Case 1

A 30 year old woman presented with pain and lump in left lower abdomen of two years duration. She had undergone caesarean section two years back. Examination revealed pallor and an intra-abdominal, nontender, firm, irregular lump measuring 10 × 8 cms with restricted mobility in the left lower abdomen. Laboratory investigations revealed microcytic hypochromic anemia. Ultrasonography (USG) of the abdomen was unremarkable. Contrast enhanced CT (CECT) scan of the abdomen showed a segment of transverse colon adherent to ileum with surrounding inflammation. An intraluminal, irregular, calcified mass in the adherent segments of the bowel was seen incorporating a tortuous, linear, radiopaque density suggestive of retained surgical sponge (Figure 1).

On laparotomy, a segment of distal ileum was found adherent to transverse colon. The serosal surfaces of bowel were normal. There was no ascites, lymphadenopathy, peritoneal deposits or hepatic metastasis. Involved segments of ileum and transverse colon were resected and gut continuity was restored by ileo-ileal and colo-colic anastomosis. On opening the resected specimen a surgical sponge lying in the lumen of the ileum and extending into the transverse colon through a fistulous communication was found. The patient made a good post-operative recovery and was discharged on 8th postoperative day.

Case 2

A 16-year-old boy presented with colicky abdominal pain and bilious vomiting for 4 days. He had undergone laparotomy for duodenal ulcer perforation 3 months back. General physical examination was unremarkable except for dehydration. Abdomen was not distended, scar of the previous surgery was healthy and visible peristalsis was present. A 4 × 6 cm firm, tender lump, moving with respiration and with a dull percussion note was found in the left upper abdomen. Bowel sounds were exaggerated. Laboratory investigations and Xray of the abdomen were unremarkable. USG of abdomen showed dilated bowel loops with hyper echoic mass in the left lumbar region. CECT scan of the abdomen showed a mass with spongiform appearance suggestive of a retained sponge (Figure 2). Laparotomy revealed distended jejunal loops proximal to a palpable mass inside the bowel lumen about 1½ foot distal to duodenojejunal flexure. The serosal surfaces of the bowel were normal and distal bowel loops were collapsed. Enterotomy revealed a retained surgical sponge which was retrieved and enterotomy incision closed primarily. The patient made an uneventful recovery.

Discussion

Retained foreign bodies (FB) constitute a mishap in modern surgery. Most common among these is an accidentally overlooked surgical sponge.[5] Retained surgical sponge is also known as gossypiboma [Gossypium (Latin): cotton; oma (Kiswahili): place of concealment][2], textiloma[1] and cottonoid. Exact incidence of gossypiboma is unknown as the condition is considered to be widely underestimated and under reported, possibly due to fear of medicolegal implications.[1,2,6,7,8] Reported incidence varies from 1 in 100-3000 for all surgical interventions, and 1 in 1000-1500 for intra-abdominal operations.[1,2,6] Gossypiboma has been reported following gynecological, abdominal, cardiothoracic, orthopedic, and neurosurgical procedures.[[1,6,9]

The clinical presentation of patients with gossypiboma is varied which causes considerable diagnostic dilemma.[1] Its presence should be suspected in any patient where the postoperative recovery was not smooth or re-admission was required for persistent symptoms.[6] Gossypiboma may cause bowel obstruction, perforation, granulomatous peritonitis, septic syndrome, fistulization to the neighboring organs, or may mimic a chronic inflammatory process like tuberculosis[10] and even malignancy.[1,2,11] At times it may be lethal,[3,6] however it may remain asymptomatic for years.[1,6] Rarely gossypiboma may migrate to the neighboring organs due to persistent pressure and subsequent erosion through their wall.[2,3,4] Intestine is the commonest organ where migration occurs, as seen with both of our patients. This is attributed to the large surface area and relatively thin wall of the intestine which provides least resistance to their transmural migration. Other organs where such migration, although uncommon, has been reported include urinary bladder, stomach and thorax (through diaphragm).[1]

Radiological features of gossypibomas are variable. Detection by plain X-ray is difficult,[11] especially when surgical sponges have not been provided with the radiopaque marker or when the marker has been fragmented or disintegrated, the presence of which may aid in diagnosis.[2,6,7] USG may be helpful and may show an echogenic, complex hypoechoic area, or cystic mass with acoustic shadow or may be normal[1,12] . CECT scan is the investigation of choice.[13,14] It may show complex mass with variable density; calcification; spongiform gas and radiopaque marker 1(if present), as was seen in patient [1]. In patient [2], since the sponge lacked a radiopaque marker it was not visible on radiological investigations. MRI is also infrequently used for diagnosis.[7] Once diagnosed, gossypibomas require removal, as morbidity and complications associated with it are high.[1,2] This usually necessitates laparotomy. However, alternative methods like laparoscopy, percutaneous extraction (with or without the help of interventional radiology)9 and endoscopic procedures have been reported.[12] Spontaneous extrusion is an extremely rare favorable outcome.[1,7]

Risk factors leading to gossypiboma include a higher mean body-mass index, emergency surgery, difficult operative procedure, surgeon’s fatigue, several sponges sticking together, poor tracking, change in nursing and surgical teams, an unplanned change in the operation and unaccountable human error.[2,12] Although importance of meticulous counting cannot be over emphasized, cases have been reported in presence of normal counts.[1,2] Some authors suggest routine X-ray screening of high-risk patients before they leave the operating room even if the count is documented to be correct, although this has not been found to be foolproof.[1,2] thers have suggested use of sponges held in forceps to prevent their intra-operative loss.[8] With technological advancement, the future holds promise for the use of hand held detectors and scanners that will either supplement or replace manual counting. Various other innovations like bar coding of instruments and sponges, radiofrequency identification and electronic surveillance systems are being developed.[15]

References