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Figure 1 Pelvic ultrasound showing large cystic mass to the right of the mid-line with wavy irregular internal echogenicity. |
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Figure 2 Ultrasound showing normal ovarian tumour markers. |
Gossypiboma revisited: a case report and review of the literature
A. P. ZBAR,* A. AGRAWAL,* I. T. SAEEDI# AND M. R.
A. UTIDJIAN§
*Surgical Directorate, and the Departments of #Histopathology, § Obstetrics and
Gynaecology, Oldchurch and Harold Wood Hospitals Romford, Essex, UK
Gossypiboma (retained surgical sponge) is a rare but preventable occurrence. In this case it presented as a chronic abdominal mass which simulated a primary small bowel tumour. The findings on pelvic ultrasonography were typical for this condition and the role of plain abdominal radiology in the gynaecological patient are highlighted.
Keywords: gossypiboma, surgical sponges.
A 28-year-old female presented with recurrent abdominal pain following a lower uterine segment. Caesarean section had been performed at the hospital some 6 months before. Examination revealed a palpable abdominal mass extending up to the umbilicus arising from the pelvis. The uterus was tender and bulky and there was no clear evidence of an adnexal mass.
The patient had presented initially 4 weeks following the Caesarean section with abdominal pain, and a pelvic ultrasound at that time was essentially normal. Pelvic ultrasonography on the second presentation showed a large cystic mass to the right of the midline, measuring 10 x 7 x 11 cm, with wavy irregular internal echogenicity (Figure 1). Variation of the direction of the ultrasound probe showed a laminated internal structure of the mass with variable acoustic shadowing posteriorly (Figure 2).
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Figure 1 Pelvic ultrasound showing large cystic mass to the right of the mid-line with wavy irregular internal echogenicity. |
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Figure 2 Ultrasound showing normal ovarian tumour markers. |
Ovarian tumour markers (CEA and CA 125) were both normal. The patient was taken to the operating theatre with a presumptive diagnosis of an ovarian tumour. At laparotomy, a large mass densely adherent to the terminal 3 feet of small bowel and the right colon with large associated local lymph nodes was evident. The uterus and ovaries, as well as the liver, were normal. Believing the mass to be malignant, it was mobilized and resected en bloc, requiring concomitant resection of the involved ileum and part of the right colon. Incision of the mass after resection revealed it to contain about 2 L of yellow seropurulent fluid and a centrally located large laparotomy pack adherent to the inside of a formed abscess cavity wall (Figure 3). The post-operative course of the patient was uneventful and she was informed of the full nature of the operative findings.
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Figure 3 Resected mass showing large laparotomy pack adherent to the inside of a formed abscess cavity wall. |
Gossypiboma, retained surgical sponge (Gossypium Latin: cotton; Boma Kiswahili: place of concealment), although uncommon is an underestimated and under-reported condition.1 There has been a recent increase in its recognition because of an influx of patients from countries where there is no uniform policy towards impregnating packs and sponges with radio-opaque strips and because of the use of multiple packs in abdominal trauma.
The presentation may be acute or relatively delayed. Acute presentations generally follow a septic course with abscess and/or granuloma formation. Delayed presentations may follow months or years after original surgery, with adhesion formation and encapsulation. Most will present as a mass or with subacute intestinal obstruction, although rarely they may result in fistula, free perforation or even extrusion.2
The diagnosis is usually made by plain abdominal radiography showing the whorl-like pattern of impregnated thread.3 Disintegration and fragmentation of the radio-opaque marker may occur over time. In this case, the importance of the use of conventional abdominal imaging as a first line investigation in gynaecologic pain with a mass is highlighted. It would appear that standard practice amongst gynaecologists is towards pelvic ultrasonography as the first investigation and here plain radiology would have made the diagnosis and might have prevented bowel resection.
Ultrasound of retained surgical sponges is diagnostic.4 Several different features may be seen, as in this case, with brightly echogenic wavy structures present in a cystic mass showing acoustic shadowing posteriorly that changes with direction of the ultrasound beam. In our patient, the presumptive diagnosis of an ovarian carcinoma was based on misinterpretation of the ultrasound findings.
Computerized tomographic scanning may show gas trapped between the surgical sponge fibres, calcification of the cavity wall in long standing cases and contrast enhancement of the rim.5 All of these features may not be distinguishable from other intra-abdominal abscesses. Generally, magnetic resonance imaging shows a mass with variable signal intensity dependent upon the amount of fluid and protein accumulation. The capsule tends to have low signal intensity on both T1 and T2-weighted images with poor Gadolinium enhancement.6
Prevention of gossypiboma is better than cure. At the time of the first laparotomy the abdomen should be thoroughly examined for retained packs, instruments and sponges, particularly where packs have been employed remotely from the site of the main surgery. This is more likely to occur, for example, where the left upper quadrant is packed after splenic flexure mobilization for low anterior resection, in the multi-trauma patient. Review of the operative notes of the Caesarean section and discussion with the original surgeon did not, in this case, reveal why or how a pack was retained. Presumably, a pack was employed during the closure and then not documented in the final count.
Most reported cases of gossypiboma occur in the presence of a normal pack count.7 This emphasizes the importance of guidelines for operative theatre record keeping as recently set down by the Royal College of Surgeons of England,8 as well as the avoidance of pack usage during fascial closure, which probably occurred in this patient. Hurried counts, which may occur in long procedures, may also contribute, and additional counts are recommended when there are changes in theatre personnel. Intra-operative radiology in specialist situations such as the multi-trauma case, should also be considered, particularly where multiple disciplines have been involved in patient management and where multiple procedures have been performed.
If the diagnosis is made early, ultrasound-assisted removal (with percutaneous abscess drainage)9 or even laparoscopic retrieval may be feasible.10
The medicolegal consequences of gossypiboma are significant. Patients may be inadvertently informed that masses might be malignant and may undergo unnecessarily invasive investigations such as angiography and unnecessarily radical extirpative surgery.
Correspondence: A. P. Zbar, Surgical Directorate, Oldchurch and Harold Wood Hospitals, Waterloo Road, Romford RM7 OBE, UK
© 1998 The Royal College of Surgeons of Edinburgh, J. R. CoIl. Surg. Edinb., 43, December, 417—418