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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 18  |  Issue : 2  |  Page : 153-155

Retained gauze in the abdomen following prior laparotomy


1 Department of Surgery, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Kano State, Nigeria
2 Department of Surgery, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Bauchi State, Nigeria

Date of Submission16-May-2020
Date of Decision11-Jan-2021
Date of Acceptance02-Aug-2021
Date of Web Publication10-Dec-2021

Correspondence Address:
Dr. Usman Mohammed Bello
Department of Surgery, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Kano State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_13_20

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  Abstract 


Retained gauze in the abdomen (Gossypiboma) is a serious complication of abdominal surgery that often leads to medicolegal lawsuits. The most important risk factor is a failure of gauze count before and after laparotomy. Other related factors in order of occurrence include abdominal, gynaecologic, urologic and vascular procedures. We herein present a case of retained gauze following prior laparotomy.

Keywords: Laparotomy, retained gauze, abdomen


How to cite this article:
Bello UM, Muktar U, Ismail NA. Retained gauze in the abdomen following prior laparotomy. Niger J Basic Clin Sci 2021;18:153-5

How to cite this URL:
Bello UM, Muktar U, Ismail NA. Retained gauze in the abdomen following prior laparotomy. Niger J Basic Clin Sci [serial online] 2021 [cited 2022 Dec 9];18:153-5. Available from: https://www.njbcs.net/text.asp?2021/18/2/153/332169




  Introduction Top


Gossypiboma is a word derived from the combination of the Latin word 'gossypium' (cotton) and the Swahili 'boma' (place of). It refers to a fabric involuntarily left in the patient during surgery and the reactions secondary to its presence in the body.[1]

Retained surgical gauze or gossypiboma in the abdominal cavity is an infrequent but serious surgical complication that may lead to medicolegal problems. The condition has not been very frequently reported due to possible concerns.[2] The presentation can be from few days to several years after the initial surgery.[3],[4],[5]

The case is of interest, especially to surgeons, to be mindful of the possibility of retained foreign body in a patient presenting with abdominal symptoms and with prior history of laparotomy.


  Case Report Top


A 25-year-old student presented with recurrent and dull left hypochondriac abdominal pain of 1-year duration. There was no associated change in bowel habit, weight loss or fever. There were no other systemic symptoms. She had prior laparotomy 7 months before presentation at a peripheral hospital on account of left-sided ovarian cyst.

On examination, she was a young woman not in painful distress, not pale, afebrile and not wasted.

Abdominal examination revealed a lower midline scar with the left hypochondrial tenderness. There was also a poorly defined mass of 6 by 6 cm in size, firm, not warm to touch and mildly tender. The swelling was not mobile. Spleen, liver and kidneys were not enlarged. There were no ascites. Examination of other systems was essentially normal.

Abdominal ultrasound scan showed a cystic mass in the left hypochondrial region, measuring about 8 cm by 10 cm in size, with irregular internal echoes. The swelling was solitary separate from spleen, no surrounding fluid collection. Abdominal computed tomography (CT) scan requested could not be done due to financial constraints. Full blood count and electrolytes and urea were essentially normal.

Impression of mesenteric cyst was made. She was booked for exploratory laparotomy. Abdominal entry was through a lower midline incision with the proximal part of the incision through a virgin area; intraoperatively, small bowel (jejunum and ileum) adhesions were noted in the pelvis and left hypochondrial region. Adhesiolysis was done after which a cystic mass was found in the left hypochondrial region on the left side of duodenojejunal junction. The cystic swelling ruptured inadvertently during the exploration. A purulent collection of about 80 ml was aspirated from the ruptured cyst, and a huge surgical gauze was seen thereafter. It was removed by careful dissection [Figure 1] and [Figure 2]. The abdomen was lavaged, and a closed drain was left in the left hypochondrial region and brought out below the left costal margin. The abdomen was closed with nylon 0 suture. She was discharged on post-operative day 10 after the removal of the sutures.
Figure 1: Gauze removed from the abdomen

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Figure 2: Gauze in between loop of small bowel at laparotomy

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  Discussion Top


The gossypiboma is one of the surgical cases, leading to medical litigations. In addition, it leads to embarrassment, humiliation and job loss. The incidence is difficult to estimate because of a low reporting rate due to medicolegal implications. However, the incidence varies between 1 out of 1000 and 1500 intra-abdominal operations.[6]

Procedure-related risk factors identified are abdominal (52%), gynaecologic (22%), urologic and vascular (10%), orthopaedic and spinal procedures (6%) and complex surgical procedures.[7]

The most important risk factor, however, is a failure of gauze and instruments count before commencing and after surgery. Other identified risk factors include damage control surgery, emergency surgical procedures, obesity and surgery involving more than one surgical team, surgery involving more than one body cavity, unexpected change in the course of a surgical procedure and the use of unusually large number of surgical gauzes during surgery.[7] In our patient, identifiable risk factors were gynaecologic surgery and probably failure of gauze count.

