Gossypiboma: An Unintentional Iatrogenic Error

Area of Science:

• Surgical Safety
• Medical Error Prevention
• Patient Complications

Background:

• Unintentional retention of surgical materials, such as gauze, is a rare but serious complication following surgical procedures.
• The diagnosis of retained surgical gauze is often challenging due to diverse clinical presentations and inconclusive imaging results.

Observation:

• A case is presented where a patient's symptoms of pain, swelling, pus discharge, and a sinus opening were initially misdiagnosed as a residual cyst.
• The actual cause was an unintentionally retained surgical gauze that had become encapsulated within the surgical site.

Findings:

• The study highlights the diagnostic difficulties associated with retained surgical gauze, emphasizing the need for heightened clinical suspicion.
• Accurate intraoperative surgical gauze counts and thorough pre-closure inspection of the surgical site are critical for preventing such incidents.

Implications:

• Implementing standardized protocols for surgical gauze management, including meticulous counting and site checks, is essential for patient safety.
• Preventing retained surgical items can avoid significant patient morbidity, reduce healthcare costs, and uphold surgical best practices.