ArticlePatient safety in surgery2017
Incidence, root cause, and outcomes of unintentionally retained intraabdominal surgical sponges: a retrospective case series from two hospitals in Togo.
Article in Patient safety in surgery, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 7 papers.
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Who cites it
7 citing papers in PubMed, 17 citations in OpenAlex.
- The illusion of malignancy: a rare case of post-hysterectomy gossypiboma misinterpreted as ovarian cancer.International journal of surgery case reports · 2026Article
- Gossypiboma following cesarean section presenting as acute abdomen and sepsis: a case report.Annals of medicine and surgery (2012) · 2025Article
- Unintentionally retained lap sponge mimicking an ovarian cyst two years after Caesarean section in a 37-year old patient: case report of a rare "never event" in Sudan.Patient safety in surgery · 2024Article
- Article
- Delayed intestinal obstruction from an unintentionally retained surgical gauze in a 24-year old woman two years after caesarean section: a case report.Patient safety in surgery · 2023Article
- Retained surgical item (Gossypiboma): a case report and literature review.Annals of medicine and surgery (2012) · 2023Article
- The sucked surgical sponge: Rare case of Gossypiboma after vaginal hysterectomy.Clinical case reports · 2019Article
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Authors and funding
4 authors at 1 institution in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundThe term gossypiboma refers to a sponge that has been forgotten in the surgical field. It is the most common retained surgical item, and constitutes a continuing problem for surgical safety. We performed a hospital-based study to examine their incidence, root cause, and outcomes, as an effort toward improving prevention.
methodsThis retrospective study covered 10 years (2006-2015) and included surgically confirmed cases of abdominal gossypibomas occurring after 45,011 abdominal and gynaecological operations in 2 public hospitals in Lome (Togo). Age, diagnosis, initial surgical procedure, evidence of textile count, and data related to the revision procedure were collected for descriptive analysis.
resultsFifteen cases of gossypibomas (11 women and 4 men) were recorded. The mean age of the patients was 27 (range 21-55) years. Initial procedures were gynaecological in 11 patients and 5 cases involved an emergency surgery. Evidence of sponge counting was found in 6cases. Gossypiboma was an incidental finding in 1 patient. The average time to onset of symptoms after the initial procedure was 2 months. The gossypiboma was removed within 7 days to 4 years after the initial procedure. Postoperative complications included enterocutaneous fistula in 2 patients, incisional hernia in 2 patients, and wound sepsis in 1 patient. Death occurred in 2 patients (13.3%).
conclusionsAlthough rare, the incidence of gossypibomas is still unacceptably high and reveals failures regarding patient safety standards. The associated morbidity and mortality are significant, yet can be reduced by an early diagnosis in the immediate postoperative period. A systematic methodical count of sponges is the cornerstone of prevention, and introducing surgical safety protocols, such as the WHO Safe Surgery Saves Lives checklist, can enhance effectiveness. There is a crucial need for safety-focused policies, which may include a never event reporting system, elaboration of prevention strategies, interventions, and evaluation.
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