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Retained surgical materials in the postoperative abdomen and pelvis
Retained Surgical Materials in the Postoperative Abdomen and Pelvis Angus R. O’Connor, MB, MRCPI, FRCR, FFRRCSI and Fergus V. Coakley, MD The imaging appearances of surgical materials in the postoperative abdomen and pelvis can be confusing and difficult to interpret. With the increasing complexity of surgical procedures and more frequent use of postoperative imaging, the radiologist needs to be familiar with the imaging characteristics of a variety of intentionally and unintentionally placed surgical materials and devices. In addition, they must be differentiated from postoperative complications such as hematoma or abscess. © 2004 Elsevier Inc. All rights reserved.
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etention of a surgical sponge or swab (also known as “gossypiboma” or “textiloma”) in the abdomen is an important clinical problem accounting for 50% of malpractice claims for retained foreign body.1 Risk factors for this occurrence include emergency surgery, unplanned change of procedure, and high patient body mass index.2 A normal sponge count does not exclude retained sponge with a correct count being reported in 22 (76%) of 29 cases in one series.1 Retained sponges cause symptoms principally through an intense inflammatory response due to foreign body reaction toward the irritant cotton fibers. This may lead to adhesions, perforation, and abscess or fistula formation. Migration of sponges into the lumen of bowel causing intestinal obstruction has also been described.3 Although many sponges will become profoundly symptomatic in the early postoperative period, it is possible for the foreign body to remain unnoticed for months or years.4 A long temporal relationship to surgery will make it less likely that the possibility will be considered and may lead to an alternative diagnosis such as malignancy.5 A wide variety of sponge sizes are available for use in the abdomen, depending on surgical requirements. Most are made of cotton and have a woven radio-opaque band to facilitate detection. The swab most commonly placed into the abdomen or pelvis in the UK is the 10 ⫻ 10-inch sponge (Fig 1),
From the Department of Radiology, Nottingham City Hospital, Nottingham, UK; Abdominal Imaging Section, Department of Radiology, University of California, San Francisco, CA Address reprint requests to Angus R. O’Connor, Consultant Radiologist, Department of Radiology, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK; e-mail: [email protected] © 2004 Elsevier Inc. All rights reserved. 0887-2171/04/2503-0009$30.00/0 doi:10.1053/j.sult.2004.03.010 290
although the smaller 4 ⫻ 4-inch variety may also be encountered. In the United States, an intermediate-sized sponge with a thick radio-opaque handle known as the laparotomy sponge is the most commonly retained swab (Fig 2).6 Plain radiographs are the most commonly requested initial investigation when a retained surgical sponge is suspected (Fig 3). Many of these films are taken in the operating room or intensive care unit and may be of suboptimal quality due to difficult patient factors. Bright-light facilities or digital manipulation, where available, should be used to assist in the interpretation. When examining these studies, it is important to ensure that the entire operative field has been included to avoid missing sponges outside the area exposed. Radiographs detect sponges by identifying the radioopaque marker. Although the body of the sponge is faintly radio-opaque, this is seldom seen in vivo. Although most sponges have radio-opaque markers, this is not always the case.1 Retained swabs or other surgical devices can also be incidentally detected on routine fluoroscopic postoperative imaging (Fig 4). CT scanning of retained surgical sponges (Fig 5) demonstrates a soft tissue density which may be difficult to separate from adjacent tissues. Associated air pockets can be present around or inside the sponge material and have been shown to persist at 6 months in vitro.7 If a marker is present, this will be prominent. Inspection of the scout radiograph may be helpful as beam-hardening artifact can make the characteristic appearances of the marker less obvious. Although most retained surgical sponges are unintentional, cotton is a potent hemostatic agent and may be used to tamponade an operative field in the setting of persistent hemorrhage. This is occasionally undertaken in severe pelvic trauma and retroperitoneal hemorrhage. A large surgical pack is often deployed for this purpose being removed
Seminars in Ultrasound, CT, and MRI, Vol 25, No 3 (June), 2004: pp 290-302
POSTOPERATIVE RETAINED MATERIALS
291
Fig 1. (A) Photograph of a 10 ⴛ 10-inch surgical swab. The dark woven radio-opaque marker is seen at the edge of the sponge. (B) Specimen in vitro x-ray demonstrates that the swab material and marker are both radioopaque, although only the latter is usually seen on in vivo radiographs. (Color version of figure is available online.)
