Gossypiboma: An Unintentional Iatrogenic Error

Abstract

Unintentional retention of a surgical gauze following a surgical intervention is uncommon but the complications can sometimes be life-threatening. Its diagnosis is challenging due to varied clinical presentations and inconclusive radiographic findings. We put forth a case which reported to us complaining of pain, swelling, pus discharge and sinus opening prejudicing our clinical and radiographic diagnosis to be a residual cyst but turned out to be unintentionally retained surgical gauze with encapsulation. The use of relatively bigger sized surgical gauze and ensuring a correct surgical gauze count intraoperatively in addition to checking the surgical site thoroughly before initiating surgical site closure is a gold standard to prevent such mishaps.

Introduction

Unintentional retention of a foreign object following a surgical intervention remains a problematic event that is most commonly reported in the literature. Among them surgical cotton gauze sponges alone account for 48–69% of retained surgical items and result in more serious tissue reaction than metal fragments [1–3].

Literature reveals that such clinical scenarios are more frequently encountered following an abdominal surgery and rarely following a surgical intervention in oral and maxillofacial region. Unintentional retention of a foreign object following a surgical intervention results in inflammatory reaction leading to granulomatous tissue response. Literature reveals that an unintentional retention of surgical sponge can lead to permanent loss of function following bowel resection and even to death due to obstruction to airway following a laryngoscopy [4]

Surgical sponge is generally used in the operative area to achieve hemostasis, for retraction, protection, surgical dissection and for general wound management. Iatrogenically retained surgical sponges result in an inflammatory condition known as gossypiboma [5]. Literature reveals that a retained surgical sponge can cause an aseptic fibrinous response resulting in encapsulation and formation of granulomas or an exudative reaction leading to an abcess [5, 6]. Clinically and radiographically this condition mimics a neoplasm or a cystic lesion. It is generally associated with pain, swelling, fever and pus discharge [6]. Few patients are asymptomatic while others take a long time to present any symptoms of inflammatory or fistula formation. The aim this paper is to put forth a case of gossypiboma in the maxillofacial region that was misdiagnosed as an odontogenic cyst.

Case Report

A 70-years-old male reported to our unit with pain and swelling in the right upper front tooth region for 15 days. Patient gave a history of undergoing surgical intervention on the left side of his upper jaw one and half year ago for the extraction of upper anterior teeth and cystic enucleation. Extraoral examination revealed a gross facial asymmetry in relation to his right middle third of face. A diffuse ill-defined swelling is noticed on the right side of his face extending mediolaterally from ala of nose to the zygoma and supero-inferiorly from the inferior orbital margin to upper lip associated with obliteration of nasolabial fold (Fig. 1). Skin appeared stretched, non-erythematous, with no visible pulsations, sinus opening and pus discharge, no vesicle/ bullae/ ulcerations. On palpation, it revealed a soft, non -compressible, non-fluctuant, tender swelling. Mouth opening was adequate.

Fig. 1.

Extraoral view of the patient

Intraoral examination revealed a partially edentulous area in the right anterior maxilla associated with a swelling extending from 11 to 14 region mediolaterally and 5 mm below the vermillion border till alveolar crest inferiorly which is associated with a patent sinus opening associated with pus discharge. Vestibular obliteration with erythematous labial mucosa was noted (Fig. 2). Fine needle aspiration revealed a purulent discharge.

Fig. 2.

intraoral clinical view of the patient

Axial section of CBCT showed a unilocular, radiolucent lesion extending from midline till 14 region mediolaterally along with a retained root stump at 11 region. Labiopalatal cortical expansion is seen in anterio-posterior direction not involving the maxillary sinus (Fig. 3). Based on the clinical and radiological examination, a provisional diagnosis of residual cyst was made. Surgical enucleation of the lesion under local anesthesia was planned. Patient consents were obtained. During the surgical intervention, a foreign body consistent with surgical gauze accommodated beneath the labial mucoperiosteal flap in the canine fossa region was retrieved, and soft tissue encapsulating the surgical gauze was excised & sent for histopathological examination (Fig. 4). Wound closure was done, and patient was discharged uneventfully with prescription of oral antibiotics and analgesics.

Fig. 3.

Axial section of CBCT view

Fig. 4.

