Gossypibomas Mimicking a Splenic Hydatid Cyst
and Ileal Tumor
A Case Report and Literature Review
Sami Akbulut & Zulfu Arikanoglu & Yusuf Yagmur &
Received: 7 April 2011 /Accepted: 10 June 2011 /Published online: 14 July 2011
# 2011 The Society for Surgery of the Alimentary Tract
Background Gossypiboma is a term used to describe a retained surgical swab in the body after a surgical procedure.
Gossypiboma is a rare surgical complication, but can cause significant morbidity and mortality. It may be a diagnostic
dilemma with associated medico-legal implications, and is usually discovered during the first few days after surgery;
however, it may remain undetected for many years.
Methods We present a gossypiboma case immigrating to small intestine, as well as a literature review of studies published in
the English language on intraluminal migration of gossypiboma, accessed through PubMed and Google Scholar databases.
Results Case of a 51-year-old man who was admitted due to vomiting, abdominal distension, and pain. He had a history of
abdominal trauma 8 years previously, and surgery had been performed at another hospital. The physical examination
revealed muscular guarding and rebound tenderness in the right lower quadrant. A splenic hydatid cyst and ileal calcified
mass were suspected based on results of abdominal computed tomography. Therefore, a laparotomy was performed.
Segmental ileal resection, end-to-end anastomosis, and splenectomy were performed. The final diagnosis was gossypiboma
in both the spleen and ileum. We performed a systemic review of the English-language literature between 2000 and 2010 in
PubMed and Google Scholar, and we found 45 cases of transmural migration of surgical sponges following abdominal
surgery. Three cases in which the gossypiboma was located in the spleen are also discussed.
Conclusion Gossypiboma should be considered as a differential diagnosis of any postoperative patient who presents with
pain, infection, or a palpable mass.
Keywords Gossypiboma.Foreign body.Retained surgical
RSSRetained surgical sponge
A retained foreign body in the peritoneal cavity after
surgical intervention is an occasional complication in
modern surgery. The most common retained foreign body
is the surgical sponge.1Retained surgical sponge (RSS),
also known gossypiboma, is used to describe a retained
surgical swab in the body after a surgical procedure. It may
lead to medico-legal problems and diagnostic dilemmas due
to the necessity for invasive diagnostic procedures and
operations.2,3Clinical symptoms both in the early postop-
erative period as well as in the months or years following
the initial surgery are often nonspecific.4Although RSS is
difficult to diagnose, a history of surgery, physical exam-
ination findings, laboratory results, and the utilization of a
variety of radiologic instruments can help to arrive at the
correct preoperative diagnosis.3,5Transluminal migration of
S. Akbulut (*):Z. Arikanoglu:Y. Yagmur:M. Basbug
Department of Surgery,
Diyarbakir Education and Research Hospital,
J Gastrointest Surg (2011) 15:2101–2107
the RSS is rare and is due to the inflammatory process,
which causes pressure necrosis of the bowel wall and
extrusion of the sponge into the gastrointestinal luminal
organs.6We report a case of retained surgical sponges
mimicking an ileal calcified mass and a splenic hydatid
cyst; we also review the English-language literature
between 2000 and 2010.
Materials and Methods
In this study, we present a gossypiboma case imitating a
splenic hydatid cyst and a calcified mass within the lumen
of the small intestine. Additionally, for the review, the
English-language literature between 2000 and November
2010 was searched in PubMed and Google Scholar using
the terms “gossypiboma,” “textiloma,” “retained surgical
sponge,” “intraluminal migration of surgical sponge,”
“retained surgical swab,” “retained surgical mop,” and
“transmural migration of surgical sponge.” The full texts
of all papers obtained were analyzed with respect to the
aforementioned criteria. Gossypiboma cases immigrating to
luminal organs within the gastrointestinal system, and
located within the spleen, were included in the study,
whereas cases located within the abdominopelvic cavity
and retroperitoneum were excluded. Only appropriate cases
based on our criteria were elected and included among
papers, and reported in a case-series manner. Data regarding
at least seven of all properties including age, sex, initial
diagnosis, initial surgery, interval, clinical presentation,
diagnostic methods, location, and surgical procedure must
have been given for the patients to be included in the study.
