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Original Article

Retained Surgical Sponges (Gossypiboma)

Kamal E. Bani-Hani, Kamal A. Gharaibeh and Rami J. Yaghan, Department of Surgery, Faculty of Medicine, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan.

OBJECTIVE: Retained surgical sponges are seldom reported due to medicolegal implications. Awareness of this problem among surgeons and radiologists is essential to avoid unnecessary morbidity. We present our experience with this entity and review the related literature. METHODS: The medical records of 11 patients who were diagnosed as having retained surgical sponges from 1990 to 2003 were reviewed. RESULTS: The incidence was 1:5,027 inpatient operations. There were four males and seven females with a median age of 45 years. The original operations were gynaecological (n = 4), general (n = 4), urological (n = 2) and laminectomy (n = 1). In seven cases, the original operation was performed on an emergency basis. Five patients were obese. A presumed correct sponge count was documented in eight cases. The median time between the original procedure and diagnosis of retained sponges was 12 months. The tentative diagnosis was intestinal obstruction (4 patients), urinary tract infection (1 patient), Crohn’s disease (1 patient) and tumour recurrence (1 patient). The correct diagnosis was suggested in the remaining four patients. Surgical removal of the retained sponges was carried out in all cases except one, in which the patient passed the sponge spontaneously through the rectum. CONCLUSION: Retained sponges are more common in obese patients and after emergency surgery. A high degree of suspicion is important for preoperative diagnosis. Despite the use of radio-opaque sponges and thorough sponge counting, this moribund mishap still occurs. Although human errors cannot be completely abolished, continuous medical training and strict adherence to regulations should reduce the incidence to a minimum. [Asian J Surg 2005;28(2):109–15]

Key Words: gossypiboma, retained surgical sponge, retained surgical swab, textiloma

Introduction is generally appreciated.6 In the last 10 years, there have been only a few reports in the literature concerning RS. In this paper, Retained postoperative foreign bodies, of which sponges are we review our experience with this entity in order to increase the most common, is a rare condition.1 This may be due to the awareness among surgeons and radiologists and, thus, avoid reluctance to publish matters that can lead to medicolegal unnecessary morbidity, which is still being encountered. implications or because it may initiate wide, critical press coverage.2,3 The condition is sometimes called “gossypiboma” Patients and methods because of the feared possibility of retained sponges (RS) causing gossip about surgeons.4,5 Despite this rarity in re- From January 1990 to December 2003, 11 patients with RS porting, RS appears to be encountered more commonly than were managed at the surgery departments of King Abdullah

Address correspondence and reprint requests to Dr. Kamal E. Bani-Hani, Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid – 22110, Jordan. E-mail: [email protected] • Date of acceptance: 11 May 2004

© 2005 Elsevier. All rights reserved.

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University Hospital and its affiliated hospitals. These hospi- tals are located in Irbid Province, which is the second largest demographic area in Jordan, containing about 1.25 million inhabitants. The military hospital in this area treats 35% of the population, while the remaining 65% of the population are treated by our University and affiliated hospitals. On average, 3,950 operations are performed at our hospital and its affili- ates each year. In our operating theatres, we apply very well- known standards that require the use of only radio-opaque sponges, which should be counted once at the start and twice at the end of all surgical procedures. If the count is incorrect, then radiography or re-exploration is to be performed. Patients’ clinical notes, radiological investigations, and operative records were retrospectively reviewed. Data regard- ing age, sex, the type of original operation, the interval between the original operation and the diagnosis of RS, clinical pres- entation, diagnostic work-up and the tentative diagnosis be- fore identifying the RS were collected and analysed.

