AJR 2003; 180:481-489
© American Roentgen Ray Society
Imaging of Retained Surgical Sponges in the Abdomen and Pelvis
Angus R. O'Connor1,
Fergus V. Coakley2,
Maxwell V. Meng3 and
Stephen Eberhardt4
1 Department of Radiology, Nottingham City Hospital, Hucknall Rd., NG5 1PB,
Nottingham, United Kingdom.
2 Department of Radiology, University of California San Francisco, Box 0628,
M-372, 505 Parnassus Ave., San Francisco, CA 94143-0628.
3 Department of Urology, University of California San Francisco, San Francisco,
CA 94143-0628.
4 Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York
Ave., New York, NY 10021.
Received June 6, 2002;
accepted after revision July 9, 2002.
Address correspondence to F. V. Coakley.
Introduction
Retention of surgical sponges or swabs in the abdomen or pelvis occurs with
a frequency of one in 100-5000 operations and accounts for 50% of malpractice
claims for retained foreign bodies
[1,
2]. A retained surgical sponge
or swab is also known as a gossypiboma, derived from gossypium
(Latin, cotton) and boma (Swahili, place of concealment). Clinically,
retained sponges may be asymptomatic or result in a granulomatous response
with abscess development, intestinal obstruction, or fistula formation.
Radiologically, gossypibomas may be confused with postoperative collections or
tumors, particularly with the increasingly common surgical use of absorbable
hemostatic materials to control hemorrhage. To provide an accurate
interpretation, radiologists need to be familiar with the imaging findings of
both inadvertent and intentional postoperative surgical sponges. The aim of
this pictorial essay is to provide an updated review of the radiologic
findings of retained surgical sponges in the abdomen and pelvis.
Radiography
Radiographs are the most commonly used method to detect retained sponges.
One cannot rely on the clinical history to indicate the correct diagnosis; a
normal sponge count does not exclude the possibility of a retained sponge. In
one series, the sponge count was reported as correct in 22 (76%) of 29
patients with retained sponges in the abdomen
[2]. Most sponges are
detectable because of an incorporated radiopaque marker (Figs.
1A,1B,2,3A,3B,4).
The body of the sponge itself may be faintly radiodense on ex vivo radiographs
but is unlikely to be seen in vivo (Figs.
1A,1B,2,3A,3B,4).
Intraoperative or portable early postoperative radiographs may be of
suboptimal quality, and hot lighting of hard-copy radiographs or digital
magnification and manipulation of soft-copy images may facilitate detection
(Fig.
5A,5B).
The adequacy of the field of view should also be evaluated, with particular
attention to partially imaged sponges at the periphery of the image (Fig.
6A,6B).
In cases complicated by fistula formation, radiographic contrast material
instillation may be helpful to define the anatomy and extent of the
abnormality (Fig.
7A,7B).
Not all sponges have visible radiopaque markers. In one series, three of 29
retained sponges lacked a visible radiopaque marker
[2]. Sponges without visible
radiopaque markers may be identified by radiographic visualization of mottled
radiolucencies, presumably due to air trapping
[3], or by cross-sectional
imaging.
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Fig. 1B. —Photographic and radiographic appearances of typical
laparotomy sponge. Radiograph of laparotomy sponge shown in A reveals
that body of sponge is only faintly radiopaque, but marker (arrow) is
easily seen.
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Fig. 2. —Abdominal radiograph obtained 5 days after surgical formation
of antegrade continence enema (ACE Malone
[10]) mechanism because of
prolonged ileus in 10-year-old boy with spina bifida. Radiopaque marker
(arrow) of laparotomy sponge is visible in right lower quadrant.
Sponge was successfully removed by laparoscopy.
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Fig. 3B. —Photographic and radiographic appearances of 4 x 4 inch
(10 x 10 cm) surgical sponge. Radiograph of surgical sponge shown in
A reveals that body of sponge is only faintly radiopaque, but marker
(arrow) is easily seen.
