Surgical Sponges in Small Animal Surgery

3 CE Credits

Phil Zeltzman, DVM, DACVS Phil Zeltzman Mobile Surgery LLC Allentown, PA Myron O. Downs, DVM, PhD, DACVS Athens Veterinary Surgery Center Athens, GA

Abstract: Sponges are commonly used in veterinary practice. Uses for sponges in the operative arena include hemostasis, retraction, protection, dissection, and general wound management. Blood loss can be quantitated by counting blood-soaked sponges. Complications may arise when sponges are retained in the patient. Sponge retention is a risk whenever sponges are used during surgery, regardless of surgical procedure. This article reviews physical characteristics and proper uses of sponges, complications of sponge retention, and techniques to avoid retained sponges.

he documented medical use of gauze dates back to the late surgical procedure. This makes it difficult to account for all of the 1800s.1 Since then, sponges have become one of the most sponges at the end of the procedure. Tcommonly used items in veterinary surgery and are thought Large laparotomy sponges come in sizes from 9 × 9 to 36 × 8 to be the most common accidentally retained surgical foreign inches. They are used mostly during abdominal and thoracic surgery bodies. Uses for sponges in the operative arena include hemo- or in deep wounds to absorb fluids; however, they can also be used stasis, retraction, protection, dissection, and general wound to “wall off” the surgical site. The friction of their coarse fibers also management. This article reviews the various types and uses of allows laparotomy sponges to be used to retract slippery visceral or- surgical sponges, complications associated with their use, and gans. Dry gauze clings to tissues more firmly than wet gauze but may techniques for preventing retained surgical sponges. Diagnosis cause more trauma to delicate tissues, which can lead to adhesions. and treatment of retained sponges are also addressed. In addition to square and rectangular sponges, there are small, round sponges, which are used for blunt dissection or for hemo- Sponge Design stasis. These include “peanut,” “cherry,” and Kittner sponges. Sur- Two main categories of sponges are used in veterinary surgery: gical patties or neurologic sponges are small sponges on strings small sponges and laparotomy sponges. Small square or rectan- or sticks. These sponges are used for delicate dissection; they can gular gauze sponges come in sizes from 2 × 2 to 8 × 4 inches and also be interposed between tissue and the suction tip during fluid are folded to be from 3 to 32 ply. Small sponges are used to absorb aspiration to decrease tissue trauma. fluids, control hemostasis, and keep the surgical field clean and Sponges can be made from natural or synthetic fibers or a dry. These “free sponges” are frequently thrown away during the blend of both (TABLE 1). Most sponges are natural and made of

Table 1. Comparison of Typical Woven and Nonwoven Sponges1,5 Absorption Absorption Time Size and Type Material Capacity (mL) (sec) Linting (µg) Weight (g)

Woven 4 × 4–inch, Cotton 5–12.5 1 31.2 2.27 12-ply

Nonwoven 4 × 4–inch, 70% rayon, 10–18.3 1 1.4 1.72 4-ply 30% polyester

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Figure 1. Photograph of typical 4 × 4–inch woven (left), nonwoven (middle), and Figure 2. Photograph demonstrating the absorptive capacity of blood by a woven woven with radiopaque marker (right) sponges used in small animal surgery. (left) and a nonwoven (right) 4 × 4–inch sponge.

