Gossypiboma: A case of retained intra-luminal surgical sponge leading to delayed diagnosis and treatment in a Nigerian patient

Abstract

Gossypiboma, a term used to describe a retained foreign body mass of cotton (sponge, abdominal mop or gauze) within the body after a surgical procedure, is an uncommon but serious surgical complication. It can manifest with various clinical presentations and often leads to delayed diagnosis and significant morbidity. This report highlights the need for a repeat exploration at the end of open abdominal surgeries as routine. The case presented is that of a young female who underwent open myomectomy in an outreach setting, and subsequently developed symptoms of an acute abdomen due to a retained abdominal mop seen at surgery. The abdominal mop seen at laparotomy had migrated transmurally and became trapped within the ileum and ileocecal junction. After removal of the intra-luminal abdominal mop and abdominal closure, she had post-operative malnutrition and anaemia that were corrected as she regained full recovery. The incidence of gossypiboma is believed to be underestimated in developing countries, and surgical sponges are the most frequently retained foreign bodies. Accurate estimates of the incidence are challenging due to socio-cultural impediments and fear of litigation. Prompt recognition and prevention of gossypiboma are crucial to avoid associated complications and improve patient outcomes.

Introduction

Gossypiboma also known as textiloma, surgical sponge or abdominal mop retained refers to the inadvertent retention of a foreign body; typically a sponge, abdominal mop or gauze within the body after a surgical procedure. It occurs in every clime and even in tertiary hospitals with all the modern ancillary aid and, in most cases the incidence is more common in emergencies than elective cases. ¹ It is a rare but significant complication that can lead to various clinical consequences and pose challenges in its diagnosis. Gossypibomas can remain asymptomatic or present with symptoms such as bowel obstruction, peritonitis, adhesions, fistula, abscess formations and erosion into the gastrointestinal tract, resulting in intestinal obstruction or passage via the rectum. ¹ The incidence of retained abdominal mops following open abdominal operation in a third-world country, like Nigeria has unfortunately been underreported due to socio-cultural impediments and fear of litigation.^2,3

In this case report, we describe the case of a young female who underwent open myomectomy during free surgeries performed by a gynaecologist in an outreach programme 3 months prior to presentation. She subsequently developed acute-on-chronic abdominal symptoms that posed a challenge in establishing a diagnosis early. Laparotomy revealed an abdominal mop that had migrated transmurally and became lodged within the ileum. This case highlights the need for high index of suspicion of possible retained foreign body following open abdominal surgeries carried out in an uncontrolled (e.g. outreaches in low-income areas) or emergency setting; and the need for the surgical team to repeat exploration of the abdomen at the end of surgery as routine, despite existing theatre checklists and protocols to prevent inadvertent retention of foreign bodies in the abdomen.

Case presentation

A 42-year-old single para 0 female civil servant with no history of medical comorbidities, presented to our outpatient clinic with a 2-week history of occasional colicky abdominal pain, primarily localized to the right flank. The pain was non-radiating and had no known aggravating or relieving factors or periodicity. The patient had an open myomectomy performed 3 months prior to presentation, by a team of gynaecologists, with anaesthetists and nurses present during a planned free medical outreach in a private health facility. However, details of the myomectomy or challenges during the surgery could not be ascertained. Initial examination findings revealed mild pallor and mild epigastric tenderness. Vital signs were stable with a weight of 77 kg, and initial investigations showed positive malaria test (2+), elevated Widal titers (>160: range), decreased haematocrit (27%: range from 35.0% to 59.0%) and total white cell count of 6.2 × 10³/μL (3.50–9.50 × 10³/μL), suggesting possible infection. The patient, after further review, was treated for malaria and typhoid enteritis, and she was discharged with antibiotics and hematinic.

