Case Report: Laparoscopy-assisted resection for intra-abdominal gossypiboma masquerading as a jejunal tumor (with video)

Introduction Intra-abdominal gossypiboma, a cotton-based retained foreign body after an abdominal surgery, is associated with various clinical manifestations and complications. Its infrequent occurrence and unpredictability make its early diagnosis particularly challenging. We herein present an atypical case of intra-abdominal gossypiboma mistaken for a jejunal tumor. Case presentation A 33-year-old female presented to the emergency room with an acute episode of progressive abdominal pain and distention, nausea, and vomiting for 20 hours. She had undergone an urgent cesarean section due to fetal tachycardia seven years prior. The initial diagnosis of small bowel obstruction (SBO) due to a jejunal tumor was established by computed tomography. Subsequent to successful medical management of the SBO, a laparoscopy-assisted resection of the mass and the adherent jejunal segment was conducted, culminating in a primary side-to-side jejunojejunostomy. Examination of the excised tissue revealed an approximately spherical fibrous mass, 6 × 6 × 5 cm in dimension, embedded in the jejunal wall, housing a 20 × 20-cm gauze. Postoperative recovery and routine follow-up ensued without complications. Conclusion In light of this case, the need for clinicians to maintain an elevated awareness and suspicion of gossypiboma should be accentuated when evaluating an intra-abdominal mass, especially in patients with a prior history of high-risk laparotomy. Laparoscopic surgery stands out as a technically proficient and minimally invasive strategy for diagnosing and treating intra-abdominal gossypiboma. Besides, it is imperative to emphasize the importance of meticulous surgical procedures and postoperative protocols to prevent such oversights, reaffirming the need for consistent intraoperative counts and checks of surgical items.

Introduction: Intra-abdominal gossypiboma, a cotton-based retained foreign body after an abdominal surgery, is associated with various clinical manifestations and complications.Its infrequent occurrence and unpredictability make its early diagnosis particularly challenging.We herein present an atypical case of intra-abdominal gossypiboma mistaken for a jejunal tumor.
Case presentation: A 33-year-old female presented to the emergency room with an acute episode of progressive abdominal pain and distention, nausea, and vomiting for 20 hours.She had undergone an urgent cesarean section due to fetal tachycardia seven years prior.The initial diagnosis of small bowel obstruction (SBO) due to a jejunal tumor was established by computed tomography.Subsequent to successful medical management of the SBO, a laparoscopy-assisted resection of the mass and the adherent jejunal segment was conducted, culminating in a primary side-to-side jejunojejunostomy.Examination of the excised tissue revealed an approximately spherical fibrous mass, 6 × 6 × 5 cm in dimension, embedded in the jejunal wall, housing a 20 × 20-cm gauze.Postoperative recovery and routine follow-up ensued without complications.

Conclusion:
In light of this case, the need for clinicians to maintain an elevated awareness and suspicion of gossypiboma should be accentuated when evaluating an intra-abdominal mass, especially in patients with a prior history of high-risk laparotomy.Laparoscopic surgery stands out as a technically proficient and minimally invasive strategy for diagnosing and treating intra-

Introduction
Gossypiboma, derived from "gossypium" (Latin for cotton) and "boma" (Swahili for place of concealment), was first documented by Wilson in 1884 (1).It represents a rare yet entirely preventable iatrogenic complication (2).By definition, a gossypiboma is a cotton-based mass within a body cavity that results from the body's reaction to a sponge or gauze inadvertently retained postsurgery.In the United States, the incidence varied from 1 in 1,000 -1,500 to 1 in 8,801 -18,760 inpatient operations in the past decades (3).Due to malpractice claims and medicolegal consequences involved, the actual incidence of gossypiboma remains unknown and definitely underestimated (4).The gossypiboma formation are reported to be significantly associated with emergency surgery, unplanned changes in procedure, morbid obesity, and multiple major procedures done in a single operation or cases in which multiple surgical teams were involved (3,5,6).
The abdominopelvic cavity was the most frequent body cavity where the foreign body left (54%), followed by vagina (22%), thorax (7%), and others (17%; including the spinal canal, face, brain, and extremities) (3).Notably, while gossypibomas are less likely to occur in laparoscopic or robotic procedures, their prevalence is higher in laparotomy (7).Intra-abdominal gossypiboma patients can present to hospital with various clinical manifestations and even significant morbidity, such as ileus, perforation, abscess collection, fistula formation, and sepsis (8,9).Due to rare and unanticipated, precise preoperative diagnosis of intra-abdominal gossypiboma is extremely challenging (10).
In alignment with the principles of the CAse REport (CARE) guidelines (11), we herein describe an unusual case of intraabdominal gossypiboma complicated by ileus and masquerading as a jejunal tumor, which was treated successfully by laparoscopyassisted resection.In light of this case, it is imperative to emphasize the importance of meticulous surgical procedures and postoperative protocols to prevent such oversights, reaffirming the need for consistent intraoperative counts and checks of surgical items.

