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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 2  |  Issue : 1  |  Page : 33-36

Gossypiboma in the scrotum with unusual cutaneous manifestations


Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna state, Nigeria

Date of Web Publication22-Sep-2012

Correspondence Address:
Ahmed Muhammed
Division of Urology, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.101270

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  Abstract 

Background: Gossypiboma is retained cotton gauze in a patient after a surgical procedure. It is generally rare with incidence ranging between 1 per 1000 and 1500. Retained gauze in the scrotum is even rarer. Gossypiboma has occurred in virtually every surgical procedure despite taking adequate precautions and performing routine gauze count. The use of radio-opaque markers and radiofrequency tags on gauze is hoped to prevent the occurrence and aid in its detection.
Case Report: A 65-year-old man presented with scrotal swelling, scrotal and groin skin nodular lesions 9 months after bilateral hydrocelectomy for vaginal hydrocele. Clinical evaluation revealed bilateral hemiscrotal swellings with a thickened hyperkeratotic skin, and multiple, firm, non-tender, nodular growths on the scrotum, groin, and mons-pubis. The enlarged scrotum contained a firm non-tender mass. The phallus was edematous and tortuous. He was also found to have metastatic carcinoma of the prostate. Scrotal ultrasound scan showed bilaterally enlarged testes with distorted echo pattern and a few abscess cavities. Multiple biopsies of the groin and scrotal nodular lesions showed non-specific chronic inflammation with no evidence of malignancy. The cause of the scrotal and groin lesions could not be determined before surgery. He had orchidectomy and scrotoplasty during which gauze was found in the scrotum.
Conclusion: Retained gauze in the scrotum is uncommon. Our patient presented with unusual cutaneous lesions, making the diagnosis very difficult. Foreign body reaction should be considered as a possible cause of unusual skin lesions when seen around a site of previous surgery.

Keywords: Gauze, scrotum, skin lesions, surgical


How to cite this article:
Hussaini MY, Muhammed A, Ahmad B, Hafeez AO, Hycinth MN. Gossypiboma in the scrotum with unusual cutaneous manifestations. Arch Int Surg 2012;2:33-6

How to cite this URL:
Hussaini MY, Muhammed A, Ahmad B, Hafeez AO, Hycinth MN. Gossypiboma in the scrotum with unusual cutaneous manifestations. Arch Int Surg [serial online] 2012 [cited 2019 Nov 15];2:33-6. Available from: http://www.archintsurg.org/text.asp?2012/2/1/33/101270


  Introduction Top


Gossypiboma or textiloma is retained cotton gauze in a patient after a surgical procedure. It is generally rare, though underreported mainly due to medico-legal reasons. However, some studies have reported the incidence to be between 1 per 1000 and 1500 operations. [1],[2] The commonest type of retained surgical gauze is the intraperitoneal type following laparotomy. [3] Retained gauze in the scrotum is very rare because of the superficial nature of the scrotum and easy and direct access to every part of it. [4] In our literature search on scrotal gossypiboma we only found one reported case, [4] but we believe it is by no means the only one as many might have gone unreported. Clinical manifestations of retained gauze are either early or late depending on the type of foreign body reaction. We present a patient with retained surgical gauze in the scrotum 9 months after hydrocelectomy manifesting with unusual cutaneous lesions causing diagnostic dilemma.


  Case Report Top


The patient was a 65-year-old man, referred from a general hospital to the urology outpatient clinic of our hospital. He presented with a 9-month history of slowly progressive scrotal swelling, 3 weeks after bilateral hydrocelectomy for a vaginal hydrocele in the referring hospital. The swelling was initially painful, but after a few weeks it settled to a mild ache and a sinus discharging scanty purulent fluid was noticed at this time. He subsequently noticed thickening of the scrotal skin with painless nodular growths of varying sizes extending to the skin of the mons-pubis and groin. There were no similar lesions in any other part of the body. He also had predominantly irritative lower urinary tract symptoms.

