Gossypiboma Case Report

An interesting case of lump abdomen—gossypiboma
Col N Dash*, Lt Col AS Kushwaha+
MJAFI 2011;67:157–158
INTRODUCTION ensheathed and encapsulated abdominal operation swab of

size 10 inches × 6 inches in diameter (Figure 1). Patient had
Lump abdomen is one of the commonest modes of presentation uneventful postoperative recovery.
in different abdominal conditions encountered in routine surgi-
cal practice. However, this case of gossypiboma is being reported
since it is extremely rare and has medico-legal implications. The DISCUSSION
case was seen at a small peripheral military hospital without
facility for advanced investigations but patient wanted relief Gossypiboma (from Latin gossipium—cotton and Kiswahili
from the medical condition. boma—place of concealment) or retained surgical sponge is a
ubiquitous medical error that is avoidable. It can cause serious
morbidity and possibly even mortality.1 Usually it is suspected in
CASE HISTORY an abdomen subjected to surgery previously.2 It has been re-
ported following surgical procedures such as abdominal, thoracic,
A young woman of 35-years presented with pain abdomen, con- cardiovascular, orthopaedic and even neurosurgical opera-
stipation, occasional vomiting and painless mass in upper and tions.3,4 Nonspecific clinical symptoms and inconclusive imag-
central part of abdomen of six months’ duration, which had been ing findings may preclude the diagnosis.5 The possibility of
growing, insidiously to its present size. Symptoms were sug- a retained foreign body (RFB) should be in the differential diag-
gestive of subacute intestinal obstruction. She did not give any nosis of any postoperative patient who presents with pain, infec-
history of loss of weight, weakness, fever and was not anaemic. tion, or palpable mass. The first diagnostic modality to rule out
She gave history of having undergone tubectomy operation a RFB should be a CT scan and often it will be the only test
five years ago at a civil hospital near her hometown. On ex- needed. The CT findings of a sponge usually describe a rounded
amination, there was mild abdominal distension with minimal mass with a dense central part and an enhancing wall. Other
tenderness around epigastric and umbilical region. There was features of retained sponges or towels include a whorl-like ap-
no ascites and no organomegaly. There was well-healed tubec- pearance with trapped air bubbles and cystic masses with in-
tomy scar at subumbilical region measuring 2 cm × 2 cm. A firm folded densities. It was difficult to reach the diagnosis in our
lump was localised at umbilical region extending up to epigas- patient prior to surgery due to lack of conclusive investigative
trium. It was 10 cm in diameter, spherical in shape and freely modalities.
mobile in all directions. Plain radiograph and ultrasound abdo- Recently, New England Journal of Medicine published an
men were done and were inconclusive. Barium swallow follow article about risk factors of RFBs. The three significant risk
through and CT scan were not available locally, being a small
station. Clinically, an omental cake of tubercular origin was
kept in mind and she was subjected to exploratory laparotomy
due to persistence of symptoms. Intra-operatively, a firm mass
entangled in omentum and adherent to transverse colon and
small bowel intensively and densely at multiple places was
revealed. Lump was dissected out intact and damaged small
bowel was repaired by resection anastomosis about 30 cm away
from fixed jejunal loop. Section of the mass revealed a well
*Sr Adv Surgery, CH SC, Pune, +Associate Professor, Department of

Community Medicine, AFMC, Pune – 40.
Correspondence: Col N Dash, Senior Advisor (Surgery) CH SC, Pune.

E-mail: [email protected]
Received: 18.10.2010; Accepted: 17.02.2011 Figure 1 Actual photograph of specimen (Gossypiboma).
MJAFI Vol 67 No 2 157 © 2011 AFMS

Dash and Kushwaha
factors were emergency surgery, unplanned change in the op- CONFLICTS OF INTEREST
eration, and BMI. The counting of sponges and instruments was
not a significant predictor in the multivariate model. Although None.
all three factors were significant, the nine-fold increase in risk
associated with emergency surgery was impressive. In addition,
in 88% of the cases where there was a RFB and counts were REFERENCES
performed, the counts were falsely called correct. The authors
recommended “radiographic screening” at the end of high-risk 1. Rajagopal A, Martin J. Gossypiboma. “A surgeon’s legacy”: report of
cases as a possible adjunct to improve detection of RFB.4 a case and review of the literature. Dis Colon Rectum 2002;45:119–120.
The best approach in preventing this problem is by meticu- 2. Gogia A, Kakar A, Byotra SP. Calcified abdominal mass: images in
lous count of surgical materials in addition to thorough explo- surgery. Indian J Surgery 2006;6:44–45.
ration of surgical site at the end of the surgical procedures. 3. Gencosmanoglu R. An unusual case of small bowel obstruction: gos-
However, this method has been found to be fraught with its prob- sypiboma—a case report. BMC Surg 2003;3:6.
lems of faulty “correct counts”. Gossypiboma carries medico- 4. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk fac-
legal implication due to the presence of the foreign body inside tors for retained instruments and sponge surgery. N Eng J Med 2003;
the abdominal cavity of the patient. It is an avoidable problem 348:229–235.
and the surgeon may face litigation. Moreover, Gossypiboma 5. Dux M, Ganten M, Lubienski A, Grenacher L. Retained surgical sponge
may be misdiagnosed as a tumour and may lead to unnecessary with migration into duodenum and persistent duodenal fistula.
invasive diagnostic procedures or extensive extirpative surgery, Eur Radiol 2002;12:S74–S77.
which may result in further complications.6 6. Zbar AP, Agrawal A, Saeed IT, Utidjian MR. Gossypiboma revisited:
Various studies have been done to develop methods and a case report and review of literature. J R Collsurg Edinb 1998;43:
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body. Electronic tagging of surgical sponge has been researched 7. Fabian CE. Electronic tagging of surgical sponges to prevent their
and found to be very useful and effective method to prevent accidental retention. Surgery 2005;137:298–301.
RFB.7,8 Gibbs et al9,10 have done a comprehensive review on 8. Gibbs VC, Coakley FD, Reines HD. Preventable errors in the operating
the subject. room. Curr Probl Surg 2007;44:281.
Our case is interesting as a big abdominal swab was pushed 9. Gibbs VC, Coakley FD, Reines HD. Preventable errors in the operating
inside the abdominal cavity through a very small tubectomy room: retained foreign bodies after surgery—Part I. Curr Probl Surg
operation wound. The young surgeons must keep this in mind 2007;44:281–337.
that retained swabs and foreign body is not only harmful to the 10. Gibbs VC. Patient safety practices in the operating room: correct-site
patient but to the surgeon in the era of consumer protection surgery and nothing left behind. Surg Clin North Am 2005;85:
and welfare. 1307–1319.
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An interesting case of lump abdomen—gossypiboma

Col N Dash*, Lt Col AS Kushwaha+

INTRODUCTION ensheathed and encapsulated abdominal operation swab of

*Sr Adv Surgery, CH SC, Pune, +Associate Professor, Department of

Correspondence: Col N Dash, Senior Advisor (Surgery) CH SC, Pune.

Received: 18.10.2010; Accepted: 17.02.2011 Figure 1 Actual photograph of specimen (Gossypiboma).

MJAFI Vol 67 No 2 157 © 2011 AFMS

MJAFI Vol 67 No 2 158 © 2011 AFMS

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