A 51-year-old man was admitted to the Surgery Department
of Diyarbakir Education and Research Hospital in Septem-
ber 2010, with the complaints of colicky abdominal pain,
intermittent abdominal distention, constipation, nausea, and
vomiting. He had undergone laparotomy twice at another
center due to trauma 8 years previously. The physical
examination revealed muscular guarding and rebound
tenderness in the suprapubic region and the right lower
quadrant. The results of a rectal examination were
unremarkable. Laboratory investigations showed the follow-
ing: blood urea nitrogen, 34 mg/dl; creatinine, 1.1 mg/dl; C-
reactive protein, 23 mg/l. The blood cell count revealed
leukocytosis at 12,500/dl, hemoglobin of 12.7 g/dl, and a
platelet count of 335,000/dl. Other serum parameters were
withinnormallimits.Plainabdominal radiographs revealeda
small intestine withfluidlevels.Computedtomography (CT)
showed a heterogeneous calcified mass within the small
intestinal lumen, suggesting the presence of tumor or foreign
body. Additionally, CTshowed a calcified mass of 10×6 cm
located in the spleen, suggesting the presence of a splenic
hydatid cyst (Fig. 1). The clinical symptoms were thought
to be consistent with a foreign body or mechanical
intestinal obstruction caused by an ileal calcified mass;
therefore, an operative decision was made. Exploratory
laparotomy was performed, revealing gross adhesions over
a loop of small bowel and a segment 50 cm proximal to the
ileocecal region containing an intraluminal hard mass
approximately 25 cm in length, without external commu-
nication to the other surrounding viscera. Segmental ileal
resection and anastomosis were performed. Upon opening
the specimen, a 30×30-cm surgical sponge was found. In
addition, a splenectomy was performed because a portion
of the sponge was located in the spleen (Fig. 2a–c). The
abdominal cavity was drained and closed. The postopera-
tive period was uneventful and the patient was discharged
on the eighth postoperative day. He has been free of
symptoms during the last 2 months.
The English medical literature published up to November
2010, in the PubMed and Google Scholar databases were
reviewed, and 42 reports concerning 48 cases meeting the
aforementioned criteria were included in this review.1–42
Thirty-six of these were written as case reports, three as
letters to the editor, two as original articles, and one as a
literature review. Thirty-eight patients were female and ten
were male, with ages ranging from 3 to 75 years (median,
41.8±16.2 years). The time from the causative operation to
presentation with a retained surgical sponge ranged from
Fig. 1 Contrast-enhanced computed tomography showing two foreign
bodies located both ileum and spleen
2102J Gastrointest Surg (2011) 15:2101–2107
10 days to 43 years. Various radiological and endoscopic
modalities were used as diagnostic tools. The most frequent
site of impaction in 45 of 48 cases was the gastrointestinal
luminal organs, especially the ileum (14 cases). Eight
sponges migrated into the colon, six into the jejunum, five
into the stomach, five into the duodenum, two into the
ileocolic region, and two into the ileojejunal region, one
into the both jejenum and colon; three were unnoted. We
found three cases in which a surgical sponge had adhered to
the spleen. In eight patients, the surgical sponge passed
spontaneously through the rectum, while in 34 of 48
patients, the retained sponge was removed by different
surgical procedures. In six of 48 patients, surgical sponges
were extracted endoscopically. The demographic features of
these patients are summarized in Table 1.
RSS is not uncommon in surgical practice; it has been
under-reported and rarely discussed because of medico-
legal problems for surgeons.7,8The incidence of an RSS is
difficult to estimate, but it has been reported to be 1 in 100
to 3,000 for all surgical procedures and 1 in 1,000 to 1,500
for abdominal surgery.2,3,8–13RSS is frequently located in
the abdominopelvic cavities, but it can also follow thoracic,
orthopedic, urological, and neurosurgical procedures.5,12,14–
Despite improvements in surgical techniques and oper-
ating room facilities, and awareness of the importance of
check counts at the end of operations, retained foreign
bodies remain a problem in many surgical clinics. Many
risk factors, such as duration and complexity of surgery,
excessive blood loss in trauma patients, surgery under
emergency conditions, unplanned procedural changes, a
change in operating room teams during the course of the
operation, and a failure to count surgical instruments and
sponges, were identified. The three most important risk
factors are emergency surgery, unplanned change in the
operation, and body mass index.2,15,17,18
Two types of foreign body reactions occur in patients
with retained sponges. The most common reaction consists
of an aseptic fibrous response resulting in adhesion,
encapsulation, and granuloma formation. Patients usually
remain asymptomatic and the retained sponges are detected
incidentally, or they present with a pseudotumor syndrome.
The other foreign body reaction in retained sponge cases
involves an exudative inflammatory reaction with abscess
formation or chronic internal or external fistula formation.
The latter is believed to be associated with transmural
migration of retained sponges.9,19–22
The clinical presentation of gossypiboma is variable and
depends on the location of the sponge. Common symptoms
and signs of gossypiboma are abdominal distention, ileus,
tenesmus, pain, a palpable mass, vomiting, weight loss,
diarrhea, abscess formation, fistula formation, and rectal
bleeding.3–5,15,23Clinical symptoms may appear in the
postoperative period or even after weeks, months, or years.
