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ISSN: Print -2349-0977, Online - 2349-4387


 
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CASE IN POINT: CLINICS IN UROLOGY
Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 148-150

Gossypiboma masquerading as a pelvic cystic lesion


Department of Urology, Lourdes Hospital, Kochi, Kerala, India

Date of Web Publication2-May-2016

Correspondence Address:
H Krishnamoorthy
Department of Urology, Lourdes Hospital, Pachalam, Kochi - 682 012, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-0977.181513

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  Abstract 

Gossypiboma or textiloma is a rare avoidable surgical disaster having medicolegal repercussions. It is a mass lesion due to a retained surgical cotton sponge accompanied by foreign body reaction. The time of presentation may range from early postoperative period to several decades later. A correct diagnosis can be made only in one-third of cases. We report an unusual case of gossypiboma in a 56-year-old female which was mistaken for pelvic cystic lesion. The diagnosis of gossypiboma was confirmed only during surgical exploration. Retained foreign body should be one of the differential diagnosis of any postoperative patient presenting with pain, infection, or palpable mass.

Keywords: Foreign body, gossypiboma, sponge, textiloma


How to cite this article:
Rathore RS, Mehta N, Pillai BS, Krishnamoorthy H. Gossypiboma masquerading as a pelvic cystic lesion. Astrocyte 2015;2:148-50

How to cite this URL:
Rathore RS, Mehta N, Pillai BS, Krishnamoorthy H. Gossypiboma masquerading as a pelvic cystic lesion. Astrocyte [serial online] 2015 [cited 2020 Oct 25];2:148-50. Available from: http://www.astrocyte.in/text.asp?2015/2/3/148/181513


  Introduction Top


A mass formed around a cotton matrix left within the body of the patient during surgical operation is termed as gossypiboma or textiloma.[1] Surgical sponge is the most common type of retained foreign body (RFB) found after abdominal surgical operation. The term “gossypiboma” is derived from the Latin word “Gossypium,” meaning cotton, and the Swahili word “boma,” meaning place of concealment.[2] In the abdomen, RFB gets surrounded by omentum and small intestines which eventually encapsulate it. During this process, the mass either erodes the intestinal wall creating fistula or compresses the intestinal wall causing obstruction.[3] Patient may present with abdominal pain, nausea, vomiting, anorexia, and weight loss. The exact incidence of gossypiboma is difficult to establish since there is high incidence of underreporting of cases due to legal implications associated with it. However, the reported incidence of gossypiboma in literature is 1 in every 3000–5000 operations and the most common site is the abdomen.[4],[5] One other study reported incidence of RFBs such as sponge, needle, or part of instrument following surgery as 0.01–0.001%, of which gossypibomas comprised 80% of these cases.[6] The difficulty in diagnosing gossypiboma is due to varied clinical presentations and the nonspecific investigative findings of these cases. We present an unusual case of gossypiboma in a 56-year-old female which was mistaken for an intra-abdominal cystic lesion with probably a malignant component.


  Case Report Top


A 56-year-old female, with past history of abdominal hysterectomy done 5 years back elsewhere for uterine fibroid, presented with vague lower abdominal pain since 4 years. There was no history of fever, vomiting, altered bowel habits, or loss of appetite. On examination, a fixed, nontender cystic mass 10 cm × 8 cm was palpable in the hypogastric region more toward the left side, overlying the region of the urinary bladder. All routine blood investigations were within normal limits. Ultrasound abdomen revealed 10 cm × 8 cm well-defined cystic lesion abutting the left lateral wall of the urinary bladder. Contrast-enhanced computed tomography (CT) scan [Figure 1] showed a well-defined pelvic cystic lesion with a hyperechoic area on the posterior region (with a density of 40–80 HU) seen abutting the urinary bladder suggestive of cyst from remnant ovarian tissue or urachal cyst. The solid components raised suspicion of coexisting malignancy. Exploratory laparotomy revealed a large cyst between sigmoid mesocolon and anterior bladder wall. The cyst during dissection got accidently ruptured and a foreign body (gauze piece) was seen with in it [Figure 2] and [Figure 3]. The foreign body was removed and thorough peritoneal lavage was given. Postoperative period was uneventful and patient recovered well.
Figure 1: Contrast-enhanced computed tomography scan shows well-defined pelvic cystic lesion abutting anterior and left lateral wall of the urinary bladder with solid components.

