Case Report
Gossypiboma: To Err is Human – A Case Report
Wasif Mohammad Ali1*, MM Ansari1, Deeba Khanam2, Shahbaz Habib Faridi1
1
2
Department of Surgery, JN Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India.
Department of Obs & Gynae, JN Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India.
_________________________________________________
ABSTRACT
Received: 08.12.2015
Revised: 14.12.2015
Accepted: 16.12.2015
*Correspondence to:
Dr. Wasif Mohammad
Ali Assistant Professor,
Department Of Surgery,
JN Medical College,
Aligarh Muslim
University, Aligarh, Uttar
Pradesh, India.
E-mail:
[email protected]
Gossypiboma (retained surgical sponge) is one of the identities that can be a disaster not only to the
carrier of operating surgeon but also for the hospital as far as the financial burden and the reputation is
concerned. The patient may have severe morbidity and in worst of the event can have mortality. The
aim of this article is to highlight the fact that the incidence is not as rare as has been reported in different
literatures and to discuss its various –clinico-radiological features, predisposing factors, measures to
avoid it and how to manage when such a calamity has occurred. This article increases the awareness
about the problem thus avoiding unnecessary morbidity/mortality to the patient as well as save the
surgeon from malpractice law suits, great psychological trauma and negative publicity.
Keywords: Gossypiboma, caesarean section
_________________________________________________________________
INTRODUCTION
It is human to make mistakes and since surgeons are also
humans so this dictum holds true to them also. The history of
retained sponges post-surgery is one such example of the
blunder that a surgeon can commit. It is referred by different
names in different literature like Gossypiboma
(latin:gossipiun meaning “cotton” and the Swahili: boma
meaning “place of concealment”), Textiloma (Latin: textile
meaning “woven fabric” and the suffix:oma, meaning
“tumour or swelling”) and gauzoma (surgical gauze).
It has been reported to occur in 1 in 100 to 3000 cases for all
surgical procedures and 1 in 1000 to 1500 for intra –
abdominal operations.[1-3] But the true incidence of retained
foreign bodies is too difficult to establish accurately because
of the gross underreporting bias as the surgeons are afraid of
medicolegal consequences (Res ipsa loquitur Latin translated
"the thing itself speaks") that will not only tarnish the
reputation but may also make them liable for the
compensation claimed by the patient particularly in the
western world where litigation rate is quite high.[3] Moreover
about one third of the patients remain symptom free.[4] These
retained foreign bodies can stimulate two types of the
pathologic responses in the body a) Exudative acute
inflammatory reaction with formation of an abscess in close
proximity to the retained sponge. Such cases present early
with features of abdominal pain, tenderness, fever and
palpable mass and rarely as faecal fistula. b) Aseptic fibrotic
reaction that forms adhesions and encapsulation resulting in
the formation of the foreign body granuloma.
The course is more clinically silent and patient may present
late with features of pain, palpable abdominal lump, weight
loss and GI discomfort.[4] We report an unusual case of
Gossypiboma presenting as fecal fistula and per operative and
post-operative findings showing the blend of the above
mentioned pathological responses.
CASE REPORT
A 22 year old female was referred to general surgery unit at
J.N Medical College with the chief complaints of pain in the
abdomen and faecal fistula through the lower midline scar
from last 15 days. The past history revealed that the patient
had caesarean section 5 months back at some remote nursing
home. She was discharged on 5thpost-operative day. The
patient developed pain in the abdomen 1 week after discharge
for which she was managed conservatively and she improved.
Since then she was having on and off pain which was relieved
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Ali WM, et al.: Gossypiboma-To Err is Human
by taking over the counter pain killers. One month back she
again complained of similar pain but this time it was
accompanied by vomiting and lump in the abdomen. She
remained admitted for 15 days after which she noticed that
there was a foul smelling discharge through the opening in the
midline scar. The discharge was pus like initially and scanty
in amount and later on became copious and foul smelling. The
patient was examined which revealed a fecal fistula along with
the lump around the umbilicus which was mildly tender, firm
and not well defined. The diagnosis of low output fecal fistula
was made.
