Gossypiboma following cesarean section presenting as acute abdomen and sepsis: a case report

Abstract

Introduction:

Gossypiboma is a problematic but rare and highly preventable surgical complication. The incidences of gossypiboma are vastly underreported; therefore, the actual incidence is unknown. Women undergoing obstetrical procedures constitute a fairly high proportion of patients with gossypibomas. Most cases present after months or years, and only a few cases have been reported that presented acutely within days.

Case presentation:

We present a case of a woman who presented with severe symptoms of intestinal obstruction leading to acute abdomen merely a week after her caesarean section. The ultrasound and CT scans could not diagnose the foreign body; hence, a provisional diagnosis of gallstone ileus was made based on ultrasound findings and the patient’s symptoms. However, an exploratory laparotomy was performed when the patient’s condition deteriorated, which then revealed a retained gauze from the patient’s abdomen.

Discussion:

Gossypibomas, although rare, can lead to serious complications such as fistulas, abscesses, and intestinal obstruction. They are often asymptomatic and discovered incidentally but can present with severe symptoms if they cause abscess formation or obstruction. Surgical sponges and gauze typically contain radiopaque markers to aid detection via ultrasound and CT scans. However, the continued use of non-radiopaque materials, especially in developing nations, contributes to delayed diagnosis and treatment. Surgical removal of the retained foreign body remains the only definitive treatment.

Conclusion:

Gossypibomas are highly preventable if care is taken by healthcare professionals. Keeping count of the packs and tagging the packs with markers is an effective method of preventing this negligence.

Introduction

Gossypiboma refers to a surgical gauze or sponge left inside the body unintentionally after a surgical procedure, surrounded by a foreign body reaction. Gossypibomas are most commonly found in the abdomen and are most often successfully detected by computed tomography (CT), radiographs, and ultrasound. Gossypibomas and often found incidentally during subsequent surgical procedures. However, they may be symptomatic, presenting with irritation, palpable mass, abdominal pain, obstruction, nausea, and vomiting in most cases. Complications of this preventable but serious condition include obstruction, abscess formation, adhesions, and fistula^[1,2].

HIGHLIGHTS

• Gossypiboma or retained surgical gauze is a rare and problematic, but highly preventable surgical complication that can result in obstruction, abscesses and adhesions formation.

• Gossypibomas usually present after months or years, however, very few incidences have been reported that presented acutely within a few days.

• We report a case of a 27-year-old female that presented with severe intestinal obstruction and sepsis merely a week after her caesarean section due to retention of surgical gauze.

• The lack of radiopaque material in the gauze made it difficult for us to diagnose the source of obstruction and sepsis on ultrasound and CT scans.

• It wasn’t until exploratory laparotomy that the gauze was detected and then removed after which the condition of the patient improved drastically.

Gossypibomas can occur in both sexes and patients of all ages; however, women undergoing gynecological or obstetric procedures constitute a fairly higher proportion. More than half of the cases of gossypiboma are detected after months, and only some cases have been reported that presented very acutely^[2]. Gossypibomas may result in serious complications and may often go undetected on scans, which delays surgical intervention. The only effective treatment for this condition is surgical removal of the mass. Therefore, all necessary steps should be undertaken to prevent this negligence and protect the patient from complications and subsequent surgery.

In this case report, we describe a 27-year-old woman who developed signs of acute abdomen and sepsis just 7 days after undergoing a cesarean section. Despite clinical deterioration, imaging failed to reveal any retained foreign body. Instead, ultrasound findings suggested cholelithiasis, leading to a provisional diagnosis of gallstone ileus. However, during surgical exploration, a retained surgical sponge – gossypiboma – was discovered as the true underlying cause. This case highlights the diagnostic challenges and potentially life-threatening complications of gossypiboma, even in the early postoperative period, and underscores the importance of maintaining high suspicion when evaluating post-cesarean complications. This case report has been conducted and reported in line with the SCARE 2025 guidelines to ensure adherence to high-quality reporting standards^[3].

