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Retained Surgical Sponge Now Online: Full-Text Articles and CE Testing at VetLearn.com Article #4 CE Retained Surgical Sponge Vassiliki Tsioli, DVM Lysimachos G. Papazoglou, DVM, PhD, MRCVS Michail N. Patsikas, DVM, PhD, DECVDI George M. Kazakos, DVM Aristotle University of Thessaloniki Thessaloniki, Greece ABSTRACT: Retained surgical sponge was diagnosed in four spayed and two castrated dogs over a 2- year period.The female dogs had undergone ovariohysterectomy and the male dogs per- ineal herniorrhaphy. Diagnosis was based on history as well as clinical and radiographic signs and was confirmed by surgical exploration. Five animals were available for follow-up (1 to 24 months) and were determined to be normal. etained surgical sponge (RSS; also PATHOPHYSIOLOGY AND known as gossypiboma,a textiloma, and CLINICAL SIGNS R cottonoid) refers to a mass of cotton Intraabdominal RSSs made of cellulose fibers matrix retained in the body. Despite the use of may cause foreign body reactions resulting from sponges made of synthetic materials, the terms their lack of inertness and inability to disinte- gossypiboma and textiloma are still commonly grate.1 Two types of reactions have been de- used. Surgical sponges are commonly used to scribed in human medicine: keep the surgical field clean and dry or to aid in countertraction. • Aseptic serofibrinous responses leading to adhesion formation, complete encapsulation, 4,6,7 EPIDEMIOLOGY and foreign body granuloma Although rarely reported, RSS represents a • Exudative responses leading to abscessation continuing problem, mainly in human surgery1–8 and, to a much lesser extent, in small animal Septic complications may manifest in the early surgery, in which few reports have appeared in postoperative period in contrast to aseptic the literature.9–13 The true incidence of RSS is encapsulations, which may go undetected for unknown, possibly because of rare occurrence or long periods.5,7,8 Fifty percent of RSSs have reluctance to admit errors that may have reportedly been found 5 years or more after sur- medicolegal implications.5,7,12 In humans, RSS gery; one-third of humans with RSSs remain reportedly occurred in one of 1,000 to 1,500 asymptomatic, and their RSSs are detected laparotomies.5 In humans, RSS occurs mainly in incidentally.5 RSSs may also penetrate hollow emergency, general surgical, gynecologic, and viscera such as the intestine, bladder, or vagina obstetric procedures.8 because of pressure necrosis, resulting in intes- Email comments/questions to a tinal obstruction, infection, or gastrointestinal Gossypiboma is derived from 7,8,14 [email protected], gossypium (“cotton” in Latin) (GI) hemorrhage due to vessel erosion. The fax 800-556-3288, or log on to and boma (“place of conceal- most common clinical signs in humans include www.VetLearn.com ment” in Swahili). malaise, fever, anorexia, weight loss, signs sec- COMPENDIUM 634 August 2004 Retained Surgical Sponge CE 635 ondary to intestinal obstruction, and bleeding from the trapped between the synthetic fibers of RSSs.4,14,15 This digestive or urogenital tract.3,6–8 pattern is considered to be characteristic of RSS. On RSS in dogs is associated with the infective, exudative CT, most RSSs demonstrate a variable-density appear- form of foreign body granuloma, resulting in clinical ance that makes interpretation difficult.16 A thin or, less signs that appear within months after surgery.12 Clinical often, thick capsule that surrounds a low-density center signs reported in dogs and cats with intraabdominal RSS has also been reported.4,15 Another rare sign on CT is include sinus discharge, palpable abdominal mass, ele- calcifications on the fibrous capsule or in the center of vated temperature, vomiting, diarrhea, painful abdomen, the RSS. Calcifications are commonly found in sponges depression, anorexia, and weight loss.12,13 In addition, that have been retained for a long time and have been in foreign body osteomyelitis9 and sarcoma formation10 contact with the GI or urinary tract.15 associated with RSS have been reported in dogs. The sonographic appearance of RSS varies, depending on the type of reaction (i.e., abscess or granuloma) that CLINICAL PATHOLOGY the sponge provokes and the presence of trapped fluid In a recent report involving eight dogs with RSS, neu- or gas.12,13 High amplitude echoes with acoustic shad- trophilia, microcytic anemia, leukopenia, thrombocy- owing may be representative of an RSS with trapped gas topenia, hyperglobulinemia, hypoalbuminemia, and or may be produced by the large number of interfaces Using sponges with radiopaque markers may increase the possibility of diagnosing retained surgical sponge. elevated alkaline phosphatase levels were detected.12 resulting from sponge fibers.4,12,15 However, in cases