Exploratory laparotomy was done and preoperatively dense
inter bowel adhesions were encountered. Bowel was also
densely adhered to the cavity, anterior abdominal wall and the
uterus. The cavity contained pus, faecal matter and the cotton
gauze which had perforated the jejunum and the ileum (Fig 3).
The jejunal perforation was closed primarily and the
ileostomy was made through the ileal perforation as the
condition of the distal bowel was not good. Histopathology of
the cavity wall showed foreign body giant cell granulation
tissue.
Fig. 1 Radiograph of abdomen in erect position showing
(a) Radiopaque marker (b) Dilated bowel loops (c) Free
gas
Fig. 3 Per-operative images
Laboratory work up showed leucocytosis (11,200/ mm3) and
anaemia (Hb% 5.6g/dl). The upright X – Ray Abdomen
showed a radiopaque marker along with the distended bowel
loops and uneven distribution of the gas pattern outside the
bowel loops (Fig 1). The Contrast enhanced Computerized
tomographic scan (CECT scan) of abdomen showed fistulous
tract connected to the cavity filled with the spilled contrast
from the bowel and a heterogeneously enhancing mass in the
cavity in infraumbilical region with dilated bowel loops and
inter bowel free gas and fluid (Fig 2).
Fig.2 CECT Abdomen showing heterogeneously
enhancing mass connected by fistulous tract with the
cavity and the bowel wall.
DISCUSSION
Surgical sponge is the most common foreign body left in the
abdominal cavity.[2] Most of the literature reports the
incidence of Gossypiboma around 0.02 to 0.1% but this is
grossly underreported by the surgeons because of the fear of
negative publicity and the medicolegal consequences.[5, 6]
In the landmark study performed by Gawande et al in 2003
three factors were shown to be statistically significant. They
included a) Emergency procedures (risk ratio, 8.8; P<0.001);
b) unplanned change in the procedure performed (risk ratio,
4.1; P=0.01) and body-mass index (risk ratio 1.1; P=0.01).[2]
Bani- Hani et al also found emergency surgery as the most
important risk factor. [7] Both Gawande AA et al and Kaiser et
al found that the count of the sponges in 69% and 76 % cases
respectively were falsely correct thus suggesting that the
sponge count is not a significant predictor of the retained
surgical sponge.[2, 8, 9] But the study by Lincourt et al 2007
contradicted the above risk factors and showed that the risk
increases when sponge counts are incorrect, with duration of
surgical procedures, multiple procedures are done in single
operation and when multiple teams are involved.[10]
The systemic review of 65 patients by Zantvoord et al 2008
found that the most common operations related with the
retained surgical sponges were gynaecological (35%) with
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hysterectomy being the commonest followed by abdominal
operations
which
included
appendicectomy
and
cholecystectomy and the mean time interval for diagnoses is
93.5 months (10 weeks to 35 years) [9-11]
The retained surgical sponge presents most commonly as
abdominal pain or irritation (42%) palpable mass (27%), fever
(12%), intestinal obstruction, intra-abdominal haemorrhage,
intra- abdominal sepsis, granulomatous peritonitis and rarely
as fecal fistula although about 6% of patients remain
asymptomatic.[12, 13] The review by Akbulut et al, 2011 found
178 cases of retained surgical sponges while Medline search
(2000 -2010) revealed 45 cases of transmural migration and
supported the earlier study by Silva CS et al, 2001 that the
migration of the surgical sponge in the intestine is a rare
phenomenon.[14, 15]
This occurs as the result of inflammatory reaction which
finally leads to the necrosis of the intestinal wall. The
peristaltic activity propels the sponge up to the distal ileum.
The bowel may then close and patient present as a case of
obstruction or if it fails to close then very rarely as faecal
fistula as happened in our case. The patient initially had
episodes of intestinal obstruction and later because of
intestinal wall erosion presented as a case of fecal fistula.
