Definition & Nomenclature

• Gossypiboma (also called textiloma) refers to a retained surgical sponge, gauze, or cotton material inadvertently left inside the patient during surgery. 

• The term comes from gossypium (Latin for cotton) + boma (Swahili for place of concealment). 

Epidemiology & Risk Factors

• The true incidence is unknown (due to underreporting for medico-legal reasons) but estimated in abdominal surgeries as 1 per 1,000 to 15,000 operations. 

• It occurs more often after intra-abdominal and gynaecological/obstetric procedures. 

• Risk factors include:

  1. Emergency or urgent operations

  2. Hemorrhagic or difficult surgeries

  3. Change of personnel during surgery

  4. Large body habitus / obesity

  5. Long surgical duration

  6. Multiple surgical packs used

  7. Inadequate sponge/instrument count procedures 

Pathophysiology & Types of Reaction

When a sponge is retained, two broad types of corporeal reactions may happen:

1. Exudative / Inflammatory (Septic) Reaction

   • Leads to abscess formation, possibly with infection.

   • Presents earlier due to symptoms (fever, pain, discharge) 

2. Aseptic / Fibrotic Reaction (Granulomatous Encapsulation)

   • The sponge becomes encapsulated by fibrous tissue and adhesions, forming a mass-like lesion (pseudo-tumor).

   • This may remain silent for years before detection. 

• The interval between the initial surgery and diagnosis may range from a few days up to 20 years (or more). 

Clinical Presentation

Because of variable timing and reaction types, presentation is variable and non-specific:

• Symptoms: Pain, fever, abdominal distension, mass, nausea, vomiting, bowel obstruction symptoms. 

• Signs: Palpable abdominal mass, signs of abscess, peritonitis, fistula formation. PMC+1

• In pregnancy, a gossypiboma may mimic an adnexal mass or tumor on imaging. 

Case example: One case report described gossypiboma in a patient at 38 weeks’ gestation, mimicking an ovarian neoplasm; the retained sponge was removed at cesarean section. 

Diagnosis

Diagnosis is often delayed due to low suspicion, variable presentation, and medico-legal concerns. Key diagnostic approaches:

• Imaging modalities:

  • X-ray (if sponge has radiopaque marker)

  • Ultrasound (may show an echogenic mass with shadows)

  • CT scan (often shows spongiform mass, internal gas bubbles, “whirl” or mottled pattern)

  • MRI / other advanced imaging in select cases.

• Clinical suspicion: In any postoperative patient with unexplained pain, fever, mass or obstruction, retained surgical item should be in the differential. 

• Intraoperative exploration if imaging and suspicion strong.

Management

• Surgical removal is the definitive treatment—usually via laparotomy, sometimes laparoscopically, depending on location and complexity. 

• Drainage of abscess (if present), debridement, and irrigation. 

• Postoperative care: antibiotics, monitoring for complications.

• In pregnancy, removal is done at the time of cesarean or depending on stability and gestational age. 

Complications & Implications

• Morbidity: Adhesions, bowel obstruction, perforation, fistulae, abscess formation, sepsis, prolonged hospital stay, multiple reoperations. 

• Mortality: Rare but possible in severe cases with sepsis or multi-organ complications.

• Legal / Medico-legal: High risk of litigation, reputational damage, medical negligence claims. 

• Emotional / Ethical: Loss of trust, ethical breach, psychological impact on patient and team.

• Cost: Increased cost of care, re-operations, imaging, prolonged hospitalization.

Prevention (Key for MRCOG / Practical)

Since prevention is better than cure, these are high-yield:

1. Strict sponge/instrument counting protocols

   • Count at opening, before closure, and after wound closure.

   • Additional counts when personnel change or in emergencies. 

2. Use of radiopaque markers on surgical sponges / packs so they show up on imaging if count discrepancy. 

3. Minimize use of small sponges that can hide; use large, easily trackable packs. 

4. Team communication & surgical safety checklists (such as WHO Surgical Safety Checklist) with “sponge count” as a mandatory element. 

5. Surgeon’s manual exploration of cavity before final closure to ensure no retained items. 

6. Bar-coding / RFID / technological adjuncts (in advanced settings) to track surgical sponges. 

MRCOG-Relevant Points / Tips for Answering in Exams

• In a scenario of postoperative fever, pain, or obstruction, always include retained surgical item (gossypiboma) in differential, especially after abdominal or obstetric surgery.

• Know that diagnosis is often delayed, and imaging features (CT with spongiform pattern) are helpful.

• Emphasize prevention, surgical safety protocols, counting, radiopaque markers, checklists.

• If asked about legal / ethical implications, mention patient harm, litigation, loss of trust.

• In pregnancy cases, mention that gossypiboma can mimic tumors or masses on imaging, complicating diagnosis.

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