SURGERY, RADIOLOGY
Computed Tomography in Gossypiboma Diagnosis: a Radiologist's Perspective
Marianna Mirchuk1,2, Markiian Verkhola3, Albina Kozyra3
WJMI 2025; 5(1):42-52
Published online: 2025.11.09
DOI: https://doi.org/10.5281/zenodo.17566515
Citation: Mirchuk, M., Verkhola, M., & Kozyra, A. (2025). Computed Tomography in Gossypiboma Diagnosis: a Radiologist's Perspective. World Journal of Medical Innovations, 5(1), 42–52. https://doi.org/10.5281/zenodo.17566515
Affilations
1Department of Radiological Diagnostics, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine.
2Ukrainian-Polish Heart Center Lviv, Lviv, Ukraine
3Department of Surgery, Lviv Regional Clinical Hospital, Lviv, Ukraine
Corresponding author. Marianna Mirchuk, MD, PhD student, Аssistant professor, Department of Radiation Diagnostics and Treatment Danylo Halytsky Lviv National Medical University Ukrainian-Polish Heart Center Lviv Lviv, Ukraine, +380975662190 annairam1990@gmail.com
Abstract
Gossypiboma, the inadvertent retention of surgical textiles, presents significant diagnostic challenges for radiologists. Computed tomography serves as an important imaging modality for the detection and characterization of these retained foreign bodies. This review examines computed tomography imaging features, diagnostic approaches, and clinical implications from a radiological standpoint. Understanding the polymorphic computed tomography appearances of gossypibomas is crucial for accurate diagnosis, as these lesions can mimic various pathological conditions, including neoplasms, abscesses, and inflammatory masses. Key imaging features include the presence of radiopaque markers, characteristic spongiform patterns, cystic transformations, and complications such as transmural migration. While computed tomography demonstrates superior sensitivity compared to other imaging modalities, diagnostic accuracy depends on radiologist awareness and correlation with surgical history.
Introduction
Gossypiboma represents one of medicine's most preventable yet persistent complications, occurring when surgical textiles are inadvertently retained within patients following operative procedures. Derived from the Latin "gossypium" (cotton) and Swahili "boma" (place of concealment), this term encompasses various retained materials, including surgical sponges, gauze pads, towels, and other textile-based surgical supplies [1].
From a radiological perspective, gossypibomas present unique diagnostic challenges due to their variable and often non-specific imaging appearances. These lesions can masquerade as tumors, abscesses, or other pathological processes, potentially leading to misdiagnosis and inappropriate management [2]. The reported incidence ranges from 0.3 to 1.0 per 1,000 abdominal operations, though underreporting likely obscures the true prevalence [3,4].
Computed tomography (CT) has emerged as the cornerstone imaging modality for gossypiboma detection, offering superior sensitivity and specificity compared to conventional radiography and ultrasonography [4]. However, successful diagnosis requires radiologists familiarity with the spectrum of CT appearances and maintaining appropriate clinical suspicion based on patient history.
This review examines gossypiboma from a radiological perspective, emphasizing CT imaging characteristics, diagnostic strategies, and clinical implications relevant to practicing radiologists.
Pathophysiology and Temporal Evolution
Understanding the pathophysiological response to retained surgical materials is fundamental to interpreting imaging findings. The body's reaction to gossypibomas follows two primary pathways that directly influence imaging appearance [5].
The acute exudative response typically occurs within days to weeks of surgery, characterized by bacterial colonization and intense inflammatory reaction. This pathway leads to abscess formation, potential sepsis, and fistula development. CT imaging during this phase demonstrates inflammatory changes, including fluid collections, enhancement patterns, and surrounding fat stranding that may obscure the underlying foreign material.
Conversely, the chronic aseptic fibrotic response develops over months to years, creating a fibrous pseudocapsule around the retained material. This encapsulation process produces the characteristic imaging findings that aid diagnosis, including the pathognomonic "spongiform" pattern seen on CT [6].
The temporal relationship between surgery and imaging presentation significantly impacts diagnostic accuracy. Early detection (within 2-6 months) accounts for approximately 78% of cases, often prompted by symptomatic presentation [7]. Late detection, sometimes occurring years after the initial surgery, typically presents as incidental findings or non-specific masses requiring careful correlation with surgical history.
