Gossypiboma

Juan E Small, MD - Case Coordinator
Cheryl Ann Sadow, MD - Radiology Discussion
Ron Firestein, MD, PhD - Pathology Discussion
Koenraad Mortele, MD - Attending Radiologist
Pablo R Ros, MD, MPH - Attending Radiologist

November 24, 2003

Presentation

Imaging Findings

Ultrasound images in the area of the adnexa show curvilinear areas of high echogenicity (some of which appear slightly lobular) within a mass that measures approximately 4.8 x 5.65 cm. Some posterior acoustic shadowing is also visible. This type of echogenicity is caused by a lesion with a heterogeneous texture, such as dermoid or teratoma. The shadowing may also suggest calcifications. The appearance is fairly characteristic of 'dermoid plug' sign. The appearance does not suggest hemangioma or a complex cyst.

An axial T1-weighted magnetic resonance image through the pelvis shows a circumscribed, fairly homogeneous mass anterior to the left psoas muscle and the vertebrae. On T1, it is isointense to [rectus] muscle. There are some areas of the inferior and medial aspect that are slightly lower in signal intensity. A T2-weighted image shows fluid attenuation with some lower-signal areas within. The fat-saturation image does not show a typical dermoid appearance. Finally, a fat-saturated T1 image with gadolinium confirms a lack of fat saturation and demonstrates peripheral enhancement. The MR appearance suggests endometrioma.

Differential Diagnosis

Diagnosis

Discussion

The gross specimen is a round, cystic mass filled with yellow fluid. On cross section, it is clear that the "mass" is actually a piece of retained surgical gauze around which a fibrous capsule has formed. Shadowing on the ultrasound images was caused by trapped air.

Discussion:

Gossypiboma is the technical term for a retained surgical sponge. It is derived from the Latin "gossypium" (cotton) and the Swahili "boma" (place of concealment). The presentation of gossypiboma is variable. The acute presentation typically consists of local inflammatory reaction. If it becomes infected, an abscess forms. The differential diagnosis in such cases includes post-operative collection, hematoma, and non-foreign body abscess. A delayed presentation, however, may develop months or even years after the initial surgery. Adhesions and encapsulation are common, and the lesion may present as a mass or subacute intestinal obstruction. In these cases, the differential diagnosis typically includes tumor.

The typical appearance of gossypiboma often includes a whirl-like pattern of radiopaque thread on radiographs. (Although in the US and many other countries surgical gauze is manufactured with radiopaque threads that are easily identified on radiographs, this is not the case in all countries.) On ultrasound, the sponge may appear as a brightly echogenic wavy structure within a cystic mass. The pattern of acoustic shadowing changes with the direction of the ultrasound beam. On CT, gas trapped within the sponge is visible, as are calcifications in the cavity wall (if long-standing); rim enhancement may also be seen. These lesions have variable signal intensity on MR, depending on the amount of fluid and protein. The capsule is typically dark on T1- and T2-weighted images.

References

Williams RG. Bragg DG. Nelson JA. Gossypiboma--the problem of the retained surgical sponge. Radiology 1978: 129: 323-326.

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