CT features and surgical management of gossypiboma: A report of four cases

Abstract

Gossypibomas, which are also referred to as textilomas or retained surgical sponges, represent foreign materials, such as cotton or sponge remnants, that are unintentionally left within a body cavity following surgical procedures. The exact prevalence of gossypibomas is difficult to determine, primarily due to concerns surrounding legal and ethical implications, which contribute to the under-reporting of such cases. These foreign objects can present at various points post-surgery, with symptoms appearing anywhere from the early recovery phase to decades after the procedure. This uncommon complication often mimics the appearance of a tumor or mass, creating diagnostic difficulties and a higher risk for further complications. Diagnosing gossypibomas remains challenging without the aid of imaging, making accurate detection harder to achieve. In this study, we highlight four distinct cases of gossypiboma, each with unique clinical manifestations and locations, confirmed through CT imaging and subsequent surgical intervention.

Objective

The purpose of our study is to describe the CT features of gossypiboma and correlate the CT findings with the clinical findings in four patients.

Introduction

Gossypibomas also referred to, as textilomas, cottonoids, or retained surgical sponges, are uncommon foreign objects, such as cotton matrices or sponges, unintentionally left within the body during surgical procedures [1,2]. The term “gossypiboma” is derived from gossypium (cotton) and boma (a place of concealment) in Swahili [3]. This uncommon surgical complication often mimics a mass or neoplasm, leading to diagnostic challenges and potential serious complications [2]. The first case was documented by Wilson in 1884. [3] However, the true incidence remains unknown, as it is underreported due to legal and ethical concerns, with publications being limited. These retained foreign bodies are found in approximately 1 in 100-5000 surgical procedures, with a higher incidence in intra-abdominal surgeries (1 in 1000-1500) [3].

Gossypibomas are most frequently found in the intra-abdominal cavity but can also occur in the chest, extremities, central nervous system, and breast [3]. A delayed diagnosis can lead to greater morbidity and mortality, often linked to emergency surgeries, extended procedures, unforeseen complications, excessive bleeding, rushed sponge counts, or changes in surgical staff. The time to diagnosis can range from the immediate post-operative period to several decades after surgery [4]. Clinical presentations vary depending on the location of the foreign body and the type of inflammatory response and imaging modalities such as CT and MRI are crucial for diagnosis, as foreign bodies can mimic tumors or abscesses.

Case presentations

Case 1

A 15-year-old male presented with a history of laparotomy 2 months ago due to abdominal trauma from a road traffic accident. Post-operation, the patient developed abdominal pain, fever, vomiting, and pus discharge from the surgical site. On physical examination, he had a palpable mass in the right hemi-abdomen. His physician ordered an abdominal CT scan.

The abdominal CT revealed a well-capsulated, spongiform-appearing structure with gas bubbles in the right hemi-abdomen, extending from the sub-hepatic region to the right iliac fossa. The structure was primarily located anterior to the ascending colon. Edematous changes were noted in the anterior abdominal wall in the right iliac fossa region, and a hypodensity was observed in segment 7 of the liver (possibly a post-traumatic insult site) (Fig. 1).

Fig. 1.

Contrast enhanced abdominal CT, axial cut through abdomen: well-capsulated spongiform appearing structure with gas bubbles in the right hemi abdomen extending from the sub-hepatic region to right iliac fossa. The structure is mainly located anterior to the ascending colon. Edematous changes are seen in the anterior abdominal wall at right iliac fossa region.

The patient underwent exploratory laparotomy, which revealed roll gauze wrapped in a thick omental cover, forming a pseudo-capsule all around, with dense adhesions to surrounding soft tissues. Adhesiolysis was performed, and the gauze was removed (Fig. 2A, B). During surgery, the surgeon also incidentally observed a Meckel’s diverticulum and noted a strong foul odor that filled the operating room (Fig. 3). The patient tolerated the surgery well and had no recurrence of symptoms.

Fig. 2.

(A) During surgery image, showing surgical sponge in the right hemi-abdomen remained during previous surgery. (B) Post surgery surgical sponge after removal.

Fig. 3.

During surgery image, showing Meckel’s diverticulum as an incidental finding.

Case 2

A 26-year-old female presented with complaints of persistent lower abdominal and pelvic pain for 3 months. It was learned from her history that she had undergone a C-section 3 months prior for delivery. Her general examinations and laboratory parameters were within normal limits. On abdominal examination, a lower abdominal scar was present, and a large cystic mass with restricted mobility and a smooth surface was palpable in the lower abdomen. Her physician referred her to our center and ordered an abdominal CT scan.

