Forgetting a surgical sponge inside a veterinary patient is a taboo yet all-too-common situation. Because of blatant underreporting, reliable statistics do not exist in veterinary surgery, and few are available in human surgery.
Sponge retention is a risk any time sponges are used in surgery, regardless of the procedure. Since retained sponges were first described in human surgery in 1884, they remain the most common accidentally retained surgical foreign bodies. This can lead to many complications after surgery, not to mention the potential of resulting medicolegal implications. Understanding the reasons for sponge retention can help you devise strategies to avoid this embarrassing pitfall.
Small sponges, especially when soaked in blood, can be difficult to see in the surgical field. Not discarding used sponges immediately increases this risk.
In deeper surgical areas, such as thoracic or abdominal body cavities, the use of small sponges creates an unnecessary risk of retention because they easily may become lost in the process. Also, using free small sponges without first attaching them to a hemostat or sponge forceps increases this risk.
Phil Zeltzman, DVM, DACVS, CVJ
A retained lap sponge attached to the jejunum seven years after a spay.
Another risk factor is not knowing how many sponges are included in a surgical pack or a sponge pack. While counting sponges after surgery is a great way to minimize the risk of retention, this practice is pointless if the initial number is unknown.
In human surgery, sponges are retained an estimated once in every 1,000 laparotomies. This number, however, is likely underestimated due to the reluctance to report such complications. While retained sponges cause no clinical signs in roughly one-third of cases, some may remain dormant for many years. One case involved a sponge recovered 19 years after the presumptive causative surgery.
Referred to commonly as gossypibomas, retained sponges also are known as textilomas or gauzomas. Retained sponges are not decomposed or absorbed by the body, so two main types of foreign-body reactions result. The first is a classic foreign-body granuloma that tries to wall off the gauze. The second is exudation and abscess formation, usually complicated by bacterial invasion.
Clinical manifestations of gossypibomas depend on the location in the body and the extent of bacterial contamination. Some complications documented in human and veterinary surgery include delayed healing, adhesions, fistulas, sinus tracts, pseudo-cysts, pseudo-tumors, pseudo-hematomas, erosion into adjacent viscera and hemorrhage secondary to vessel erosion.
Several human reports describe compete transluminal migration. This amazing situation involves a sponge that was retained inside the abdomen but outside the intestine. The sponge migrates through the intestinal wall, goes down the intestine and is eventually expelled through the natural route. Also available are case reports of osteomyelitis, in which a retained sponge was incorporated into the bone and could not be removed completely.
Diagnosing a gossypiboma is not easy, especially if the sponge does not contain a radiopaque marker. Clinical signs again depend on the location and the physical disturbances caused. This may include a palpable mass, abscess, pain at the surgical site, fever, vomiting, peritonitis, ileus or signs of sepsis.
Survey radiographs show that retained sponges can have various appearances. Most times, a characteristic whirl-like configuration is caused by the presence of gas trapped between the sponge fibers. Calcification may occasionally be seen, depending on the body’s reaction to the sponge. While a radiopaque marker can help immensely in finding a retained sponge, these may be hidden beneath overlying bony structures. It is therefore recommended to take at least two orthogonal radiographs when searching for a retained sponge.
Upper gastrointestinal barium series or barium enemas may help in locating sponges in the GI tract. Sinograms or fistulograms may be useful in fistulous or sinus tracts. The gauze network becomes filled by the contrast material. Ultrasonography, CT and MRI are helpful, depending on the properties of the retained sponge and the presence of gas or fluids inside of it.
Treatment of a retained sponge involved exploratory surgery and removal of the gossypiboma. It may require excision of an organ the sponge is attached to, such as part of the intestine. Acute awareness of the risk of forgetting a surgical sponge in a body cavity is critical at every moment of every surgery. Taking simple precautions will help decrease or eliminate the risk of retained surgical sponges.
Phil Zeltzman, DVM, DACVS, CVJ
Proper use of lap sponges under a Balfour retractor (ovarian tumor).
10 Ways to Prevent Retained Surgical Sponges
- Always know how many sponges are present in a surgical pack or sponge pack.
- Before and after surgery, count sponges to ensure that none are missing.
- During surgery, survey the surgical field routinely for sponges.
- Take care when using sponges for packing off as these sponges can easily become hidden in blood or lost under surrounding tissues.
- Do not leave dry or used sponges near the surgical field or on surgical drapes.
- Discard used sponges as soon as possible.
- Never use free small sponges inside body cavities.
- Inside body cavities, attach sponges to sponge forceps or a hemostat.
- In thoracic and abdominal surgery, use sponges with radiopaque markers or ribbons.
- In thoracic and abdominal surgery, use large laparotomy sponges instead of smaller gauze sponges.
Avoid Pinching Pennies
Don’t be stingy with gauze squares. The medical and legal consequences of forgetting a sponge vastly outweigh the cost of a humble gauze square. How much one costs depends on the size, type and quality of the sponge. It also depends on your supplier.
Here are rough guidelines for nonsterile sponge prices:
- A 4-by-4-inch gauze square should cost less than 10 cents.
- A 12-by-12-inch laparotomy sponge should cost less than 50 cents.
Food for thought.
Dr. Phil Zeltzman is a board-certified veterinary surgeon and author. His traveling practice takes him all over Eastern Pennsylvania and Western New Jersey. You can visit his website at www.DrPhilZeltzman.com, and follow him at www.facebook.com/DrZeltzman.
Zee Mahmood, a veterinary student at the St. Matthew’s University School of Veterinary Medicine, contributed to this article.
Originally published in the March 2016 issue of Veterinary Practice News. Did you enjoy this article? Then subscribe today!