after 24-48 hours (Fig 6). Review of the operative note or discussion with the surgeon may clarify the situation. More permanent surgical material, such as surgical clips (Fig 7) or hernial mesh (Fig 8), can also cause diagnostic confusion on CT, particularly if there is an associated local complication which makes interpretation difficult. Again, clinical review or examination of the scout image may be helpful. In addition to temporary placement of packing swabs, absorbable hemostatic sponges (Fig 9) may be used intra-operatively to control bleeding. The most commonly used of these are gelatin sponge (Gelfoam; Pharmacia and Upjohn, Kalamazoo, MI) or oxidized reabsorbable cellulose (Surgicel; Ethicon, Somerville, NJ) and are grad-
ually absorbed over time. The described CT appearances of these absorbable materials are of mixed or low attenuation masses with central and occasionally peripheral gas collections (Fig 10).8 These appearances may be confused with postoperative abscesses or collections.9 In this situation, a discussion with the surgeon may be conclusive. If not, serial CT examination can be performed as the material should become absorbed over a period of weeks. If the patient’s condition does not permit this, fine needle aspiration can be performed. Retained surgical sponges are usually removed once they have been identified. Such surgery may be difficult and traumatic due to local inflammatory change and adhesion of the sponge to adjacent
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O’CONNOR AND COAKLEY
Fig 2. Intra-operative radiograph demonstrates the radio-opaque marker of a laparotomy sponge (arrow), the most commonly retained swab in the United States.
tissues. CT may be useful to assess suspected local complications following swab removal (Fig 11). The MR appearances of surgical sponges are once again of a soft tissue density, which may be better appreciated than at CT scanning due to superior soft tissue contrast. The radio-opaque marker which is so helpful in swab recognition on CT is not well seen at MR imaging and may lead to diagnostic confusion. On T1 imaging, retained sponges typically have a well-defined thick capsule (Fig 12), which may enhance with contrast administration.8 The internal pattern is generally of low signal although high signal change has been reported.10 T2 imaging may demonstrate a characteristic “whirled” internal configuration.8,11 Packing sponges may also cause difficulty on MR imaging where they may be confused with bowel loops or postoperative collections (Fig 13). Clinical information is helpful in this setting. The MR appearances of absorbable hemostatic sponges have been described in a series of five patients and
consist of intermediate T1 and high T2 signal intensity.12 Retained surgical instruments such as retractors or forceps are generally obvious on plain film imaging, although they may have a confusing appearance on CT due to beam hardening artifact. Surgical needles may be overlooked or dismissed as metal clips if located in an unfavorable imaging plane (Fig 14). CONCLUSIONS
Retention of surgical swabs is a common postoperative complication which may occur in the presence of a normal sponge count. Risk factors include emergency surgery, unplanned procedures, and high patient body mass index. Radiographs identify sponges by the presence of a radio-opaque marker, although these are not present on all swabs. CT scanning demonstrates a soft tissue mass. If a radio-opaque marker is present, its nature may be best appreciated on the scout radio-
POSTOPERATIVE RETAINED MATERIALS
293
Fig 3. 73-year-old female 6 months post elective abdominal aortic aneurysm repair complaining of abdominal pain. A supine abdominal film demonstrates the radiographic marker of a 10 ⴛ 10-inch surgical sponge (arrow), which was subsequently removed at laparotomy. (Case courtesy of Mr. J.B. O’Connor, Waterford Regional Hospital.)
graph due to beam hardening artifact. MR appearances are nonspecific on T1 imaging, but on T2 studies, a “whirled” internal configuration is often seen. Temporary placement of surgical packs and use of absorbable gelatin or oxidized cellulose may
simulate retained sponges or postoperative collections. Discussion with the surgeon will usually resolve confusion, although serial examination or fine needle aspiration may be needed if doubt persists.