Results

The incidence of RS in our hospitals was 1:5,027 inpatient operations. The Table details the characteristics of all the patients. There were four males and seven females with a median age of 45 years (range, 20–64 years). In seven cases Figure 1. Plain X-ray of the abdomen of Patient 9, who presented with a palpable abdominal mass 23 months after emergency laparotomy (63.6%), the original operation was performed on an emer- and splenectomy for a ruptured spleen following a motorcycle gency basis. Five patients (45.5%) were obese. A presumed accident. Note the radio-opaque marker of the retained swab. correct swab count was documented in the operative notes of the original procedures in eight cases (72.7%). In the remaining was suspected in only four (36.4%) cases (Table; Patients 2, 6, three cases (all emergency procedures), no documentation 9 and 10). The diagnosis was suggested by plain X-ray in regarding swab count was found. Definitive diagnosis of RS Patients 2 and 9 (Figure 1), by barium enema in Patient 10

Table. Characteristics of the 11 patients with retained surgical sponges

Patient Sex Age (yr) Original operation Interval (mo) Clinical presentation Tentative diagnosis

1 F* 51 Hysterectomy† 148 Intestinal obstruction Adhesive obstruction 2 M 64 Laminectomy 108 Back pain Retained swab 3 F 38 Hysterectomy† 172 Abdominal mass Tumour recurrence 4 F 40 Hysterectomy† 112 Intestinal obstruction Adhesive obstruction 5 M* 49 Cholecystectomy 117 Intestinal obstruction Adhesive obstruction 6 F 20 Pyelolithotomy 113 Fever Retained swab 7 M* 22 Appendectomy† 115 Discharging sinus Crohn’s disease 8 F 43 Hysterectomy† 119 Intestinal obstruction Adhesive obstruction 9 F* 53 Splenectomy† 123 Abdominal mass Retained swab 10 F* 45 Appendectomy† 124 Abdominal mass Retained swab 11 M 62 Prostatectomy 112 Urinary retention Urinary tract infection

*Obese patient; †emergency surgery.

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examination revealed a vague, ill-defined, irregular, firm, non- tender, mobile lump in the right iliac fossa with high-pitched bowel sounds. Routine laboratory investigations were normal. Plain abdominal X-rays and ultrasound examination were not rewarding. Barium enema revealed a normal colon with an irregular radiolucent intraluminal filling defect about 50 cm proximal to the ileocaecal junction (Figure 2). The delayed film showed a barium-coated cast of the lesion. Barium follow- through examination was planned, but following the intake of castor oil, the patient passed a 4 = 4 inch swab per rectum. The terminal ileum was normal on X-ray and the patient’s symp- toms disappeared. Barium follow-through examination 6

▼

Figure 2. Barium enema for Patient 10 reveals dilated ileal loops with irregular radiolucent intraluminal filling defect (arrow) in the terminal ileum. Figure 3. Abdominal computed tomography scan for Patient 6, who presented with wound infection and fever 3 months following left pyelolithotomy. Note the hypodense mass with a thick periph- (Figure 2) and by abdominal computed tomography (CT) in eral rim (arrowhead) and the characteristic appearance of a soft- Patients 6 and 9 (Figures 3 and 4). The median time interval tissue mass with air bubbles and whirl-like patterns. between the original procedure and diagnosis of RS was 12 months (range, 2–108 months). All patients had morbidity as a result of the RS, and no swab was found incidentally. There was no mortality. In nine patients, the RS were removed by open surgery (Patients 1–9). In Patient 10, the RS was passed spontaneously through the rectum, while in Patient 11, the RS was removed cystoscopically. Patient 10 represents a rare event of RS with transileal migration and spontaneous passage of the sponge through the rectum. She was a 45-year-old obese woman who presented with right iliac fossa pain that was associated with abdominal distension for 6 months prior to admission. Her medical history showed that she had undergone appendectomy at our hospital 2 years before. The surgical record showed that the appendectomy was difficult due to adhesions around the Figure 4. Abdominal computed tomography scan for Patient 9. caecum, but there was no concomitant bowel trauma. There Note the presence of a large rounded non-homogeneous mass was no documentation regarding the swab count. Abdominal containing air bubbles with a mesh-like appearance.

