A Gossypiboma From Kazakhstan

Surgical sponges are particularly challenging given their frequent use, small size, and the difficulty in distinguishing a blood-soaked sponge in a hemorrhagic surgical field. Retained surgical foreign bodies are rare, largely preventable potentially dangerous complications. The clinical course of retained surgical sponges can be prolonged and asymptomatic or can progress to an acute exudative phase with infection and/or fistula formation. ¹ There are various reports of gossypiboma mimicking tumor in multiple locations including the chest, abdomen, retroperitoneum, and even the cranium. ^{2 -4} Imaging alone is not reliable for distinguishing between remnant thyroid, recurrent carcinoma, and gossypiboma. ^1,5,6

The potential morbidity associated with retained surgical sponges is significant. In our case, resection of the recurrent laryngeal nerve (RLN) resulted directly from the inadvertent retention of a retained surgical sponge and highlights the significant morbidity associated with this preventable complication. Meticulous sponge count and a thorough surgical site inspection prior to wound closure can help in avoiding gossypiboma formation and associated morbidity. ^7,8 Although gossypiboma is rare in routine clinical practice, diagnosis of gossypiboma should be considered in the setting of postsurgical chronic wound infection and/or persistent drainage.

Gossypiboma is a term used to describe a mass forming around a surgical sponge that is inadvertently retained at the end of the surgery. We present a case of gossypiboma in the neck. A 54-year-old Kazakhstani man with a recurrent neck mass referred to Massachusetts Eye and Ear for evaluation and surgical management. The patient initially presented to Massachusetts General Hospital for endocrine evaluation for further management following total thyroidectomy and neck dissection for papillary thyroid carcinoma performed in Kazakhstan. The history was unremarkable except for postoperative wound drainage lasting for 2 months with a spontaneous resolution. On examination, there was a firm, nonfluctuant, 4.0-cm right-sided neck mass, a thickened cervical scar. The patient had a strong voice and normal vocal cord movements on laryngoscopy. The cytology showed reactive follicular hyperplasia. The imaging revealed scattered subcentimeter right lateral neck lymph nodes which were considered as suspicious for malignancy in the context of the unusual right thyroid bed mass (Figures 1, 2A and B). Considering possible remnant thyroid tissue or recurrent malignancy, multidisciplinary discussion favored surgery. The patient was informed about the potential need for RLN resection due to the proximity of the mass to the expected RLN course, scarring and adhesions from past surgery, and prolonged postoperative drainage. Intraoperatively, the mass was densely adherent to the carotid sheath, trachea, larynx, and RLN and was difficult to dissect. Thin, brown fluid was draining from the mass inferiorly. There was a layer of tissue on the posterolateral aspect of the mass, intraoperatively it could not be determined whether this was benign thyroid tissue, malignancy, or just a region of dense scar. The RLN was intentionally sacrificed to remove the mass in its entirety. The resected specimen revealed densely fibrotic tissue surrounding a surgical sponge (Figure 3). Final histopathology diagnosis was gossypiboma with no identifiable thyroid tissue. Culture grew rare propionibacterium acnes, which was appropriately treated. He was discharged home on postoperative day 1 with no evidence of further infection or hypocalcemia and good swallowing with no evidence of aspiration. He was subsequently treated with radioactive iodine. The patient remained disease-free with no evidence of further complication after 1 year post radioiodine treatment. The patient has since moved to another state and further follow-up is not available.

Figure 1.

Transverse gray-scale ultrasound image of the right thyroid bed demonstrates a 4.8-cm, hyperechoic curvilinear structure (white arrows) with complete posterior acoustic shadowing.

Figure 2.

Axial (A) and coronal (B) noncontrast-enhanced CT images demonstrate a well-defined, rounded focus of soft tissue without any calcification or gas in the right thyroid bed with a mildly hyper dense rim (arrows). Right tracheal wall is mildly flattened with no evidence of invasion. CT indicates computed tomography.

Figure 3.

A dissected view of mass shows the surgical gauze surrounded by a capsule.