Gossypiboma

Gossypiboma, textiloma or more broadly Retained Foreign Object (RFO) is the technical term for a surgical complications resulting from foreign materials, such as a surgical sponge, accidentally left inside a patient's body

1. Gossypiboma

2. Gossypiboma ,  textiloma  or more broadly  Retained Foreign Object (RFO)  is the technical term for a  surgical complications resulting from foreign materials, such as a surgical sponge, accidentally left inside a patient's body. The term "gossypiboma" is derived from the  Latin word   gossypium (“ cotton wool, cotton”) and the suffix  - oma , meaning a tumor or growth.

3. "Textiloma" is derived from  textile (surgical sponges have historically been made of cloth), and is used in place of gossypiboma due to the increasing use of synthetic materials in place of cotton

4. Incidence The actual incidence  is difficult to determine, possibly due to a reluctance to report occurrences arising from fear of legal repercussions, but retained surgical sponges is reported to occur once in every 3000 to 5000 abdominal operations  and are most frequently discovered in the abdomen. The incidence of retained foreign bodies following surgery has a reported rate of 0.01% to 0.001% , of which gossypibomas make up 80% of cases

5. Risk Factors

6. Items Retained Surgical instruments Surgical sponges Towels Suture needles Accessory items

7. Location of gossypiboma Frequent sites of gossypiboma formation include: Thoracic cavity pleural cavity pericardial cavity Abdominal cavity Pelvic cavity

8. Pathophysiology Surgical sponges are made of cotton, an inert material that does not stimulate any specific biochemical reaction except adhesion and granuloma formation. Two major types of reaction occur in response to retained surgical foreign bodies.

9. The first type is an exudative, acute inflammatory reaction, with the formation of an abscess in close proximity to the retained sponge. This usually occurs in the early postoperative period and may involve secondary bacterial contamination The second reaction is an aseptic fibrinous response , resulting in tissue adhesions and encapsulation and eventually foreign body granuloma.

10. Presentation variable. In some cases, a retained surgical sponge(RSS) may be discovered by accident during a radiographic examination or during an unrelated surgical procedure .   a mass or abdominal pain or, more commonly, as an incidental finding on a routine postoperative radiograph. Sponges initially placed in the chest or abdomen can erode through the skin or into the GI tract, creating a fistula or an intestinal obstruction , appear in a bowel movement, or cause hematuria

11. The most common symptoms of RSS are Pain palpable mass vomiting weight loss diarrhea abdominal distention tenesmus .

12. Complications The main complications of RSS are: Abscess development Adhesion Obstruction Fistula Peritonitis Erosion of urinary or GI tissues Migration of the sponge into the lumen of GI system.

13. Workup Imaging modalities Because RSS symptoms are usually nonspecific and may appear years after surgery, the diagnosis usually comes from imaging studies and a high index of suspicion . In advanced countries , surgical gauze is manufactured with radiopaque threads that are easily identified on radiographs, but this is not the case in all countries.

14. Plain Radiograph If the sponge contains a radiopaque marker, the diagnosis can be made easily by plain radiograph The most impressive imaging finding are the curved or banded radiopaque lines on plain radiograph

15. Ultrasound May appear as a well-defined mass containing wavy, bright, internal echogenic structure with a hypoechoic rim and a strong posterior shadow.

16. CT Scan Spongiform appearance with gas bubbles . Low-density mass with a thin enhancing capsule. Calcifications deposited along the network architecture of a surgical sponge.

17. Differentiation from abscess and hematoma may be difficult to discern on CT scan. The use of a 3-dimensional CT scan gives a clearer, less ambiguous depiction of the object

18. MRI MRI usually shows a well-defined mass with a fibrous capsule that exhibits : low signal intensity on T1-weighted images high signal intensity on T2-weighted images .

19. Management of Clinical Consequences Depends on its location. Patients should be offered removal of the Retained Surgical Sponge after it is recognized . In cases where the patient is asymptomatic and the sponge is detected by chance, surgical removal should be recommended after the patient has been informed about the possible complications of the retained sponge.

20. RSSs are usually removed by open surgery In selected cases, minimally invasive techniques (endoscopy and laparoscopy) may be used. Endoscopy may be useful when the RSS has migrated within the lumen of a hollow organ accessible by endoscopy (such as the stomach ). Laparoscopy for RSS is rarely performed, since the RSS is usually large and hard and has caused extensive adhesions or intensive granuloma formation

21. Prevention Preventing Retained Surgical Sponge is far more important than cure. To prevent gossypiboma, sponges are counted by hand before and after surgeries. This method was codified into recommended guidelines in the 1970s by the Association of periOperative Registered Nurses (AORN ).  Other guidelines have been promoted by the  American College of Surgeons  and T he  Joint Commission for prevention of Retained Surgical Instruments.