Fig 4. 58-year-old female 2 days post laparoscopic cholecystectomy with common duct exploration. T-tube cholangiogram demonstrates opacification of the biliary tree with free drainage of contrast to duodenum. A radio-opaque marker in the right flank (arrow) was presumed to represent a retained 4 ⴛ 4-inch surgical swab. Subsequent laparotomy showed that the marker was from a retained surgical bag whose purpose is to prevent trauma to the gall bladder during its removal through the laparoscopy port.
294
O’CONNOR AND COAKLEY
Fig 5. 29-year-old female 2 days following emergency caesarean section. (A) Scout examination for CT abdomen shows multiple 4 ⴛ 4-inch surgical swabs. (B) Axial imaging demonstrates surgical markers with an associated pocket of air (arrow). (C) Multiple lucencies are seen in the sponge substance (s) due to air trapping. (Case courtesy of Dr. J.C. Jobling, Nottingham City Hospital.)
POSTOPERATIVE RETAINED MATERIALS
Fig 6. 40-year-old male with complex pelvic fracture following road traffic accident. (A) Postoperative radiograph demonstrates diastasis of the symphysis pubis and external fixation. A surgical pack (arrow) has been temporarily placed in the lower pelvis to control persistent bleeding. A suprapubic catheter is noted (arrowhead). (B) 66-year-old female with extensive retroperitoneal/pelvic hemorrhage of unknown cause. A source of bleeding was not identified at laparotomy and a large surgical pack was placed to obtain hemostasis (arrow). A small pleglet of Surgicel is seen (arrowhead) adjacent to the right pelvic haematoma (h).
295
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O’CONNOR AND COAKLEY
Fig 7. 72-year-old female with history of colorectal carcinoma and metastases in segments 8 and 2 of the liver. (A) Ultrasound examination 2 months post-metastectomy of both liver lesions demonstrates acoustic shadowing and an apparent mass lesion in the right lobe felt to represent recurrent calcified metastatic disease. (B) CT scanning demonstrates multiple surgical clips which were the cause of the acoustic shadowing. There is no evidence of tumor recurrence.
POSTOPERATIVE RETAINED MATERIALS
Fig 8. 44-year-old male with feculent discharge from an anterior abdominal wall surgical port site following laparoscopic incisional hernia repair. (A) Fistulography and subsequent CT scanning demonstrates a collection of contrast (arrowhead) posterior to the hernial mesh (arrow) consistent with a localized perforation due to trauma of the mesh on adjacent colon. (B) Repeat CT scan after 2 months of conservative treatment shows the collection (c) has collapsed with associated retraction of the medial aspect of the hernial mesh (arrow) from the anterior abdominal wall.
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Fig 9. Absorbable surgical materials used in the abdomen. (a) Surgicel (oxidized absorbable cellulose); (b) Curaspon (absorbable gelatin sponge); (c) Kaltostat (calcium sodium alginate). (Color version of figure is available online.)
Fig 10. CT scan performed for fever 8 days after total abdominal hysterectomy and debulking of ovarian carcinoma in a 43-year-old woman. A mixed gas, fluid, and soft tissue density mass is noted adjacent to the right pelvic side wall (arrow). Surgicel packing had been used intraoperatively. Appearances are similar to adjacent bowel, but no communication with bowel could be established on contiguous images. In view of the history of fever, the collection was aspirated yielding a small volume of sero-sanguinous fluid which was sterile on culture. (Reproduced with permission from Am J Roentgenol 180:481489, 2003.)