100% cotton yarn.2 To improve gauze quality, rayon, a synthetic Therefore, rubbing may promote further bleeding. Generalized cap- fiber, was introduced in the 1940s. Virtually all of the nonwoven illary oozing from an organ such as the liver can also be controlled sponges used in the United States today are made of rayon or by pressure pad hemostasis or by packing the wound. synthetic fiber blends (e.g., rayon and polyester).2 Woven spong- The absorption capacity of a sponge depends on its size, com- es are formed by interlacing two sets of yarn. In contrast, non- position, and degree of saturation.5 Blood loss can be quantitated woven sponges are made directly from fibers through a variety by counting blood-soaked sponges.5 A typical dry, 4 × 4-inch, of technologies. 12-ply woven sponge has been shown to absorb between 5 and Both woven and nonwoven sponges are prone to linting. How- 12.5 mL of heparinized bovine blood (FIGURE 2).1,5 A comparable ever, nonwoven sponges produce less lint. For example, a typical 4 × 4–inch, 4-ply nonwoven sponge absorbs between 10 and 18.3 4 × 4–inch, 12-ply woven sponge has been shown to release 31.2 mL of blood.1,5 Nonwoven sponges are therefore much more µg of lint, while a 4 × 4–inch, 4-ply nonwoven sponge generates absorbent than woven sponges.1 1.4 µg.1 Although rarely recognized in veterinary surgery, lint has A 12 × 12–inch woven laparotomy sponge moistened with been associated with an increased risk of granuloma, adhesions, sterile saline solution before use can absorb approximately 50 and infection in humans.2 Manufacturers attempt to reduce the mL of blood.5 An accurate determination of blood loss may be amount of lint by washing sponges. difficult, and it is important to know how much blood a specific Laparotomy sponges typically contain a radiopaque marker type and brand of sponge can absorb. Woven sponges are pre- or ribbon that facilitates detection by radiography (FIGURE 1). The ferred by most surgeons.2 Nonwoven sponges are not a popular radiopaque inserts are usually made of barium sulfate or plastic.3 choice, probably because However, the shape of the radiopaque marker may change with of factors such as price, folding and twisting of the sponge. Although radiopaque sponges product availability, and Key Points are more expensive, they should be used in all thoracic and familiarity.2 abdominal surgical procedures. Sponges can also be • Nonwoven sponges absorb more weighed to quantitate blood blood and produce less lint than Sponges in Surgery loss.5 For this purpose, it woven sponges. Surgical sponges can be used for several purposes during surgery: can be assumed that a 4 × • Blood loss can be estimated by hemostasis, protection, retraction, blunt dissection, and wound 4–inch dry sponge has a counting blood-soaked sponges. management. negligible weight and that 1 mL of blood represents 1 g. • Sponges are thought to be one Hemostasis Even though sponges of the most common accidentally Maintaining a dry field is very important throughout the surgical provide an efficient means retained surgical foreign bodies. procedure because it facilitates better visualization of anatomic struc- of hemostasis and blood • Retained surgical sponges can lead tures in the operative site. Applying direct pressure to low-pressure removal, they should not to serious complications. bleeding vessels with a dry or moistened sponge is an effective way to be overused. Other meth- perform hemostasis after the incision of skin and subcutaneous tis- ods for blood removal, • Techniques for reducing the risk of sues. Applying pressure to vessels leads to stasis of blood flow, which such as suction, may be sponge retention include sponge initiates the coagulation cascade. The tissues should be compressed more appropriate if large counts, tagging, and the use of or blotted for at least 4 minutes, not rubbed or wiped.4 Gauze is abra- amounts of blood need to radiopaque markers. sive, and wiping creates microlesions as well as dislodges blood clots. be removed quickly.

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Nosocomial transmission of Serratia marcescens in a veterinary hospital was described by Fox et al7 after the use of cotton sponges soaked in 0.025% benzalkonium chloride. This antiseptic loses its bactericidal properties when in contact with cotton fibers because it is absorbed into the fibers and becomes diluted to concentrations that are no longer bactericidal. Methods for Reducing the Risk of Sponge Retention Numerous techniques can be used to reduce the risk of sponge retention (BOX 1 and BOX 2). The most basic is to regularly survey the surgical field to identify errant sponges. A small sponge may be difficult to see, especially when it is soaked with blood or buried in a deep surgical field. Small sponges should not be placed inside a body cavity unless they are appropriately tagged. Tagging involves attaching sponges to an instrument, such as hemostatic or sponge forceps. Small sponges should be thrown away once they are blood soaked. Whether they are used or new, Figure 3. Intraoperative photograph depicting the use of laparotomy sponges inter- they should not be left on the drape or near the surgical field. posed between the Balfour retractor and the edges of the abdominal incision. This Instrument surgical packs should contain a defined number of 16-year-old chow mix presented with an ovarian stromal tumor and metritis. small or laparotomy sponges. This number will vary with the type of pack or the procedure. Individual sponge packs should also Protection and Retraction contain a defined number of sponges. Some companies bundle Once the abdominal or thoracic cavity has been entered, saline- sponges in packs of 10. moistened laparotomy sponges are placed around the edges of Counting sponges before and after a surgical procedure is, the incision to protect soft tissues and exposed organs from ab- unfortunately, not a common practice in veterinary surgery. This dominal or rib retractors (FIGURE 3). The sponges also prevent quick and simple safety measure is routine in human surgery, in sliding of the retractors. Further access to the abdomen or the which it is the responsibility of the scrub nurse, who usually per- thorax can be facilitated by using more moist laparotomy sponges forms a triple count. For example, for an abdominal procedure, to “pack off” or separate organs and provide a working space.1 the count is done before surgery, immediately before closure of Organs such as intestines can be held aside in wet laparotomy the abdominal wall, and after skin closure. A special container sponges to keep them moist. The edges of the same sponges can