Case presentation
In November 2022, a 33-year-old Han Chinese female patient was referred to our emergency room with progressive abdominal pain (colicky in nature; sudden onset, continuous, crushing in character) and distention, nausea, and vomiting for 20 hours.She had undergone an urgent cesarean section because of fetal tachycardia 7 years previously.There were no underlying comorbidities or family history of malignancies with her.On admission, she was subfebrile with slightly abnormal vital signs (Temperature, 37.5°C; Blood pressure, 108/72 mmHg; Heart rate, 102 beats per minute; Respiratory rate, 19 beats per minute).Physical examination showed abdominal distention, slight rebound tenderness in the periumbilical area, and a painless palpable mass in the lower quadrant with metallic bowel sounds.The result of digital rectal examination was unremarkable.
The preliminary suspected diagnosis of SBO due to a jejunal tumor and mild intestinal volvulus was established by above clinical findings.The physical condition of the patient was optimized and elective laparoscopic exploration was then scheduled for her (12).Intraoperatively, a solitary jejunal mass was found to be the possible lead point of intestinal volvulus and subsequent SBO.Therefore, laparoscopy-assisted resection surgery was performed according to the following steps (13,14): (1) adhesionlysis and complete mobilization of the intra-abdominal mass; (2) extracorporeal resection with wide surgical margin of the mass and segmental jejunum (15); (3) primary side-to-side jejunojejunostomy; (4) check for a safe anastomosis and no intestinal volvulus under laparoscopy (16); (5) peritoneal irrigation and drainage placement (Supplementary Material Figure S1; Supplementary Material Video S1).The procedure lasted 115 minutes, with estimated blood loss of 20 ml.
Gross examination of the resected specimen demonstrated a 6 × 6 × 5 cm in dimension, approximately spherical mass of fibrous hyperplasia adherent to the jejunal wall, which contained a 20 × 20cm surgical gauze (Figure 2).Given potential medicolegal consequences, histopathologic examination was not conducted.Because of the possibility of negative result under effective antibiotics treatment preoperatively, the gauze was not sent to bacteriology examination.Postoperatively, the patient was transferred back to the general medical ward.Complying with the pathway of enhanced recovery after surgery, the course of postoperative rehabilitation was uneventful, with first flatus on postoperative day (POD) 1 and oral feeding beginning on POD 2. The patient was discharged on POD 6 without any complications.So far, the regular follow-up of 9 months has been unremarkable.The timeline with corresponding clinical data from the period of care is shown in Figure 3.

