ArticlePatient safety in surgery2024
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.
Article in Patient safety in surgery, 2024. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 3 papers.
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Who cites it
3 citing papers in PubMed.
- Chronic gossypiboma mimicking a peri-appendiceal abscess after prior Cesarean sections: a rare surgical "never event".Patient safety in surgery · 2025Article
- Unintentionally retained surgical gauze presenting as chronic infected fistula to the surgical wound: a report of two cases.Patient safety in surgery · 2025Article
- Chronically retained gauze (gossypiboma) resembling a mature cystic teratoma after Cesarean delivery: a case report.Patient safety in surgery · 2025Article
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7 authors.
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Abstract
introductionThis case report reports an unusual occurrence of gossypiboma, which refers to the accidental retention of surgical materials like sponges in the peritoneal cavity. The term is derived from "gossypium" (cotton) and "boma" (place of concealment). Its incidence varies with surgical type, posing diagnostic challenges due to nonspecific symptoms and equivocal imaging. Despite its rarity, gossypiboma poses significant risks, including intestinal obstruction and abscess formation. CASE PRESENTATION: A 37-year-old woman with ten previous pregnancies and an emergent caesarean section presented with abdominal pain. Examination and ultrasound suggested an ovarian cyst. During surgery, a 10 × 10 cm gauze-filled mass adherent to the ovary and jejunum was found. Postoperatively, she recovered well with no complications. The patient was treated with intravenous fluids and antibiotics for five days post-surgery and recovered without any complications. She was discharged from the hospital five days after the procedure.
conclusionTo the best of our knowledge, this is the first reported case of gossypiboma in Sudan in 2024, highlighting diagnostic challenges and the need for preventive protocols. Root cause analysis of accidents, enhanced training, application of advanced technologies and a collaborative culture in the operating room can prevent the occurrence of such incidents. This case underscores the importance of meticulous surgical protocols and continuous improvement in safety measures to prevent retained surgical items, ensuring patient safety and optimal outcomes.
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