POSTOPERATIVE RETAINED MATERIALS
299
Fig 11. Removal of retained gall bladder bag complicated by iatrogenic liver injury and biliary peritonitis. (A) Control film prior to T-tube cholangiogram in a 58-year-old female following laparoscopic cholecystectomy (same patient as Fig 4) reveals a retained gall bladder bag. After operative removal, the patient developed severe abdominal pain. (B) CT scanning demonstrates a liver laceration (arrow) and intra-hepatic biloma (b) in the inferior right lobe. (C) Image at a more cranial level shows extensive ascites (arrow). Percutaneous drainage yielded bile.
300
O’CONNOR AND COAKLEY
Fig 12. MR imaging of a retained sponge in a 56-year-old man complaining of frequency 5 months after radical retropubic prostatectomy. (A) Axial spin-echo T1 (500/15 ms) image following contrast demonstrates a well-defined thick walled structure anterior to the contrastfilled bladder. (B) Axial fast spin-echo T2 (4000/ 105 ms) weighted image demonstrates the whirled configuration of the sponge body. The sponge was surgically removed.(Reproduced with permission from AJR Am J Roentgenol 180:481-489, 2003.)
POSTOPERATIVE RETAINED MATERIALS
301
Fig 13. 38-year-old female 3 months after pelvic exenteration for recurrent cervical carcinoma. MR imaging was requested to evaluate a persistently draining perineal wound. (A) Axial T2 weighted images at the level of the femoral heads (f) demonstrate a dilated small bowel loop (sb). Posteriorly, a well-defined mixed signal structure was noted suspicious for a postoperative collection (arrow). (B) At a more inferior level, well-defined masses can be seen in association with surrounding high signal fluid (arrow) and an air-fluid interface. Correlation with the patient’s case notes revealed the perineum had been packed with surgical swabs. (C) On T1 imaging, the discrete appearance of the sponges cannot be identified.
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O’CONNOR AND COAKLEY
Fig 14. Retained surgical needle. (A) Plain film demonstrates a retained needle in the right flank (arrow). (B) CT scanning localizes the needle to the subcutaneous tissues (arrow).
REFERENCES 1. Kaiser CW, Friedman S, Spurling KP, et al: The retained surgical sponge. Ann Surg 224:79-84, 1996 2. Gawande AA, Studdert DM, Orav EJ, et al: Risk factors for retained instruments and sponges after surgery. N Engl J Med 348:229-235, 2003 3. Silva CS, Caetano MR, Silva EA, et al: A complete migration of retained surgical sponge into ileum without sign of open intestinal wall. Arch Gynecol Obstet 265:103-104, 2001 4. Roumen RM, Weerdenburg HP: MR features of a 24-yearold gossypiboma. A case report. Acta Radiol 39:176-178, 1998 5. Ben Meir D, Lask D, Koren R, et al: Intrarenal foreign body presenting as a solid tumor. Urology 61:1035, 2003 6. Dhillon JS, Park A: Transmural migration of a retained laparotomy sponge. Am Surg 68:603-605, 200. 7. Kopka L, Fischer U, Gross AJ, et al: CT of retained surgical sponges (textilomas): Pitfalls in detection and evaluation. J Comput Assist Tomogr 20:919-923, 1996
8. O’Connor AR, Coakley FV, Meng MV, et al: Imaging of retained surgical sponges in the abdomen and pelvis. AJR Am J Roentgenol 180:481-489, 2003 9. Young ST, Paulson EK, McCann RL, et al: Appearance of oxidized cellulose (Surgicel) on postoperative CT scans: Similarity to postoperative abscess. AJR Am J Roentgenol 160:275277, 1993 10. Kuwashima S, Yamato M, Fujioka M, et al: MR findings of surgically retained sponges and towels: Report of two cases. Radiat Med 11:98-101, 1993 11. Matsuki M, Matsuo M, Okada N: Case report: MR findings of a retained surgical sponge. Radiat Med 16:65-67, 1998 12. Naik KS, Carrington BM, Yates W, et al: The postcystectomy pseudotumour sign: MRI appearances of a modified chronic pelvic haematoma due to retained haemostatic gauze. Clin Radiol 55:970-974, 2000
R