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months later did not show any bowel abnormality. Over a In seven of our patients (63.6%), the original operations 24-month period of follow-up, the patient remained were performed on an emergency basis. Compared with ran- asymptomatic. domly selected controls who underwent the same type of operation during the same 6-month period, RS are nine times Discussion more likely after emergency surgery, and four times more likely when an unexpected change in the surgical procedure is The incidence of RS in this study lies in the middle of reported undertaken.3 In our study, a presumed correct swab count was figures.3,7–9 The incidence of RS is difficult to estimate because documented in eight patients (72.7%). In the remaining three some patients remain asymptomatic and are never discovered, emergency procedures, no documentation regarding swab and because of the lack of documentation of some diagnosed count was found. In the series of Gawande et al,3 sponge and cases. However, the reported incidence varies between 1/1,000 instrument counts were performed in only 66.7% of cases and and 1/3,000 procedures.7–9 Gawande et al report that the the counts were reported as correct for 88% of patients with incidence of RS and retained instruments varies from 1/8,801 retained objects. Emergency operations are significantly more to 1/18,760 inpatient operations at non-specialty acute-care likely to involve a failure to perform a count of sponges and hospitals, corresponding to one case or more each year for a instruments. In such situations, disorganization is increased typical large hospital.3 They suggest that these rates are under- so that it becomes more difficult to keep track of swabs and estimated because they were calculated only on the basis of instuments.3 In one series reporting 29 cases of RS, a false malpractice claims, and because the operations that form the correct sponge count was observed in 22 cases (76%), no denominator for their calculation included large numbers sponge count was performed in three cases (10%), and false- of procedures that were unlikely to result in RS.3 It has been negative intraoperative X-ray results were responsible for estimated that more than 1,500 cases of retained foreign sponge retention in another three cases (10%). In the remain- bodies occur annually in the USA.3 The occurrence of approxi- ing case, the sponge count was incorrect but the surgeon mately one RS per year in our hospitals continues to be a declined to delay wound closure or obtain an intraoperative X- source of significant morbidity with serious consequent medi- ray.6 In our opinion, emergency surgery is, to a large extent, colegal implications. Despite the use of radio-opaque sponges performed by junior surgeons, who may underestimate the and proper counting, the mishap continues to occur. The value of strict compliance with operating-theatre regulations, problem lies in the human factor. No documentation of a adding to the higher incidence of RS. More involvement of complete sponge count was found in the files of three patients. senior staff in emergency situations might reduce the inci- Human errors cannot be abolished, but must be reduced to dence of RS. a minimum. In this regard, strict adherence to operating- Five of our patients (45.5%) were obese. Patients with RS theatre rules, continuous medical education for all personnel usually have a higher mean body mass index than controls.3 In working in theatres, and the implication of failure to conduct addition to the huge amount of room in the abdomen of obese punishments are the corner stones. At King Abdullah Teach- patients in which to lose a sponge or instrument, obesity may ing Hospital, which is the largest hospital serving the area, increase the technical difficulty of the operation. This may special quality assurance and operating-theatre committees place extra stress on the surgeon,3,14 and in addition to the fear were recently established with clear written bylaws. of postoperative complications, surgeons may subconsciously The female preponderance among this study group rush to finish their procedures as quickly as possible.14 was consistent with the experience of others. For example, RS may lead to serious consequences such as bowel or Apter et al10 and Botet del Castillo et al11 report that RS is most visceral perforation, obstruction or fistula formation, sepsis frequent after gynaecological procedures, followed by upper or even death.3,15 In the current report, RS resulted in severe abdominal operations. Gawande et al report that 63% of their morbidity; four patients presented with intestinal obstruction patients with RS were females, although patient gender was and one with a discharging sinus secondary to the RS. Ten not a risk factor for RS in their study.3 Also, in keeping with the patients (91%) required re-operation to remove the RS and to experience of others, nine of our cases occurred in relation manage its complications. The mean interval between the to intra-abdominal procedures,12,13 while the remaining two original operation and the diagnosis of RS in our patients was cases followed prostatectomy and laminectomy. For obvious 2.4 years. This is consistent with that reported by others.16 anatomical reasons, RS are rare after spinal surgery.12 The clinical presentation and the time interval between the

