Gossypiboma‐Induced Acute Abdomen Highlighting the Importance of Surgical Safety Protocols: A Case Report

ABSTRACT

Gossypiboma, the medical term for a retained surgical sponge, is a rare but serious postoperative complication, accounting for nearly 50% of malpractice claims related to retained foreign bodies. Despite its importance, it is often underreported due to medicolegal concerns. Clinical manifestations include abdominal pain, nausea, and vomiting, often necessitating surgical intervention. A 56‐year‐old African male presented with small bowel obstruction 2 months post‐appendicectomy. CT imaging suggested small bowel obstruction without a clear etiology. Exploratory laparotomy revealed a retained surgical gauze within a perforated ileal segment, managed via resection and anastomosis with uneventful recovery. The diagnosis was delayed because the gauze did not contain a radio‐opaque marker, making it difficult to detect on imaging. Gossypiboma can lead to severe complications such as adhesions and bowel perforation. Although spontaneous expulsion may occur, surgical removal is often required. Prevention remains the best approach, through meticulous surgical sponge counts, use of radio‐opaque markers, intraoperative imaging, and advanced tracking technologies. This case underscores the importance of strict adherence to surgical safety protocols, which can prevent such avoidable events and enhance better patient outcomes.

Key Clinical Message

Gossypiboma is a preventable cause of postoperative morbidity. Strict adherence to surgical safety protocols, including standardized gauze counts, exclusive use of radio‐opaque marked sponges, intraoperative verification, and regular quality‐assurance audits, is essential to prevent retained surgical items, delayed diagnosis, avoidable re‐operations, and patient harm.

1. Introduction

A gossypiboma, also known as a retained surgical sponge, refers to a mass of cotton material (such as gauze) accidentally left inside the body following surgery. The term “gossypiboma” originates from the Latin word “gossypium,” which refers to cotton, and the Swahili word “boma,” denoting a place where something is hidden [1]. Among retained surgical items, sponges are the most frequently reported, though other objects such as artery forceps, needles, or broken instruments may also be left behind [2].

The incidence of gossypibomas is considered low, although this could be attributed to underreporting that stems from concerns over potential litigation. Gossypibomas account for approximately 50% of malpractice claims related to retained foreign bodies post‐surgery. Reported estimates suggest an occurrence of about 100 out of every 5000 surgical procedures and approximately 1 in 1000 to 1500 abdominal surgeries [1].

Patients typically present with symptoms such as abdominal pain, nausea, vomiting, anorexia, and weight loss. These manifestations often result from bowel obstruction or complications such as malabsorption due to multiple intestinal fistulas or bacterial overgrowth within the bowel lumen [2].

We present a unique case of spontaneous bowel perforation and partial intraluminal migration of the retained surgical sponge, a rare but significant complication of gossypiboma.

2. Case Report

2.1. History and Examination

A 56‐year‐old African male presented with a 2‐day history of severe epigastric pain, rated 8/10 in intensity, accompanied by vomiting, constipation, and fever. He had initially sought care at a peripheral facility, where he received artemether‐lumefantrine, metronidazole, phloroglucinol, and bisacodyl before referral. Two months earlier, he had undergone an appendicectomy at another facility, though detailed surgical records were not available. Since that procedure, he reported experiencing intermittent mild abdominal pain, which he managed on his own with over‐the‐counter analgesics. He had no known chronic illnesses, allergies, or other surgical history.

On general examination, the patient appeared dehydrated and in pain, though afebrile, with no other remarkable findings. Vital signs revealed a blood pressure of 131/86 mmHg, a pulse rate of 60 bpm, a temperature of 36.9°C, a respiratory rate of 21 breaths per minute, and an oxygen saturation of 100%. Abdominal examination showed a Lanz incision scar with slight abdominal distension. There was generalized tenderness, most pronounced in the periumbilical region and right lower quadrant, accompanied by guarding. Percussion revealed a hypertympanic note, and bowel sounds were reduced. The rest of the systemic examination was unremarkable.

2.2. Investigations

CT abdominopelvic with contrast: Small bowel obstruction with a transition point at the terminal ileum, no mass or lymph nodes identified, possible adhesions (Figure 1).

FIGURE 1.

(A) Small bowel obstruction with a transition point at the terminal ileum (blue arrow). (B) The red arrow represents the small bowel fecalization sign, indicating the level of obstruction, with associated narrowing of the small bowel at this point.

Full hemogram: Hb 15.50 g/dL (normal), MCV 87.60 fL (normal), MCH 30.00 pcg (normal), WBC 9.60 × 10⁹/L (elevated), Neutrophils 7.65 × 10⁹/L (elevated), Lymphocytes 0.90 × 10⁹/L (low), Plt 406.00 × 10⁹/L (elevated).

