Acute Bowel Obstruction Due to Transmural Migration of Gossypiboma: A Case Report

Introduction

Gossypiboma, also known as a retained surgical sponge, is a rare but potentially serious complication that arises from surgical procedures. The term “gossypiboma” is derived from the Latin words “gossypium”, meaning cotton, and the Swahili word “boma”, meaning place of concealment.¹ It is also referred to by other synonyms such as Gauzoma, Textiloma, Cottonoma, and Muslinoma. Gossypiboma can have significant implications for patient health, leading to increased morbidity and mortality rates. While some cases may remain asymptomatic for an extended period, ranging from years to even several months following the operation, others can present with symptoms as early as 3–12 weeks or as late as 5–7 years post-surgery.²

When a surgical sponge is unintentionally left inside the patient’s body, it acts as a foreign object and can give rise to various complications. Intra-abdominal gossypiboma can cause the formation of abdominal or pelvic abscesses, fistulas, or even migrate through the bowel wall.³ These complications can have a significant impact on the patient’s well-being. In this case study, we report a specific case of a retained surgical sponge that resulted in acute bowel obstruction due to its complete transmural migration into the small bowel. By presenting this case, we aim to highlight the potential risks associated with gossypiboma and emphasize the importance of its timely detection and management.

Case Report

We present the case of a 26-year-old female patient who was admitted to the hospital with a history of abdominal pain persisting for 20 days. The patient reported experiencing colicky abdominal pain, as well as symptoms of nausea, vomiting, and constipation over the past three days. The patient’s medical history revealed a previous cesarean section performed seven months ago. Upon physical examination, there were no significant findings of abdominal distention. However, mild tenderness was observed in the paraumbilical region, and increased bowel sounds were noted. No abnormal findings were detected during the digital rectal examination. Blood tests indicated mild leukocytosis, while a urine examination revealed the presence of white blood cells and epithelial cells. An abdominal and pelvic ultrasound was performed, which revealed fatty liver and cystitis. Additionally, an abdominal X-ray was conducted and revealed the presence of radiopaque material in the abdomen (Figure 1).

Figure 1 Abdominal X-ray(red arrow) showing the presence of radiopaque material(abdominal compress) in the abdomen.

Based on the clinical findings, the patient underwent an exploratory laparotomy. During the operation, a distended loop of the small bowel was identified. By carefully manipulating the small bowel, a firm loop of ileum located 70cm away from the ileocecal valve was discovered. The distal intestine appeared normal in size, with only a small pointed serosal scratch observed on the wall of the affected loop. An incision was made over the loop, revealing a surgical sponge lodged within it (Figure 2). The sponge was carefully removed, and the bowel was repaired.

Figure 2 Intraoperative photograph(Blue arrow) showing the surgical sponge lodged within the loop of the ileum.

Following the surgery, the patient’s post-operative course was uneventful. She was discharged from the hospital after six days and remained in good health during the eight-month follow-up period. This case highlights the importance of considering gossypiboma, or retained surgical sponges, as a potential cause of abdominal symptoms in patients with a history of previous surgery. Timely detection and intervention, such as exploratory laparotomy, are crucial in preventing complications and ensuring favorable patient outcomes.

Discussion

The retention of surgical sponges in the peritoneal cavity is an infrequent but avoidable medical error. The reported incidence of gossypiboma, or retained surgical sponges, varies between 1 in 100 and 1 in 3000 for all surgical interventions and between 1 in 1000 and 1 in 1500 for intra-abdominal operations.¹ Several factors contribute to the retention of sponges, including emergency surgery, unexpected changes in the surgical procedure, disorganization, hurried sponge counts, long operations, unstable patient condition, inexperienced staff, inadequate staff numbers, and obesity.¹ Gossypiboma can elicit two types of body responses: exudative or septic fibrosis. Complications of gossypiboma include adhesion formation, fistula formation, abscess formation, and transmural migration. The retained foreign body causes pressure necrosis of the bowel wall and can partially or completely migrate into the bowel lumen. Subsequently, the perforation created can close spontaneously after migration is complete.² Patients with gossypiboma often present with symptoms such as abdominal pain, anorexia, nausea, vomiting, and weight loss, which can result from obstruction or a malabsorptive-type syndrome caused by intra-abdominal bacterial overgrowth or multiple intestinal fistulas.⁴ Plain abdominal radiography can aid in diagnosis when a radiopaque marker of the retained surgical sponge is visible. However, this imaging method may not be effective when markers are disintegrated or fragmented over time. Ultrasonography can detect retained surgical sponges, which appear echogenic and create delineated acoustic shadows. Additionally, computed tomography (CT) scans may reveal spongiform gas bubbles and a low-density mass with prominent and prolonged rim enhancement, suggestive of a retained surgical sponge.⁵ In our patient’s case, the presence of a radiopaque marker on the surgical sponge allowed for diagnosis through plain radiography. Surgical exploration remains the preferred treatment for gossypiboma. However, in certain cases, surgical intervention may not be necessary as spontaneous migration can occur, leading to the expulsion of the foreign material through the anus during defecation. Percutaneous approaches are applicable for the removal of readily accessible foreign bodies but are not suitable for intra-abdominal foreign bodies. Laparoscopic methods have also been employed to remove gossypiboma.⁶ To prevent the retention of foreign bodies inside patients, three essential measures should be implemented. First, meticulous counting of all surgical materials should be performed. Second, thorough exploration of the surgical site at the conclusion of procedures is crucial. Lastly, the routine use of surgical textile materials that have a radiopaque marker can enhance visibility and aid in the detection of retained surgical sponges.⁷

Conclusion

Gossypiboma is an avoidable complication resulting from the retention of surgical sponges inside the peritoneal cavity. Vigilant sponge counting, thorough exploration of the surgical site, and the use of radiopaque markers on surgical textile materials are key measures to prevent such occurrences. By implementing these preventive measures and raising awareness among healthcare professionals, we can enhance patient safety and minimize the risks associated with gossypiboma.