be used for hemostasis or to clean the surgical field. 13 Sponges may also be used as packing material to protect vital Box 1. Ten Ways to Prevent Retained Surgical Sponges areas or surgical sites from contamination with blood, exudate, in- 1. Count sponges before and after the surgical procedure. gesta, or feces. They can be placed into the oropharynx to collect blood during oral surgical procedures. Laparotomy sponges can be 2. Routinely survey the surgical field for hidden sponges, and immediately placed strategically around segments of the gastrointestinal tract discard any found. that are to be entered or resected. The number of sponges placed 3. Be especially careful when sponges are used for packing off. should be recorded, and care should be taken to remember to remove these sponges at the conclusion of the surgical procedure. 4. Throw used 4 × 4–inch sponges away as soon as possible. Blunt Dissection 5. Never place a free small sponge inside a body cavity. Sponges can be used to facilitate blunt dissection of delicate 6. Attach 4 × 4–inch sponges to a hemostat or sponge forceps for use tissues by using a single ply of gauze wrapped around the index in deep areas. finger. Procedures in which blunt dissection is used include cas- 7. Never leave dry or used sponges on the surgical drapes or near the tration, perineal urethrostomy, and mastectomy. surgical field. Wound Management 8. Know how many sponges are supposed to be in surgical packs and The use of sponges in wound management has been reviewed sponge packs. elsewhere.6 Sponges have been used in the primary or contact 9. Use sponges with radiopaque markers, especially for thoracic and layer of dry-to-dry, wet-to-wet, and wet-to-dry bandages. In the abdominal surgery. latter two types, isotonic crystalloid solutions are used to moisten the gauze. Sponges are used to absorb exudates and to facilitate 10. Use large laparotomy sponges in abdominal and thoracic procedures. microscopic debridement of soft tissue wounds.

