The retention of gauze swabs in the peritoneal cavity is an infrequent but avoidable medical error. It can lead to serious morbidity and even mortality because it is not anticipated and is frequently misdiagnosed. Retained surgical sponge should be considered in the differential diagnosis of any postoperative patient with unresolved or unusual problems [1,2].

A 31-year-old woman presented to our surgical clinic in Prince Zaid Bin Al-Hussein Hospital in April 2001 with an upper abdominal mass that had been noticeable for several months.

The patient had undergone laparotomy and splenectomy 2.5 years earlier in October 1998 due to internal bleeding from a ruptured spleen after blunt abdominal trauma. This procedure was performed by the surgical team present in the hospital at that time. Sponge-counting measures are, and were, routinely performed before and after each procedure in the operating rooms in the hospitals of the Royal Medical Services and only X-ray detectable sponges are used. The patient had a smooth postoperative course until she presented with the abdominal mass.

After removal of the sponge, the patient recovered well and was followed-up in the clinic for about 2 years, during which time she remained in good health and was satisfied with the results of surgery.

The actual incidence of surgical sponge retained at operation is difficult to estimate but has been reported to be 1 in every 3000 procedures [3]. This inadvertent complication most frequently occurs after gynaecological and upper abdominal surgical procedures [3,4].

The preoperative diagnosis of a retained gauze swab is difficult and requires skill and experience in the analysis of the investigations performed for the patient [2]. Patients with forgotten intraperitoneal foreign bodies may present with pseudotumour (gossypiboma) [5,6], intestinal obstruction, erosion into the bowel or vessels, fistula formation or septic syndrome [2,7]. The interval between the operation and the development of symptoms in patients with retained swabs varies from a few days up to 28 years reported in a female patient aged 70 years following ureterolithotomy [3]. In our case the presentation was as pseudotumour and the interval was 2.5 years after the first operation (splenectomy).

If a patient makes a complaint about a surgical error the procedure at this hospital is as follows. The hospital will form a committee with at least two expert specialist physicians to investigate the doctor(s) and the staff nurses who performed the surgery and to decide the appropriate steps to take depending on the magnitude of complications. Penalties range from a discount in salary to a delay in promotion or both. In our case, there was no complaint from the patient or her family and they were thankful to the group of doctors who saved the patient’s life in the first operation and to the group of doctors who discovered and removed the foreign body from the abdomen without any further complications.

Despite the rarity of reports of retained surgical sponge, operating teams should take care to count swabs used in all procedures at risk for retained sponge and use only gauze swabs with radio-opaque markers. In addition, the surgeon should not unquestioningly accept correct count reports but should develop the habit of performing a brief but thorough routine postoperative wound and cavity exploration before wound closure.

7. Ibrahim IM. Retained surgical sponge. Surgical endoscopy, 1995, 9(6):709–10.