Examination revealed a well-preserved man; he had symmetrical bilateral hemiscrotal swelling with a thickened hyperkeratotic skin, and multiple, firm, non-tender, skin-covered, nodular growths of varying sizes on the scrotum, groin, and mons-pubis. There was a discharging sinus on the anterior surface of the scrotum in the midline, the posterior surface of the scrotum was free of lesions, and the skin appeared normal. The phallus was edematous and tortuous [Figure 1]. Digital rectal examination was suggestive of prostate cancer. A diagnosis of prostate cancer with scrotal and groin lesions was made. The lesions were thought to be either an unusual site of prostate cancer metastasis, Kaposi's sarcoma, retroviral skin lesions, or filarial lymphedema.
Figure 1: Scrotal and groin nodular lesions with a single discharging sinus on the scrotum

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Scrotal ultrasound scan showed bilaterally enlarged testes with distorted echo pattern and a few abscess cavities. Abdominal ultrasound scan showed metastatic lesions in the liver. Prostate-specific antigen was elevated and transrectal ultrasound (TRUS) showed an enlarged prostate with hypoechoic lesions in the peripheral zone. This necessitated prostate biopsy and it yielded a malignant histology. Filarial worms could not be demonstrated on blood film, and because of the suspicion of Kaposi's sarcoma, HIV screening was done which turned out to be negative. Multiple biopsies of the groin and scrotal nodular lesions showed non-specific chronic inflammation with no evidence of malignancy on histology. We could not arrive at the cause of the bizarre scrotal and groin lesions prior to exploration.

Patient was scheduled for scrotoplasty and bilateral subcapsular orchidectomy as part of palliation for the advanced cancer of the prostate. Intraoperatively, the thickened scrotal skin was very difficult to incise and there were a few pockets of scanty abscess collection. In addition, a piece of surgical gauze was found buried in the scrotum, surrounded by dense adhesions walling it off with thick purulent fluid, and a tract continuous with the single sinus on the scrotal skin [Figure 2]. Bilateral subcapsular orchidectomy was performed. The diseased scrotal skin was excised along with the underlying fibrotic dartos tissue. Scrotoplasty was effected with the residual unaffected posterior scrotal skin [Figure 3]. The patient did well postoperatively.
Figure 2: The single gauze found intraoperatively is held by forceps

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Figure 3: Final appearance after completion of procedure

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  Discussion Top


Gossypiboma or textiloma describes the inadvertent retention of cotton sponge in a patient following a surgical procedure. The incidence is generally underestimated due to several factors; underreporting because of the medico-legal implications, some patients remain asymptomatic and never present to the hospital, and the estimated incidence is calculated with the denominator that includes a large number of procedures with very low incidence of retained gauze. [5] From several published data, the incidence has been estimated to be between 1 in 1000 and 1500 operations on average. [1],[2] The commonest type is the intraperitoneal type after laparotomy; however, it has been reported virtually in all operations in every part of the body, including limbs, [6] brain, tooth canal, and as in the case presented here, the scrotum. [4]

It is difficult to make a preoperative diagnosis of gossypiboma because of the non-specific nature of its clinical manifestations and radiological features. [7] If the sponge does not have any radiological marker on itself, it is usually difficult to identify and may simulate hematoma, granulomatous process, abscess formation, cystic masses, or neoplasm (pseudotumor). [5],[8] They could migrate to regions distant from the site of surgery, making the suspicion of gossypiboma even less likely. [9],[10] The clinical manifestations and the time of presentation depend on the type of host response to the presence of the cotton gauze (foreign body reaction). Basically, two types of foreign body reactions have been described pathologically: an exudative reaction leading to abscess formation and an aseptic fibrinous reaction with adhesion, encapsulation culminating in granuloma formation. [2],[7] The latter tends to present much later than exudative reaction. Surgical sponges have been retrieved as late as 40 years after surgery. [11]

Retained gauze in the scrotum is extremely rare because of the superficial nature of the site, and the limited and easily accessible space within the scrotum. [4] We were only able to find a single report of retained gauze in the scrotum and this followed an inguinal orchidectomy. [4] It is probably not the only case as many go unreported. In our own patient, it followed hydrocelectomy. It was a large vaginal hydrocele of several years and the surgery was probably done by an inexperienced occasional surgeon. The traditional perioperative gauze count might have been inaccurate or overlooked because of the assumed "unlikely" occurrence of retained gauze at the site. Despite all the routine and sometimes extreme precautions aimed at prevention of retained surgical sponge, it is unlikely to be eliminated completely. [2],[3] Generally, retained surgical gauze is common in emergency surgeries, abdominal surgeries, and in obese patients; a sudden change in surgical procedure, long operations, hurried sponge count, and inexperienced staff have also been shown to increase the incidence. [2] The recent introduction of radiofrequency identification (RFID), in which surgical gauze is tagged with radiofrequency identification chips and scanned with barcode scanner, is aimed at eliminating human error in sponge count. [12]

