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the term gossypiboma , derived from the latin word  gossypium  ( cotton ) and the swahilli  boma 
the condition may manifest as an exudative inflammatory reaction with formation of abscess or aseptic fibrotic reaction with formation of a mass ( 2 ) .
the patient may present early with features of sepsis or may remain asymptomatic or may present with non - specific symptoms months or years after the operation .
although early recognition of this problem will ensure institution of appropriate treatment , every measure should be taken to prevent this complication .
herein , we report a case of gossypiboma presented as an abdominal lump 7 years after open cholecystectomy .
a 54-year - old woman presented with a 2-years history of dull aching pain in the upper abdomen and 1 year history of an abdominal swelling .
she developed fever and purulent discharge from the wound in the immediate postoperative period which was treated conservatively .
on examination a large non - tender mass with restricted side to side mobility was found in the right hypochondrium extending up - to the right lumber region .
blood investigations revealed hemoglobin of 8.5gm / dl , leukocyte count of 9600/mm , serum bilirubin of 2.9 mg / dl and alkaline phosphatase of 507 u / l .
the plain abdominal radiography did not show any sign of a radio - opaque marker in the abdomen . however , contrast enhanced abdominal computerized tomography revealed a 1512x10 cm round well - defined soft - tissue mass with multiple septae .
ct scan abdomen ( both oral and intravenous contrast ) showed a mass in right upper quadrant with displacement of gut loops towards the left .
the mass showed contrast enhanced internal septa ( white arrow ) a radio - opaque material was seen in the lesion raising the suspicion of a foreign body .
common bile duct was dilated and contained a stone which was removed endoscopically . at exploration ,
a large globular lesion was found which was densely adhered to the adjacent structures ( anterior abdominal wall , omentum , transverse colon , and antrum of the stomach ) .
en - bloc resection of the mass along with the adhered transverse colon was done ( figure-2 ) . cut
section of the mass showed a large surgical sponge and a foreign body within it ( figure-3).the patient had an uneventful recovery and she was well at 19-month follow - up .
operative photograph showing a large mass ( white arrow ) with adherent transverse colon ( black arrow ) .
cut section of the mass showing a large sponge ( white arrow ) and a radio - opaque marker ( black arrow ) within it .
gossypiboma or a mass of cotton that is retained in the body following surgery is rarely seen in daily clinical practice .
although the real incidence is unknown , it has been reported as 1 in 100 to 3000 for all surgical interventions and 1 in 1000 to 1500 for intraabdominal operations ( 3,4 ) the clinical presentation of gossypiboma varies and depends on the location of the sponge and the type of reaction .
there are 2 types of foreign body reaction in pathology : an exudates reaction leading to abscess formation or chronic internal or external fistula formation , and an aseptic fibrinous reaction resulting in adhesion , encapsulation , and eventual formation of granuloma of various size .
they usually remain asymptomatic or present with pseudotumor syndrome , as in our case . because , the symptoms of gossypiboma are usually nonspecific and may appear years after surgery , the diagnosis of gossypiboma usually comes from imaging studies and a high index of suspicion .
the most impressive imaging finding of gossypiboma is the curved or banded radio - opaque lines on plain radiograph .
the ultrasound feature is usually a well - defined mass containing wavy internal echogenic focus with a hypoechoic rim and a strong posterior shadow .
on ct scan , a gossypiboma may manifest as a cystic lesion with internal spongiform appearance with mottled shadows as bubbles , hyperdense capsule , concentric layering , or mottled mural calcifications ( 6 ) . when no radio - opaque marker is seen on x - ray or ct ,
the characteristic internal structure of the gauze granuloma is best visualized on magnetic resonance imaging .
it may appear as a low - signal - intensity lesion on t2-weighted images with wavy , striped or spotted appearance ( 7 ) .
nosher and siegel ( 8) described six patients in whom percutaneous extraction was successfully performed for removal of foreign bodies . besides diagnostic and therapeutic difficulties
the presence of a foreign body inside the patient can be easily proved and the patient may litigate the responsible surgeon because this is an avoidable problem .
moreover , gossypiboma may be misdiagnosed as a malignant tumor and lead to unnecessary invasive diagnostic procedures or extensive extirpative surgery ( as in our case ) which may result in further complications ( 9 ) .
avoidance of leaving foreign bodies inside the patients could be possible by implementation of three measures : meticulous count of all surgical materials , thorough exploration of the surgical site at the conclusion of the procedures and routine use of surgical textile materials impregnated with a radio - opaque marker .
gawande et al ( 3 ) published an article about risk factors of retained foreign bodies ( rfbs ) .
of the 8 risk factors , the authors identified [ emergency operation , unexpected change in operation , more than one surgical team involved , change in nursing staff during procedure , body mass index ( bmi ) , volume of blood loss , female sex , and surgical counts ] only 3 were found to be statistically significant by multivariate logistic regression .
the 3 significant risk factors were emergency surgery , unplanned change in the operation , and bmi .
the counting of sponges and instruments was not a significant predictor in the multivariate model .
although all 3 factors were significant , the 9-fold increase in risk associated with emergency surgery was impressive .
in addition , in 88% of the cases where there was a rfb and counts were performed , the counts were falsely called correct .
the authors recommended  radiographic screening  at the end of high risk cases as a possible adjunct to improve detection of rfb .
although human errors can not be completely avoided , continuous medical training and strict adherence to rules of the operation room should reduce the incidence of gossypiboma to a minimum .
gossypiboma is very rare in clinical practice . despite its clinical importance 
 , it carries some medico legal implications . 
 we report a case of gossypiboma in a 54 years old female who presented with pain and a slowly growing lump in the abdomen 7 years after open cholecystectomy . 
 computed tomography ( ct ) scan of the abdomen showed a mass with enhanced internal septae and a radio - opaque marker within it , raising the suspicion of a foreign body . 
 she underwent excision of the mass along with a segment of densely adherent transverse colon . 
 post - operative recovery was uneventful and the patient was well at 19-month follow up .