The patient re-presented 3 weeks later with worsening symptoms, including generalized abdominal pain, frequent loose stools, vomiting, loss of appetite and significant unintentional weight loss. Physical examination revealed a chronically ill-looking patient who was febrile, pale and moderately dehydrated with a weight of 70 kg. Abdominal examination showed moderate epigastric tenderness with slight increase in bowel sounds. Laboratory investigations revealed serum potassium of 3.22 mmol/L (3.5–5.1 mmol/L), a haematocrit of 24% (35.0%–59.0%), and a nonreactive serology test. Abdomino-pelvic ultrasound suggested enterocolitis to rule out acid peptic disease. She was readmitted and resuscitated. Oesophagogastroduodenoscopy and abdominal computerized tomography (CT) scan were requested but could not be done due to the patient’s financial constraints. During her hospital stay, the patient’s condition continued to deteriorate. She experienced persistent vomiting, decreased appetite, passage of frequent loose stools and further weight loss of about 3 kg, and a total of 47 kg in 4 months after the myomectomy. She was chronically ill-looking and pale on further evaluation, but afebrile. Her abdomen was mildly distended, locally tender in the right upper abdomen, but soft. There was no organomegaly.

She later gave consent for the initially declined abdominal CT scan, 3 days after the second admission (when she had philanthropic support). This revealed dilated bowel loops with mottled hypodensities in the caecum, ascending colon, and transverse colon, suggestive of faecal impaction. Additionally, the CT scan raised suspicion of post-surgical adhesions, secondary mechanical bowel obstruction, adenomyosis and fatty liver (Figure 1(a)–(c)).

Figure 1.

Abdominopelvic CT scan of a 42-year-old female clinically diagnosed with intestinal obstruction. (a) scanogram, (b) coronal view (showing mottled hypodensities in the caecum (red arrow), ascending (blue arrow) and transverse colon (light green arrow), (c) axial view (yellow arrow points at ascending colon).

The patient was preoperatively resuscitated and diagnosed with intestinal obstruction secondary to post-operative adhesions and malnutrition with severe anaemia, keeping in view the possibility of enteric typhoid perforation, and booked for emergency exploratory laparotomy on the fourth day of readmission. She underwent exploratory laparotomy after adequate optimization, which revealed multiple ileal-ileal and ileal-uterine adhesions. Three major ileal perforations with the more proximal one being about 130 cm from the ileocaecal junction were found in regions of dense multiple ileal adhesion with pockets of pus after adhesiolysis. An intra-luminal mass measuring 15 × 7 cm was identified in the middle ileal perforation about 120 cm from the ileo-caecal junction (Figure 2(a)).

Figure 2.

(a) Intraoperative photograph showing the retained intra-luminal abdominal mop in a 42-year-old female before removal. (b) Intraoperative photograph showing the retained intra-luminal abdominal mop in a 42-year-old female being retrieved out of one of the ileal perforations. (c) Post-operative photograph of intra-luminal ileal abdominal mop that was removed.

With further dissection and adhesiolysis, the intra-luminal ileal abdominal mop was extracted through the perforation between the proximal and distal (about 100 cm from ileocaecal junction) ileal perforations; and approximately 60 cm of the ileal segment with multiple (major and minor) perforations was resected (Figure 2(b)).

Bowel continuity was established through ileo-ileal anastomosis. The resected ileal segment (Figure 2(c)) was sent for histological examination, but this did not reveal any significant findings. The patient had post-operative protein-energy malnutrition and anaemia that were corrected. The overall post-operative state 10 days later was satisfactory, with the restoration of bowel function and resolution of symptoms. This case report conforms to CARE guidelines. ¹¹