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Box 2. RFID, the Wave of the Future for Surgeons? and makes it easier to remove them. The loop is also radiopaque. Despite their large size, these sponges can also be retained in a body A study investigated the use of radio-frequency identification (RFID) technology cavity and should be counted before and after surgery. to avoid retained sponges.9 This technology is used in numerous industries (e.g., to prevent theft in clothing stores). The RFID chips—the size of a Complications of Surgical Sponge Retention nickel—were attached to laparotomy sponges. Human surgeons then used Since the first published report of a retained surgical sponge in a handheld wand to detect the sponges. Detection accuracy was 100%, with human surgery in 1884, surgical sponges continue to be thought of no false-positive and no negative readings. Despite these impressive results, as one of the most common accidentally retained surgical foreign the study authors insist that human error is still possible. bodies.11 Retained sponges are a “specter” for surgeons because of the resulting complications and medicolegal implications. Pittsburgh-based ClearCount Medical Solutions recently attained FDA approval There are no definitive published data regarding the incidence for its SmartSponge System based on RFID technology. The system is “designed of retained surgical sponges in human or veterinary surgery. One to replace the antiquated method of manual counting,” according to a company report estimated that sponges are retained in humans approxi- statement. mately once in every 1000 laparotomies.12 This number may be underestimated because of the reluctance to report this compli- cation.13 In about one-third of cases, retained surgical sponges can be used to discard used sponges, which helps in counting cause no clinical signs.12 Some remain dormant for a very long them (FIGURE 4). period of time. In human surgery, surgical sponges have been re- Despite standardized protocols for counting sponges, the covered up to 19 years after the presumptive causative surgery.14 problem of retained sponges persists in the operating room. The pathophysiology of retained surgical sponges has been Technology that improves sponge detection may reduce the risk well described in the human literature. A retained surgical to patients. Radio-frequency identification (RFID) and bar-code sponge can be referred to as a gossypiboma, which is a mass com- systems have been investigated successfully in human surgery.8,9 posed of a cotton matrix within the body.3 Retained sponges are These systems are more expensive than a simple hand count but also called textilomas, gauzomas, or cottonoids. Sponges are inert more effective at tracking discrepancies.9 and nonabsorbable and, therefore, do not take part in any spe- In fact, a difference in count does not always indicate a retained cific decomposition such as phagocytosis or biochemical reac- sponge. In one human study, most discrepancies were due to tion such as hydrolysis.3,14 However, a retained sponge can result a misplaced item (59%). A documentation error was found in in two types of foreign body reactions. The first one is a clas- 38% of the cases, and a miscount was responsible only 3% of sic foreign body granuloma to try to “wall off” the sponge: an the time.10 aseptic fibrinous response leads to adhesions and encapsulation. Large laparotomy sponges can be used for abdominal and tho- In rare cases, calcium may be deposited in the fibrous capsule.3 racic surgery. Because they are larger, fewer are required and they are The second reaction is exudation and abscess formation, which easier to see. These sponges have a loop sewn to one corner, usually is usually associated with bacterial invasion. The number of blue, which can be clamped to the surgical drape. This loop enables bacteria needed to produce an abscess is reduced in the presence the surgeon to know how many sponges are in the surgical field of a foreign body.12 In some cases, a retained sponge can undergo sterile encapsulation and remain dormant for years. The abdomen is the most likely location for a sponge to be retained because of the depth of the surgical site and the tortu- ous nature of the intestines, mesentery, and omentum. However, retained sponges have been recovered from a variety of locations in humans, including the abdominal cavity, the thoracic cavity, the neck, and the lumbar spine.12,15–17 Clinical manifestations of retained surgical sponges depend on the presence of bacterial contamination and the location of the sponge within the body cavity.12 Complications described in the human and veterinary literature include fistulas, chronic sinus tracts, delayed healing, mechanical intestinal obstruction, peritonitis, adhesions, erosion into adjacent viscera, pancreatic pseudocyst, pseudotumor, pseudohematoma, and hemorrhage secondary to vessel erosion.13,14,17–19 Several reports of erosion and complete transluminal migration of a retained surgical sponge into the gastrointestinal tract have been published.14,18 Extrusion Figure 4. At the University of Illinois, a special container is used to discard used sponges, which helps in counting them. of laparotomy sponges through the rectum has also been reported as a sequela of transmural migration.13

