CASE REPORT – OPEN ACCESS

International Journal of Surgery Case Reports 77 (2020) 206–209

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International Journal of Surgery Case Reports

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Textiloma presenting as a lump in abdomen: A case report

Rajiv Sonarkar, Raju Wilkinson, Zansher Nazar ∗ , Giriraj Gajendra, Shreyas Sonawane
N. K. P. Salve Institute of Medical Sciences, Nagpur, Maharashtra, India

a r t i c l e i n f o a b s t r a c t

Article history: INTRODUCTION: Textiloma or Gossypiboma is a mass comprising of cotton matrix within the body left
Received 6 October 2020 accidentally during a surgical procedure. It is estimated that retained surgical foreign bodies occur one in
Received in revised form 18 October 2020 every 5,500–18,760 inpatient operations but the incidence may be as high as one out of every 1,000–1,500
Accepted 18 October 2020
abdominal cavity operations, and even more common during emergency surgeries. There have also been
Available online 23 October 2020
rare case reports of Transmural migration of retained surgical swab which is a rare phenomenon. But
even rarer is the incidence of retention of swab inside the small intestine in the previous procedure.
Keywords:
PRESENTATION OF CASE: A 29-year-old female coming with chief complaints of pain in abdomen since 1
Case report
Gossypiboma
year which was colicky in nature, present all over abdomen, non-radiating. The pain aggravated on eating
History taking food. Patient also noticed a lump in her abdomen since past 1 year. Abdomen was opened and the bowel
Laparotomy was inspected. Enterotomy was performed and two swabs were removed from the intestine.
Swabs DISCUSSION: Prevention of this condition can be achieved by meticulous count of surgical materials in
Medicolegal addition to thorough exploration of surgical site at the conclusion of operations and also by routine use
of surgical textile materials impregnated with a radio opaque marker.
CONCLUSION: Although rare, a diagnosis of retention of swab or surgical instruments must be considered
in cases of vague lumps in abdomen or in cases of intestinal obstruction, especially if the patient has had
previous history of laparotomy.
© 2020 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction defined shape, surgical sponges is the commonest to be left inside

[5].
Gossypiboma is a mass comprising of cotton matrix within the The presentations that may occur following retention of surgical
body left accidentally during a surgical procedure. The body may sponges are pain, abdominal mass, obstruction, peritonitis, adhe-
react to this foreign body through an exudative inflammatory reac- sion, fistulas, abscess formation, erosion into gastrointestinal tract
tion or an aseptic fibrotic reaction in order to encapsulate the cotton or extrusion of laparotomy pad via the rectum (Figs. 2 and 3).
material and result into a mass [1]. This iatrogenic, unintentional In most of such cases, the swab gets retained in the pelvic and
but avoidable misfortune, often under-reported, has damaging the abdominal flanks due to its space. There have also been rare case
effects upon the health of patients, and entails embarrassment reports of Transmural migration of retained surgical swab which is
as well as medico-legal consequences [2,3]. It is estimated that a rare phenomenon. But even rarer is the incidence of retention of
retained surgical foreign bodies occur one in every 5,500–18,760 swab inside the small intestine in the previous procedure (Fig. 4).
inpatient operations but the incidence may be as high as one out We report a case of gossypiboma inside the intestinal cavity
of every 1,000–1,500 abdominal cavity operations, and even more presenting as a case of lump in abdomen in a tertiary care hospital.
common during emergency surgeries.
The most common retained foreign body during surgery is a
woven cotton surgical sponge, which includes both laparotomy 2. Case report
pads and smaller sponges (Fig. 1).
A variety of objects have been reported to be left in the abdom- Patient was a 29-year-old female coming with chief complaints
inal cavity like surgical sponges, haemostatic forceps and pieces of of pain in abdomen since 1 year which was colicky in nature,
drainage tubes [3,5]. Due to its small size, common usage and ill- present all over abdomen, non-radiating. The pain aggravated on
eating food. Patient also noticed a lump in her abdomen since past
1 year. History of 1–2 episodes of non-bilious vomiting on and off.
∗ Corresponding author at: Room F2-12, Vindhyachal Hostel, NKP Salve Institute History of loss of appetite and weight loss since 1 year. Patient gave
of Medical Sciences, Hingna Road, Nagpur, Maharashtra, India. a past history of similar complaints 12 years back for which she
E-mail address: zanshernazar@gmail.com (Z. Nazar). was admitted and diagnosed with abdominal tuberculosis. She was

https://doi.org/10.1016/j.ijscr.2020.10.081
2210-2612/© 2020 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).
 CASE REPORT – OPEN ACCESS
R. Sonarkar et al. International Journal of Surgery Case Reports 77 (2020) 206–209

Fig. 1. Lump over Umbilical and Hypogastric region of abdomen.