Discussion

Retained foreign bodies, specifically surgical sponges, are a recognized and potentially serious complication that should be considered in post-operative patients presenting with dull chronic abdominal pain, infection, or a palpable mass. Delayed recognition and treatment can occur, as was the case in this report, highlighting the importance of considering this possibility early on, especially in indigent patients. The actual incidence of retained surgical sponge following abdominal surgeries is difficult to estimate due to underreporting.^2,3 This may account for the varied reported incidence of approximately 1 in 300 to 1 in 1500 surgeries, with surgical sponges being the most commonly retained foreign bodies.^1,2 Gossypibomas are frequently found in the abdomen (56%), pelvis (18%) and thorax (11%).^2,5 Other forms of retained foreign bodies in the abdomen include artery forceps, metallic instruments, surgical needles, surgical drains and rubber tubes.^4,6 Retained sponge in the abdomen, is one of the known, but avoidable complications of abdominal surgeries. It’s more likely to occur when surgery is done in a non-ideal setting and negligence or ignorance on the part of the surgical team and theatre personnel.^5,6

Pre-operative diagnosis is based on a high index of suspicion. Typically, pre-operative diagnosis is based on clinical evaluation, plain abdominal radiographs and ultrasound scans. Abdominal CT scan is the primary diagnostic modality for identifying retained foreign bodies, typically showing a rounded mass with a dense central part and an enhancing wall. Magnetic resonance imaging may be less reliable due to the radiopaque marker not being visible due to disintegration or fragmentation of the radio-opaque marker over time.^5,8 Despite these modalities, some patients are diagnosed on the operating table during laparotomy,^7,9 like in the index case. Intraoperative radiographs, occasionally done may not provide clear visualization of sponges, particularly in obese patients, as surgical markers can become twisted or folded, leading to atypical imaging appearances. Therefore, relying solely on intraoperative radiographs may not be sufficient for detection.^8,9

Gossypiboma causes two types of response in the body. The first type results in the formation of foreign body granuloma which is usually clinically asymptomatic. This is thought to be mostly caused by a fibrous reaction to the gauze that results in adhesions and encapsulation of the foreign material.^7,10 Eventually, the gossypiboma may undergo calcification, disruption, partial absorption, or diffusion. The second type is characterized by exudative inflammatory reaction with abscess formation, in which the body tries to eliminate the foreign material by eliciting extensive inflammatory response; which can result in significant symptoms in the patient. This may eventually result in a foreign body sinus, enterocutaneous fistula formation, or transmural migration of the foreign body into the gut via peristaltic aid, with resultant intestinal obstruction, or extrusion of the gossypiboma.^7,10

The preferred treatment for a retained foreign body, especially in low- and middle-income countries, is open removal, although laparoscopic approaches are increasingly being considered due to their advantages, such as early ambulation, reduced post-operative pain, improved cosmetic outcomes and shorter hospital stays. Prevention is key, and a systematic approach should be implemented to reduce the incidence of retained foreign bodies. Performing counts before, during and after surgery, as recommended by the Association of Registered Nurses of the United States, and maintaining an optimal operating room environment endorsed by the American College of Surgeons, are essential steps.^7,8 Additionally, implementing surgical safety protocols like the World Health Organization (WHO) checklist can further enhance patient care and safety. ¹⁰ Proper training and guidelines for surgical residents and operating room staff regarding counting methods should be incorporated into the curriculum. Once a diagnosis of a gossypiboma is made, the appropriate course of action is surgical removal to prevent further complications, especially in low- and middle-income countries.

Conclusion

In conclusion, preventing retained foreign bodies, including gossypiboma coupled with a high index of suspicion in post-operative chronic abdominal pain, is crucial in surgical practice in low- and middle-income countries. These incidents can result in significant morbidity or mortality, increased costs and potential medico-legal implications. The fact that this incidence is still occurring suggests negligence especially in peripheral hospitals and during free surgeries in outreaches. Addressing this issue requires a collaborative effort from the entire surgical team, emphasizing standardized protocols and adhering strictly to them, as well as improved communication, and a culture of safety in the operating room. More importantly, there is a need for the surgeon and his team to repeat exploration of the abdomen, as routine, at the end of a laparotomy; despite assurance of a complete instrument and swab count.