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original operation and diagnosis of RS are variable and depend ing the ileal wall. The sponge probably eroded into the termi- on the location of the RS and the type of reaction RS can evoke. nal ileum and the defect in the bowel was sealed by adhesion to Most commonly, aseptic fibrinous inflammatory reactions the anterior abdominal wall. As far as we know, this spontane- and adhesions encapsulate the RS in omentum and nearby ous elimination of RS after ingestion of laxatives has not organs. Accordingly, the diagnosis is difficult because of the previously been reported. Mason reported spontaneous pas- less severe symptoms and the delay in onset from previous sage of RS per rectum,2 but unlike our case, the patient had surgery. Patients usually remain asymptomatic and the RS are undergone laparotomy 6 days earlier and the sponge was detected incidentally, or they present with pseudotumour milked from the terminal ileum to the caecum on the assump- syndrome.7,17,18 In none of our patients was the RS found tion that the palpable intraluminal mass was solid faecal incidentally, but in one patient, a tentative diagnosis of recur- material. Manabe et al also reported a case of spontaneous rent tumour was suggested. In sharp contrast to this, in one expulsion of RS through the rectum.20 Crossen and Crossen study, incidental discovery of intra-abdominal swabs was re- reported 37 cases in which the sponges were extruded into the ported in 22 of 29 patients with RS.6 Kokubo et al report nine bowel and were passed by the rectum, 24 cases in which the patients with RS, with an interval between the previous opera- sponges were found within the bowel at surgery and 10 cases tion and CT ranging from 1 month to 18 years.16 None of their in which the sponges were found in the process of penetrating patients had symptoms, although some had an asymptomatic the intestinal wall.26 abdominal mass. Although current surgical swabs are labelled with radio- On the other hand, a cotton sponge may lead to an exuda- opaque markers, which facilitate their detection, the diagnosis tive inflammatory reaction, with an abscess or chronic inter- of gossypiboma is not easy and a high index of suspicion must nal or external fistula formation. This usually presents much be present. The markers may be distorted by folding, twisting earlier than the fibrinous reaction sequel.10 The resultant or disintegration over time.5 The diagnosis was possible using abscess and the pressure exerted by the foreign body may lead plain X-ray in only two of our patients. Moreover, even in the to an external opening (as happened with Patient 7, who pres- presence of a radio-opaque marker, RS can be difficult to ented with a discharging sinus in the right lower abdomi- visualize and may be overlooked, or an erroneous diagnosis nal quadrant following appendectomy), or this may force an may be made.27,28 In one study involving 10 patients with RS, opening into an adjacent adherent hollow organ such as the all the swabs had radio-opaque markers, but the diagnosis was stomach, intestine, bladder, sigmoid colon or vagina (as hap- made by plain X-ray in only four patients, supplemented by CT pened with Patient 10).4,10,19,20 A fold of sponge then pen- or ultrasound in two of these.11 Revesz et al reported that false- etrates into the lumen of that organ, permitting the migration negative rates in detecting RS in an experimental study varied of the swab into the organ lumen and leading to partial or between 3% and 25% according to the type of sponge used.27 complete intestinal obstruction or gastrointestinal haemor- This emphasizes, for both experienced surgeons and residents rhage secondary to vessel erosion.4,11,17,18,21,22 The distal ileum in training, the importance of using only sponges that have is the usual site of impaction, as in Patient 10. Internal extru- radio-opaque markers during surgical procedures, diligence sion of RS has been reported to occur into all parts of the and accurate sponge counts before the procedure and both intestinal tract, with the most frequent sites being the ileum before and after closure of the abdomen, and the need to and colon.2 During this erosion process, which may take years, perform a methodical examination of the abdomen before most patients are symptomatic and present with abdominal wound closure, especially in obese patients and during emer- pain, nausea, vomiting, anaemia, an abdominal mass, diar- gency surgery.6,29 All measures should be taken to avoid RS. rhoea, malnutrition, weight loss or intestinal obstruction.11,23,24 Some of the reported cases of RS appear to result from failure Alternatively, the RS may be spontaneously expulsed per rec- to adhere to these standards.3 tum without any serious problems after a variable period of Ultrasound, CT scan or magnetic resonance imaging 10 days to 15 years. The peristaltic activity of the intes- (MRI)12,16,28,30 are usually necessary procedures, especially in tine helps in propelling the foreign body.17,20,25,26 chronic cases, because the lesion may mimic a malignant Patient 10 represents a rare event of RS, with transileal mass.9,31 They are valuable in facilitating the diagnosis in most migration and spontaneous passage of the sponge through cases. CT usually reveals a hypodense mass with a thick pe- the rectum. In this patient, the sponge took about 18 months ripheral rim. The characteristic appearance of a soft-tissue following appendectomy to produce symptoms by penetrat- mass with air bubbles and a whirl-like or spongiform pat-