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Few published reports in the veterinary literature concern retained surgical sponges, especially in comparison to the human literature. Teague et al20 described two cases of foreign body osteomyelitis secondary to retained surgical sponges. In both cases, the gauze was incorporated into the bone and could not be entirely removed. Staphylo- coccus aureus was cultured in both cases. Pardo et al21 reported a case of a primary jejunal osteosarcoma Figure 6. Lateral abdominal radiograph of an 8-year-old female German shepherd. The radiopaque marker of a laparotomy sponge is visible. The only surgery performed Figure 5. Ventrodorsal abdominal radiograph associated with a retained was an ovariohysterectomy 7 years prior. from a spayed mixed-breed dog demonstrating surgical sponge in a spayed a retained sponge. Note the whirl-like 7-year-old chow chow. configuration characteristic of gas trapped 14 FIGURE 6 between the fibers. A chronic nonhealing a retained surgical sponge ( ). However, these markers sinus wound in the flank of can sometimes be missed because of overlying bony structures.19 a spayed mixed-breed dog At least two orthogonal radiographic views should be used when was associated with a retained surgical sponge.22 The radiograph- trying to detect a retained surgical sponge. ic presentation was similar to that of retained surgical sponges In human surgery, one study suggests that routine radiographs reported in the human literature. Several additional cases have taken intra- or postoperatively in “selected, high-risk categories of been described years after ovariohysterectomy was performed, operations” could be used as a screening test for retained sponges.28 whether it was elective or as treatment of pyometra.23–26 This method is judged to be cost-effective compared with the cost of Other reported cases of sponge retention involve perineal herni- the potential medical and legal complications.28 The high-risk cases orrhaphy,23 laparotomy to remove a cryptorchid testicle,24 celiotomy identified in the study are those involving an unexpected change in for intestinal biopsy,24 and a bite wound to the thigh.24 One case of procedure, emergency surgeries, and overweight patients.28 osteosarcoma, presumed secondary to a retained sponge, was diag- Upper gastrointestinal series (“barium swallow”) or barium nosed 9 years after surgery for anterior cruciate ligament rupture.27 enemas can be helpful if the contrast agent delineates an intralu- In another case, a retained sponge near the bladder caused hematu- minal sponge.1,17,18,20 A fistulogram or a sinogram can be a useful ria and mimicked a bladder tumor on ultrasonography.26 technique to characterize a fistulous or a sinus tract, Diagnosis particularly if the contrast Diagnosis of a retained surgical sponge can be difficult, par- material fills the network of ticularly if the sponge does not contain a radiopaque marker. A the gauze3,17,22,24 (FIGURE 7). retained surgical sponge may be suspected in a patient with a history Other imaging tech- of a surgical procedure. Clinical signs depend on the location niques have been used to of the retained sponge and the physical disturbance it causes. detect retained surgical Signs may include a palpable abdominal mass, chronic pain in sponges but sometimes the vicinity of the surgical site, vomiting, peritonitis, postopera- have limited specificity. tive ileus, tenesmus, protrusion of a sponge through the rectum, With ultrasonography, re- bladder disturbances, abscess formation, fever, signs of sepsis, tained sponges strongly fistulas, or sinus tracts.4,18 In some animals, the retained sponge attenuate the sound beam, causes no clinical signs, and the sponge is an incidental finding. creating an intense and Retained surgical sponges have various appearances on survey sharply delineated acous- radiographs.17,22 The presence of gas trapped between the fibers tic shadow.19 A hypoechoic gives a characteristic whirl-like configuration22,24 (FIGURE 5). The mass with an irregular hy- origin of this gas can be the atmosphere, the intestines, or bac- perechoic center was also Figure 7. Fistulogram after a contrast agent was injected in an open wound in the right teria.3 Peripheral calcification can sometimes be seen.3 The pres- described.24 Computerized flank of the dog depicted in Figure 5. ence of a radiopaque marker can greatly facilitate the diagnosis of tomography of a retained

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Figure 8. Photograph of a sectioned encapsulated mass surgically removed from the dog depicted in Figures 5 and 7. The incised capsule revealed a retained Figure 9. The encapsulated laparotomy sponge was adhered to the jejunum of the sponge, which caused a chronic nonhealing sinus wound in the dog’s flank region. dog depicted in Figure 6. A jejunal resection and anastomosis was performed.

