Residual hemostatic material (Surgicel) mimicking endometriosis: a case report of gossypiboma

A 24-year-old woman with no significant past medical or surgical history, a BMI of 22 kg/m 2 , and regular menstrual cycles presented to the gynecology department with sudden abdominal pain on the morning of admission. Her last menstrual period was approximately 3 weeks earlier. She described intermittent abdominal pain of varying intensity, accompanied by nausea without vomiting. She had no symptoms such as burning or frequent urination. Initial infectious workup, including white blood cell count and C-reactive protein levels, was within normal limits at admission. On abdominal examination, mild tenderness was present in the right lower quadrant without rebound tenderness or guarding. No abdominal distension was noted. Vital signs on admission were stable, with no evidence of hemodynamic instability. Abdominal and pelvic ultrasound showed normal abdominal organs and a normal-sized uterus. Two cystic structures were identified in the right ovary: one measuring 40 × 23 mm with internal echoes and fibrin stranding, suggestive of a hemorrhagic cyst, and another cyst measuring 21 mm with homogeneous internal echoes, possibly indicative of an endometrioma or another hemorrhagic cyst. A moderate-to-large amount of free fluid was also seen in the pelvis, particularly around the right ovary, in Morrison’s space, and between the intestines (Fig. 1 ). Accordingly, a decision was made to perform a laparotomy and cystectomy. Figure 1. Pelvic ultrasonography showed a normal-sized uterus with no intrauterine pathology. In the right adnexa, a 40 × 23 mm cystic lesion containing echogenic internal debris and fibrin strands was identified, suggestive of a hemorrhagic cyst. A second 21 mm cystic lesion with homogeneous, low-level internal echoes was also noted, raising suspicion for an endometrioma or a hemorrhagic cyst. Moderate-to-large free fluid with internal echoes was present in the pelvis, including the pouch of Douglas, the perihepatic region (Morrison’s pouch), and between bowel loops. Pelvic ultrasonography showed a normal-sized uterus with no intrauterine pathology. In the right adnexa, a 40 × 23 mm cystic lesion containing echogenic internal debris and fibrin strands was identified, suggestive of a hemorrhagic cyst. A second 21 mm cystic lesion with homogeneous, low-level internal echoes was also noted, raising suspicion for an endometrioma or a hemorrhagic cyst. Moderate-to-large free fluid with internal echoes was present in the pelvis, including the pouch of Douglas, the perihepatic region (Morrison’s pouch), and between bowel loops. In the postoperative period, the patient experienced nausea, vomiting, and recurrent fevers between 38 and 39°C, despite receiving antibiotics such as ceftriaxone and clindamycin. On the advice of the infectious diseases team, her antibiotic regimen was changed to imipenem (500 mg every 6 hours) and vancomycin (1 g every 12 hours). With the fever persisting over the next 5 days, a repeat ultrasound was performed, which showed normal abdominal organs, and treatment with meropenem was continued. On further investigation, the diagnosis of brucellosis was confirmed. After improvement in symptoms and fever, the patient was discharged in good general condition 12 days after admission. In the following weeks, the patient complained of recurrent abdominal pain and occasional mild fever, which prompted further investigations. Approximately 60 days after the operation, a new ultrasound was performed. On this examination, a thin-walled cystic mass measuring 92 × 68 × 90 mm was seen adjacent to the uterus and right ovary. The cyst contents were uniform and contained floating particles. Additionally, the right ovary was compressed against the wall of the cyst. These findings were reported as being in favor of a complex endometrioma. Another ultrasound 20 days later by a different radiologist revealed a cystic lesion measuring 82 × 57 × 52 mm with echogenic and fibrotic contents, suggesting an inclusion cyst (Fig. 2 A and B). Figure 2. (A and B) A second ultrasound shows echogenic band-like material within the pelvic cavity, suggesting a possible residual foreign body. (C) A subsequent ultrasound shows a reticular, confluent mass adjacent to the right ovary. (A and B) A second ultrasound shows echogenic band-like material within the pelvic cavity, suggesting a possible residual foreign body. (C) A subsequent ultrasound shows a reticular, confluent mass adjacent to the right ovary. Approximately 2 months later, the patient underwent additional ultrasounds at another center on consecutive days. The first ultrasound identified serpentine-shaped, amorphous material floating in fluid in the posterolateral pelvis, with overall dimensions of 67 × 39 mm; the right ovary appeared compressed without a clear cyst wall. The next day, another ultrasound showed a 60 × 40 mm cystic mass in the right adnexa, between the ovary and uterus, with an echogenic internal band suggestive of a foreign body. After it was confirmed that instrument and sponge counts during the initial surgery were correct, further evaluations were conducted. The final ultrasound reported a 74 × 50 mm reticular, interconnected mass adjacent to the right ovary (Fig. 2 C). The patient was scheduled for diagnostic laparoscopy. Diagnostic laparoscopy revealed severe pelvic adhesions and marked inflammatory changes surrounding the right adnexa. After extensive adhesiolysis, multiple retained Surgicel fragments measuring approximately 3 × 2 × 5 cm were identified and removed from the previous surgical site. Due to severe inflammatory involvement of the right fallopian tube, a right salpingectomy was performed. The abdominal cavity was irrigated thoroughly, and hemostasis was confirmed at the end of the procedure (Fig. 3 ). The patient was discharged in good general condition after 3 days of observation in the ward. At the 6-month follow-up, no signs of fever or abdominal pain were reported. From the patient’s perspective, the definitive diagnosis and surgical removal provided significant relief from the chronic anxiety and physical discomfort associated with the delayed diagnosis. Figure 3. Diagnostic laparoscopy showing removal of retained Surgicel fragments from the pelvic cavity. Diagnostic laparoscopy showing removal of retained Surgicel fragments from the pelvic cavity.