Retrieved surgical gauze

Histologic examination of the specimen revealed dense amorphous connective tissue with collagen fibers interspersed with numerous blood vessels and multiple focal granulomas exhibiting epitheloid cells, macrophages, lymphocytes and plasma cells suggestive of granulomatous tissue (Fig. 5).

Fig. 5.

Histopathological view of the surrounding soft tissue

Discussion

Face is a highly vascular anatomical area. Any surgical interventions performed on the face would lead to profuse bleeding, in spite of using the vasoconstrictors, which necessitates use of various techniques for hemostasis. Most commonly employed is the digital pressure control using gauze packs, in order to control bleeding and provide a clear surgical field. However, its efficacy is still questionable.

With the advent of lasers and piezoelectric techniques, promising results were obtained due to the delivery of optimal visibility with decreased blood loss [7, 8]. It is noteworthy that such equipment is unavailable in most of the clinical setups in the rural India, where clinicians revert back to conventional techniques like gauze packing for controlling the intraoperative bleeding.

Other alternatives like the use of high vaccum suctions is seen as a viable option, in clearing the surgical field during intervention thus preventing excessive accumulation of blood indirectly leading to less usage of surgical gauzes [9]. In addition, it is advocated that the use of large size gauze pieces, will reduce the possibility of missing gauze pieces in the operation area and is often reported in various general and maxillofacial surgical procedures [10]. These retained masses lack radio opaque markers which makes it difficult to recognize on radiological studies [11]. Though the incidence of gossypiboma is very rare in the oral maxillofacial region, literature reveals that 15 cases have been reported in the last 10 years [12].

Clinically and radiologically, it mimics a cystic or tumorous lesion with widely variable presentation like radiolucent lesions on plain radiographs and hypodense in CT and CBCT scans which were proved to be the most effective methods in diagnosing.¹³ Ultrasonography serves an alternative diagnostic method which shows echogenic masses with intense sharply delineated acoustic shadows or hypoechogenic masses with complex echogenic foci [13]. Among all these, MRI gives the best picture of internal structure of a gauze granuloma [14]. Confocal laser scanning is a recent advance in identifying the microscopical changes within the tissue associated with the foreign body entrapment [13].

In the present case report, complete history, thorough clinical and radiological examination correlated similar findings of an infected cyst. On exploration surprisingly, it revealed a gauze piece which was entrapped in the soft tissue of upper labial vestibule. Histologically, it showed a dense amorphous connective tissue with collagen fibers. Multiple focal granuloma detected with some areas of infective form of fungus and budding yeast cells.

A previous study categorized iatrogenic complications based on etiology into accidental, faulty technique, errors in judgment, failure to identifying anatomical structure and adverse reaction to drugs [15]. It was observed that nearly 40% of iatrogenic complications were accidental, and 25% were due to faulty techniques or failure to adhere to routines. Literature reveals that iatrogenic mandibular fracture following removal of third molar, iatrogenic osteomyelitis following an extraction of a tooth secondary to fracture, unintentional retention of needle hub at the operated site and unintentional retention of suction tip at surgical site are few of the most notable iatrogenic complications in oral & maxillofacial surgery [16–18].

Precision in treatment planning and attention to detail during execution is essential to obtain a successful outcome in addition to preventing iatrogenic complications. It is noteworthy that such mishaps can happen unintentionally even in hands of an experienced surgeon. Hence the authors would like to emphasize that operator should mandatorily check the surgical areas before closure and count the surgical gauze pieces which were used intraoperatively.

Conclusion

Considering the fact that a surgical sponge plays a pivotal role in achieving hemostasis, retraction, protection & surgical dissection; its use is inevitable. Even though there are only a few reported cases of unintentional retention of surgical gauze; there may be many undocumented cases in the maxillofacial region. Taking into consideration, the psychological impact an individual can be subjected to, due to an unintentional retention of a surgical gauze in addition to the deleterious effects it can cause, the clinicians should be more vigilant in evaluating the surgical area before closure.

Author contribution

SB Operating surgeon, Data analysis & manuscript preparation, VS Operating surgeon, Data analysis & manuscript preparation, UKU Operating surgeon, Design of study, Data acquisition, data analysis & manuscript preparation, PKR Data collection & manuscript preparation.

Funding

Self funded.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Institutional ethical clearance obtained.

Informed consent

Patient consents taken.