of Cytologic examination after fine-needle aspiration of purely granulomatous lesions without abscessation, the the abdominal mass may allow identification of the acoustic properties may differ and the strongly echo- granulomatous nature of the tissue response.13 genic interfaces associated with acoustic shadowing have not been identified.13 DIAGNOSTIC IMAGING When sinus tracts are present, sinography may reveal Because of localized gas lucency resulting from air an RSS by filling its network of fibers.3,12 trapped between sponge fibers, conventional abdominal radiography may be used to detect RSS.8,12 Gas lucency DIFFERENTIAL DIAGNOSIS may appear speckled or vortex-like, persist for a long The differential diagnosis of intraabdominal RSS may time, and be mistaken for feces if recognized as a GI include the presence of a hematoma or an intestinal structure.12,14 mass.12,16 The speckled gas pattern due to RSS, as visual- Including radiopaque markers in sponges can make ized on plain radiographs, may be misinterpreted as feces them easier to detect on plain radiographs.1,5 The size unless it is recognized as a non-GI mass.12 On CT, an RSS and pattern of such markers may influence detection of with a radiopaque marker could be mistaken for a calcified RSS.2 However, some markers may twist, fold, or disin- hematoma.14 With ultrasonography, an RSS can be differ- tegrate over time or be superimposed over bony struc- entiated from an intestinal tumor, although they have simi- tures, making them difficult to see on plain radio- lar signs. With tumors, the gas-filled cavity communicates graphs.5,8 In addition, surgical clips may mimic the directly with the intestinal lumen on an ultrasonogram. pattern of radiopaque markers.14 This is not usually the case with RSS granulomas unless Abdominal computed tomography (CT) in humans migration into the intestinal lumen has occurred.12 may reveal a well-defined mass surrounded by a thick wall and internal heterogeneous densities, all represent- DIAGNOSIS ing the various contents of RSS: the synthetic-fiber for- The presence of nonspecific clinical signs and difficulty eign body, granuloma formation, and abscessation.8 A identifying RSS radiologically are responsible for difficul- spongiform pattern has resulted from gas bubbles ties in making the correct diagnosis. Diagnosing RSS August 2004 COMPENDIUM 636 CE Retained Surgical Sponge Sponge Counts in Human Medicine gical procedure and those with a high body mass index.18 A long, complex operation may cause a surgeon to lose track In human medicine, sponge, sharps, and instrument counts are relied on to eliminate the potential to of a surgical sponge. Time constraints may lead to incorrect leave foreign bodies in patients. The Association of sponge counts, especially in emergencies and unstable 5,7 periOperative Registered Nurses (AORN) recommends patients. In addition, personnel changes between the ini- counting instruments and sponges four separate times tial and last sponge count may increase the possibility of an during a procedure, but the counting process has not incorrect count.5 The risk of RSS might be less in dogs been standardized. The scrub and circulating nurses than in humans because of the smaller abdominal cavity share the legal responsibility for counting and and shorter, less complicated surgeries in dogs.12 confirming the number of sponges, but surgeons are often named in lawsuits involving RSSs. PREVENTION Recommendationsa Using radiopaque-marked sponges is recommended to • Sponges should be counted in all procedures. prevent RSS.7,12 The surgical team, including surgeons and • Sponges should be counted concurrently in the nurses, is responsible for following proper surgical proce- operating room by a nurse and another scrubbed person. dures and handling sponges correctly, including counting • Sponges should be counted before a cavity or any part sponges at the beginning of a procedure and before closing of a cavity is closed. the incision8 (see box on this page). After a change in per- • Types and sizes of sponges should be kept to a sonnel, the new personnel should perform two sponge minimum. All sponges used should be detectable counts.5,7 The abdomen should be meticulously explored radiographically. before closure to ensure that all sponges have been • Counted sponges should not be removed from the removed.5,7 In emergency or high-risk surgery or when a operating room during a procedure. sponge count is uncertain, routine intraoperative radi- • Radiographically detectable sponges should not be ographic screening should be conducted before closing an used as dressings. incision.5,7,18 aAdapted from Philippine College of Surgeons: Operating Room Standards. without radiopaque markers is more challenging than when markers
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