surgical sponge reveals a heterogeneous density that depends on stasis and estimating intraoperative blood loss. Retained surgical the presence of gas trapped within the mesh.14,19 Magnetic reso- sponges are a very important medicolegal problem in surgery, and nance imaging characteristics of a retained surgical sponge are they will remain a problem as long as nonabsorbable materials those of abnormal fluid collections of high protein content such are used in the manufacture of surgical sponges. It is conceiv- as abscesses and exudates.19 able that minimally invasive surgery will decrease the risk of retained surgical sponges. Research is needed to develop materials Treatment that would combine the advantages of woven and nonwoven Once diagnosed, retained surgical sponges can be retrieved by sponges. Until the ideal sponge is manufactured, surgeons need exploratory surgery (FIGURE 8) or laparoscopy.13,20,21,22,27 to avoid retained surgical sponges. Some of the best ways to min- Acutely retained sponges can be removed by reexploring imize the possibility of forgetting a sponge include awareness of the surgical site. Adhesions should be gently broken down to free the risk, tagging, using radiopaque markers, immediate sponge the sponge. Chronically retained sponges may appear as discrete, disposal, and sponge counts. encapsulated nodules or diffuse adhesive lesions involving several visceral structures, such as the intestines (FIGURE 9). Well- References encapsulated sponges should be removed in toto to ensure that all 1. Hall SD, Ponder RB. Nonwoven wound care products. Ostomy Wound Manag sponge fibers are removed. When this is not feasible, the capsule 1992;38(6):24-32. 2. Ponder RB, Krasner D. Gauzes and related dressings. Ostomy Wound Manag can be incised and the sponge removed. Occasionally, en bloc 1993;39(5):48-60. resection must be performed to ensure removal of the sponge. 3. Olnick HM, Weens HS, Rogers JV. Radiological diagnosis of retained surgical spong- Care must be taken not to es. JAMA 1955;159(16):1525-1527. injure vital structures during 4. Crowe DT Jr, Bjorling DE. Peritoneum and peritoneal cavity. In: Slatter D, ed. Textbook dissection. of Small Animal Surgery. 2nd ed. Philadelphia: WB Saunders; 1993:176. Clinical Pearls 5. Wagner AE, Dunlop CI. Anesthetic and medical management of acute hemorrhage Surgical sponges can be during surgery. JAVMA 1993;203(1):40-45. • A 4 × 4–inch, 12-ply woven sponge identified by histopatho- 6. Swaim SF, Wilhalf D. The physics, physiology and chemistry of bandaging open can absorb between 5 and 12.5 mL logic examination. Cotton wounds. Compend Contin Educ Pract Vet 1985;7:146-154. of blood. fibers in a pathologic spec- 7. Fox JG, Beaucage CM, Folta CA, et al. Nosocomial transmission of Serratia marc- imen are virtually invisible escens in a veterinary hospital due to contamination by benzalkonium chloride. J Clin • A 4 × 4–inch, 4-ply nonwoven Microbiol 1981;14(2):157-160. under normal light. How- sponge absorbs between 10 and 8. Greenberg CC, Diaz-Flores R, Lipsitz SR, et al. Bar-coding surgical sponges to ever, they are visible under 18.3 mL of blood. improve safety: a randomized controlled trial. Ann Surg 2008;247(4):612-616. polarized light.20 9. Macario A, Morris D, Morris S. Initial clinical evaluation of a handheld device for • A 12 × 12–inch woven laparotomy detecting retained surgical gauze sponges using radiofrequency identification technology. sponge moistened with sterile saline Conclusion Arch Surg 2006;141(7):659-662. 10. Greenberg CC, Regenbogen SE, Lipsitz SR, et al: The frequency and significance of solution before use can absorb Despite their simplicity, discrepancies in the surgical count. Ann Surg 2008;248(2):337-341. about 50 mL of blood. sponges provide an effective 11. Wilson CP. Foreign bodies left in the abdomen after laparotomy. Gynecol Tr 1884; means of achieving hemo- 9:109-112.