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tern10,16,32–35 is demonstrated in Figures 3 and 4. When no 10. Apter S, Hertz M, Rubinstein ZJ, et al. Gossypiboma in the early post- radio-opaque marker is seen on plain X-ray or CT scan, the operative period: a diagnostic problem. Clin Radiol 1990;42:128–9. 11. Botet del Castillo FX, Lopez S, Reyes G, et al. Diagnosis of retained characteristic internal structure of the gauze granuloma is abdominal gauze swabs. Br J Surg 1995;82:227–8. 28 best visualized on MRI. 12. Van Goethem JW, Parizel PM, Perdieius D, et al. MR and CT imaging Barium follow-through may show distorted or adherent of paraspinal textiloma (gossypiboma). J Comput Assist Tomogr 1991; loops and grossly irregular mucosal patterns with segments of 15:1000–3. 13. Fernandez Lobato R, Marin Lucas FJ, Fradejas Lopez JM, et al. narrowing and dilatation. In the presence of an intraluminal Postoperative textilomas: review of 14 cases. Int Surg 1998;83:63–6. sponge, as in Patient 10, a filling defect may be seen with 14. Couper RT. Risk factors for retained instruments and sponges after retention of contrast material on the delayed films because of surgery. N Engl J Med 2003;348:1724–5. contrast penetration into the sponge mesh. The bowel wall 15. Gonzalez-Ojeda A, Rodriguez-Alcantar DA, Arenas-Marquez H, et expands around the barium-coated foreign body and the over- al. Retained foreign bodies following intra-abdominal surgery. Hepatogastroenterology 1999;46:808–12. all pattern closely resembles that of lymphosarcoma of the 16. Kokubo T, Itai Y, Ohtomo K, et al. Retained surgical sponges: CT and 10,17,18 small bowel. US appearance. Radiology 1987;165:415–8. In conclusion, prevention of RS is far more important 17. Gupta NM, Chaudhary A, Nanda V, et al. Retained surgical sponge than cure. Although RS is relatively rare, wide awareness of after laparotomy. Unusual presentation. Dis Colon Rectum 1985;28: this problem is mandatory to avoid unnecessary morbidity. 451–3. 18. Serra J, Matias-Guiu X, Calabuig R, et al. Surgical gauze pseudotumor. Early recognition and removal of the RS surgically, endo- Am J Surg 1988;155:235–7. scopically4,36 or laparoscopically37,38 is necessary to prevent 19. Kato K, Kawai T, Suzuki K, et al. Migration of surgical sponge most complications related to their presence. The results retained at transvaginal hysterectomy into the bladder: a case report. depend on the timing of intervention. If the sponge is retained Hinyokika Kiyo 1998;44:183–5. [In Japanese] 20. Manabe T, Goto H, Mizuno S, et al. A case of retained surgical for a long time, adhesions result in considerable morbidity sponge penetrated into the sigmoid colon. Nippon Igaku Hoshasen during the second operation. Despite the use of sponges with Gakkai Zasshi 1997;57:279–80. [In Japanese] radio-opaque markers and thorough sponge counting, this 21. Fujita K, Ichikawa T. Encapsulated paravesical foreign body. J Urol moribund mishap still occurs. 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