CT Imaging Protocol and Technical Considerations
Optimal CT imaging of suspected gossypibomas requires careful attention to technical parameters and acquisition protocols. Standard contrast-enhanced CT with both arterial and portal venous phases provides comprehensive evaluation of the foreign material and surrounding inflammatory response [8].
Image acquisition should utilize thin-section collimation (≤2.5 mm) to maximize spatial resolution for detecting small retained fragments or characteristic internal architecture. Multiplanar reconstructions in sagittal and coronal planes often prove valuable for demonstrating the relationship between gossypibomas and adjacent structures [9].
Contrast administration helps differentiate inflammatory changes from normal postoperative findings and identifies complications such as fistula formation or vascular involvement. However, the retained textile material itself typically remains non-enhancing, appearing as a central hypodense or mixed-density focus within an enhancing rim of inflammation [1,9–11].
Window and level settings require adjustment for optimal visualization. Standard soft tissue windows may obscure subtle density differences within the foreign material, while wider windows can better demonstrate internal architecture and gas patterns characteristic of certain gossypiboma types [12]
Radiographic Appearance Classifications
Radiopaque Marker-Containing Gossypibomas
The most straightforward radiological diagnosis occurs when retained sponges contain radiopaque markers. These appear as high-attenuation linear or curvilinear structures within the mass on CT, creating characteristic streak artifacts [12]. The markers, typically composed of barium sulfate, appear as dense white lines that may be straight, curved, or coiled depending on the sponge configuration.
However, radiopaque markers are present in only 20-30% of cases, limiting the utility of this finding [13]. When present, these markers provide pathognomonic evidence of retained surgical material, making diagnosis virtually certain. The surrounding inflammatory response may vary from minimal to extensive, depending on the chronicity and presence of secondary infection.
Spongiform Pattern Gossypibomas
The spongiform pattern represents the most characteristic CT appearance of gossypibomas [14]. The internal appearance shows a complex meshwork of varying densities, with areas of low attenuation representing trapped air and higher attenuation regions corresponding to textile material and inflammatory debris. This creates a heterogeneous, "Swiss cheese" or sponge-like appearance that is virtually pathognomonic when present (Figure 1).
Figure 1. A 38-year-old woman went to the emergency department. On CT scans, the lesions appeared as spongy masses with poorly defined contours (A, B, C, D, E, F, G, H). The phases: native (A, E), arterial (B, F), delayed (4 min.; C, G and 20 min.; D, H). In this case, 3 days after the removal of the uterus and ovaries, extravasation of contrast was observed from the right ureter (yellow arrow: C, D, H).
The spongiform pattern of gossypiboma typically develops in a true granuloma that has been present for more than three months and represents a mature inflammatory response with stable fibrous encapsulation (Figure 2). The surrounding tissues usually demonstrate minimal active inflammation, and there may be no significant mass effect on adjacent structures.
Figure 2. A 53-year-old patient's axial (A) and coronal (B) CT scans. This form corresponded to a true granuloma, somewhat old (initial surgeries were performed more than 3 months before imaging), with calcified material appearing (yellow arrow; A, B).
Cystic Gossypibomas
Some gossypibomas undergo central necrosis and liquefaction, creating a predominantly cystic appearance on CT [15]. These lesions present as well-defined, low-attenuation masses with thick, enhancing walls and occasionally internal septations.
The cystic transformation typically occurs in chronic cases where the inflammatory response has led to central breakdown of the retained material. The resulting cavity contains fluid that may be simple or complex, depending on the presence of debris or secondary infection. The wall enhancement pattern usually demonstrates smooth, uniform thickening distinct from the irregular enhancement seen in malignant cystic lesions.
This appearance can be particularly challenging diagnostically, as cystic gossypibomas may closely mimic other cystic abdominal masses, including cystic neoplasms, infected collections, or developmental cysts. Correlation with surgical history becomes crucial in these cases.
Mixed Inflammatory Pattern
Acute or subacute gossypibomas often present with mixed inflammatory patterns that can be the most diagnostically challenging [16]. These lesions appear as poorly defined, heterogeneous masses with extensive surrounding inflammatory changes.
The CT appearance includes irregular margins, mixed internal density, surrounding fat stranding, and possible associated fluid collections. The retained textile material may be obscured by the extensive inflammatory response, making definitive diagnosis difficult without strong clinical suspicion (Figure 3).