The presentation can occur from immediately after abdominal closure, few weeks to many years after surgery. However, many usually go undiagnosed.[3],[4],[5]

Patients that present early, present with features due to the septic complications of the foreign body, i.e., fever, abdominal pain and tenderness. Others present with enterocutaneous fistula if bowel erosion developed.[3] Those presenting much later, may present with 'abdominal mass', intestinal obstruction secondary to adhesions[1],[4],[5] and rarely passage of the foreign body per rectum.[8]

Ultrasonography, CT scan and magnetic resonance imaging are the diagnostic investigations. However, most at times, the findings are non-specific due to the absence of radiological marker in the sponges used, especially in our hospitals.[4],[5],[6],[7],[8]

As soon as the diagnosis is made, treatment is timely surgical intervention. In early cases of laparoscopic removal where available may be attempted.[9] In those that presented late, open surgical removal is the best option due adhesion that has set in.[1],[2],[3],[4],[5]

The most important preventive strategy is gauze and instruments count before the commencement of the surgery and at the end of the procedure before wound closure to make sure that they correspond with the initial count.[6] Where possible this gauze should have a radiological marker and held with long forceps to allow easy identification during surgery. Some studies, however, have found falsely correct gauze and instruments count in re-operated cases with retained foreign bodies.[3] This could probably be due to distraction by talking to colleagues during the counting process.

In an effort to reduce human error, a hand-held device has been developed to assist in counting and detecting retained gauze which is tagged with barcode using radiofrequency technology.[10]


  Conclusion Top


Retained surgical gauze is a potentially preventable surgical catastrophe. It is also a major cause of embarrassment and legal lawsuit even to the most experienced surgeon. Hence, all efforts should be made in preventing the occurrence, especially in high-risk surgeries and patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sethi D, Kataria S, Garg M, Marwah S. Postoperative adhesive intestinal obstruction from gossypiboma. Ann Med Health Sci Res 2012;2:206.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Garg M, Akash DA. A review of medico-legal consequences of gossypiboma. A Review of Medicolegal Consequences of Gossypiboma. 2010;32:358-61.  Back to cited text no. 2
    
3.
Ukwenya PM, Ahmed A, Dogo P, Nmadu P. The retained surgical sponge following laparotomy; forgotten at surgery, often forgotten at diagnosis. Our experience. Niger J Surg Res 2006;8:164-8.  Back to cited text no. 3
    
4.
Aminian A. Gossypiboma: A case report. Cases J. 2008; 1: 220. Available from: https://casesjournal.biomedcentral.com/articles/10.1186/1757-1626-1-220. [Last accessed on 2019 May 05].  Back to cited text no. 4
    
5.
Susmallian S, Raskin B, Barnea R. Surgical sponge forgotten for nine years in the abdomen: A case report. Int J Surg Case Rep 2016;28:296-9.  Back to cited text no. 5
    
6.
Lata I, Kapoor D, Sahu S. Gossypiboma, a rare cause of acute abdomen: A case report and review of literature. Int J Crit Illn Inj Sci 2011;1:157-60.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Stawicki SP, Evans DC, Cipolla J, Seamon MJ, Lukaszczyk JJ, Prosciak MP, et al. Retained surgical foreign bodies: A comprehensive review of risks and preventive strategies. Scand J Surg 2009;98:8-17.  Back to cited text no. 7
    
8.
Butt UI, Shafiq AB, Umar M, Ashfaq M, Ayyaz M. Transmigration and spontaneous passage of a gossypiboma documented on contrast study. Ann Med Surg (Lond) 2019;38:42-4.  Back to cited text no. 8
    
9.
Yuen PM, Rogers MS, Chang AM. Laparoscopic removal of retained surgical gauze after vaginal hysterectomy. Eur J Obstet Gynecol Reprod Biol 1994;57:209-10.  Back to cited text no. 9
    
10.
Wiederkehr JC, Gama RR, Wiederkehr HA, Stelmasuk K, Carvalho CA, Wiederkehr BA. Radio-frequency identification of surgical sponges in the abdominal cavity of pigs. Ann Med Surg (Lond) 2014;3:31-3.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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