A Case Report on Gossypiboma: A Glitch in Safe Surgical Practice

Inadvertent retention of surgical cotton gauze or cotton material in the surgical field is described as Gossypiboma. It is a rare event in orthopedic surgery, and hence the diagnosis is obscured in the setting of early surgical site infection (SSI) and is often initially mistaken with breach in the aseptic technique, improper autoclaved instruments, long duration of surgery, poor surgical environment, or decreased immunity of the patient.

We present a case of SSI of the hip with impending sepsis in an elderly female with a missed diagnosis of retained cotton mop at the surgical site. Thorough evaluation of the post-operative radiographs helped arrive at the diagnosis. Debridement, removal of the mop, and antibiotic coverage, with watchful post-operative progress, were vital in healing of the wound.

Gossypiboma is a preventable surgical error. The aim of this study is to emphasize the importance of the surgical safety checklist, which largely contributes to safe patient care. Retained gauze piece must be considered in the evaluation of early SSI at the outset to prevent devastating consequences.