Figure 3. A 40-year-old woman's axial CT scans after 10 pregnancies and 3 days after the extirpation of the uterus and ovaries (A, B, C), and follow-up after 10 days (D, E, F). The phases: native (A, D), arterial (B, E), delayed (10 min.; C, F). During this period, a granuloma began to form, characterized by clear and regular borders. A process of granuloma formation that looks like an encapsulated sponge and is described as a “spongiform” gossypiboma, but in this case, the fatty tissue is dense, so there is a risk of abscessing.
These cases may present with signs of active infection, including gas formation, rim enhancement, and adjacent organ involvement. The inflammatory response can be so extensive as to mimic peritonitis or other acute abdominal conditions (Figure 4).
Figure 4. A 38-year-old patient was admitted to the emergency department 2 weeks after the first operation. The native phase (A, D), arterial phase (B, E), and delayed phase (10 min.; C, F) demonstrate two “spongiform” gossypibomas, but with a risk of abscessing. In this case, there was extravasation of contrast from the left ureter (yellow arrow; C, F).
Complications, Advanced Imaging Findings and Special Circumstances
One of the most interesting radiological phenomena associated with gossypibomas is transmural migration into hollow viscera [17–22]. This complication can involve the gastrointestinal tract, urinary bladder, or other hollow organs, creating diagnostic challenges as the foreign material may mimic intraluminal masses or tumors. CT findings of transmural migration include identification of the retained material within the organ lumen, often with associated wall thickening and inflammatory changes at the site of erosion. The migration pathway may be visible as a tract extending from the original surgical site to the involved organ. Gastrointestinal migration is most common, with gossypibomas eroding through bowel walls and appearing as intraluminal filling defects. These may be mistaken for polyps, tumors, or other intraluminal pathology without appropriate clinical correlation.
Fistula formation represents a serious complication that is well-demonstrated on CT imaging [23]. These abnormal communications may develop between the gossypiboma and adjacent organs or external surfaces, creating complex pathological processes. CT findings include identification of the abnormal communication tract, often best demonstrated on coronal or sagittal reconstructions. Contrast studies may be necessary to fully delineate the fistulous communication and assess its extent. The presence of gas or contrast material in unexpected locations should prompt careful evaluation for fistula formation.
Large gossypibomas can cause mechanical bowel obstruction through direct mass effect or inflammatory adhesions [24]. CT demonstrates the characteristic findings of bowel obstruction, including proximal bowel dilatation, wall thickening, and identification of the transition point at the level of the foreign material. The obstructing mass may show typical gossypiboma features or may be obscured by secondary inflammatory changes. Careful attention to the relationship between the mass and adjacent bowel loops is essential for proper evaluation.
Recent reports have identified gossypibomas as potential complications of vacuum-assisted closure therapy, where foam materials may be inadvertently retained in wound beds [25,26]. These cases require specific attention to superficial locations and may benefit from high-resolution imaging techniques.
The increasing complexity of endovascular procedures has introduced new categories of retained foreign bodies that may require specialized imaging approaches [27]. CT angiography may be necessary to identify retained guidewires, stents, or other interventional materials.
Modern surgical safety initiatives, including the implementation of surgical safety checklists [28], have shown promise in reducing gossypiboma incidence. Radiologists play a crucial role in these quality improvement efforts by providing accurate diagnoses and participating in root cause analyses when prevention fails.
The integration of radiofrequency identification (RFID) technology and other tracking systems represents an evolving area where radiological expertise may be required for validation and troubleshooting [29].
Differential Diagnosis
The polymorphic nature of gossypibomas creates an extensive differential diagnosis that varies based on imaging appearance and anatomical location [30–32].
Neoplastic Lesions
Chronic gossypibomas, particularly those with the spongiform pattern, can closely mimic neoplasms. The well-defined margins and heterogeneous internal architecture may suggest primary or metastatic tumors. However, the lack of aggressive features, such as invasion of adjacent structures and the presence of characteristic internal architecture, helps differentiate gossypibomas from malignant lesions.
Cystic gossypibomas may mimic cystic neoplasms, particularly mucinous tumors or cystic metastases. The uniform wall thickness and lack of solid enhancing components favor gossypiboma over malignant cystic lesions [32].
Inflammatory Conditions
Acute gossypibomas with extensive inflammatory changes may be indistinguishable from abscesses or other infectious processes. Both conditions can present with rim-enhancing fluid collections, surrounding fat stranding, and gas formation. The identification of internal textile architecture, when visible, provides the key differentiating feature.
