Chronic gossypiboma mimicking a peri-appendiceal abscess after prior Cesarean sections: a rare surgical “never event”

Abstract

Gossypiboma, a retained surgical sponge, is a rare but serious “never event.” It poses a significant diagnostic challenge due to its nonspecific and variable clinical presentation, which often mimics other conditions like intra-abdominal abscesses or tumors. A 34-year-old woman with a history of two previous Cesarean sections presented with abdominal pain and vomiting. Physical examination revealed a firm, tender mass in the right iliac fossa. An ultrasound suggested a diagnosis of acute appendicitis with a peri-appendiceal abscess. During diagnostic laparoscopy, a large inflammatory mass adherent to the cecum and terminal ileum was found, leading to conversion to open laparotomy. The mass was excised and found to be a Gossypiboma; a retained surgical sponge encased in a thick fibrous capsule. An appendectomy was performed, and the patient had an uneventful postoperative recovery. This case underscores two critical points in clinical practice. First, a high index of suspicion for gossypiboma is essential in any patient with a prior surgical history who presents with an unexplained mass or pain, as it can mimic common conditions like complicated appendicitis. Second, and more importantly, this represents a profound failure in operative safety protocols. The occurrence of a retained surgical item is universally classified as a preventable “never event,” highlighting a breakdown in systematic safeguards rather than merely an individual error. The ultimate goal must be prevention through a multi-faceted strategy. This includes rigorous adherence to manual sponge counts, the integration of technological adjuncts such as radio-frequency tagged sponges, and the cultivation of a meticulous safety culture within the operating room to protect patients from this avoidable harm.