Laparoscopic approach to pelvic gossypibomas with abscess formation: a case series

Pelvic gossypibomas may remain undiagnosed for years, presenting with non-specific gastrointestinal, genitourinary, or systemic symptoms. Imaging, including ultrasound and CT, is essential for diagnosis. Laparoscopy offers a safe, effective approach for adhesiolysis, foreign body removal, and management of associated complications, including abscesses and organ compression.

Laparoscopic management of postoperative pelvic gossypibomas is feasible, safe, and effective, even in complex cases with adhesions, abscess formation, and proximity to vital structures. This minimally invasive approach provides excellent outcomes, rapid recovery, and high patient satisfaction, highlighting its role as a preferred alternative to open surgery in selected patients.

Gossypiboma, also known as a retained surgical sponge, is a rare but serious postoperative complication resulting from inadvertent retention of a sponge during surgery. These retained sponges are often discovered incidentally through imaging studies or during reoperations and pose significant concerns for patient safety and medico-legal implications due to potential prolonged morbidity and, in some cases, mortality if not promptly addressed[1]. The reported incidence is approximately 1 in 1000–1500 intra-abdominal surgeries, although the true frequency is likely underestimated due to underreporting[2]. Retained surgical sponges account for about 69% of all retained surgical items, with the remainder involving instruments such as forceps, retractors, or electrodes[3]. HIGHLIGHTS Laparoscopy enables safe and effective removal of retained pelvic surgical gauze with minimal invasiveness. Gossypibomas may clinically and radiologically mimic abscesses or neoplasms, frequently presenting with chronic pelvic pain and local compressive symptoms Imaging studies, especially ultrasound and CT, are essential for diagnosing retained foreign bodies postoperatively. Laparoscopic retrieval permits precise adhesiolysis and ensures the preservation of surrounding organs, despite the presence of dense inflammatory adhesions Timely intervention prevents long-term complications such as fistulas, organ dysfunction, and chronic infections. The clinical presentation of gossypibomas is highly variable and depends on factors including the size and location of the retained sponge and the host’s inflammatory response. Patients may remain asymptomatic for long periods or present with nonspecific symptoms such as vague abdominal pain or a palpable mass. An exudative inflammatory reaction often leads to abscess formation around the foreign body, while an aseptic fibrinous response results in encapsulation within avascular fibrous tissue[4]. In some cases, the sponge may migrate into adjacent hollow viscera, causing perforation, fistula formation, or intestinal obstruction, with the small intestine being the most commonly affected site due to its extensive surface area and thin wall[5]. This case series presents three rare pelvic gossypiboma cases arising in distinct clinical contexts, post-hysterectomy, post-cesarean section, and post-orchiectomy, highlighting the varied symptomatology and anatomical complexity of retained foreign bodies (RFBs). All cases were successfully managed laparoscopically, despite dense adhesions, abscess formation, and close proximity to critical structures such as the bladder, adnexa, and ureters. These cases demonstrate the feasibility, safety, and effectiveness of laparoscopic management in complex pelvic gossypibomas, reinforcing its consideration as the preferred approach when appropriate. This report has been prepared in accordance with the PROCESS 2025 guidelines[6]. Case presentations Case 1 A 61-year-old woman presented with chronic deep pelvic pain radiating to the lumbar region, abdominal distension, intermittent diarrhea, low-grade fever, intermittent dysuria, and hematuria. She had a history of total abdominal hysterectomy performed 2 years earlier for symptomatic uterine fibroids and recurrent urinary tract infections refractory to antibiotics. On examination, her abdomen was soft with localized lower abdominal tenderness. Laboratory tests revealed WBC 18 400/mm3 and CRP 126 mg/l, with normal serum creatinine of 1.1 mg/dl; urinalysis showed numerous pus and epithelial cells. Pelvic ultrasonography demonstrated a 7 × 8 cm fluid collection with a foreign body adherent to the sigmoid colon and ileum, and contrast-enhanced CT confirmed a pelvic abscess containing a large retained gauze. After thorough counseling and informed consent, diagnostic laparoscopy was performed using three ports. Intraoperatively, a large pelvic abscess with purulent fluid and retained gauze surrounded by dense adhesions involving bowel loops was encountered (Fig. 1). During adhesiolysis, an iatrogenic bladder opening occurred and was repaired with double-layered Ethibond sutures; a suprapubic catheter was placed. The gauze was completely removed, the abscess drained, the cavity irrigated, and a 16 F drain left in place. Figure 1.: Laparoscopic view showing extraction of a large pelvic gossypiboma closely adherent to the ileum and sigmoid colon, with concurrent abscess drainage. Postoperatively, broad-spectrum IV antibiotics were administered, and recovery was uneventful; the drain was removed on postoperative day 4 and the suprapubic catheter on POD 10. Histopathology revealed chronic inflammatory changes, and a 4-year follow-up confirmed the patient remained asymptomatic and highly satisfied with the minimally invasive approach. Case 2 A 42-year-old woman presented with intermittent lower abdominal pain and distension, mainly in the suprapubic and right iliac fossa regions, associated with altered menstrual cycles and intermittent menorrhagia. She had a history of cesarean section 18 months prior. Physical examination revealed mild suprapubic tenderness without peritoneal signs. Laboratory tests showed WBC 12 600/mm3 and CRP 48 mg/l, with normal serum creatinine. Pelvic ultrasonography demonstrated a localized abscess containing echogenic material suggestive of a retained gauze adherent to the right lower anterior abdominal wall, and CT confirmed a well-encapsulated abscess with a small retained gauze. Laparoscopy revealed a fibrous mass adherent to the lower anterior abdominal wall, appendix, and right adnexa. The mass and retained gauze were excised laparoscopically, while preserving the right ovary and fallopian tube, and a concurrent laparoscopic appendectomy was performed. The pelvic cavity was irrigated, and a 16 F drain placed (Fig. 2). Figure 2.: Laparoscopic view demonstrating extraction of a right lower abdominal wall gossypibomas closely adherent to the right adnexa. The patient tolerated the procedure well; enteral feeding was resumed on POD 1, the drain was removed on POD 3, and she was discharged in good condition. Four-year follow-up showed the patient remained asymptomatic, with no recurrence, and she expressed high satisfaction with the minimally invasive approach. Case 3 A 36-year-old male presented with chronic right iliac fossa pain for several years, low-grade fever, and worsening renal function due to hypertensive nephropathy. His past surgical history included right orchiectomy 24 years earlier for an atrophic pelvic testis. Examination revealed localized tenderness in the right iliac fossa, and laboratory investigations showed WBC 11 800/mm3, CRP 39 mg/l, and elevated serum creatinine 2.1 mg/dl. Pelvic ultrasonography revealed a fluid collection with echogenic material consistent with a retained gauze, closely adherent to the right ureter and iliac vessels, causing hydroureteronephrosis; contrast-enhanced CT was contraindicated due to renal impairment. A right-sided DJ stent was placed preoperatively. Laparoscopy revealed a dense inflammatory mass with purulent fluid adherent to the right pelvic wall, ureter, and iliac vessels, and the gauze was removed in fragments without injury to surrounding structures. Incidental appendiceal inflammation was addressed with laparoscopic appendectomy, the pelvic cavity irrigated, and a 16 F drain placed (Fig. 3). Postoperative recovery was uneventful, enteral feeding was tolerated early, and the patient was discharged on POD 3. Figure 3.: Laparoscopic view showing extraction of a gossypibomas from the right pelvic wall, closely adherent to the right ureter and iliac vessels. Follow-up over 3 years showed resolution of the pelvic collection, improved renal function (creatinine 1.6 mg/dl), DJ stent removal after 4 months, and no residual gauzoma. The patient remained asymptomatic and highly satisfied with the outcome.