Renal function tests: Cl⁻ 99.03 mmol/L (normal), BUN 4.81 mmol/L (normal), Creatinine 87.37 Umol/L (elevated), eGFR 89.58 mL/min/1.73 m² (G3a), Na⁺ 134.38 mmol/L (low), K⁺ 4.99 mmol/L (low), HCO₃ ⁻ 18.51 mmol/L (low).

CRP: 12.83 mg/L (elevated).

Others: Serum Amylase, Serum Lipase, Random Blood Glucose, and Liver Function Tests were unremarkable.

2.3. Differential Diagnosis and Diagnosis

The patient was admitted to the surgical ward and underwent an exploratory laparotomy on Day 1 due to suspected small bowel obstruction attributed to possible adhesions from the CT scan images. Intraoperatively, adhesions and a walled‐off perforation of the distal ileum were noted, with a folded surgical gauze lodged within the perforation, 15 cm from the ileocecal valve (Figures 2 and 3). No radio‐opaque marker was present on the gauze (Figure 4).

FIGURE 2.

(A, B) Walled off bowel perforation causing obstruction, approximately 2.5 cm × 0.8 cm in size.

FIGURE 3.

Mobile obstructing mass in the distal ileum, 15 cm from the ileocecal valve.

FIGURE 4.

Extracted gauze soaked in fecal matter, lacking a radio‐opaque marker. The gauze, in its rolled‐up form, measured approximately 5 cm × 3 cm, and when unrolled measured 20 cm × 20 cm.

2.4. Outcome

The gauze was milked to the proximal ileum and extracted, after which the perforated bowel segment was resected, followed by a two‐layered hand‐sewn end‐to‐end anastomosis using silk 2/0 and vicryl 2/0 sutures. Hemostasis was achieved, the abdomen was irrigated, and a drain was placed. The resected segment was sent for histopathology, which showed bowel ulceration and perforation, with the presence of mucosal ulcers, peyer's patches, and marked inflammation with fibrinous exudate. The specimen was negative for malignancy. Postoperatively, the patient was kept nil per os (NPO) for 3 days, with the nasogastric tube and drain removed on Day 3. He tolerated oral feeding well and was discharged in stable condition and had an unremarkable post‐op period.

3. Discussion

Gossypiboma is the most frequently retained foreign material in the body following surgical operations, posing significant risks to patients, potentially leading to morbidity and even mortality [1, 2]. Several factors contribute to the occurrence of gossypiboma. The technical expertise, proficiency, and attentiveness of the surgeon and theater nursing staff are crucial [2, 3]. Emergency surgeries, in particular, pose a heightened risk for gossypiboma [1, 3]. During procedures with significant hemorrhage, there is often a necessity for numerous sponges and pads, increasing the likelihood of inadvertent retention if vigilance among the surgical team is compromised [3]. Key risk factors associated with gossypiboma include emergency operations, team fatigue, unexpected changes in the surgical procedure, and patients with a high body mass index [2, 3]. In our case, we were unable to identify a specific risk factor, as the surgery was performed at an external facility and the corresponding operative records were inaccessible.

Computed tomography provides a more definitive diagnosis where available [4]. In this particular case, however, the retained gauze did not contain a radio‐opaque marker, making it difficult to identify during CT interpretation. CT scans can reveal a distinct, brightly echogenic structure within a cystic mass. However, the presence of air bubbles and calcifications on CT may sometimes cause confusion with an abscess [4]. Other imaging techniques such as x‐rays, ultrasonography, magnetic resonance imaging (MRI), and upper gastrointestinal contrast radiographs have also been shown to aid in diagnosis [1].

A retained surgical sponge or cotton material can induce two main types of tissue reactions [5]. An exudative response may lead to abscess formation, whereas a fibrotic reaction can cause adhesions and mass lesions [5]. Although retained sponges remain sterile, they can trigger inflammation, resulting in an exudative abscess with potential secondary bacterial invasion [6]. Over time, this can progress to aseptic fibrinous reaction or granulation tissue formation around the foreign body [7]. Such processes can contribute to delayed healing, the development of chronically draining sinuses, or even erosion into adjacent hollow organs by fistulization [7]. In some cases, sponges may migrate into the bowel wall without an identifiable entry point at re‐exploration [5]. Once within the bowel lumen, peristalsis can propel the sponge forward [8]. If it traverses the ileocecal valve, it may be expelled during defecation; otherwise, it can cause complications such as intestinal obstruction, malabsorption, or hemorrhage [8]. This migration and fistulization are thought to result from inflammation and bowel pressure, leading to necrosis of the bowel wall at the affected site and subsequent closure of the defect [7]. In our case, the retained gauze was initially located within the peritoneal cavity but became adherent to a segment of bowel, precipitating a localized inflammatory response. This ultimately resulted in spontaneous perforation of the affected bowel segment, allowing the gauze to migrate intraluminally, where it subsequently caused bowel obstruction.