etention of a surgical sponge or swab (also known as “gossypiboma” or “textiloma”) in the abdomen is an important clinical problem accounting for 50% of malpractice claims for retained foreign body.1 Risk factors for this occurrence include emergency surgery, unplanned change of procedure, and high patient body mass index.2 A normal sponge count does not exclude retained sponge with a correct count being reported in 22 (76%) of 29 cases in one series.1 Retained sponges cause symptoms principally through an intense inflammatory response due to foreign body reaction toward the irritant cotton fibers. This may lead to adhesions, perforation, and abscess or fistula formation. Migration of sponges into the lumen of bowel causing intestinal obstruction has also been described.3 Although many sponges will become profoundly symptomatic in the early postoperative period, it is possible for the foreign body to remain unnoticed for months or years.4 A long temporal relationship to surgery will make it less likely that the possibility will be considered and may lead to an alternative diagnosis such as malignancy.5 A wide variety of sponge sizes are available for use in the abdomen, depending on surgical requirements. Most are made of cotton and have a woven radio-opaque band to facilitate detection. The swab most commonly placed into the abdomen or pelvis in the UK is the 10 ⫻ 10-inch sponge (Fig 1),
From the Department of Radiology, Nottingham City Hospital, Nottingham, UK; Abdominal Imaging Section, Department of Radiology, University of California, San Francisco, CA Address reprint requests to Angus R. O’Connor, Consultant Radiologist, Department of Radiology, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK; e-mail: [email protected] © 2004 Elsevier Inc. All rights reserved. 0887-2171/04/2503-0009$30.00/0 doi:10.1053/j.sult.2004.03.010 290
although the smaller 4 ⫻ 4-inch variety may also be encountered. In the United States, an intermediate-sized sponge with a thick radio-opaque handle known as the laparotomy sponge is the most commonly retained swab (Fig 2).6 Plain radiographs are the most commonly requested initial investigation when a retained surgical sponge is suspected (Fig 3). Many of these films are taken in the operating room or intensive care unit and may be of suboptimal quality due to difficult patient factors. Bright-light facilities or digital manipulation, where available, should be used to assist in the interpretation. When examining these studies, it is important to ensure that the entire operative field has been included to avoid missing sponges outside the area exposed. Radiographs detect sponges by identifying the radioopaque marker. Although the body of the sponge is faintly radio-opaque, this is seldom seen in vivo. Although most sponges have radio-opaque markers, this is not always the case.1 Retained swabs or other surgical devices can also be incidentally detected on routine fluoroscopic postoperative imaging (Fig 4). CT scanning of retained surgical sponges (Fig 5) demonstrates a soft tissue density which may be difficult to separate from adjacent tissues. Associated air pockets can be present around or inside the sponge material and have been shown to persist at 6 months in vitro.7 If a marker is present, this will be prominent. Inspection of the scout radiograph may be helpful as beam-hardening artifact can make the characteristic appearances of the marker less obvious. Although most retained surgical sponges are unintentional, cotton is a potent hemostatic agent and may be used to tamponade an operative field in the setting of persistent hemorrhage. This is occasionally undertaken in severe pelvic trauma and retroperitoneal hemorrhage. A large surgical pack is often deployed for this purpose being removed
Seminars in Ultrasound, CT, and MRI, Vol 25, No 3 (June), 2004: pp 290-302
POSTOPERATIVE RETAINED MATERIALS
291
Fig 1. (A) Photograph of a 10 ⴛ 10-inch surgical swab. The dark woven radio-opaque marker is seen at the edge of the sponge. (B) Specimen in vitro x-ray demonstrates that the swab material and marker are both radioopaque, although only the latter is usually seen on in vivo radiographs. (Color version of figure is available online.)