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Fig. 4. —Intraoperative radiograph obtained because of incorrect
sponge count in 54-year-old woman who underwent urethral suspension.
Radiopaque marker (arrow) of 4 x 4 inch (10 x 10 cm)
laparotomy sponge is visible in pelvis. Sponge was identified and removed.
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Fig. 5A. —Value of soft-copy image manipulation is illustrated in
radiographs obtained because of incorrect sponge count in 24-year-old woman
who underwent cesarean delivery. Original image settings result in generally
underpenetrated radiograph, and questionable density (arrow) is
faintly identified over left sacral ala.
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Fig. 5B. —Value of soft-copy image manipulation is illustrated in
radiographs obtained because of incorrect sponge count in 24-year-old woman
who underwent cesarean delivery. Radiograph shows that after digital
manipulation of window width and window level, marker (arrow) of 4
x 4 inch (10 x 10 cm) sponge is identified.
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Fig. 6A. —Importance of scrutinizing periphery of image is illustrated
in radiographs obtained in 62-year-old woman after abdominal aortic aneurysm
repair. Initial radiograph shows partially imaged laparotomy sponge marker
(arrow) at edge of image.
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Fig. 6B. —Importance of scrutinizing periphery of image is illustrated
in radiographs obtained in 62-year-old woman after abdominal aortic aneurysm
repair. Second radiograph centered to include more of left side of abdomen
shows three additional sponge markers (arrow). Sponges were
surgically removed.
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Fig. 7A. —Retained sponge in 30-year-old woman after right
hemicolectomy and partial small-bowel resection for Crohn's disease.
Fistulograms were requested 2 weeks after surgery because of wound dehiscence
and discharge. Image shows contrast material flowing into small opening in
lower part of wound and fistula passing superiorly around marker (straight
arrow) of retained 4 x 4 inch (10 x 10 cm) surgical sponge,
ending in communication with biliary tract, and draining to duodenum
(curved arrow).
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Fig. 7B. —Retained sponge in 30-year-old woman after right
hemicolectomy and partial small-bowel resection for Crohn's disease.
Fistulograms were requested 2 weeks after surgery because of wound dehiscence
and discharge. Magnified image of retained sponge shown in A reveals
sponge marker in greater detail.
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CT
On CT, retained sponges are typically seen as a soft-tissue density mass
and may show a whorled texture or a spongiform pattern with contained gas
bubbles [4]. Sterile gas
bubbles may be persistent and can still be seen at 6 months after placement of
surgical sponges in bath water
[5]. Inspection of the scout
radiograph may be helpful (Fig.
8A) because beam-hardening artifacts on the axial images may make
the characteristic appearances of the marker less obvious
(Fig. 8B). A retained sponge
should not be misinterpreted as fluid collection, although adjacent abscess
formation may be seen (Fig.
9A,9B,9C).
The described CT appearances of absorbable hemostatic sponges, which may be
made of gelatin sponge (Gelfoam; Pharmacia and Upjohn, Kalamazoo, MI) or
oxidized reabsorbable cellulose (Surgicel; Ethicon, Somerville, NJ)
(Fig. 10), are of mixed or
low-attenuation masses containing focal central collections of gas
[6,
7] (Figs.
11 and
12), although we have also
observed peripheral gas collections (Fig.
13). Abscess formation can coincidentally complicate a surgically
packed operative site [7];
therefore, the knowledge that absorbable hemostatic sponges have been used
should not deter the radiologist from further investigation in the appropriate
clinical setting. Differentiation of absorbable hemostatic sponges from other
surgical sponges is facilitated by the usual presence of a radiopaque marker
in the latter. The use of absorbable sponges varies with local surgical
practice, but they are typically used by urology, gynecology, or general
surgeons to arrest bleeding or oozing that cannot be controlled by
suturing.
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Fig. 9A. —Retained sponge in 69-year-old man 4 weeks after aortofemoral
bypass. Radiograph obtained to check position of feeding tube shows marker
(arrow) of retained laparotomy sponge in central abdomen.