Discussion
A systematic literature search was conducted in the PubMed database utilizing medical subject headings and text words related to "intra-abdominal gossypiboma" to acquire relevant case reports published till October 13, 2023.The search strategy and syntax for PubMed database are shown in Supplementary material Table S1.The studies with initial misdiagnosis as intra-abdominal tumor met the eligible criteria.Systematic reviews, case series with unavailable individual patient data, and articles with non-English languages or animal subjects were excluded.The general characteristics of the enrolled studies were extracted and entered into a preplanned electronic form (Table 1).The pooled data were summarized in a narrative and descriptive way.
in transitioning economies could definitely contribute to higher incurrence rate of intra-abdominal gossypiboma to some extent.Female patients accounted for 75% of the included cases (15/20).Previous obstetrics and gynecology surgery remained the leading cause of intra-abdominal gossypiboma (9/20), followed by open cholecystectomy (4/20), gastrectomy (4/20), urinary operations (2/ 20), and other laparotomies.The interval between the previous procedures to the present diagnosis of intra-abdominal gossypiboma ranged from 2 months to 40 years.The most common diagnostic tools were CT and ultrasonography (US).In terms of tumor, the predominant misdiagnosis for these patients as well as our reported case was gastrointestinal stromal tumor (GIST).
The optimal approach to dealing with this iatrogenic surgical complication is prevention.For surgeries associated with high risk of retained surgical sponge (RSS) as mentioned above, repeated sponge counting at the key time point (such as beginning and ending of the operation, handover of surgical team, closure of the peritoneum, and every 3 hours) should be advocated and emphasized (2).All the surgeons, assistants, and operating theater nurses should take a meticulous and responsible attitude towards the patient's life and postoperative quality of life.On the other hand, the application of radiopaque marker and quick response code within the surgical sponge is highly advisable (36-38).However, routinely postoperative plain films to identify RSS is not recommended.Small sponges should be abandoned during laparotomy while surgical compresses should be employed only intraperitoneally and one by one.A thorough intraperitoneal exploration prior to closure of the peritoneum is also crucial to minimize the risk of RSS.In a word, the prevention of RSS requires a high sense of responsibility, standardized clinical practice, diversified knowledge, and shared information.
As mentioned above, intra-abdominal gossypibomas are associated with unpredictable clinical presentations and the possibility of a long interval between the previous surgery and current episode (9).It may be discovered most frequently by a different surgeon rather than the one who did the previous procedure.It is critical for clinicians to hold a high index of suspicion of intra-abdominal gossypiboma when evaluating the episode of new symptoms in these patients with a distant history of high-risk laparotomy.Radiologic examinations (including CT, US, and MRI) can help establish preliminary diagnosis (10).For intraabdominal gossypiboma presenting as a mass, the common differential diagnoses include GIST, tumor of the small bowel and colon, retroperitoneal tumor, and intra-abdominal abscess.Noticeably, the gossypiboma and abscess can co-exist in the same patient.The role of percutaneous biopsy under the guidance of US or CT and histopathologic examination in the diagnosis of an intraabdominal mass should be emphasized, once a malignancy tumor cannot be ruled out (27).Furthermore, gastrointestinal endoscopy, as well as cystoscopy and ureteroscopy, can be applied to identify transmural migration and sometimes remove the RSS (32, 39).For a long time, redo exploratory laparotomy remains the frequent and vital method to finally confirm the diagnosis and treat this specific patient population.However, with minimal invasion and improved visualization, laparoscopic and robotic-assisted approaches have been placed high hopes in the management of gossypiboma, especially with preoperatively ambiguous diagnosis (40,41).
In conclusion, our case report accentuates the need for clinicians to maintain an elevated awareness and suspicion of gossypiboma when evaluating an intra-abdominal mass, especially in patients with a prior history of high-risk laparotomy.Laparoscopic surgery stands out as a technically proficient and minimally invasive strategy for diagnosing and treating intra-abdominal gossypiboma.

FIGURE 2
FIGURE 2Gross examination of the surgical specimen demonstrated a 6 × 6 × 5-cm, approximately spherical mass of fibrous hyperplasia adherent to the jejunal wall (A-C), which contained a 20 × 20-cm gauze (D).

FIGURE 1
FIGURE 1Computed tomography of the abdomen and pelvis indicated (A, B) dilated proximal bowel loops and multiple air-fluid levels due to (C) a 6.1 × 5.7cm, approximately spherical, well-delineated heterogeneous cystic and hyperdense jejunal mass and (D) mild intestinal volvulus, without indicators of intestinal ischemia or necrosis.

TABLE 1
General characteristics of the included case reports regarding intra-abdominal gossypiboma with initially suspected diagnosis as tumor.