after 24-48 hours (Fig 6). Review of the operative note or discussion with the surgeon may clarify the situation. More permanent surgical material, such as surgical clips (Fig 7) or hernial mesh (Fig 8), can also cause diagnostic confusion on CT, particularly if there is an associated local complication which makes interpretation difficult. Again, clinical review or examination of the scout image may be helpful. In addition to temporary placement of packing swabs, absorbable hemostatic sponges (Fig 9) may be used intra-operatively to control bleeding. The most commonly used of these are gelatin sponge (Gelfoam; Pharmacia and Upjohn, Kalamazoo, MI) or oxidized reabsorbable cellulose (Surgicel; Ethicon, Somerville, NJ) and are grad-
ually absorbed over time. The described CT appearances of these absorbable materials are of mixed or low attenuation masses with central and occasionally peripheral gas collections (Fig 10).8 These appearances may be confused with postoperative abscesses or collections.9 In this situation, a discussion with the surgeon may be conclusive. If not, serial CT examination can be performed as the material should become absorbed over a period of weeks. If the patient’s condition does not permit this, fine needle aspiration can be performed. Retained surgical sponges are usually removed once they have been identified. Such surgery may be difficult and traumatic due to local inflammatory change and adhesion of the sponge to adjacent
292
O’CONNOR AND COAKLEY
Fig 2. Intra-operative radiograph demonstrates the radio-opaque marker of a laparotomy sponge (arrow), the most commonly retained swab in the United States.
tissues. CT may be useful to assess suspected local complications following swab removal (Fig 11). The MR appearances of surgical sponges are once again of a soft tissue density, which may be better appreciated than at CT scanning due to superior soft tissue contrast. The radio-opaque marker which is so helpful in swab recognition on CT is not well seen at MR imaging and may lead to diagnostic confusion. On T1 imaging, retained sponges typically have a well-defined thick capsule (Fig 12), which may enhance with contrast administration.8 The internal pattern is generally of low signal although high signal change has been reported.10 T2 imaging may demonstrate a characteristic “whirled” internal configuration.8,11 Packing sponges may also cause difficulty on MR imaging where they may be confused with bowel loops or postoperative collections (Fig 13). Clinical information is helpful in this setting. The MR appearances of absorbable hemostatic sponges have been described in a series of five patients and
consist of intermediate T1 and high T2 signal intensity.12 Retained surgical instruments such as retractors or forceps are generally obvious on plain film imaging, although they may have a confusing appearance on CT due to beam hardening artifact. Surgical needles may be overlooked or dismissed as metal clips if located in an unfavorable imaging plane (Fig 14). CONCLUSIONS
Retention of surgical swabs is a common postoperative complication which may occur in the presence of a normal sponge count. Risk factors include emergency surgery, unplanned procedures, and high patient body mass index. Radiographs identify sponges by the presence of a radio-opaque marker, although these are not present on all swabs. CT scanning demonstrates a soft tissue mass. If a radio-opaque marker is present, its nature may be best appreciated on the scout radio-
POSTOPERATIVE RETAINED MATERIALS
293
Fig 3. 73-year-old female 6 months post elective abdominal aortic aneurysm repair complaining of abdominal pain. A supine abdominal film demonstrates the radiographic marker of a 10 ⴛ 10-inch surgical sponge (arrow), which was subsequently removed at laparotomy. (Case courtesy of Mr. J.B. O’Connor, Waterford Regional Hospital.)
graph due to beam hardening artifact. MR appearances are nonspecific on T1 imaging, but on T2 studies, a “whirled” internal configuration is often seen. Temporary placement of surgical packs and use of absorbable gelatin or oxidized cellulose may
simulate retained sponges or postoperative collections. Discussion with the surgeon will usually resolve confusion, although serial examination or fine needle aspiration may be needed if doubt persists.
