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Surgical foreign bodies are retained more commonly than is suspected. About 50% will become symptomatic in the form of erosion into the bowel or vessels, fistulae, abscesses, obstruction, bleeding, or chronic pain. Expeditious removal is recommended. Laparoscopic retrieval is feasible especially if discovered early.
The retained surgical sponge seems to be an ongoing problem. Despite the fact that reports of retained surgical sponges are comparatively rare, this problem seems to be more prevalent than is generally appreciated. Even though counting sponges is a tedious task, it should nonetheless be performed with the utmost attention. Although the presence of radiopaque wires in the sponges is helpful in locating these, it does not prevent surgical sponges from being forgotten. These retained sponges can result in serious conditions such as septic complications or pseudo-tumour formation, which in turn might lead to extensive diagnostic and secondary surgical procedures.
Retained surgical sponge is an infrequently reported condition that may be recognized incidentally during the early postoperative period, produce serious complications, or remain dormant for years. Clinical manifestations of the retained surgical sponge are a function of bacterial contamination and of the location of the sponge within the body cavity. Few sequelae follow external extrusion but internal erosion may lead to abscess, fistulas, and intestinal obstruction. Prevention requires constant sensitivity of the surgeon to this potential threat to the safe practice of surgery. The surgeon must account for an incorrect sponge count by adequate examination of the operative field and by roentgenographic studies when the issue remains in doubt. A correct sponge count does not fully preclude a retained sponge, however, and inspection of the operative field should be routine in all patients at risk.
Commonly used surgical sponges and appliances all have standardized, readily recognized opaque markers visible on radiographs. When these markers are identified on postoperative radiographs, they should be assumed to represent retained surgical sponges or appliances. With the rare exception of thoracotomy dressings, these marked materials are seldom, if ever, used as external bandaging materials. AP and lateral radiographs should provide an immediate answer as to the location of any retained surgical device. The early recognition of these retained surgical sponges should eliminate most complications related to their presence.
Postoperative retained surgical sponges or other foreign bodies are usually underreported. Radio-opaque materials are usually detected on follow-up radiological investigations, but radiolucent materials such as sponges create diagnostic problems and clinically mimic various abdominal pathologies. Introduction of spiral computed tomography, magnetic resonance imaging and dedicated ultrasonography has enabled clinicians to find these foreign bodies at the earliest opportunity to avoid disastrous complications. Spontaneous transmural migration and expulsion per rectum of more than one sponge without sequelae is also possible. We report one such interesting case.
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.
Retention of surgical sponges is rare. They cause either an aseptic reaction without significant symptoms or an exudative reaction which results in early but nonspecific symptoms. Computed tomography is very useful for recognition of retained sponges. The appearance of retained sponges is widely variable. Air trapping into a surgical sponge results in the spongiform pattern which is characteristic but unfortunately uncommon. A low-density, high-density, or complex mass is found in the majority of cases, but these patterns are not specific. Sometimes, a thin high-density capsule may be seen. Rim or internal calcification is a rare finding. Finally, a radiopaque marker is not a reliable sign. Differentiation from abscess and hematoma is sometimes difficult.
Retained surgical sponges are usually discovered in the abdominal cavity, sometimes years after the surgical procedure, and the typical reaction is formation of a foreign-body granuloma, often called gossypiboma or textiloma. In this instance, an extraskeletal osteosarcoma, associated with the granulomatous reaction to a retained surgical sponge adjacent to the stifle, was diagnosed in an 11-year-old Labrador Retriever 9 years after repair of a ruptured cranial cruciate ligament. Radiographic detection of linear foreign material in the soft tissue mass was the basis for a diagnosis of gossypiboma. The mass was surgically excised. Histologically, fibers consistent with those of cotton gauze were associated with the granulomatous inflammation and the osteosarcoma. Amputation or radiation therapy was declined; the dog was treated conservatively with doxycycline and deracoxib. Three months after surgical excision, the dog was euthanized because of local recurrence of the mass along with lameness and decreased appetite.
Surgically acquired foreign bodies are well known but not widely reported. Only seven articles pertaining to this subject were found in the current neurosurgical literature. Are they a denied neurosurgical reality? In this report with a concededly provoking title, the authors elucidate clinical and medicolegal aspects of retained surgical sponges, with emphasis on spinal procedures. To highlight particulars, a case is presented in which a retained surgical sponge was encountered as the cause of progressive low back pain and tender swelling in the scar area after instrumented posterolateral lumbar spinal fusion combined with pedicle screw fixation for lumbosacral spondylolisthesis 4 years earlier. However, until today, no reported neurosurgical patient has suffered a serious complication due to a retained surgical sponge. The authors wish to remind the neurosurgical community to learn from unpleasant clinical and medicolegal experiences in other specialties before serious complications occur, and we suggest rigorous standardization of intraoperative habits to avoid this hazardous complication.