The term gossypiboma derives from the Latin “gossypium” (cotton) and the Swahili “boma” (place of concealment), with the first reported case described by Wilson in 1884[7]. RFBs occur more frequently in emergency operations, up to nine times higher than in elective procedures, and are four times more likely when the operative plan changes unexpectedly[8]. Notably, up to 88% of RFBs occur despite correct sponge counts. Gawande et al estimated the incidence to range from 1 in 8801–18 760 inpatient surgeries[3], while a Level I trauma center reported an incidence of 1 in 700 emergency procedures[9]. Most RFBs involve the abdomen (74%) or thorax (11%)[10]. Female predominance, particularly in gynecologic surgery, has been attributed to small incisions relative to the operative field[11], consistent with two of our cases. Risk factors include emergency surgery, intraoperative procedural changes, obesity[3], and communication failures within the surgical team[12]. Wan et al reported pain (42%), palpable mass (27%), and fever (12%) as the most common presentations, while 6% remained asymptomatic. Adhesions (31%), abscesses (24%), and fistulae (20%) were frequent complications[1]. Morbidity approaches 50%, and mortality ranges between 11 and 35%[13,14]. Our findings align with these observations, as all three patients presented with symptoms attributable to inflammatory or suppurative responses surrounding the retained sponge, consistent with reports of abscess formation and adhesion-related pain in the literature. Radiographs may reveal radiopaque markers, but these can be distorted or absent, and metallic clips may lead to false positives[15]. Typical radiographic signs include a whorled or spongiform pattern with mottled air densities. Ultrasound usually shows a heterogeneous mass with echogenic foci and posterior acoustic shadowing[16]. CT remains the most reliable modality, demonstrating a characteristic spongiform mass, encapsulation, and trapped air[16,17]. MRI aids differentiation from tumors, typically revealing a well-defined, thick-walled mass with a whorled T2 pattern[18]. These modalities were crucial in our series, where CT imaging guided diagnosis and operative planning in all patients, underscoring the indispensable role of imaging in distinguishing gossypibomas from pelvic tumors, adnexal masses, or inflammatory lesions. Prevention relies on meticulous sponge and instrument counts, use of radiopaque materials, minimizing staff turnover, and structured team communication. Four counts are recommended: when items are unpacked, before the procedure, at the start of closure, and during skin closure[3]. National and international guidelines promote standardized safety protocols, including WHO and ACS recommendations. Technologies such as barcoded sponges and radiofrequency identification (RFID) systems significantly reduce manual counting errors[19,20]. Additional measures include avoiding small sponges during laparotomies, mandatory use of radiopaque markers, thorough cavity exploration before closure, and obtaining radiographs when counts are uncertain[21,22]. RFID tagging, electronic article surveillance, and barcode tracking represent emerging strategies to further reduce RFB incidence[23]. Once diagnosed, treatment is surgical removal. Laparoscopy offers numerous advantages over laparotomy, including reduced pain, fewer wound complications, faster recovery, shorter hospitalization, and better cosmetic outcomes[24]. These advantages were clearly observed in our series, where laparoscopy allowed successful retrieval of gossypibomas despite dense adhesions and distorted pelvic anatomy. Compared with open surgery, laparoscopy provided superior visualization and access to deep pelvic compartments, minimized tissue trauma, and enabled efficient drainage of abscess collections while preserving adjacent organs. Although technically challenging in the presence of adhesions or abscesses, laparoscopy is increasingly feasible due to advanced energy devices such as the Harmonic scalpel, which allow precise dissection with minimal thermal injury. Childers et al highlighted timing as critical; laparoscopic retrieval is optimal within 1 week of the index surgery, before dense adhesions and pseudotumor formation develop[10]. Nevertheless, laparoscopy remains effective even in delayed cases and should be considered the preferred approach when the patient is stable and no organ invasion or major vascular involvement is suspected[25]. However, limitations include reduced feasibility in hemodynamically unstable patients, cases with suspected bowel perforation requiring resection, or massive adhesive disease precluding safe trocar placement. Despite these challenges, contemporary evidence and our experience strongly favor laparoscopy as the first-line approach when feasible. In comparison with the published literature, our cases reinforce multiple key themes: the essential diagnostic value of CT imaging, the feasibility and safety of laparoscopic retrieval even in complex pelvic presentations, and the ongoing importance of prevention through rigorous counting systems and adoption of modern tracking technologies. These cases demonstrate that minimally invasive management provides excellent operative and postoperative outcomes, supporting its growing role in the treatment of gossypibomas across diverse clinical settings.