Retained surgical materials, such as sponges or absorbable hemostatic agents (e.g., Surgicel), represent a rare and potentially dangerous postoperative complication [ 1 , 2 ] . Also known as gossypiboma or textiloma, this phenomenon may result in a wide range of clinical symptoms, including chronic pain, fever, and pelvic mass, as well as more complex complications, and may delay diagnosis due to its clinical similarity to abscess, tumor, or primary infection [ 2 – 4 ] . Most reported cases involve retained surgical sponges, which are most often found in the abdomen (approximately 56%), pelvis (18%), and chest (11%) [ 5 ] . Several factors are responsible for increasing the risk of gossypiboma, including emergency surgeries, prolonged operating time, many operating teams working at the same time, sudden intraoperative alterations in surgical strategies, miscount of surgical instruments and gauze, and unexpected and uncontrolled blood loss [ 4 ] . HIGHLIGHTS Retained absorbable hemostatic agents, such as Surgicel, can rarely cause gossypiboma. A Surgicel-induced foreign-body reaction may mimic endometriotic pelvic masses on imaging. Serial ultrasound examinations led to a delayed but progressive diagnostic suspicion. Diagnostic laparoscopy confirmed retained Surgicel and enabled definitive treatment. Awareness of this entity can prevent misdiagnosis and unnecessary repeat interventions. HIGHLIGHTS Retained absorbable hemostatic agents, such as Surgicel, can rarely cause gossypiboma. A Surgicel-induced foreign-body reaction may mimic endometriotic pelvic masses on imaging. Serial ultrasound examinations led to a delayed but progressive diagnostic suspicion. Diagnostic laparoscopy confirmed retained Surgicel and enabled definitive treatment. Awareness of this entity can prevent misdiagnosis and unnecessary repeat interventions. The clinical manifestations of this complication are diverse and may appear anywhere from a few weeks to years after surgery. In some cases, patients remain asymptomatic, which makes diagnosis more difficult. Imaging tools such as ultrasound, plain radiography, and especially CT scans play a key role in identifying this lesion. Ultrasound and radiography might be valuable if there is an apparent marker in the residual material on imaging, but in most cases, CT scanning facilitates diagnosis [ 6 ] . This complication not only increases the patient’s clinical risk but also incurs costlier treatment due to a longer hospital stay and additional diagnostic tests [ 7 ] . Furthermore, it is important to note that ovarian masses can rarely be associated with complex neurological complications, such as autoimmune encephalitis [ 8 ] . Due to the potential legal and professional implications, most of the published literature on gossypiboma has been presented as case reports or reviews of a limited number of cases. In this report, a rare case of retained Surgicel hemostatic material after ovarian surgery in a young woman is presented. The purpose of this report is to emphasize the importance of the differential diagnosis of gossypiboma in patients with a history of surgery and chronic abdominal symptoms, as well as the necessity of strict adherence to surgical safety principles to prevent such complications. This case report has been prepared in line with the SCARE checklist [ 9 ] .

