Lower abdominal gossypiboma mimics ovarian teratoma: a case report and review of the literature

Gossypiboma is referred to as a surgical gauze or towel retained inadvertently in the human body during surgery and the resulting reactions. Although it is a rare and preventable occurrence, this challenging medical situation which may induce considerable morbidity and at times even mortality, is a serious and potentially dangerous medico-legal problem [1, 2]. Herein, we report a case of lower abdominal gossypiboma after a cesarean section presenting as an abdominal cystic lump mimicking ovarian teratoma and review of related literature.

A 32-year-old woman was admitted to our hospital Obstetrics and Gynecology Department with intermittent left lower abdominal pain about half month. She had undergone cesarean section through abdominal incision at a suburban maternity hospital 8 years earlier. The results were uneventful. In the follow-up, the patient suffered sometimes from mild intermittent left lower abdominal pain, but eased 1–2 days without any treatment, the problem was explained with postoperative adhesion, and not performed further advanced examinations. She denied any history of fever, vomiting, constipation, or body weight loss at that stage. On physical examination, a lower midline laparotomy scar was noted; a smooth, round, mobile, nontender mass was palpable in the left hypochondrium. On bimanual pelvic examination, a 5 cm × 8 cm mass was felt in the left adnexa region. Blood tests including tumor marker carcino-embryonic antigen (CEA), carbohydrate antigen 199 (CA199), and carbohydrate antigen 125 (CA125) were within normal values. Ultrasound detected a well-encapsulated cystic mass in the left lower quadrant. The lesion showed echogenic foci and multiple linear reticular echogenic structures within it, without blood flow (Fig. 1a). Noncontrast computerized tomography (CT) scan revealed a well-defined, heterogeneous, bulky lesion consisted of hypodense cystic and hyperdense linear components, abutting the adjacent small bowel and sigmoid colon (Fig. 1b).

The patient was optimized and taken up for elective laparoscopic exploratory operation. Upon operation, a well-circumscribed firm mass was found, which was about 6 cm × 5 cm, densely adhered to the adjacent greater omentum, sigmoid colon, and intestine, and could not be removed by laparoscopic operation. The uterine and bilateral ovaries were normal except a 3.7 cm × 3.5 cm right ovary cyst. After enucleating the right ovary cyst and consulting the general department surgeon, the operation stopped. The patient was transferred to general department, and laparotomy via a prior surgical incision line under general anesthesia after bowel preparation was performed. At operation, adhesive omentum and sigmoid colon were separated, and the small bowel was too dense to separate, so the densely adhesive intestine loop and the mass were en blocly resected (Fig. 2a). The cut section demonstrated a surgical sponge without a radiopaque marker and yellowish, amorphous liquid material embedded within the fibrotic tissue (Fig. 2b). The histological findings demonstrated fibrous encapsulation containing a large number of foreign-body giant cells reaction (Fig. 2c). The patient was discharged on the 8th postoperative day with uneventful postoperative course and remained symptom-free at 6 months follow-up.

Gossypiboma is a rare and preventable challenging medical situation. If the diagnosis is neglected and not intervene timely, it may cause detrimental impact on patient and the healthcare staff. Once detected or suspected, appropriate surgical intervention should be performed promptly. Most importantly, preventing is much more crucial than curing in order to avoid this highly undesired potential complication.