The interval between the probable causative operation and
Fig. 2 Peroperative photographs of gossypibomas. a View of a mass,
about 25 cm in length, extending into ileum. b Removal of retained
surgical sponge into the spleen. c Gross specimen of gossypiboma in
an opened ileal lumen
J Gastrointest Surg (2011) 15:2101–2107 2103
Table 1 Transmural migration of retained surgical sponge to the gastrointestinal luminal organs and splenic sponge: review of the literature (2000–2010)
Age Sex Initial diagnosis
De Compos 2010 58
AP, Weight loss
Segmental jejunal and colonic
2104 J Gastrointest Surg (2011) 15:2101–2107
Table 1 (continued)
Age Sex Initial diagnosis
Enterocutanous fistula US
Pull-through operation 10 days
Sacral discharge from
Enterocutanous fistula Fistulography
Descending Colon Right hemicolectomy
Renal cell carcinoma Nephrectomy+
AP abdominal pain, V vomiting, C constipation, TAH transabdominal hysterectomy, Obst intestinal obstruction findings, UN unnoted, CT computed tomography, US ltrasonography
1 Jejunocolic fistulae, 2 ileocecocutaneus fistulae, 3 ileojejunal fistulae, 4 ileoileal fistulae, 5 ileosigmoidal fistulae, 6 spontaneous discharge, 7 jejunojejunal fistulae, 8 duodenoileocolic fistulae
J Gastrointest Surg (2011) 15:2101–21072105
the diagnosis of RSS is reportedly from 1 day to
28 years.5,10,20,33Cruz et al.18found this interval to be
6 months to 33 years, while it was found to be 10 weeks to
35 years by Zantvoord et al.20This interval was found to be
10 days to 43 years in our study.
The main complications of abdominal gossypiboma are
bowel or visceral perforation, obstruction, peritonitis,
adhesion, abscess development, fistula formation, sepsis,
and migration of the sponge into the lumens of gastroin-
testinal or urinary systems.15,23
According to the literature, migration of a sponge into
the bowel is rare compared with the formation of an
abscess, chronic fistula, or foreign body granuloma.4,19
Abdominal gossypibomas can migrate into the stomach,
duodenum, jejunum, ileum, colon, or bladder without any
apparent opening in the wall of these luminal organs. The
ileum is the most common part of the intestine into which
migration takes place, followed by the jejunum and
duodenum.24Cruz et al.18retrospectively analyzed a total
of 21 gossypiboma cases reported in the English literature
between 1940 and 2001 and showed that of the cases
analyzed, 11 migrated to the ileum while seven migrated to
the jejunum, one to the duodenum, one to the rectum, and
one to the stomach wall. Zantvoord et al.20found the
migration rates following an analysis of a total of 65
gossypiboma cases reported in different languages between
1960 and 2007 to be as follows: 22 to the ileum, seven to
the jejunum, six to the duodenum, five to the colon, and
two to the stomach. The results of our literature study also
support the results of these two studies.
The diagnosis of RSS is difficult to reach because the
clinical symptoms are nonspecific and the imaging findings
are often inconclusive. However, plain radiography, barium
studies, endoscopy, ultrasonography (US), CT, and magnetic
resonance imaging (MRI) are useful for diagnosis.4,11
Plain radiographs suggest the diagnosis if the surgical
sponge is calcified or when a characteristic “whirl-like”
pattern is present. In the presence of radiopaque markers,
surgical sponges can be easily diagnosed by direct
radiography. However, if surgical sponges penetrate and
migrate to the inside of the small bowel or bladder, it is
difficult to locate them.1,5
Barium studies are helpful in cases of intraluminal
migration of the textile in which the exact location can be
ascertained. Perforation of the bowel wall and fistulous
communication with the cavity containing the foreign body
or adjacent bowel loop is best demonstrated by this
modality.6,7,14,16,25–28US images can be classified into
two groups: cystic and solid. The mainstay of investigation
is considered to be US images that show a hyper-reflective
mass with a hypoechoic rim, along with a strong posterior
shadow. However, ultrasonic sensitivity may be low in the
early postoperative period because of intestinal gas disten-
sion.5,16CT scans may show air trapped between surgical
sponge fibers, calcification of cavity walls and contrast-
enhanced rims, which may not be distinguishable from
other intra-abdominal abscesses.2,3,5–7,15,23MRI usually
shows a well-defined mass with a fibrous capsule that
exhibits low signal intensity on T1-weighted images and
high signal intensity on T2-weight images.23
Endoscopy (panendoscopy and colonoscopy) is a meth-
od used in both the diagnosis and treatment of intraluminal
A correct preoperative diagnosis is made in about one-
third of cases. Depending on the form of presentation,
differential diagnoses are proposed. The differential diag-
noses of gossypiboma include fecaloma, hematoma, ab-
scess, and tumor.5,28
RSSs should be removed as soon as diagnosed. Various
techniques are used for the removal of RSSs, depending on the
clinical presentation and facilities available: percutaneous
techniques, laparoscopy, and laparotomy.7,15,26,29–31However,
a few cases have been reported in the literature in which the
RSS spontaneously discharged during defecation.8,16,17,32,33
Prognosis is excellent if the RSS is removed immediately
after diagnosis.17However, a mortality rate of 10% to 17.6%
has been reported in the older medical literature and is
associated with delayed diagnosis and treatment.18,20
In conclusion, RSS should be considered as a
differential diagnosis of any postoperative patient who
presents with pain, infection, or a palpable mass. Also,
we strongly advise using only sponges with radiopaque
markers during operations and additional systematic
wound/body cavity examinations, even when the sponge
count is reportedly correct.
procedures; AS and SH contributed in writing the article and review of
the literature as well as undertaking a comprehensive literature search;
SA and AZ contributed in the design and manuscript preparation.
AS, AZ and YY performed the surgical
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