Gossypiboma, the unintentional retention of surgical materials such as sponges or hemostatic agents (e.g., Surgicel), is a rare and important complication after surgery. In a review of 14 cases at a medical center in Yemen, it was found that most cases occurred during gynecological surgeries, especially in emergency procedures. The median time to onset of symptoms was approximately 37 days after surgery, which is consistent with the delayed onset of symptoms (60 days after surgery) [ 6 ] . According to case studies by Akbulut and Pezzilli, prolonged surgery, unexpected bleeding, multiple surgical teams, and inaccurate instrument counts are among the major risk factors for this complication (Table 1 ) [ 10 , 11 ] . Table 1 Previously reported cases of retained surgical materials and the similarities in delayed presentation and misleading imaging findings. Author/year Type of retained material Surgical procedure Time to presentation Main symptoms Imaging findings Management Akbulut et al [ 9 ] Surgical sponge Abdominal/Pelvic surgery Weeks to years Mass-like lesion mimicking abscess or tumor CT/US Surgical removal Pezzilli et al [ 10 ] Retained surgical material Abdominal surgery Fever, chronic pain, inflammatory symptoms Confused with chronic inflammation or neoplasm Reoperation Piozzi et al [ 11 ] Abdominal surgery Pain, obstruction, granulomatous reaction Cystic or heterogeneous mass resembling abscess/tumor Surgical exploration Previously reported cases of retained surgical materials and the similarities in delayed presentation and misleading imaging findings. Moreover, the clinical symptoms of gossypiboma can vary from abdominal pain and fever to intestinal obstruction and fistula. In the present case, the patient had persistent pain and fever after surgery, which led to repeated hospitalizations and multiple investigations, imposing a high clinical and economic burden [ 12 ] . On the other hand, another study emphasized the laparoscopic removal of gossypiboma. Similarly, in the present case, severe adhesions and sponge entrapment, especially in minimally invasive procedures, made diagnosis and removal challenging. Furthermore, it has been shown that symptoms of gossypiboma may range from abdominal pain and fever to tumor-like masses and intestinal obstruction, and may even appear years after surgery, similar to our case, where symptoms appeared 2 months after surgery [ 13 ] . A recent article on the sonographic presentation of Surgicel noted that this material can be seen as banded structures or echogenic particles in cystic masses, and may appear similar on imaging to ovarian lesions or foreign bodies [ 14 ] . In our patient, multiple sonographic findings also showed a misleading appearance. Piozzi et al reported that all forms of gossypiboma, including those that lead to obstruction or granulomatous reaction, can be easily confused with abscess, tumor, or chronic inflammation [ 12 ] . Consistent with our case, sonography revealed a cyst-like mass that was initially interpreted as an endometrioma or inclusion cyst, whereas the actual underlying cause was retained Surgicel. Surgicel is an oxidized regenerated cellulose material commonly used for hemostasis during gynecologic surgery. Although it is generally absorbable, delayed degradation may occur in the presence of extensive tissue inflammation, hemorrhage, or postoperative adhesions-conditions frequently encountered in endometriosis surgery. Persistent retained Surgicel may trigger a foreign-body granulomatous reaction, fibrosis, and chronic inflammatory exudation. This reaction results in mass-like lesions that can closely mimic endometriomas, abscesses, or adnexal tumors on imaging studies. In the present case, severe pelvic inflammation and postoperative adhesions likely contributed to the prolonged persistence of Surgicel and its misleading sonographic appearance [ 15 ] . Furthermore, the differential diagnosis of complex pelvic masses must include ovarian abscesses. As highlighted in recent literature, adnexal abscesses can pose significant diagnostic dilemmas and are often difficult to distinguish from other abnormal pelvic tumors on imaging alone, even in complex physiological states such as pregnancy [ 16 ] . This further underscores the broader clinical challenge of relying solely on sonographic features for definitive diagnosis of atypical adnexal lesions, often necessitating eventual surgical exploration. In the diagnosis of gossypiboma, ultrasound, CT, and MRI can assist in diagnosis, although the findings may be mistaken for other masses. Plain radiography can be effective if surgical gauze contains a radiopaque marker. Otherwise, CT is often the preferred modality for diagnosis. Although neither CT nor MRI was performed in the present case, these modalities could have provided additional diagnostic information and may help differentiate retained surgical material from complex adnexal masses in similarly ambiguous clinical situations. A key takeaway from this case is the necessity for rigorous and continuous monitoring of surgical instruments and gauze, even during laparoscopic procedures. Implementing strategies such as the use of radioactive tracers or RFID tagging systems may significantly mitigate the risk of such errors [ 10 ] .

Gossypiboma is an important but often-overlooked diagnosis in patients with a history of surgery and nonspecific abdominal or pelvic symptoms. Residual hemostatic agents, such as Surgicel, can mimic ovarian or inflammatory masses and delay diagnosis. Given this possibility, appropriate imaging and, when necessary, diagnostic laparoscopy can help prevent further complications. Clinicians should consider retained absorbable hemostatic agents in the differential diagnosis of persistent pelvic masses following gynecologic surgery.