An uncommon complication of any surgery is iatrogenic retained foreign body. This condition is gossypibomas. In this case report, we present cases of middle-aged females who had undergone total abdominal hysterectomy and came to us with feature of intestinal obstruction. She was diagnosed radiologically, and later a review surgery was performed. A prompt diagnosis and treatment is necessary to reduce morbidity and mortality of this condition. It is to emphasize that any post-operative patient who present to us with complaints of pain or obstruction, the differential diagnosis must include retained foreign body (gossypibomas).
Keywords: Computed tomography, entrapped air bubbles, gossypibomas, medical errors, surgical sponges, retained foreign body
The terminology of gossypibomas has been derived from 2 Latin words “gossipium0″ which means cotton and ” Swahili boma” for place of concealment. It describes a mass within a patient’s body comprising a cotton matrix surrounded by a reactive granuloma. Gossypibomas can often present, clinically or radiologically, similar to tumors and abscesses, with widely-variable complications and manifestations, making diagnosis difficult and causing significant patient morbidity and further mortality. It is important in 2 ways; firstly, it presents as a complication of surgical procedure and secondly, once diagnosed, it can lead to medico-legal complication.  Aim of our case report is to clear the dilemma of diagnosing this condition to some extent and to emphasize on the fact that mere exact counting of sponges before operation field closure is important for its prevention.
A 45-year-old woman presented to us with intermittent pain, gradually progressive abdominal distension, and off and on fever for last 1 month after a hysterectomy operation for multiple fibroids. On clinical examination, she was febrile. Local physical examination of abdomen revealed an ill-defined, mildly tender pelvic swelling on left side. Laboratory investigations showed mild leucocytosis with neutrophil predominance. Initially, an ultrasound was done, which revealed a large, mixed echogenic mass in the pelvis on left side. For proper evaluation, computed tomography of the lesion was done. Computed tomographic (CT) scan demonstrated a large well-defined soft tissue mass showing internal particulate matter with entrapped air bubbles (thick white arrow) in pelvis related superior to urinary bladder fundus and inferiorly extending up to vaginal vault. Lesion has well-defined enhancing wall with perifocal fat stranding (thin white arrow). Mass effect noted over small bowel loops, which were seen at its periphery [Figure 1]. A provisional diagnosis of a retained surgical sponge with surrounding inflammation was considered. At laparotomy, a surgical sponge was found with surrounding inflamed mesentery. Post-operatively, patient made an unremarkable recovery and was subsequently discharged on the seventh day.
A 30-year-old woman presented with off and on pain in left side of abdomen 15 days after cesarean section. On clinical examination, a vague lump was seen in left lumbar region. Laboratory investigation revealed mild leucocytosis. On USG, a moderate size highly echogenic mass seen in left lumbar region. Plain [Figure 2]a and contrast enhanced [Figure 2]b CT scan showed a lobulated well-defined thin rim enhancing low-density mass with entrapped air bubbles. Inflammatory changes were seen in surrounding mesentery. Findings were suggestive of retained gauze piece. There was no evidence of surrounding fluid collection. On interaction with the obstetrician, it was found out that the operating surgeon had placed gauze piece to control intra-operative hemorrhage. At laparotomy, a gauze piece was found with surrounding inflamed mesentery. Post-operative period was unremarkable.
Gossypibomas as an uncommon complication can occur following any surgery, which requires opening of abdomen and usage of swabs. It can be following cardiac, abdominal, thorax, orthopedic, or even after neurosurgery. As this condition has medical legal aspects attached to it, the exact incidence is difficult to quote. GI tract surgery and gynecologic surgery account for about 75% of reported gossypibomas.
Higher risk is seen in emergency setting, involvement of more than one surgical team, shifting of staff during procedure or while performing more than one surgical procedure at a time.  A similar case was reported by Prasad et al. 
Every action has a reaction and thus the body reacts to retained foreign body by 2 ways, either by forming an inflammatory mass encapsulating the retained foreign body, or by an aseptic fibrinous response. In latter case, the patient remains asymptomatic for years indifferent to former where patient present with acute septic course. These reactions are responsible for unwarranted morbidity and mortality. The patient gives history of operation may be asymptomatic or present with vague complaints of pain, fever discomfort, anorexia, nausea, vomiting. Gossypibomas that erode the abdominal viscera and enter inside the lumen may also present with features of obstruction, perforation, sinus formation depending upon site of concealment.  Such cases have a high fatality rate.
The physical examination may reveal tenderness at a particular site, a palpable mass or may be non-specific. The general counts may be normal or may shows leucocytosis. Plain radiography may be normal or may reveal a radio opaque material with whirl-like pattern. Whirl is composed of threads of the retained foreign body. Ultrasound reveals a hypo-echoic mass, which is encapsulated, shows dense posterior shadows. Air compressed between gives hyperechoic signals. There is no flow in contrast to a mass, which is usually vascular.
Computed tomography is the best modality for diagnosis. Sponge is seen as a rounded mass with dense central part and trapped air bubbles. Marked rim enhancement is characteristic for gossypibomas. Capsule thickness may be variable. Different materials have different pictures.  On magnetic resonance examination, the condition has variable signal intensity. Radiological appearance may vary, depending on type of material and anatomic location. Diffusion-weighted images may help to distinguish abscess from gossypibomas as abscess is diagnosed with reduction in diffusion, but diffusion increase in gossypibomas.
An early recognition of this entity with appropriate treatment will reduce the further morbidity and mortality. , In our case, evidence of gas in the lesion prompted us for a provisional diagnosis of gossypibomas. It was later confirmed by operation and was removed.
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]