The abdominal CT revealed a low-density, heterogeneous, spongiform mass containing gas bubbles, with an externally enhancing wall and a hypodense focus in the midline pelvis, superior to the urinary bladder and anterior to the uterus. There was communication with the uterine cavity through a defect in the anterior uterine wall above the level of the uterine cervix. No further follow-up for the patient was performed (Fig. 4A, B).

Fig. 4.

(A) Contrast enhanced abdominal CT, Axial cut through pelvis: low density heterogeneous spongiform mass containing gas bubbles with an external enhancing wall and hypodense focus in the midline pelvis superior to the urinary bladder and anterior to the uterus and there is communication with the uterine cavity through a defect in the anterior uterine wall above the level of uterine cervix. (B) Sagittal cut through pelvis: low density heterogeneous spongiform mass containing gas bubbles with an external enhancing wall and hypodense focus in the midline pelvis superior to the urinary bladder and anterior to the uterus and there is communication with the uterine cavity through a defect in the anterior uterine wall above the level of uterine cervix.

Case 3

A 65-year-old female presented with complaints of right lower quadrant pain for 2 years, which had become severe and was associated with vomiting, nausea, anorexia, and constipation for the past 3 days. It was learned from her history that she had undergone a cholecystectomy for gallbladder stones 3 years ago.

On abdominal examination, an encapsulated, spongiform-appearing structure with gas bubbles and a metallic marker was noted in the right iliac fossa, appearing to be inside the bowel loop and communicating with the ileal loops. There was also small bowel dilatation with diffuse wall thickening proximal to this area (Fig. 5A, B).

Fig. 5.

(A) Contrast enhanced abdominal CT: axial cut through iliac region: well-capsulated spongiform appearing structure with gas bubbles and metallic marker in the right iliac fossa that appears to be inside the bowel loop as communicating with ileal loops. (B) Axial cut through iliac region shows small bowel dilatation with diffuse wall thickening proximal to the capsulated structure.

The patient underwent surgery under sterile conditions and general anesthesia. All small bowel loops were dilated. A mass-like structure was palpable in the ileocecal valve region, so a right hemicolectomy was performed, and a diversion ileostomy was created. An incision was made on the specimen, revealing an abdominal compress sponge surrounded by pus collection in the lumen of the terminal ileum. The pus was removed, and the abdomen was closed in 2 layers. After sterile dressing, the patient was shifted to recovery and discharged after 3 days in good condition.

Case 4

A 50-year-old female presented with severe abdominal pain, nausea, vomiting, intermittent fever, and chills for 1 month. She had a history of a hysterectomy 3 months ago, followed by a second surgery for abscess drainage 1 month later. Her physician referred her to our center and ordered an abdominal CT scan.

The abdominal CT revealed a spongiform, circumscribed, encapsulated mass in the right upper quadrant with a radio-opaque marker (Fig. 6).

Fig. 6.

Contrast enhanced abdominal CT, axial cut through iliac region: spongiform circumscribed encapsulated mass in the right upper quadrant with a radio-opaque marker.

The patient underwent surgery under sterile conditions and general anesthesia. A Pfannenstiel incision was made over the previous scar. Approximately 500 mL of thick pus was evacuated. After inspection, a foreign body, identified as an abdominal compress sponge, was found in the Douglas pouch and removed. Abdominal lavage with 2 liters of saline was performed, and a drain tube was placed in the pouch of Douglas. The incision was closed, and the patient was shifted to recovery and discharged after 4 days in good health (Fig. 7A, B).

Fig. 7.

(A) During surgery image, showing surgical sponge removal from right iliac fossa remained during previous surgery. (B) Removal of pus retained around the surgical sponge.

Discussion

Retained foreign bodies following surgery are a major medico-legal concern and are frequently under-reported. The most effective management for this preventable complication is prevention, which involves a meticulous count of all surgical materials, thorough inspection of the surgical site after the procedure, and the regular use of radio-opaque surgical textiles. Gossypiboma must be suspected in any patient with unexplained symptoms, a palpable mass, or fistula formation, particularly if there is a history of previous surgery. CT scans serve as the primary imaging technique for pre-operative diagnosis. Increasing awareness and employing a thorough diagnostic approach can help prevent delays in diagnosis and management, which could otherwise worsen the patient’s condition.