Fig. 4. Mounted specimen of the swab.

operated for the same but no documentation was available. Patient

was also given 18 months of AKT therapy.
On Examination, she was afebrile. Her pulse was 86/mins and
her Blood Pressure was 120/80 mmHg. Per Abdomen examination
revealed a lump of size 8 × 5 cm at umbilical and hypogastric region.
Skin over the lump was normal. Lump was mobile did not move
with respiration. Tenderness was present over lump site. Guarding
was present. There was no local rise of temperature at the lump
site. Dull note was present on percussion. Auscultation revealed
bowel sounds at the lump site. A midline vertical scar was present
indicative of previous surgery.
X ray abdomen was inconclusive. Ultrasound abdomen revealed
linear echogenicity with post acoustic shadowing in the abdomen
with features likely suggestive of calcified mass.
CECT Abdomen revealed an ill-defined mass with calcification
and air foci in jejunum loop suggestive of bezoar with likely intus-
susception and focal inflammatory changes.
Following the CT report, a psychiatric evaluation was done for
this patient to rule out trichotillomania, pica or any eating dis-
orders. Patient’s psychiatric evaluation did not reveal any such
abnormalities.
Patient was prepared for surgery and was performed by an Asso-
ciate Professor with 20 years of experience in the field of general
surgery and was assisted by two junior residents with 3 years of
specialized training.
Abdomen was opened and the bowel was inspected. Evidence of
previous bowel anastomosis was seen. Hard lump was felt within
the bowel loop. Enterotomy was performed. There was presence
of hard material inside the bowel. Bowel was milked and hard
material was pulled out of the bowel. Upon cleaning and further
inspection, the hard material was recognized as swabs retained
from previous surgery. Two swabs were removed from the intes-
tine. The intestine was properly washed and closed. Warm saline
Figs. 2 and 3. Removal of Swab from the small bowel. wash was given and the abdomen was closed.

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R. Sonarkar et al. International Journal of Surgery Case Reports 77 (2020) 206–209

Patient recovered well postoperatively and was put on full oral 4. Conclusion
diet on day 5. Patient’s weight was recorded on discharge and after
1 month of follow up. An increase of 5 kg weight was recorded. Although rare, a diagnosis of retention of swab or surgical instru-
Patient also noted relief of previous symptoms and also had an ments must be considered in cases of vague lumps in abdomen or
increased appetite. in cases of intestinal obstruction, especially if the patient has had
previous history of laparotomy.
The embarrassment faced by the surgeon and the medico legal
3. Discussion implications of this iatrogenic complication are tremendous and all
preventive measures should be taken to avoid this as no excuse is
The first case of retained surgical sponge was described by Wil- justifiable.
son in 1884. The incidence is estimated to be 1 in 5500 surgeries
[4]. The abdomen is the most common site (56%), followed by the
Declaration of Competing Interest
pelvis (18%) and the thorax (11%) [2].
The operation during which the surgical swab or gauze is left
There were no conflicts of interest in the making of this article.
behind is usually abdominal and often pelvic, where the deepness
of the region facilitates the disappearance of blood socked pieces
of gauze under the bowel or retractors. But in our case the swab Funding
was neither left in the abdomen nor in the pelvis, but was retained
inside the small intestine just near the site of previous surgery. There were no expenditures in the making of this article and
The presentation may be acute or relatively delayed and patho- thus no need for funding for this research.
logically two types of foreign body reactions can be induced. One
is an aseptic fibrinous response that creates adhesions and encap- Ethical approval
sulation, resulting in a foreign body granuloma. This occurrence
usually follows a rather silent clinical course. The other response is The study is exempt from ethical approval.
an exudative type that leads to abscess formation with or without
secondary bacterial infection [8]. The development of an abscess
Consent
represents the body’s attempt to extrude the foreign material either
externally or internally into hollow viscus [6].
Written informed consent was obtained from the patient for
The most unusual sequela is the erosion of the sponge into
publication of this case report and accompanying images. A copy
the intestine [7]. The retained sponge may lie partially or entirely
of the written consent is available for review by the Editor-in-Chief
within the bowel lumen, or it may eventually pass per rectum. Elim-
of this journal on request.
ination of the sponge may occur as early as two weeks following
laparotomy or it may be delayed as long as several years.
Plain abdominal radiograph can help diagnosis, when a radio Author’s contribution
opaque marker of the swab is seen. However, this imaging method
is not helpful when these markers are disintegrated or fragmented All Authors have contributed to the case report.
over time [9]. Ultrasonography and CT appearances of retained
surgical sponges may be widely diverse. Sonographically, retained Registration of research studies
surgical sponges are echogenic and they create an intensive and
sharply delineated acoustic shadow. This acoustic shadow can be As this case report does not involve any new device or surgical
present even in the absence of air and calcification [10]. On CT scans, technique, the research has not been linked with research registry.
in addition to spongioform gas bubble, a low density mass with
prominent and prolonged rim enhancement may suggest a retained Guarantor
surgical sponge granuloma [11].
In our scenario the surgical swab retained in our patient lacked Dr. Zansher Khan Nazar.
a radio opaque marker; thus, the diagnosis was not possible
with plain radiograph. Ultrasonography could only reveal post
acoustic shadowing, possibly because the retained surgical swab Provenance and peer review
was present completely within the lumen of small bowel. CT
scans could not differentiate the mass between a swab and a Not commissioned, externally peer-reviewed.
bezoar.
Though the diagnosis of left out foreign body can be made by SCARE 2018 guidelines
taking careful history, clinical examinations and by doing some
necessary investigations, yet some patients are diagnosed on the The work has been reported in line with the SCARE 2018 criteria.
operating table during re-laparotomy. Surgical exploration is the Reference of the Guidelines have been mentioned in the references
answer to the problem [9]. section.
In 2003, Gawande and colleagues [3] described the most com-
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