Fig 4. 58-year-old female 2 days post laparoscopic cholecystectomy with common duct exploration. T-tube cholangiogram demonstrates opacification of the biliary tree with free drainage of contrast to duodenum. A radio-opaque marker in the right flank (arrow) was presumed to represent a retained 4 ⴛ 4-inch surgical swab. Subsequent laparotomy showed that the marker was from a retained surgical bag whose purpose is to prevent trauma to the gall bladder during its removal through the laparoscopy port.
294
O’CONNOR AND COAKLEY
Fig 5. 29-year-old female 2 days following emergency caesarean section. (A) Scout examination for CT abdomen shows multiple 4 ⴛ 4-inch surgical swabs. (B) Axial imaging demonstrates surgical markers with an associated pocket of air (arrow). (C) Multiple lucencies are seen in the sponge substance (s) due to air trapping. (Case courtesy of Dr. J.C. Jobling, Nottingham City Hospital.)
POSTOPERATIVE RETAINED MATERIALS
Fig 6. 40-year-old male with complex pelvic fracture following road traffic accident. (A) Postoperative radiograph demonstrates diastasis of the symphysis pubis and external fixation. A surgical pack (arrow) has been temporarily placed in the lower pelvis to control persistent bleeding. A suprapubic catheter is noted (arrowhead). (B) 66-year-old female with extensive retroperitoneal/pelvic hemorrhage of unknown cause. A source of bleeding was not identified at laparotomy and a large surgical pack was placed to obtain hemostasis (arrow). A small pleglet of Surgicel is seen (arrowhead) adjacent to the right pelvic haematoma (h).
295
296
O’CONNOR AND COAKLEY
Fig 7. 72-year-old female with history of colorectal carcinoma and metastases in segments 8 and 2 of the liver. (A) Ultrasound examination 2 months post-metastectomy of both liver lesions demonstrates acoustic shadowing and an apparent mass lesion in the right lobe felt to represent recurrent calcified metastatic disease. (B) CT scanning demonstrates multiple surgical clips which were the cause of the acoustic shadowing. There is no evidence of tumor recurrence.
POSTOPERATIVE RETAINED MATERIALS
Fig 8. 44-year-old male with feculent discharge from an anterior abdominal wall surgical port site following laparoscopic incisional hernia repair. (A) Fistulography and subsequent CT scanning demonstrates a collection of contrast (arrowhead) posterior to the hernial mesh (arrow) consistent with a localized perforation due to trauma of the mesh on adjacent colon. (B) Repeat CT scan after 2 months of conservative treatment shows the collection (c) has collapsed with associated retraction of the medial aspect of the hernial mesh (arrow) from the anterior abdominal wall.
297
298
O’CONNOR AND COAKLEY
Fig 9. Absorbable surgical materials used in the abdomen. (a) Surgicel (oxidized absorbable cellulose); (b) Curaspon (absorbable gelatin sponge); (c) Kaltostat (calcium sodium alginate). (Color version of figure is available online.)
Fig 10. CT scan performed for fever 8 days after total abdominal hysterectomy and debulking of ovarian carcinoma in a 43-year-old woman. A mixed gas, fluid, and soft tissue density mass is noted adjacent to the right pelvic side wall (arrow). Surgicel packing had been used intraoperatively. Appearances are similar to adjacent bowel, but no communication with bowel could be established on contiguous images. In view of the history of fever, the collection was aspirated yielding a small volume of sero-sanguinous fluid which was sterile on culture. (Reproduced with permission from Am J Roentgenol 180:481489, 2003.)