A history of prior surgery is therefore a key diagnostic clue when evaluating patients with suspected gossypiboma at any location [2]. Colicky abdominal pain, nausea, vomiting, signs of malabsorption, or a palpable abdominal mass in a patient with a history of intra‐abdominal surgery raise suspicion of gossypiboma [5]. However, because these symptoms are often nonspecific and may be mild, cases can remain undetected for months or even years, thus requiring a high index of suspicion [1].

The mainstay treatment for gossypiboma is surgical exploration [2]. In some cases, spontaneous intraluminal migration can lead to the expulsion of the foreign material through the anus during defecation. Rarely, transmural migration from the bowel can occur, allowing partial or complete expulsion through the cervix and vagina, or even through the urethra, though obstruction or perforation may result [8]. For cases where the foreign bodies are easily accessible, percutaneous routes may be considered for removal, though this approach is not suitable for intra‐abdominal foreign bodies. Laparoscopic methods have also been successfully utilized for the removal of retained gauze [2].

Gossypiboma is a preventable condition, contingent upon ensuring accurate sponge counting at the outset and prior to closure of the abdomen. Traditionally conducted manually, the World Health Organization (WHO) guidelines recommend that this count be performed audibly before the surgery begins, before closure of any viscous space and at the end of surgery before fascial and skin closure, involving at least two individuals [2, 9]. In this case, there is a possibility that the guidelines may not have been adhered to during the surgery, hence the retained foreign body. Intra‐abdominal swabs should strictly be “mounted on a stick” and should utilize only those with radio‐opaque markers, according to The National Safety Standards for Invasive Procedures 2023 guidelines [10]. In cases of uncertainty, intra‐operative x‐rays can be employed to verify the count of gauze containing radio‐opaque material. Emerging technologies for gauze tracking include electronic article surveillance systems, which use electronically detectable tagged surgical sponges, as well as barcoding all sponges for detection with barcode scanners. However, widespread adoption of these innovations has been slow, and human error continues to pose a risk—reinforcing the need for strict adherence to standardized safety protocols [2].

In this case, the absence of a radio‐opaque marker on the gauze further complicated the diagnosis, emphasizing the challenges of detecting retained foreign bodies postoperatively. Additionally, the case highlights the critical role of meticulous gauze counts and surgical safety protocols in preventing such occurrences. The successful surgical management and uneventful recovery further underscore the importance of timely intervention in cases of suspected gossypiboma. Gossypiboma carries significant medicolegal implications, as it is considered a preventable iatrogenic error and a breach of standard surgical care. Despite being well recognized, its true incidence is likely underestimated due to underreporting driven by fear of litigation and professional repercussions [11, 12]. Retained surgical items are among the most common causes of malpractice claims in surgery, often resulting in legal liability financial penalties, and reputational damage to healthcare providers and institutions [13, 14]. This underscores the importance of strict adherence to established perioperative safety protocols, proper documentation, and institutional accountability [12, 15]. Furthermore, fostering a culture of transparency and nonpunitive reporting may improve patient safety outcomes and reduce recurrence of such events [12].

3.1. Strengths and Limitations

This study underscores the critical importance of adhering to established surgical safety guidelines while also shedding light on the clinical presentation, diagnostic challenges, and intraoperative findings of a retained surgical gauze—an event often underreported due to medicolegal concerns. The use of comprehensive investigations, including imaging, laboratory tests, and histopathology, enhanced the diagnostic process and allowed exclusion of other potential differentials. Intraoperative images and specimen findings provided additional objective evidence, further strengthening the case. Beyond its clinical relevance, this report also contributes to regional literature by highlighting a surgical safety issue that remains highly pertinent within the local context. However, certain limitations should be acknowledged. The patient underwent his initial appendicectomy at another facility, where operative records were unavailable, making it unclear whether the surgical checklist or intraoperative counts were performed.

4. Conclusion

Retained surgical sponges should be considered in any patient with obstructive symptoms after abdominal surgery. This case of gossypiboma‐induced bowel obstruction and perforation emphasizes the importance of rigorous surgical safety protocols, including dual sponge counts, radio‐opaque markers, and meticulous documentation. Prevention through strict adherence to safety protocols is essential to avoid serious morbidity. Early recognition of gossypiboma in patients with postoperative obstruction is critical to prevent severe complications and improve outcomes.

Author Contributions

Priyanka Panwar: conceptualization, writing – original draft. Jack Okumu: conceptualization, resources, supervision, validation, writing – original draft. Daisy Denga: resources. James Kariuki: writing – review and editing. O. W. Sibuor: writing – review and editing.

Funding

The authors have nothing to report.

Consent

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

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

All data relevant to this case report have been included within the manuscript. No additional data are available for review.