Retained surgical cotton gauze can produce serious adverse consequences such as bowel perforation, obstruction, or fistula formation; abscess formation; sepsis; and even death. The rarity of scrotal gossypiboma and the unusual cutaneous manifestations of the index case made preoperative suspicion less likely. The chronic inflammatory nodular skin lesions appear to follow the lymphatic drainage of the scrotum. They probably represent multiple discrete foreign body granulomatous reactions that developed around phagocytosed cotton gauze by scavenging macrophages. The subcutaneous fibrosis and lymphatic obstruction gave rise to the observed lymphedema of the scrotum and penis. We could not find a report of a similar case; however, cases of unusual clinical presentations including pseudotumor formation abound in literature. [8],[11],[13]

Prevention of retained gauze still requires the utmost precautions in the intraoperative period irrespective of the type of surgery. Routine and accurate gauze count, avoidance of use of free gauze while working in cavities or spaces, the use of gauze with radio-opaque X-ray markers, and more recently radiofrequency tagged gauze and other measures will go a long way to minimize the incidence of gossypiboma.


  Conclusion Top


Retained surgical sponge is generally rare, but has occurred in virtually all operative procedures. Retained gauze in the scrotum is even less common, and our patient presented with unusual cutaneous lesions, making the diagnosis very difficult. Foreign body reaction should be considered as a possible cause of unusual skin lesions when seen around a site of previous surgery.

 
  References Top

1.Sun HS, Chen SL, Kuo CC, Wang SC, Kao YL. Gossypiboma: Retained surgical sponge. J Chin Med Assoc 2007;70:511-3.  Back to cited text no. 1
[PUBMED]    
2.Gawande AA, Studdert DM, Oraw EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. NEJM 2003;348:229-35.   Back to cited text no. 2
    
3.Lauwers PR, Van Hee RH. Intraperitoneal gossypibomas: the need to count sponges. World J Surg 2000;24:521-7.   Back to cited text no. 3
[PUBMED]    
4.Herman LK. Removal of a gauze sponge from the scrotum, two and a half years after an operation for double inguinal hernia. Ann Surg 1909;49:814-9.  Back to cited text no. 4
    
5.Moslemi MK, Abedinzadeh M. Retained intraabdominal gossypiboma five years after bilateral orchiopexy. Case Report Med 2010;2010:420357.   Back to cited text no. 5
    
6.Amol CP, Govind SK, Sunil GK. Textiloma in the leg. Indian J Orthop 2007;41:237-8.  Back to cited text no. 6
    
7.Wan W, Le T, Riskin L, Macario A. Improving safety in the operating room: A systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol 2009;22:207-14.  Back to cited text no. 7
[PUBMED]    
8.Deger RB, LiVolsi VA, Noumoff JS. Foreign body reaction (gossypiboma) masking as recurrent ovarian cancer. Gynec Oncol 1995;56:94.   Back to cited text no. 8
    
9.Dhillon JS, Park A. Transmural migration of retained laparotomy sponge. Am Surg 2002;68:603-5.  Back to cited text no. 9
[PUBMED]    
10.Lin TY, Chuang CK, Wong YC, Liao HC. Gossypiboma: migration of retained surgical gauze and spontaneous transurethral protrusion. BJU Int 1999;84;879-80.  Back to cited text no. 10
    
11.Rajkoviæ Z, Altarac S, Papeš D. An unusual cause of chronic lumber back pain: Retained surgical gauze discovered after 40 years. Pain Med 2010;11:1777-9.  Back to cited text no. 11
    
12.Rogers A, Jones E, Oleynikov D. Radio frequency identification (RFID) applied to surgical sponges. Surg Endosc 2007;21:1235-7.  Back to cited text no. 12
    
13.John PH, Howard BH, Pierce BI, Judd WM. Gossypiboma (retained surgical sponge) and recurrent bladder neck contracture after radical retropubic prostatectomy and bilateral pelvic lymph node dissection. J Urol 1997;157:1356- 7.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Discussion
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