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Figure 2: Excised pelvic mass with gauze piece entangled in it.

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Figure 3: Gauze piece after separating it from pelvic mass.

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  Discussion Top


The possibility of gossypiboma should be in the differential diagnosis of all postoperative patients who present with symptoms of pain, infection, and palpable lump. Risk factors for accidently leaving foreign bodies in the abdomen during surgery include emergency operation, unplanned change in nature of operation, more than one surgical team involved, change in nursing staff during the procedure, higher body mass index, and excessive blood loss. The details of the surgical procedure done previously in our patient were not known.

The best diagnostic modality to diagnose gossypiboma would be a CT scan of the region. The CT findings of a sponge usually include rounded mass with a dense central part and an enhancing wall, often with whorl-like appearance with trapped air bubbles with varying densities. Magnetic resonance imaging features can be confusing because the radiopaque marker is not magnetic or paramagnetic hence not visible. Intraoperative radiograph may not always pick up leftover sponge, though gauze or towel is impregnated with radiopaque tags or markers.[7] The markers could be easily misinterpreted as calcifications, intestinal contrast material, wires, or surgical clips. The radiological appearance of the gossypiboma in the present case was varied and misleading. The usual treatment of a gossypiboma is removal of the foreign body with thorough toileting by open surgery, endoscopic, or laparoscopic approaches.[8] One possible complication during surgical exploration of gossypiboma is perforation of adjacent and adherent bowels. In some instances, attempts to remove the RFB may cause more harm than the item itself, especially when the foreign body is a needle or small part of a surgical item. Therefore, such harmless RFB may be left alone. However, retained sponges can be the source of recurrent symptoms and complications and hence should always be removed. In our patient, there were no intra- or post-operative complications following surgical exploration of gossypiboma.

New technologies are being developed that will hopefully decrease the incidence of RFB in surgical practice. An electronic article surveillance system which uses a tagged surgical sponge has been recommended which can be identified electronically.[9] Bar codes can be applied to all sponges and with the use of a bar code scanner the sponges can be counted on the back table. The use of radiofrequency identification systems also holds much hope for application in the area of detection of sponges.[1]


  Conclusions Top


A foreign body left behind after an operation is a medicolegal issue and often underreported.[1],[5] Despite its low incidence, the diagnosis of RFB should be considered in all patients presenting with unexplained symptoms, mass or fistulae and should be carefully evaluated. CT scan remains the primary modality of preoperative diagnosis. Gossypiboma should always be explored and removed due to potential complications associated with them. Prevention is the best management for this entirely avoidable complication.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kohli S, Singhal A, Tiwari B, Singhal S. Gossypiboma, varied presentations: A report of two cases. J Clin Imaging Sci 2013;3:11.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Lu YY, Cheung YC, Ko SF, Ng SH. Calcified reticulate rind sign: A characteristic feature of gossypiboma on computed tomography. World J Gastroenterol 2005;11:4927-9.  Back to cited text no. 2
    
3.
Aminian A. Gossypiboma: A case report. Cases J 2008;1:220.  Back to cited text no. 3
    
4.
Kiernan F, Joyce M, Byrnes CK, O'Grady H, Keane FB, Neary P. Gossypiboma: A case report and review of the literature. Ir J Med Sci 2008;177:389-91.  Back to cited text no. 4
    
5.
Manzella A, Filho PB, Albuquerque E, Farias F, Kaercher J. Imaging of gossypibomas: Pictorial review. AJR Am J Roentgenol 2009;193 6 Suppl: S94-101.  Back to cited text no. 5
    
6.
Gibbs VC, Coakley FD, Reines HD. Preventable errors in the operating room: Retained foreign bodies after surgery – Part I. Curr Probl Surg 2007;44:281-337.  Back to cited text no. 6
    
7.
Revesz G, Siddiqi TS, Buchheit WA, Bonitatibus M. Detection of retained surgical sponges. Radiology 1983;149:411-3.  Back to cited text no. 7
    
8.
Karahasanoglu T, Unal E, Memisoglu K, Sahinler I, Atkovar G. Laparoscopic removal of a retained surgical instrument. J Laparoendosc Adv Surg Tech A 2004;14:241-3.  Back to cited text no. 8
    
9.
Fabian CE. Electronic tagging of surgical sponges to prevent their accidental retention. Surgery 2005;137:298-301.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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