22. History Unclear if there were sponge counts prior to 1901 Sponge counts - 1901 Needle counts - 1976 Instrument counts - mid ‘80s Accessory items - early ‘90s

23. Separate counts are recommended: Before the procedure to establish a baseline and identify manufacturing packaging errors (ie, initial count) When new items are added to the field Change of scrub person or circulator/runner. Before closure of a cavity within a cavity (eg, uterus) When wound closure begins At skin closure or at the end of the procedure when counted items are no longer in use (ie, final count)

24. Accurate counting of all surgical sponges during a procedure is should be the priority of all members of surgical team. Unnecessary activity and distractions should be curtailed during the counting process to allow the scrub person and circulator to focus on counting tasks.

25. The scrub person should maintain awareness of the location of soft goods (eg, sponges, towels, textiles); and instruments on the sterile field during the course of the procedure. It is the scrub person's responsibility to: Verify the integrity and completeness of sponges when they are counted. Confirm that instruments or devices that are returned from the operative site are intact . Speak up when a discrepancy exists.

26. The surgeon(s) and surgical first assistant(s) should be aware of all soft goods, instruments, and sharps used in the surgical wound during the course of the procedure. The surgeon does not perform the count but should facilitate the count process by: Communicating placement of surgical items in the wound to the perioperative team for notation (eg, whiteboard). Acknowledging awareness of the start of the count process. Removing unneeded soft goods and instrumentation from the surgical field at the initiation of the count process. Performing a methodical wound exploration when closing counts are initiated. Accounting for and communicating about surgical items in the surgical field. Notifying the scrub person and circulator about surgical items returned to the surgical field after the count.

27. Anesthesia care providers should maintain situational awareness and engage in safe practices that support the prevention of Retained Surgical Instruments. Situational awareness is the process of recognizing a threat and taking steps to avoid the threat.. Anesthesia care providers should not use counted items. Anesthesia care providers should verify that throat packs, bite blocks, and other similar devices are removed from the oropharynx and communicate to the perioperative team when these items are inserted and removed.

28. Cost and Legal Ramifications Prevention of RSS is of key importance to avoid not only morbidity and mortality but also medicolegal consequences. The cost of an Retained Surgical Sponge can be significant, as it may lead to patient harm , increased hospital stays , and litigation . Damages awarded to plaintiffs vary markedly according to circumstances, injury, and the state/country in which the case was tried . The psychologic trauma and negative publicity for the surgical care providers can be significant.

29. Emerging Technologies Physically counting surgical items by the OT staff before and after procedures is the most common policy .   New technologies are being developed that may increase the efficiency and accuracy of accounting for surgical items . Barcode and Radiofrequency identification technology have been incorporated into cotton sponges to help improve the reliability of counting these products.

30. Radiofrequency identification system Detects sponges sponge have RF sensors. RF sensors Sponge absorbs low frequency radio waves and return it to the wand to indicate its presence.

31. . Barcodes can be applied to all sponges, and with the use of a barcode scanner Electronic tagging of surgical sponges involves a device that gives off a signal indicating the presence of an RSS when it is swept across a surgical site.

32. Take Home Message Preventing an RSS is far more important than cure. Multidisciplinary approaches may help to avoid retained foreign objects. New technologies may help to reduce the incidence of retained foreign objects. There should be high index of suspicion of RSS in patients with past history of surgery. RSSs should be included in the differential diagnosis of a soft-tissue mass detected in a patient with a history of surgery.

33. Please pay attention when counting sponges. Your few seconds can lessen the undue morbidity and mortality

34. References Yildirim S, Tarim A, Nursal TZ, et al. Retained surgical sponge (gossypiboma) after intraabdominal or retroperitoneal surgery: 14 cases treated at a single center.  Langenbecks Arch Surg.  2006;391:390–395. Gawande AA, Studdert DM, Orav EJ, et al. Risk factors for retained instruments and sponges after surgery.  N Eng J Med.  2003;348:229–235. Institute of Medicine.  To Err is Human: Building a Safer Health System . Washington, DC: National Academy Press; 2000. Greenberg CC, Gawande AA. Retained foreign bodies.  Adv Surg.  2008;42:183–191. Miller MR, Elixhauser A, Zhan C, Meyer GS. Patient safety indicators: using administrative data to identify potential patient safety concerns.  Health Serv Res.  2001;36:110–132. Gibbs VC, Auerbach AD. The retained surgical sponge. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, editors. Making health care safer: a critical analysis of patient safety practices. Rockville, MD: Agency for Healthcare Research and Quality; 2001, p. 255–257. Gibbs VC, McGrath MH, Russell TR. The prevention of retained foreign bodies after surgery.  Bull Amer Coll Surg. 2005;90:12–14; 16. Gibbs VC. Patient safety practices in the operating room: correct-site surgery and nothing left behind.  Surg Clin North Am.  2005;85:1307–1319. Joint Commission Resources. Foreign objects retained after surgery. http://www.jcrinc.com/Foreign-Objects-Retained-After-Surgery. Accessed November 28, 2012