Pathologically, body can produce two types of reaction against gossypiboma; one is an aseptic fibrinous inflammatory reaction and adhesion that results in encapsulation of gossypiboma in the omentum and surrounding organs, these patients remain asymptomatic and are diagnosed incidentally. The other one is an exudative inflammatory reaction causing an abscess formation, which may be superimposed by secondary bacterial infection and fistula formation into adjacent hollow organs or to external environment [3,4].

Diagnosing gossypibomas is difficult due to their similarity to benign or malignant tumors. Clinical diagnosis is often challenging, making imaging essential for accurate identification. Radiologic features, though not always specific, are vital in establishing a diagnosis, and a multimodality approach along with patient history correlation is necessary [5]. Radiographs, particularly when the sponge contains a radiopaque marker, can reveal curved or banded radio-opaque lines, although a radiolucent sponge may lead to diagnostic confusion [3,6]. Ultrasound can differentiate gossypibomas into cystic or solid categories. The cystic type appears as a lesion with a zigzag hyperechoic pattern, while the solid type presents as a complex mass with prominent posterior acoustic shadowing, possibly due to retained sponge, calcifications, or air bubbles [3,4]. CT scans usually reveal a low-density, heterogeneous cystic lesion with a spongiform appearance, mottled shadows, concentric layers, or calcifications [4,6]. On MRI, gossypibomas in the abdomen and pelvis appear as a well-defined mass with low signal intensity on T1-weighted imaging (T1WI), high signal on T2-weighted imaging (T2WI), and a dark capsule in both T1WI and T2WI, with peripheral enhancement when gadolinium contrast is used [3,6].

Conclusion

Retained foreign bodies after surgery represent a significant medico-legal issue and are often under-reported. Prevention remains the most effective management for this avoidable complication, which includes a careful count of all surgical materials, a thorough exploration of the surgical site at the end of the procedure, and the routine use of radio-opaque surgical textiles. Gossypiboma should be considered in any patient presenting with unexplained symptoms, a palpable mass, or fistula formation, especially with a history of prior surgery. CT scans are the primary imaging modality for pre-operative diagnosis. Raising awareness and ensuring a diligent diagnostic approach can help prevent delays in diagnosis and management, which may otherwise exacerbate the patient’s condition.

Authorship contributions statement

Dr. Hidayatullah Hamidi: Dr. Hamidi is the Head of Radiology Department at the French Medical Institute for Mothers and Children (FMIC), Kabul, Afghanistan. He conceptualized and designed the study. Dr. Hamidi was responsible for diagnosing all the cases in the case series, ensuring follow-up with the surgeons, and reviewing the draft manuscript. Additionally, he supervised the other authors and facilitated communication among the authors.

Dr. Hashmatullah Osmani: Dr. Osmani is a resident in Radiology Department at the French Medical Institute for Mothers and Children (FMIC), Kabul, Afghanistan. He wrote the original draft of the manuscript and revised the manuscript following feedback from all the authors. Dr. Osmani was also responsible for selecting the images used in the case series.

Dr. Homayoon Ghairatmal: Dr. Ghairatmal is a treating surgeon in Surgery Department at the French Medical Institute for Mothers and Children (FMIC), Kabul, Afghanistan. He managed and followed the patients throughout their treatment. Dr. Ghairatmal also documented the surgical procedures and contributed operational images.

Dr. Mohammad Mujib Sakhi: Dr. Sakhi is a treating surgeon in Surgery Department at the French Medical Institute for Mothers and Children (FMIC), Kabul, Afghanistan. He managed and followed the patients, wrote the operation procedures, and contributed operational images.

Declarations

Ethics approval and consent to participate

The manuscript has got ethical review exemption from ethical review committee of the authors’ institution as case reports are exempted from review according to the institutional ethical review committee’s policy. Written consent is obtained from the participants for publishing the case.

Consent to publish

Written consents are obtained from the participants for publishing the case.

Availability of data and materials

Data available on request due to privacy/ethical restrictions.

Authors’ contributions

The authors have equal contribution in the submission and take public responsibility for its content.

Patient consent

We confirm that informed consent was obtained from all patients at the time of imaging. Each patient agreed that their anonymized clinical data and images could be used for educational and research purposes, including potential publication in scientific journals. All identifying information has been removed to ensure patient confidentiality.