Erosion of a retained surgical sponge into the intestine is an unusual occurrence and may make its appearance months or years later. The demonstration of a distended bowel by the barium-impregnated mass with multiple polypoidal filling defects in a patient who has undergone previous laparotomy should lead the physician to suspect a retained surgical sponge. Surgical intervention is rewarding.
Retained surgical sponge is an unpleasant surprise in clinical practice. Intraluminal migration of the retained sponge, though rare, can lead to intestinal obstruction and other complications. We describe two cases of retained surgical sponge, both following gynaecological surgery, presenting several years after surgery with features of subacute intestinal obstruction, malabsorption and several years after surgery with features of subacute intestinal obstruction, malabsorption and sever hypoproteinemia which reverted after surgical removal.
A thread of surgical sponge was found by colonoscopy at the sigmoid colon wall in the tip of a granuloma. The patient was a 50-year-old woman who complained of diarrhea and had a history of Cesarean section and complete hysterectomy. A radiopaque thread that used to be part of the surgical sponge was demonstrated with plain pelvic X-ray films. Abdominal CT study revealed the gossypibioma including a radiopaque thread in front of the sacrum. The patient was admitted for endoscopic extraction. Upon endoscopic observation, no thread was found and the fistula had also disappeared. The surgical sponge was considered to have been spontaneously expelled from the fistula during the intervening 22-day period.
A surgical sponge left in the peritoneal cavity at cesarean section eroded into the bowel and caused obstruction 3 years later. This unusual case is presented.
Because the appearances of a retained surgical sponge and the radiopaque portion of an in situ Snyder Hemovac flat silicone drain are similar at radiographic evaluation, confirmation should be obtained that a patient in whom a retained surgical sponge is suspected does not have this type of drain in place. The difference between the two items is especially difficult to discern in large patients or in patients with overlying dressings or a gas-distended abdomen.
A retained surgical sponge in the peritoneal cavity is an occasional misadventure in modern surgery. Such a sponge can migrate into the intestinal lumen, but its mechanism is still unknown. A piece of surgical sponge, measuring 4 x 4 centrimetres, was placed at different sites of the abdominal cavity of Wistar rats. Inspite of the absence of infection, entry of the sponge into the intestinal lumen was shown microscopically in 10 out of 36 rats. Parallel statistical analysis by Cutler-Ederer estimation was found to be 0.58 of condition probability at 6 months. Transmural migration of a retained surgical sponge was not only associated with different sites placing in the abdominal cavity (P = 0.680), but also whether a seromuscular incision was made or not (P = 0.306). A hypothesis, based on a study of microscopic and macroscopic pathology, is proposed as four stages: foreign body reaction, secondary infection, mass formation and remodeling.
We describe here a case in which a retained surgical sponge progressed into the perirenal space and posterior pararenal space from the pelvic cavity. Sonography, CT, and T1-weighted MR image analyses could not show clearly the characteristic structure of the surgical sponge, but T2-weighted MR imaging showed a folded fabric appearance within the cystic mass. Surgical findings confirmed a lobulated cystic mass containing yellowish fluid and a surgical sponge.
Seven cases of pathologically proven retained surgical sponge were reviewed and classified into four types, depending on CT and US findings. Type I: CT shows a mass with tiny gas bubbles, and sonogram shows an echogenic area with strong posterior shadow. Type II: CT shows an irregular high density mass with no gas bubble, and sonogram shows an echogenic area with strong posterior shadow. Type III: CT shows a low density mass with irregular internal high density areas, and sonogram shows a cystic mass with zigzag internal components. Type IV: CT shows an elliptic high density mass with low density area internally. Judging from the experiment and operative findings, these patterns were decided by the number and status of the gauze, volume of the exudate and hematoma, and status of the granulation. The author concludes that these characteristic CT and US findings, together with a history of surgery, permit the correct diagnosis of retained surgical sponge.
The radiographic and ultrasonographic signs in eight dogs with a surgical or pathologic diagnosis of retained surgical sponge were reviewed. The most frequent previous surgery was ovariohysterectomy, either as an elective procedure or to treat pyometra. The median elapsed time between surgery and diagnosis of retained surgical sponge was 9.5 months (range 4 days to 38 months). Five dogs had a draining sinus; four had a palpable abdominal mass. Radiologic signs included localized, speckled or whirl-like gas lucency, abdominal mass, and non-focal soft tissue swelling. Survey radiography and sinography were considered diagnostic for retained surgical sponge in 4/7 (57%) and 3/5 (60%) dogs, respectively. The combined use of survey radiography and sinography enabled detection of 6/7 (86%) sponges. In each dog that had ultrasonography, a hypoechoic mass was found that had an irregular hyperechoic centre. The possibility of retained surgical sponge should be considered in animals with a history of previous surgery and a sinus or abdominal mass.