Fistula is the abnormal communication between two epithelial surfaces, either to the skin or to the lumen of any organ. A retained foreign object is any item left inside a patient after a surgery; sponges account for 69% or retained foreign objects and generate intestinal obstruction or perforation among other complications. Risk factors include emergency surgery, long procedures, massive bleeding and obesity. The course is variable and may present as acute or chronic disease, with a mortality rate of 28%¹.

A 65-year-old female patient, with a history of a cesarean section 30 years before, presented with a palpable tumor in the hypogastrium after having lost 40 kg following nutritional treatment. She had no fever and her cardiovascular and respiratory function were normal. The abdomen was asymmetric due to lipodystrophy, with an infraumbilical median scar; the bowel sounds were normal and tympany was preserved. Palpation revealed a non-tender, mobile tumor formation with stony-hard consistency, welldefined limits and no adherence to deep layers. The computed tomography scan showed an elongated, heterogeneous, calcified mass with bubbles inside below the musculoaponeurotic layer, measuring 15 × 7 × 8 cm, with mass effect and no interfaces. An exploratory laparotomy was indicated. The abdomen was approached via a midline supraumbilical and infraumbilical incision. A stony-hard formation was observed at 50 cm from the ileocecal valve, with multiple adhesions to the surrounding small bowel (Fig 1). The rest of the abdominal exploration was normal. After ligation of the mesentery, the compromised area of the intestine was resected and a two-layer anastomosis was constructed with interrupted suture of Vycril 3.0. After checking adequate hemostasis, a drain was placed in the right iliac fossa, the aponeurosis was closed using 4-0 nylon suture and the skin was sutured.

Figure 1 A: the foreign body occupies the entire intestinal lumen. Both segments of the intestinal loops are intimately adhered. B: graphical comparison of the gossypiboma size. 

The patient evolved with favorable outcome and tolerated oral intake on postoperative day 4. She was discharged on postoperative day 6. During the follow-up visit 15 days later she remained without complications. The pathology examination reported adhesions between loops with fistulization and an intraluminal mass of calcified material corresponding to a foreign body (Fig. 2).

Figure 2 A. surgical specimen treated with formalin. The opened compromised segment allows visualization of the foreign body. B: removal of the foreign body from the intestinal lumen, visualized as a stony-hard mass with certain level of decay and calcification. C: both segments involved are communicated. 

Retained foreign objects are also known as gossypibomas². Their incidence is unknown as they are often the cause of lawsuits and are not reported. Emergency surgeries, unexpected change in surgical procedure, life-threatening conditions, obesity, blood loss >700 mL and fatigue are mentioned as risk factors in the reviews consulted. Other factors include difficult procedures and night shifts. Retained foreign objects are classified in acute or chronic according to their clinical presentation and type of foreign body reaction. The acute presentation appears within days after surgery and is characterized by exudative reactions that cause abscesses and enterocutaneous fistulas. The chronic presentation appears months or years later and is characterized by adhesions, with development of a fibrous capsule and, finally an aseptic granuloma which can manifest with non-specific symptoms and is the most common presentation. The foreign object may induce an early inflammatory response, fistulas develop when the body tries to eliminate the material. The response can also be slower and create adhesions and a pseudocapsule containing the foreign object, which can lead to intestinal obstruction or perforation and sepsis⁴.

Gossypibomas may be found free or can migrate from the abdominal cavity to another viscus in an attempt of the body to get rid of it but without compromising the viscus. Migrations can occur to the thorax, stomach and intestinal loops causing common bile duct obstruction and jaundice, and to the urinary bladder leading to the development of fistulas.

Acute intestinal obstruction is the most common clinical presentation due to extrinsic compression or intrinsic obstruction when the retained foreign object does not pass through the ileocecal valve, causing intestinal obstruction at this level (the most common presentation). When the gossypiboma passes the ileocecal valve, it can be discharged with feces, as it occurred in one case reported in India. Another presentation is an acute exudative inflammatory response with development of an abscess with or without secondary infection and development of fistulas, peritonitis and fatal sepsis. Clinical manifestations include diffuse abdominal pain, palpable abdominal mass, severe intestinal obstruction or sepsis; abdominal pain is the most frequent symptom and is sometimes associated with fever. The history of previous surgery is the main factor to suspect the diagnosis. The value of ultrasound and computed tomography (CT) scan is well-known, but there are no specific imaging tests for the diagnosis of gossypibomas. Ultrasound demonstrates an echogenic structure with echolucent components that cast an acoustic shadow. Acute gossypibomas appear in CT scans as heterogeneous masses containing trapped air which may or may not be surrounded by a hyperdense ring. Chronic gossypibomas appear as non-enhanced tumors with calcifications inside on CT scans, and this finding is the most specific sign. Magnetic resonance imaging has not demonstrated more efficacy than CT.

Once the diagnosis has been made, surgical removal should be carried out. Open surgery is still the procedure of choice although nowadays, with the advances of minimally invasive surgery, alternative procedures are emerging in the literature. Nosher and Siegel published their experience with six patients who underwent percutaneous retrieval of intra-abdominal foreign objects without complications⁶. However, this method is currently not well supported, since in most cases the presence of fistulas or adhesions are causes of conversion to open surgery because the greater omentum, small intestine and mesentery, and large intestine and mesocolon form part of the gossypiboma wall. Intestinal obstruction (58.3%), intra-abdominal abscesses (16.7%) and peritonitis (16.7%) are the most common complications associated with gossypibomas reported by the international literature. Mortality rate ranges between 11 and 35%⁵.

From a medical-legal point of view, being prosecuted for a gossypiboma is equivalent to being found guilty, although there may be acquittals. In their defense, surgeons argue that extreme complex procedures or emergency surgeries result in chaotic surgical fields crowded with instruments, and they must struggle with bleeding or with their own exhaustion in stressful and prolonged situations. Leaving an object, beyond all reasonable doubt, demonstrates surgeon’s negligence, even if he/she was not personally in charge of that object; surgeons are responsible for their team’s performance, which is guided and coordinated by them. The statement “The surgeon is ultimately responsible” is becoming less applicable and less true. Every member of the team has some level of responsibility.