High index of suspicion is required to make the diagnoses of
Gossypiboma as the signs and symptoms are quite vague and
the patient may present after variable period of time. Imaging
is the usual modality employed for making the diagnoses. X
rays may reveal a radio opaque shadow of the marker and gas
may be seen near it, away from the distribution of the faecal
matter as shown in our case. It may also show the
characteristic whorl like pattern (threads of cotton sponge).
The Ultrasound will show a well-defined mass containing
wavy, bright internal echogenic structure with hypo echoic
rim and a strong posterior shadow.[9,16] The CT will show
sharply outlined mass with a thick dense, enhanced wall. The
centre is heterogeneous with a wavy striped and /or spotted
appearance. In late cases there may be mottled calcification
and gas bubbles.[17] On contrast enhancement the
enterocutaneous fistula and the cavity containing sponge can
also be visualised as shown in our case.
In their article Zahiri et al 2011 have stressed “Prevention of
three “never events” in the operating rooms – Fires,
Gossypiboma and wrong site surgery”.[18] Various
international bodies have set the guidelines like the
Association of Perioperative Registered Nurses (AORN)
have strongly recommended that only the sponges that can be
detected at radiography should be used and counts of sponges
, needles and instruments should be performed multiple times
before, during and after the operation.[19] We also strictly
adhere to this policy. Newer technologies are also coming up
like use of sponges with barcodes, radiofrequency
identification technology and electronic tagging of the
sponges which can be identified by the device that gives
signals when it is swept across the surgical site. Despite all
efforts and adherence to the guidelines still the surgeon can
commit the mistake as to “Err Is Human”. When there is
suspicion of Gossypiboma we should immediately take the
help of the radiologist and should clearly mention on request
form that “kindly search for retained foreign body/ sponge”
and once the diagnoses is confirmed immediate surgery
whether open or laparoscopic should be performed to retrieve
it.
The Leapfrog Group has considered retained foreign bodies
as “Always Wrong” errors and has recommended full
disclosure and apology to the patient and/or family, reporting
of the event to the Joint Commission on the Accreditation of
Healthcare Organizations or a similar agency, root cause
analysis and waiving of all costs directly related to the
event.[20] But in the given scenario where the risk of carrier
assassination and financial burden on the treating surgeon is
very high author supports the view that the surgeons can have
an anonymous reporting system. This will lead to a more
accurate assessment of the incidence and causes of these
events so that efforts can be made to reduce them as well as
monitoring the efficacy of these programmes.
CONCLUSION
Retained surgical sponge is a universal phenomenon though
grossly underreported for the fear of medico legal and
financial implications. A high index of suspicion is required
when the patient presents with signs and symptoms of
obstruction and/or faecal fistula following surgery to make the
diagnoses of Gossypiboma. The confirmation is done by
imaging and once confirmed no delay should be made in reoperating the patient to retrieve the sponge.
What this study adds:
1. What is known about this subject?
This article highlights the fact that the incidence is not as rare
as has been reported in different literatures and therefore as it
can be a disaster not only to the career of operating surgeon
but also for the hospital as far as the financial burden and the
reputation is concerned. Moreover, we have discussed its
various –clinico-radiological features, predisposing factors,
measures to avoid it and how to manage when such a calamity
has occurs.
2. What new information is offered in this study?
This article increases the awareness about the problem thus
avoiding unnecessary morbidity/mortality to the patient as
well as save the surgeon from malpractice lawsuits, great
psychological trauma and negative publicity.
ACKNOWLEDGEMENTS Declared none.
CONFLICTS OF INTEREST None declared.
FUNDING No funding source.
International Archives of BioMedical and Clinical Research | Oct-Dec 2015 | Vol 1 | Issue 2
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Ali WM, et al.: Gossypiboma-To Err is Human
ETHICS COMMITTEE APPROVAL Approved.
Patient consent: Written informed consent was obtained
from the patient for publication of this Case report and any
accompanying images.
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Accessed June 23, 2009.
Cite this paper as:
Ali WM, Ansari MM, Khanam D, Faridi SH.
Gossypiboma: To Err is Human – A Case Report. Int
Arch BioMed Clin Res. 2015 Dec;1(2):29-32
Copyright: © the author(s) and publisher IABCR. This
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