Laparoscopic removal of pelvic gossypibomas complicated by abscess formation is feasible, safe, and associated with favorable recovery. This minimally invasive approach allows for complete excision of retained surgical sponges, effective abscess drainage, and preservation of adjacent structures, offering reduced perioperative morbidity, shorter hospital stay, and rapid postoperative recovery. Laparoscopy should be considered a preferred alternative to open surgery in selected patients, with preventive measures such as strict surgical counts, use of radiopaque sponges, and postoperative imaging remaining essential to avoid such complications. Ethical approval This case report does not require ethical approval because it involves a case series that are anonymized and does not include any identifiable personal information. Consent The author provides consent for publication. Written informed consents were obtained from the patients for publication of this case series and any accompanying images. Copies of the written consents are available for review by the Editor-in-Chief upon request. Sources of funding The author received no financial support for the research, authorship, or publication of this case series. Author contributions W.A.: was responsible for the conception and design of the case series, surgical management of the patients, data collection, literature review, drafting and revising the manuscript, and final approval for publication. Conflicts of interest disclosure The author declares no conflicts of interest. Guarantor Dr Wail Alqatta. Research registration unique identifying number (UIN) This is not a First-in-Man case report. The intervention described has been previously reported in the literature. Provenance and peer review Not commissioned; externally peer reviewed. Data availability statement All data relevant to the case are included in the article.

Not applicable.

1. Wan W, Le T, Riskin L, et al. Improving safety in the operating room: a systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol 2009;22:207–14. 6. Agha RA, Mathew G, Rashid R, et al. Revised Preferred Reporting of Case Series in Surgery (PROCESS) guideline: An update for the age of artificial intelligence. Premier J Sci 2025;10:100080. 9. Teixeira PG, Inaba K, Salim A, et al. Retained foreign bodies after emergent trauma surgery: incidence after 2526 cavitary explorations. Am Surg 2007;73:1031–34. 11. Sankpal J, Tayade M, Rathore J, et al. Oh My Gauze !!!- A rare case report of laparoscopic removal of an incidentally discovered gossypiboma during laparoscopic cholecystectomy. Int J Surg Case Rep 2020;72:643–46. 14. Gonzalez-Ojeda A, Rodriguez-Alcantar DA, Arenas-Marquez H, et al. Retained foreign bodies following intra-abdominal surgery. Hepatogastroenterology 1999;46:808–12. 15. Kopka L, Fischer U, Gross AJ, et al. CT of retained surgical sponges (textilomas): pitfalls in detection and evaluation. J Comput Assist Tomogr 1996;20:919–23. Thought you might appreciate this item(s) I saw in International Journal of Surgery Case Reports. Your message has been successfully sent to your colleague. Some error has occurred while processing your request. Please try after some time. Export to End Note Procite

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