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Fig. 9C. —Retained sponge in 69-year-old man 4 weeks after aortofemoral
bypass. Axial CT image obtained at level inferior to B shows fluid
collection (arrow). Sponge was removed surgically, and adjacent
collection was drained and found to be an abscess.
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Fig. 11. —CT scan obtained because of fever 3 months after bilateral
salpingo-oophrectomy for tuboovarian abscess in 43-year-old woman. Axial CT
image shows ill-defined soft-tissue density mass (arrow) with mottled
lucent center in left lower quadrant. Review of operative note confirmed
absorbable hemostatic sponge (Gelfoam, Pharmacia and Upjohn, Kalamazoo, MI;
Surgicel, Ethicon, Somerville, NJ) had been used to control bleeding in left
pelvis. Mass was considered to represent residual absorbable sponge and
gradually resolved on subsequent serial CT scans (not shown).
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Fig. 12. —CT scan obtained because of fever 8 days after total
abdominal hysterectomy, bilateral salpingo-oophrectomy, and debulking of stage
III ovarian cancer in 43-year-old woman. Mixed gas, fluid, and soft-tissue
density mass (arrows) with appearance similar to bowel are seen in
right pelvis, but no communication with bowel could be established on
contiguous images (not shown). Review of operative note confirmed absorbable
hemostatic sponge (Surgicel; Ethicon, Somerville, NJ) had been used to control
bleeding in pelvis. CT-guided aspiration yielded sterile serosanguineous
fluid. Mass was considered to represent residual absorbable sponge.
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Fig. 13. —CT scan obtained because of pain 5 days after total abdominal
hysterectomy for leiomyomata in 35-year-old woman. Mixed gas, fluid, and
soft-tissue density mass (arrows) are seen in central pelvis. Review
of operative note confirmed absorbable hemostatic sponge (Gelfoam; Pharmacia
and Upjohn, Kalamazoo, MI) had been used to control bleeding in pelvis. Mass
was considered to represent residual absorbable sponge and was not visible on
CT scan obtained 6 weeks later.
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MR Imaging
On MR imaging, a retained sponge is typically seen as a soft-tissue density
mass with a thick well-defined capsule and as a whorled internal configuration
on T2-weighted imaging [8]
(Fig.
14A,14B).
The MR imaging appearances of retained absorbable hemostatic sponges have been
described in a series of five patients
[9] and consist of intermediate
T1 and high T2 signal intensity. A complex mixed signal internal pattern
similar to the whorled appearance of other retained surgical sponges may be
seen on T2-weighted images, as may an increased signal peripheral zone on
T1-weighted images.
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Fig. 14A. —MR images of retained sponge obtained in 56-year-old man who
complained of urinary frequency 5 months after radical retropubic
prostatectomy. Axial spin-echo T1-weighted MR image (TR/TE, 500/15) after
injection of contrast material shows that sponge is identified as low-signal
structure anterior to contrast-filled bladder. Peripheral enhancement of
thick-walled capsule (arrow) is noted.
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Fig. 14B. —MR images of retained sponge obtained in 56-year-old man who
complained of urinary frequency 5 months after radical retropubic
prostatectomy. Axial fast spin-echo T2-weighted MR image (4000/105) shows
"whirled" configuration of sponge body (arrow). Sponge
was surgically removed.
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Conclusion
Awareness of the typical radiologic appearances is critical to the
diagnosis of retained surgical sponges or swabs. Inadvertently retained
sponges are often clinically unsuspected and may be first recognized by
imaging. A high index of suspicion is required because a history of an
incorrect sponge count is frequently lacking and because a radiopaque marker
is not always visible. CT or MR imaging may be helpful in problematic cases.
Radiologists need to be aware that intentional placement of absorbable
hemostatic sponges is an increasingly common surgical technique because these
sponges may mimic an abscess or collection on CT performed after surgery.
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Introduction
Radiography
