History

A 2-year-old spayed female Greater Swiss Mountain Dog was evaluated because of a 1- to 2-month history of urinary incontinence and licking at the vulva. Treatment with phenylpropanolamine was partially successful, but some incontinence remained. The only known surgical procedure the dog had undergone was ovariohysterectomy at 6 months of age.

Clinical and Gross Findings

Physical examination revealed a possible mass in the caudal portion of the dog's abdomen. Important abnormalities were not detected via clinicopathologic analyses and urinalysis. Aerobic bacterial culture of a urine sample yielded no growth. Abdominal radiography revealed a mass located just cranial to the urinary bladder. Abdominal ultrasonography revealed a structure (4 × 6 cm) located cranial to and left of the urinary bladder; the structure contained fluid and was associated with strong acoustic shadowing. Results of cytologic examination of a sample of the fluid (aspirated with ultrasound guidance) were indicative of suppurative inflammation with occasional intracellular bacteria.

The dog underwent surgery, and an oval mass was found in the caudal portion of the abdomen. The mass had omental adhesions and a firm attachment to the left apex of the urinary bladder. The omental adhesions were transected, and a 2- to 3-cm-diameter area of the bladder wall was resected with the mass. The urinary bladder wall was closed routinely. After removal, the oval mass (5 × 6.5 × 7 cm) appeared to be well circumscribed and firm. On cut section, the wall of the mass was tan, firm, and fibrous with a ring of hemorrhage surrounding a soft center, which contained apparent foreign material (Figure 1). A sample was collected from the center of the mass for culture, which yielded growth of Escherichia coli and Staphylococcus pseudointermedius, both of which were susceptible to fluoroquinolones.

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Photograph of the cut surface of an abdominal mass removed from a young spayed female dog that had a 1- to 2-month history of urinary incontinence and licking at the vulva. Notice that the wall of the formalin-fixed mass is tan, firm, and fibrous and that a ring of hemorrhage surrounds a soft center.

Citation: Journal of the American Veterinary Medical Association 236, 11; 10.2460/javma.236.11.1181

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Formulate differential diagnoses from the history, clinical findings, and Figure 1—then turn the page →

Histopathologic Findings

The mass was submitted for routine processing and histologic examination. The mass was well circumscribed and had a fibrous connective tissue capsule surrounded by typical adipose tissue (Figure 2). Polarized light microscopy revealed that the center of the mass was composed of refractive foreign material, consistent with gauze sponge fibers. The fibers were surrounded by epithelioid macrophages that extended to the fibrous connective tissue. Areas of fibrin exudation and hemorrhage were present within the central cavity.

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Photomicrographs of a section of the mass removed from the dog in Figure 1. A—In this image, foreign material is surrounded by epithelioid macrophages and a fibrous connective tissue capsule. B—The foreign material appears refractive when the same area is viewed by use of polarized light. H&E stain; in both panels, bar = 50 μm.

Citation: Journal of the American Veterinary Medical Association 236, 11; 10.2460/javma.236.11.1181

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Morphologic Diagnosis

Focal granuloma with intralesional refractive foreign material (gauze sponge fibers), consistent with gossypiboma.

Discussion

The dog recovered well from anesthesia and surgery and did not develop immediate or long-term complications. Gossypibomas, also known as textilomas, are retained surgical sponges that induce a localized sterile inflammatory reaction and development of sterile abscesses, granulomas, adhesions, or fistulas. Clinical signs vary with specific localization of the lesions and can be vague, making diagnosis difficult. Gossypibomas are an uncommon and life-threatening but preventable sequela of surgery in both veterinary and human medicine. The incidence of gossypibomas in veterinary medicine has not been studied, to our knowledge, and there are only a few published reports.^1–8 A search of biopsy reports for dogs filed over an 8-year period (July 2001 to July 2009) at the Athens Veterinary Diagnostic Laboratory yielded 10 cases of gossypibomas among 89,411 biopsy specimen submissions (1 case/8,941 biopsy submissions). On the basis of mostly malpractice claims, the incidence of gossypibomas in humans has been reported to range from 1 case/1,000 inpatient operations to 1 case/18,706 inpatient operations.⁹ However, most retained sponges can be grossly identified and they are not necessarily submitted for histologic evaluation. The calculated rate of 1 case/8,941 biopsy specimen submissions at our laboratory is likely a considerable underestimation but within the range reported for people. Underestimation in human medicine is attributable to a combination of a low reporting rate (because of legal implications) and frequent out-of-court settlement.^9,10

To reduce the incidence of retained foreign bodies, the American College of Surgeons has an official position statement recommending consistent application and adherence to standardized counting procedures, use of radiographically detectable items, and use of radiography or other technological applications (eg, barcode tracking and radiofrequency identification [RFID] systems) as indicated.¹¹ Although use of radiopaque sponges has helped to decrease the incidence of gossypibomas, there are limitations to this preventative measure.¹² Sponges may be difficult to impossible to detect on a single radiographic view, especially if the x-rays must also pass through denser tissue such as bone.¹⁰ Radiopaque markers may be distorted by folding, twisting, or disintegration over time.¹⁰ More importantly, radiographic views are often obtained after completion of surgery; a second surgical procedure is required to remove a retained sponge, and the patient is at repeated risk for surgical complications, including infection.¹² Marking of sponges with RFID tags is reliable, and the tags can be accurately detected through the skin of a human patient during or immediately after surgery, even while wet with blood.¹² The use of RFID-tagged sponges in veterinary species, which often have variably thick skin and fur, has not been evaluated to our knowledge.

As highlighted by the case of this report, retained sponges that are not radiopaque can potentially be identified in dogs via routine radiography as well as via ultrasonography. In a study⁸ of 8 dogs with retained surgical sponges, radiography revealed localized areas of radiolucency that had a speckled or whirl-like gas appearance in 5 dogs; radiolucent areas were associated with an abdominal mass in 3 of those dogs. Ultrasonographically, a retained sponge in dogs or humans can appear as a hypoechoic mass with irregular hyperechoic center^6,8; however, unlike the ultrasonographic appearance of an intestinal neoplasm, the hyperechoic center is not continuous with the intestinal lumen.⁸ In the dog of this report, the ultrasonographic findings were similar to those described previously for dogs with gossypibomas,⁸ and the strong acoustic shadowing was suggestive of foreign material. In 1 report⁶ of a cat with an abdominal granuloma secondary to a retained surgical sponge, similar radiographic and ultrasonographic findings were described.

In humans and other animals, a gossypiboma should be considered as a cause of unresolved or unusual problems that develop after surgery and can be diagnosed by use of a combination of radiography, ultrasonography, and gross and histologic examinations of lesions. In human and veterinary medicine, the consistent use of patient safety practices (eg, radiopaque sponges) and standardized instrument and sponge counting during surgery is recommended to reduce the postoperative incidence of retained foreign bodies.