Gossypiboma: a rare cause of chronic vaginal discharge after laparoscopic hysterectomy.

To cite: Nigam A, Kumari A. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014206635 DESCRIPTION A 47-year-old woman presented with chronic vaginal discharge for the last 1 year. She had a laparoscopic hysterectomy 1 year earlier for fibroid uterus. The patient was asymptomatic until 1 month postsurgery, when she developed foul smelling vaginal discharge. She received antibiotic treatment along with vaginal pessaries providing minimal relief. Her abdominal ultrasound was unremarkable. Speculum examination revealed a small pus discharging sinus at the vaginal vault. Vaginal examination revealed induration and mild pain at the vaginal vault. Pus culture sensitivity revealed staphylococcus infection, which was treated accordingly; however, the discharge persisted. Her ultrasonography was unremarkable. A CT scan (figure 1) revealed a 3.5 cm rounded wall lesion present in relation to the rectosigmoid junction with peripheral enhancement and air loculi within, suggestive of a gossypiboma or abscess. The patient was taken for laparoscopy in view of the possibility of retained gauze from her earlier laparoscopy, but nothing was found at the vault. A probe was inserted into the sinus site from the vagina and the sinus was dilated; the opening was extended to one side with a knife, revealing a small gauze piece, which was taken out and the incision site closed. The patient responded well to treatment. There are numerous cases where surgical sponges have been reportedly left behind after open surgery but it is rare to find sponges left after laparoscopic surgeries as these are generally not used in laparoscopic surgeries. It is postulated that while closing the vaginal vault from the vaginal side a small gauze piece must have been used to achieve haemostasis by compression and forgotten about. As most large sponges are radio opaque, they can be picked up on routine X-ray, but small gauze pieces used in surgeries, especially vaginal surgeries, are not radio opaque and thus cannot be picked up by routine X-rays. A CT scan is the most important diagnostic modality for the evaluation of retained sponges; it shows a rounded mass with a dense central part and an enhancing wall. It may also show trapped air bubbles and cystic masses. It has been observed that the main factors causing retention of foreign bodies are emergency surgery, unplanned change in mode or type of surgery and a high body mass index. Surgeons should use small gauze pieces carefully after opening the abdominal cavity or if they are performing vaginal surgery, especially once the pouch of douglas is opened. The use of radiologically opaque sponges is recommended in the surgical site and, while closing the surgical site, methodical examination and counting of instruments and sponges is mandatory. It is recommended that an instrument and sponge count be performed before as well as after surgery by two staff members.