POSTOPERATIVE RETAINED MATERIALS
299
Fig 11. Removal of retained gall bladder bag complicated by iatrogenic liver injury and biliary peritonitis. (A) Control film prior to T-tube cholangiogram in a 58-year-old female following laparoscopic cholecystectomy (same patient as Fig 4) reveals a retained gall bladder bag. After operative removal, the patient developed severe abdominal pain. (B) CT scanning demonstrates a liver laceration (arrow) and intra-hepatic biloma (b) in the inferior right lobe. (C) Image at a more cranial level shows extensive ascites (arrow). Percutaneous drainage yielded bile.
300
O’CONNOR AND COAKLEY
Fig 12. MR imaging of a retained sponge in a 56-year-old man complaining of frequency 5 months after radical retropubic prostatectomy. (A) Axial spin-echo T1 (500/15 ms) image following contrast demonstrates a well-defined thick walled structure anterior to the contrastfilled bladder. (B) Axial fast spin-echo T2 (4000/ 105 ms) weighted image demonstrates the whirled configuration of the sponge body. The sponge was surgically removed.(Reproduced with permission from AJR Am J Roentgenol 180:481-489, 2003.)
POSTOPERATIVE RETAINED MATERIALS
301
Fig 13. 38-year-old female 3 months after pelvic exenteration for recurrent cervical carcinoma. MR imaging was requested to evaluate a persistently draining perineal wound. (A) Axial T2 weighted images at the level of the femoral heads (f) demonstrate a dilated small bowel loop (sb). Posteriorly, a well-defined mixed signal structure was noted suspicious for a postoperative collection (arrow). (B) At a more inferior level, well-defined masses can be seen in association with surrounding high signal fluid (arrow) and an air-fluid interface. Correlation with the patient’s case notes revealed the perineum had been packed with surgical swabs. (C) On T1 imaging, the discrete appearance of the sponges cannot be identified.
302
O’CONNOR AND COAKLEY
Fig 14. Retained surgical needle. (A) Plain film demonstrates a retained needle in the right flank (arrow). (B) CT scanning localizes the needle to the subcutaneous tissues (arrow).
REFERENCES 1. Kaiser CW, Friedman S, Spurling KP, et al: The retained surgical sponge. Ann Surg 224:79-84, 1996 2. Gawande AA, Studdert DM, Orav EJ, et al: Risk factors for retained instruments and sponges after surgery. N Engl J Med 348:229-235, 2003 3. Silva CS, Caetano MR, Silva EA, et al: A complete migration of retained surgical sponge into ileum without sign of open intestinal wall. Arch Gynecol Obstet 265:103-104, 2001 4. Roumen RM, Weerdenburg HP: MR features of a 24-yearold gossypiboma. A case report. Acta Radiol 39:176-178, 1998 5. Ben Meir D, Lask D, Koren R, et al: Intrarenal foreign body presenting as a solid tumor. Urology 61:1035, 2003 6. Dhillon JS, Park A: Transmural migration of a retained laparotomy sponge. Am Surg 68:603-605, 200. 7. Kopka L, Fischer U, Gross AJ, et al: CT of retained surgical sponges (textilomas): Pitfalls in detection and evaluation. J Comput Assist Tomogr 20:919-923, 1996
8. O’Connor AR, Coakley FV, Meng MV, et al: Imaging of retained surgical sponges in the abdomen and pelvis. AJR Am J Roentgenol 180:481-489, 2003 9. Young ST, Paulson EK, McCann RL, et al: Appearance of oxidized cellulose (Surgicel) on postoperative CT scans: Similarity to postoperative abscess. AJR Am J Roentgenol 160:275277, 1993 10. Kuwashima S, Yamato M, Fujioka M, et al: MR findings of surgically retained sponges and towels: Report of two cases. Radiat Med 11:98-101, 1993 11. Matsuki M, Matsuo M, Okada N: Case report: MR findings of a retained surgical sponge. Radiat Med 16:65-67, 1998 12. Naik KS, Carrington BM, Yates W, et al: The postcystectomy pseudotumour sign: MRI appearances of a modified chronic pelvic haematoma due to retained haemostatic gauze. Clin Radiol 55:970-974, 2000