (USG), computed tomography (CT), and magnetic resonance imaging (MRI). In our case, the gossypiboma was misidentified as a tumoral mass of uterus with malignant characteristics on MRI. CT scan was then advised as a further work up plan
A 35-year-old woman, previously healthy and without known coexisting conditions, presented for CT scan to our department with complaints of per vaginal bleeding and discharge since the last 8 months. Ultrasound was performed showing fibroid uterus and MRI was done showing a large uterine mass with possibility of malignancy. She has had a caesarian 9 months back, after which she had constant complaints of vaginal discharge which later on turned into irregular
heavy vaginal bleed and significant abdominal discomfort. During abdominal ultrasound, a heterogeneous mass with calcifications and malignancylike vascular features was detected in uterine pelvis, raising the suspicion for large uterine fibroid. From an outside facility, pelvic MRI revealed a 7 x 7 cm (TR x AP) sarcomatous mass in the anterior wall of the uterine myometrium causing compression upon the endometrial cavity with associated flow voids. Concerns were raised for uterine fibroid with sarcomatous
changes. CT scan was advised by the gynecologists to further evaluate the disease, which showed bulky uterus with a heterogeneous mass containing mottled air lucencies (spongiform appearance) involving the anterior myometrium causing significant exophytic bulge. An echogenic/calcific focus was also identified within this lesion giving streak artifacts. This heterogenous area collectively measured 61 x 57 mm (AP x CRANIO-CAUDAL). Increased parametrial stranding and peri colonic inflammation was noted. Mass-effect was seen upon the base of bladder which shows mild focal wall thickening . The patient underwent exploratory laparotomy and per operative findings included walled off pus collection of 500 ml along with retrieval of a large sponge incorporated into the anterior wall of uterus and adherent to the posterior wall of urinary bladder. Subtotal hysterectomy along with abdominal lavage was successfully done.
Manzella et al.2 outlined the typical radiological characteristics of gossypiboma using ultrasound (USG), computed tomography (CT), and magnetic resonance imaging (MRI). Ultrasound typically reveals a well-defined mass with a wavy internal echo, which may appear solid or cystic, with possible air content and acoustic shadowing from calcifications. CT imaging often shows a low-density, heterogeneous mass with a high-density external wall, sometimes presenting a spongiform pattern with air. The mass may exhibit a soft-tissue density with a whorled texture or gas bubbles. MRI findings usually include a softtissue density mass with a thick, well-defined capsule, hypointense on T1-weighted images and hyperintense on T2-weighted images. Gossypiboma can be confused with abscesses, hydatid cysts, tumors, radiation necrosis, and post-traumatic osteosarcoma.2 A systematic review indicated that gossypibomas are predominantly found in the abdomen (56%), with an average diagnostic delay of 6.9 years.3 42% of patients experienced pain or irritation, while 6% were asymptomatic.3 Imaging modalities such as computed tomography (CT) and X-ray may lack consistent radiological features for the prompt diagnosis of gossypiboma. Retained gauze, which is radiopaque, often presents with a heterogeneous spongiform appearance, sometimes featuring air bubbles or calcifications. 6 Over time, calcium deposits may create a calcified reticulate rind sign, a characteristic feature associated with gossypibomas,7 this was also seen in our case on CT scan. These masses can range from cystic lesions to tumor-like entities.8 Ultrasound is utilized as an adjunctive tool to differentiate between solid and fluid components of the mass, particularly when pseudotumor syndrome is considered.9 This report describes the most common surgical mistake while mostly misdiagnosed initially due to vague clinical symptoms and patient presentation. The patient underwent surgery after 9 months of the initial complaints since she was in a post partum period, leading to misdiagnosis as a sequel of caeserian section. MRI reported as a sarcomatous uterine mass which was further diagnosed as gossipyboma on CT scan. Findings were confirmed subsequently on exploratory laparotomy. Patient remained well after the surgery.
Postoperative retention of foreign bodies, although rare, remains a significant and underreported surgical issue with serious implications. The diverse presentations of retained items can present a diagnostic challenge for clinicians. Identifying risk factors and maintaining vigilance can facilitate timely intervention. Computed tomography (CT) remains the primary imaging modality for diagnosing retained foreign bodies. To mitigate the risk of such complications, measures such as verifying surgical instrument counts, standardizing intraoperative staff hand-offs, and promoting open communication among the surgical team are essential. This report underscores the on going issue of retained foreign bodies and emphasizes the need to consider gossypiboma in patients who have undergone emergent surgical procedures. Future research should focus on optimizing communication and protocols within the operating room to prevent these errors.
