Selected Articles from the
Journal Abdominal Surgery

This article originally appeared in the Winter 2009 / Spring 2010 issue of the Journal.

Retained Sponge, is it Still a Problem in Surgical Practice?

Ehab Akkary MD
Assistant Professor in General Surgery,
Director of Bariatric Surgery, West Virginia University
School of Medicine, Morgantown, WV

Daniel J. Singer
Medical Student, Wayne State University, Detroit, MI

Daniel Holloway MD
Staff Surgeon, Sinai Grace Hospital, Detroit, MI

Corresponding author:
Ehab Akkary MD,
Department of General Surgery,
West Virginia University School of Medicine
PO Box 9238 Health Sciences Center
One Medical Center Drive
Morgantown, WV 26506-9238
Tel: 304-598-4890
E-mail: ehabakkary@yahoo.com

Key Words
sponge; gossypiboma; foreign body; sepsis; intra-abdominal abscess

Retained Surgical Sponge (RSS), also known as gossypiboma, is a persistent but poorly understood surgical problem that may result in major injury including bowel perforation, sepsis, and death ¹. The retention of sponges and instruments is considered to be avoidable, and when it occurs, it can lead to major malpractice suits and attract wide, critical media coverage. Estimates suggest that errors occur in 1 of every 1000 to 1500 intra-abdominal operations ^2,3.

The incidence of RSS is difficult to estimate for various reasons. Some patients remain asymptomatic and are never discovered, others do not file a claim, and many cases are not documented due to fear of medicolegal implications or media criticism ⁴. Gawande et al stated an incidence of 1/8801 to 1/18,760 which might be an underestimate because it was calculated on the basis of malpractice claims, or because of the inclusion of large numbers of laparoscopic, endoscopic, or catheterization procedures that are unlikely to result in a forgotten sponge ⁵. Sixty nine percent of patients required reoperation for removal of the object and management of complications. In twenty two percent, the retained foreign object resulted in small bowel fistula, obstruction, or visceral perforations; and there was one mortality ⁵. In another study conducted by Bani-Hani et al, ninety one percent of patients required re-operation to remove the retained sponge and manage the resulted complications, including bowel obstruction and fistulae ⁴. Kaiser et al reported that 26 out of 29 patients needed a second operation to remove the foreign body and drain any associated abscess, One case was complicated by pulmonary embolism in that study.

Risk factors for RSS, according to a univariate analysis, include emergency operations, unexpected change in the procedure, high body mass Index (BMI) and lack of a sponge or instrument count. Compared with randomly selected controls who underwent the same type of operation, RSS is 9 times more likely after an emergency operation and 4 times more likely when an unexpected change in the surgical procedure is undertaken⁵.

RSS is a persistent and often underestimated problem that represents a significant cause of morbidity and mortality, malpractice, and critical media attention. The universal guidelines should be strictly followed as stated by the American College of Surgeons in October 2005; only radioopaque sponges should be used, accurate sponge counts should be performed before the procedure, and before and after closure of the abdomen. Also, a meticulous examination of the abdomen should be done before closure ⁴. However, counts are not always sufficient. Many cases of retained foreign bodies in which counts were performed involved a final count that was erroneously thought to be correct. These findings suggest that screening of high-risk patients at the end of the procedure should be considered even when counts are documented as correct. The primary method currently available is radiographic screening, ideally performed before the patient leaves the operating room. In morbidly obese patients, a 4-quadrant abdominal X-rays or CT scan should be considered if single flat X-ray film is inadequate for screening of the whole abdomen.

REFERENCES

1. Gonzalez-Ojeda A, Rodriguez-Alcantar DA et al. Retained Foreign Bodies Following Intra-abdominal Surgery. Hepatogastroenterology. 1999;46:808-12.

2. Hyslop JW, Maull KI. Natural History of the Retained Surgical Sponge. South Med J. 1982;75:657-60.

3. Jason RS, Chisolm A, Lubetsky HW. Retained Surgical Sponge Simulating a Pancreatic Mass. J Natl Med Assoc. 1979;71:501-3.

4. Bani-Hani KE, Gharaibeh KA, Yaghan RJ. Retained Surgical Sponges (Gossypiboma). Asian J Surg. 2005; 28(2):109-15.

5. Gawande AA, Studdert DM, Orav EJ et al. Risk Factors for Retained Instruments and Sponges After Surgery. N Engl J Med. 2003; 348(3):229-35.

6. Kaiser CW, Friedman S, Spurling KP et al. The Retained Surgical Sponge. Ann Surg. 1996; 224(1):79-84.