Year : 2010  |  Volume : 13  |  Issue : 3  |  Page : 261--263

An unusual case of thoracic gossypiboma

Rakhi K Retnamma1, Suresh G Nair2, B Umadethan3, P Manoj4,  
1 Department of Cardiac Anesthesia, Amrita Institute of Medical sciences, Edappaly, Cochin, Kerala, India
2 Department of Anesthesia, Amrita Institute of Medical sciences, Edappaly, Cochin, Kerala, India
3 Department of Forensic Medicine, Amrita Institute of Medical sciences, Edappaly, Cochin, Kerala, India
4 Department of Cardiothoracic and Vascular Surgery, Amrita Institute of Medical sciences, Edappaly, Cochin, Kerala, India

Correspondence Address:
Rakhi K Retnamma
Anesthesia Office, AIMS, Edappally, Cochin, Kerala

How to cite this article:
Retnamma RK, Nair SG, Umadethan B, Manoj P. An unusual case of thoracic gossypiboma.Ann Card Anaesth 2010;13:261-263

How to cite this URL:
Retnamma RK, Nair SG, Umadethan B, Manoj P. An unusual case of thoracic gossypiboma. Ann Card Anaesth [serial online] 2010 [cited 2022 May 21 ];13:261-263
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Full Text

The Editor,

An intrathoracic gossypiboma is extremely rare and a seldom-reported condition, possibly because of medicolegal issues associated with it. Confusing configurations on X-ray and computed tomography (CT) further increase the delimma in diagnosis. Very often, this condition remains undiagnosed for years together. A case of intrathoracic gossypiboma following closed mitral valvotomy (CMV) in a young man aged 21 years at our hospital is presented and the legal issues associated therein are discussed.

A 21-year-old male was admitted with fever and joint pain. He had been suffering from rheumatic heart disease with valvular involvement since the last 9 years. The erythrocyte sedimentation rate and C reactive protein were raised and suspecting rheumatic reactivation, treatment with aspirin and antibiotics was started. With this treatment, he showed significant symptomatic improvement.

Transthoracic echocardiogram did not show any vegetation. Cardiologists were of the opinion that no active intervention was necessary. Incidentally, his chest X-ray showed left upper zone homogenous opacity [Figure 1], which, when further evaluated with a CT chest [Figure 2], showed a left apical fluid density lesion with some hyperdense soft tissue component within it. The possibilities were loculated pleural effusion, pulmonary blastoma and hydatid cyst and, hence, CT-guided aspiration was deferred. An exploratory thoracotomy was considered appropriate at this instance. He had history of having undergone CMV 6 years ago with a long, postoperative stay of 10 days in the ICU following CMV as the thoracotomy wound got infected with abscess formation. An array of chest X-rays and CT chests were taken before discharge on the 30 th day, by which time his wound had healed well. The CT and X-ray of the chest showed consolidation for which he was treated with antibiotics.{Figure 1}{Figure 2}

He was premedicated with 2 mg lorazepam and 150 mg ranitidine. After infective endocarditic prophylaxis, induction was performed with propofol 4 mg/kg and fentanyl 3m/kg and isoflurane inhalation. After adequate relaxation was achieved with pancuronium 0.1 mg/kg, a 37F left-sided double-lumen tube was inserted into the trachea. The patient was positioned in left thoracotomy position after proper isolation of the lung, which was confirmed with bronchoscopy.

On thoracotomy, dense adhesions were found at the CMV incision site. Exploration of the mass revealed a pseudotumor containing yellow purulent fluid. As the mass was strongly adherent to the apical and the mediastinal tissue, it could not be dissected out en mass. Further exploration revealed a surgical sponge still well preserved after 7 years [Figure 3].{Figure 3}

Histopathology was consistent with gossypiboma and the pus was sterile. The postoperative period was uneventful. The drains were removed on the 14 th postoperative day and the patient was discharged on the 18 th postoperative day.

The term gossypiboma (Latin Gossypium-cotton, Kiswahili, boma-place of concealment) denotes a cotton foreign body that is retained inside the patient during surgery. Foreign bodies are essentially inert in gossypiboma and can lead to an aseptic foreign body reaction with fibroblastic reaction and encapsulation. Most patients are, therefore, asymptomatic. [1]

The actual incidence of retained sponge is difficult to estimate but has been reported to be one in every 3,000 procedures. This is mostly seen in gynecological and upper abdominal surgeries. [2],[3] Surgical sponge is the most common forgotten foreign body. [3] The increased depth of the operating field, as in cases of thoracotomy, facilitates the disappearance of a surgical sponge behind the retractors that are used to keep the lung away from the surgical field. [4]

The preoperative diagnosis of a gossypiboma is difficult, as is evident from the X-ray and the CT shown. The radiological appearance of gossypibomas is protean. [5] Park et al, have described a contrast-enhanced CT showing spongiform air bubbles within the ovoid mass that had a thick capsule in his study of the changes seen in gossypibomas over10 years. [6] The ovoid mass, seen on CT chest in our case, had a homogenous appearance without any evidence of air bubbles, which pointed toward either loculated pleural effusion, pulmonary blastoma or hydatid cyst.

Gossypibomas have serious operative and medicolegal consequences as when misdiagnosed as a malignant tumor, leading to unnecessary invasive diagnostic procedures or extensive extirpative surgery, which may result in further complications.

In the present case, the detection of a surgical swab in the thoracic cavity and the postoperative investigations (CT chest and skiagrams), showing suspicious mass at the site of operation after the first surgery of closed mitral valvotomy, are evidences in support of negligence. The legal maxim called "Res ipsa loquitor," which means "the things which speak for itself'" holds true here. As per this dictum, the surgical swab found in the chest cavity could only have been left behind by the surgeon himself. This is considered as a speaking proof of negligence. The doctor and his colleagues/assistants had exclusive control of the instrumentality that caused the injury.

Nevertheless, recent emphasis in the US courts is to consider that a team failure has occurred and the blame for this is spread across the provider spectrum (nurses, MD, OR techs, hospital, but usually not anesthesia). Many a surgeon has been exonerated on the basis of a correct count toward the end of the procedure.

The present case comes under the law of "Tort" and the discussion is incomplete without it. In law, "Tort" is an injury or wrong committed to a person or property of another. When the negligence of the doctor has resulted in pain, suffering and mental agony, compensation has to be paid to the plaintiff. He is also entitled to claim the expenses he has incurred in respect of the treatment he had undergone during the period after the operation as well as the costs in connection with the second operation.

In conclusion, a retained sponge in the thoracic cavity raises an issue of human fallibility. There is a growing body of literature analyzing human factors in the study and prevention of accidents in the theatres. Invariably, lack of proper communication is the reason behind many errors and accidents in a psychologically and organizationally complex environment of the operation theatre. Retained foreign bodies were most likely to occur during an emergency operation, after an unexpected change in the operative procedure and in obese patients. Routine exploration of the abdomen or any cavity that has been opened before closure, use of only sponges with radioopaque markers, two counts after fascial closure and by the new personnel on permanent relief of either the scrub person or the circulating nurse and routine intraoperative X-rays are also a useful adjunct to the swab counts.

In summary, a combination of counts, surgeon and nurse diligence and radiological examination is the best solution to the riddle of gossypiboma that is prevalent now.


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