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12. Hyslop JW, Maull KI. Natural history of the retained surgical sponge. South Med J secondary to retained surgical sponges. Vet Med 1978;73(10):1279-1286. 1982;75(6):657-660. 21. Pardo AD, Adams WH, McCracken MD, et al. Primary jejunal osteosarcoma associated 13. Childers JM, Caplinger P. Laparoscopic retrieval of a retained surgical sponge: a with a surgical sponge in a dog. JAVMA 1990;196(6):935-938. case report. Surg Laparosc Endosc 1993;3(2):135-138. 22. Zeltzman PA, Downs MO, Girard EM. What is your diagnosis? JAVMA 14. Risher WH, McKinnon WM. Foreign body in the gastrointestinal tract: intraluminal 1998;212(2):193-194. migration of laparotomy sponge. South Med J 1991;84(8):1042-1045. 23. Papazoglou LG, Tsioli V, Patsikas VT, et al. Retained surgical sponges. Compend 15. Williams RG, Bragg DG, Nelson JA. Gossypiboma: the problem of the retained Contin Educ Pract Vet 2004;26(8):634-644. surgical sponge. Radiology 1978;129:323-326. 24. Merlo M, Lamb CR. Radiographic and ultrasonographic features of retained surgical 16. Gifford RR, Plaut MR, McLeary RD. Retained surgical sponge following laminectomy. sponge in eight dogs. Vet Radiol Ultrasound 2000;41(3):279-283. JAMA 1973;223(9):1040. 25. Frank JD, Stanley BJ. Enterocutaneous fistula in a dog secondary to an intraperito- 17. Serra J, Matias-Guiu X, Calabuig R, et al. Surgical gauze pseudotumor. Am J Surg neal gauze foreign body. JAAHA 2009;45(2):84-88. 1988;155(2):235-237. 26. Deschamps JY, Roux FA. Extravesical textiloma (gossypiboma) mimicking a bladder 18. Gupta NM, Chaudhary A, Nanda V, et al. Retained surgical sponge after laparotomy: tumor in a dog. JAAHA 2009;45(2):89-92. unusual presentation. Dis Colon Rectum 1985;28(6):451-453. 27. Miller MA, Aper RL, Fauber A, et al. Extraskeletal osteosarcoma associated with 19. Terrier F, Revel D, Hricak H, et al. MRI of a retained sponge in a dog. Magn Reson retained surgical sponge in a dog. J Vet Diagn Invest 2006;18(2):224-228. Imaging 1985;3:283-286. 28. Gawande AA, Studdert DM, Orav EJ, et al. Risk factors for retained instruments and 20. Teague HD, Alsaker R, Braden TD, et al. Two cases of foreign-body osteomyelitis sponges after surgery. N Engl J Med 2003;348(3):229-235.

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1. Which of the following methods is/are effective for 6. What are the two main foreign body reactions commonly minimizing sponge retention? associated with retained surgical sponges? a. discarding sponges immediately after use a. fistula and abscess formation b. using laparotomy sponges b. foreign body granuloma and sinus formation c. tagging sponges with surgical instruments c. sterile encapsulation and abscess formation d. all of the above d. foreign body granuloma and abscess formation

2. Which statement concerning RFID technology is true? 7. Which statement concerning the absorptive capacity of a. In one study of its use in laparotomy sponges, detection sponges is true? accuracy was 100%. a. Nonwoven sponges absorb more blood than woven b. Radiography is used to detect sponges with RFID chips. sponges. c. RFID stands for request to find inappropriate devices. b. Woven sponges absorb more blood than nonwoven sponges. d. Ultrasonography is used to detect sponges with RFID chips. c. Nonwoven sponges and woven sponges absorb equal volumes of blood. 3. How much blood can a 4 × 4–inch, 12-ply woven sponge d. The greater absorptive capacity of woven sponges is absorb? related to their greater absorption rate. a. <5 mL 8. What is the origin of gas within a retained sponge? b. 5 to 12.5 mL a. atmospheric air c. 12.5 to 15 mL b. intestinal gas d. 15 to 20 mL c. bacteria 4. Compression with a sponge initiates clotting by d. all of the above a. initiating stasis of blood flow. 9. Which statement concerning use of a surgical sponge for b. creating microlesions. hemostasis is true? c. acting as a foreign body. a. Direct pressure for 4 seconds is recommended to achieve d. all of the above hemostasis. 5. Assuming that a 4 × 4–inch dry sponge has a negligible b. Wiping is the most effective way to achieve hemostasis. weight, how much would it weigh if it is soaked in 5 mL c. Wiping disrupts blood clots and should be avoided. of blood? d. none of the above a. 2.5 g 10. Most woven surgical sponges are made of b. 5 g a. silk. c. 7.5 g b. rayon and polyester. d. 10 g c. wool and cotton. d. cotton.

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