Case presentation

A 27-year-old woman with a known history of reactive Hepatitis C presented to the emergency department with severe pain around her lower abdominal surgical scar. Seven days earlier, she had undergone an emergency cesarean section with bilateral tubal ligation at 37 weeks of gestation. This was her fourth cesarean delivery, performed at the city’s largest tertiary care center. On examination, she was tender over the lower abdomen, and her surgical wound was oozing serosanguinous discharge. She was started on intravenous cephalosporin, and her wound was cleaned and dressed under sterile conditions.

Two days into her hospital stay, she developed progressive abdominal distension, worsening pain, constipation, and a low-grade fever. We administered intravenous paracetamol and continued broad-spectrum antibiotics. Later that day, she experienced sharp, unrelenting abdominal pain with absolute constipation and recurrent vomiting. Her abdomen was significantly distended – clinically equivalent to a 24-week gravid uterus – with absent bowel sounds. No masses were palpable. A per vaginal examination revealed foul-smelling lochia rubra. Her vital signs showed a temperature of 38.2°C, blood pressure of 95/68 mmHg, and heart rate of 90 bpm. Laboratory investigations showed leukocytosis with a WBC count of 18 000/μL and 90.7% neutrophils. Arterial blood gas analysis revealed pH 7.42, pCO₂ 35 mmHg, pO₂ 65 mmHg, and bicarbonate 25.1 mmol/L. Liver function tests were within normal limits. Blood cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA), confirming a diagnosis of sepsis. Abdominal ultrasonography revealed gallstones but no signs of obstruction, fluid collection, or foreign body. A CT scan showed a suspicious, calcified structure in the distal ileum but was inconclusive. We made a provisional diagnosis of gallstone ileus.

The patient was started on intravenous vancomycin. She had not passed stool for 4 days. Nasogastric decompression yielded 300 cc of bilious fluid, which relieved some distension, but tenderness persisted. Her condition deteriorated rapidly. She became drowsy, and her Glasgow Coma Scale (GCS) score dropped to 12. We transferred her to the intensive care unit. A multidisciplinary team consisting of a general surgeon, obstetrician, and urologist decided to proceed with an exploratory laparotomy due to her worsening condition and inconclusive imaging.

The laparotomy was performed on the 15th postoperative day. Intraoperatively, we found dilated and inflamed loops of small intestine with multiple adhesions. The bowel loops and mesentery were matted around a firm mass located in the distal ileum, approximately 40 cm proximal to the ileocecal valve. No frank pus was observed, but the peritoneal cavity contained turbid fluid. On careful dissection, we uncovered a retained abdominal surgical gauze (Figs. 1 and 2), tightly entangled with the intestinal loops and mesentery, causing a partial obstruction and dense inflammatory adhesions. Due to necrosis and compromised viability of the involved segment, approximately 45 cm of the distal ileum was resected. We performed a hand-sewn, two-layer, end-to-end anastomosis using absorbable sutures. A cholecystectomy was also performed due to previously confirmed cholelithiasis. Before closing the abdomen, we identified a grossly inflamed appendix and carried out an appendectomy. The uterus, ovaries, and fallopian tubes appeared normal. A surgical drain was placed in the pelvis, and the abdomen was closed in layers.

Figure 1.

A surgical ABD gauze being extracted from the abdomen during a laparotomy.

Figure 2.

The surgical ABD gauze extracted from the patient’s abdomen and displayed on a white cloth.

Postoperatively, the patient remained in the ICU on intravenous antibiotics and analgesics. Her condition gradually improved. Repeat blood work on postoperative day 5 showed normalized WBC count and resolution of sepsis. She was discharged 12 days after surgery in stable condition. Follow-up evaluations at 3- and 10-days post-discharge confirmed continued clinical improvement and stable recovery.

