Gossypiboma discovered 24 years after prostate surgery, a forgotten but never forgiven complication

Abstract

Forgetting gauze or “a surgical drape” inside a patient after surgery is a rare medical error. It can lead to severe complications, high hospital costs and medico-legal implications. As a result, this complication is often not reported, mainly to avoid retaliation and because it can initiate extensive critical press coverage. This technical oversight may be just the tip of an iceberg concerning the reality of surgical errors; therefore, the entire surgical team must focus on prevention, continuing medical education and strict adherence to protocols and counting guidelines to minimize their incidence. We present the case of a 76-year-old patient with an acute abdomen; after an initial evaluation, a gossypiboma was discovered, which was forgotten 24 years after prostatectomy.

Gossypiboma, the Never Event; a Case Report

“…There are two main reactions for retained foreign bodies in the abdomen; either an aseptic fibrinous response that creates adhesions, granuloma, and calcifications, such as in our case the inflammatory reaction was unique it had encased the gauze in well shape circler hard mass with stony resonance and excluded it from the surrounding organs, or an exudative response leading to the formation of abscesses, fistulas, or intestinal obstruction [2] [5] [7]. Furthermore, diagnosing Gossypioma preoperatively is a burdensome matter, at times, the images are equivocal and misleading; it can be an X-ray, ultrasound, or CT.…”

“…Among existing literature review, a Gossypioma is a rare finding [1] [4] [8], it can also be called a retained surgical item (RSI), cottonoid, cottonballoma, muslinoma, textiloma, and gauzeoma [5]. Meanwhile, the most common places to be found are the abdomen, thorax, and pelvis [2]; in this case, the retained gauze was within the abdominal cavity and the patient presented as a case of complete small bowel obstruction (2). While the reporting of such cases is lacking because of the fear of medico-legal pursuits or even reputation damage among hospital staff [3] [5] [8] [9].…”

“…In the surgical field, we utilize gauze and surgical instruments daily, and the complications can be divided into avoidable versus non-avoidable. The term Gossypioma in the literature indicates a retained surgical sponge or gauze which accidentally left behind in a prior surgery [1] [2]. Misplacing a sponge inside the patient is a tremendous mistake and can be easily preventable; as it's classified as a human factor error [2] [3].…”

“…The term Gossypioma in the literature indicates a retained surgical sponge or gauze which accidentally left behind in a prior surgery [1] [2]. Misplacing a sponge inside the patient is a tremendous mistake and can be easily preventable; as it's classified as a human factor error [2] [3]. The incidence is severely underreported in the literature due to several points such as legal consequences, and the reputation of the hospital or even the surgeons.…”

‘Chest gossypiboma after spinal surgery, not so easy to forget’

“…Surgery is the only treatment and should be performed as soon as possible to prevent pain, sepsis, fistulas and even death [ 1 , 11 ]. This event is one of the worst safety violations causing severe morbidity, mortality and medicolegal problems, and is simultaneously a preventable condition [ 12 ].…”