Discussion

Gossypiboma is a rare but preventable postoperative complication caused by a retained surgical item, typically gauze or sponge. Common complications include adhesions leading to intestinal obstruction, fistula formation, and abscesses^[4]. Although not routinely encountered in daily clinical practice, gossypibomas can have significant morbidity when misdiagnosed or left untreated. In our case, the patient presented with acute abdominal symptoms and sepsis just 7 days after an emergency cesarean section. Cholelithiasis on ultrasound led to a provisional diagnosis of gallstone ileus^[5]. However, no foreign body was identified on ultrasound, CT, or MRI. The use of non-radiopaque gauze likely contributed to this diagnostic challenge. The condition deteriorated rapidly, and exploratory laparotomy revealed a gossypiboma. Misdiagnosis in such cases is not uncommon, particularly when radiological findings are inconclusive. Our case was further complicated by MRSA-positive sepsis, which likely resulted from surgical site contamination. Although the patient was reactive for Hepatitis C, her liver function tests (LFTs) were normal, and she showed no signs of jaundice, ruling out hepatic causes such as ascites.

Several risk factors are associated with retained surgical items, including emergency procedures, intraoperative changes, long operative times, inexperienced surgical teams, and high BMI^[4,5]. Our patient underwent an emergency cesarean section due to premature labor at a busy tertiary care facility. Despite the high standard of care, this critical error occurred. Varlas et al similarly reported a case in a 28-year-old woman who presented 11 months after an emergency cesarean hysterectomy^[6].

The clinical presentation of gossypiboma can be either acute or delayed, with most cases reported months or even years after the surgery. The longest duration recorded is 23 years^[1,7]. The body typically mounts two types of reactions: an exudative reaction that causes abscess formation and a fibrinous reaction that leads to adhesions and encapsulation – often occurring in sequence^[4]. Our case shares similarities with the report by Alsuhaimi et al, where a woman presented with bowel obstruction 2 months after a cesarean section due to a retained sponge^[8]. However, our patient’s presentation within a week makes this case unique in its acute onset. Gossypibomas can sometimes be identified via radiography due to the presence of radiopaque markers in surgical sponges. For instance, Aminian documented a case where a retained sponge was initially detected on X-ray and later confirmed by CT, 5 years after the cesarean section^[9]. Unfortunately, non-radiopaque sponges are still used in some low-resource settings, contributing to delayed diagnosis and intervention. As a result, 75% of gossypibomas are only discovered during reoperations^[10].

Preventive strategies are essential. These include strict surgical count protocols, use of radiopaque materials, and technological advancements like radiofrequency identification (RFID) chips^[11]. These tools, while not universally available, can significantly reduce human error. Even in resource-limited settings, consistent sponge counts and visible tagging methods can prevent such catastrophic outcomes. Ultimately, gossypiboma reflects a lapse in surgical safety and accountability. Despite being avoidable, it can lead to severe patient harm. Our case underlines the importance of stringent intraoperative protocols, especially in high-pressure tertiary centers in developing countries where staff may be overburdened. Improved staffing, continuous training, and access to safer surgical tools are crucial in minimizing such risks and upholding patient safety.

Conclusion

This case underscores the diagnostic challenge of gossypiboma, especially when non-radiopaque materials are used, leading to delayed intervention despite imaging. It highlights the preventable nature of retained surgical items and emphasizes the critical need for strict surgical safety protocols, such as sponge counts and the use of radiopaque or radiofrequency-tagged materials. Institutional factors like understaffing and resource limitations must also be addressed to reduce such avoidable and serious complications.

Ethical approval

This case report does not contain any personal information that could lead to the identification of the patient. Therefore, it is exempted from ethical approval. Our institution does not require ethical approval for reporting individual case report or case series.

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Source of funding

Not applicable.

Author contributions

M.A., E.I., W.M., S.A., N.J., M.Z.Q., and S.M.N.: writing of the original draft; E.I.: conceptualization and resources; N.J., K.Q., K.R., and M.Z.Q.: review and editing of the manuscript; M.A., N.J., and M.Z.Q.: supervision throughout the writing of the case report.

Conflicts of interest disclosure

The authors declare no conflicts of interest.

Guarantor

Muhammad Affan.

Research registration unique identifying number (UIN)

Not applicable.

Provenance and peer review

Not invited.

Data availability statement

Data sharing is not applicable to this article.