Chronic inflammatory conditions such as inflammatory pseudotumors or organizing hematomas may also mimic gossypibomas. These conditions typically lack the characteristic internal architecture seen in textilomas [31].
Postoperative Changes
Normal postoperative inflammatory changes can obscure or mimic gossypibomas, particularly in the early postoperative period. Seroma formation, fat necrosis, and granulation tissue can all create masses that may be confused with retained foreign bodies.
The evolution of postoperative changes over time typically differs from gossypibomas, with gradual resolution rather than the stable or progressive appearance characteristic of retained foreign materials [30–32].
Clinical Management Integration
CT findings significantly influence clinical management decisions regarding gossypiboma treatment. The imaging characteristics help determine intervention urgency, with acute inflammatory changes suggesting the need for prompt surgical removal to prevent complications.
For chronic, asymptomatic gossypibomas, CT findings guide the decision between surgical removal and conservative management. Factors, including lesion size, anatomical relationships, and complication presence, all influence treatment planning [33,34].
Serial CT imaging plays a crucial role in monitoring patients with gossypibomas, particularly those managed conservatively. Regular follow-up can detect complication development, size changes, or migration to new locations.
The critical role of CT in gossypiboma diagnosis necessitates comprehensive training for radiology residents and practicing radiologists. Educational programs should emphasize recognition of various imaging patterns and the importance of clinical correlation.
Mock cases and continuing medical education programs help maintain diagnostic skills and awareness. Integration of gossypiboma cases into residency training curricula ensures that new radiologists develop appropriate recognition skills early in their careers [18,33].
Diagnostic Strategies and Pitfalls
The most critical aspect of gossypiboma diagnosis is maintaining appropriate clinical suspicion based on surgical history [35]. Any patient presenting with an unexplained abdominal mass following previous surgery should be evaluated for possible retained foreign bodies, regardless of the time interval since the procedure.
Communication with the referring clinician regarding specific surgical procedures, complications, and postoperative course can provide valuable context for image interpretation. The absence of documented sponge count discrepancies does not exclude gossypiboma, as studies indicate that up to 88% of retained foreign bodies occur despite "correct" surgical counts [36,37].
The timing of imaging relative to the initial surgery significantly impacts the likelihood of gossypiboma and influences imaging appearance. Early postoperative imaging may show only subtle changes that could be attributed to normal inflammatory response, while chronic cases may present as well-established masses requiring differentiation from neoplasms.
Optimal imaging protocols should be tailored to the specific clinical scenario. In cases of high clinical suspicion, thin-section CT with multiplanar reconstructions and careful attention to window settings maximizes diagnostic sensitivity.
Laparoscopic removal of gossypiboma material has been shown in Figure 5 (A, B, C).
Figure 5. Laparoscopic removal of gossypiboma material: covered with a mucous layer (А); with a special challenge of separating the gossypiboma from the adjacent intestines, parenchymal organs, and mesentery (B); the gossypiboma, which can be a source of infection and requires rapid and prompt surgical removal (C).
Comparative Imaging Modalities
While CT remains the primary imaging modality for gossypiboma diagnosis, ultrasonography can provide valuable supplementary information [38]. Gossypibomas typically demonstrate hyperechoic interfaces with posterior acoustic shadowing, though this appearance is non-specific and can be seen with various foreign bodies.
Ultrasound is particularly useful for superficial locations and in patients where CT is contraindicated. However, the operator-dependent nature of ultrasound and limitations imposed by bowel gas and patient habitus restrict its utility as a primary diagnostic tool.
MRI can provide superior soft tissue contrast and may help characterize the relationship between gossypibomas and adjacent structures [39,40]. The multiplanar capability and lack of ionizing radiation make MRI attractive for certain patient populations.
However, MRI is less sensitive than CT for detecting gas patterns and calcifications within gossypibomas, and the longer acquisition times may limit its practical utility for emergency evaluations. The characteristic internal architecture may be less apparent on MRI compared to CT.
Plain radiographs retain importance for detecting radiopaque markers when present, but have limited sensitivity for non-opaque materials [41]. The simplicity and availability of radiography make it useful for initial screening in appropriate cases, but normal radiographs do not exclude gossypiboma.
Prevention and Future Directions
From a radiological perspective, prevention efforts focus on improving detection sensitivity and reducing diagnostic delays. This includes education regarding the various imaging appearances of gossypibomas and the importance of maintaining clinical suspicion in appropriate cases [42,43].
Intraoperative imaging protocols may be implemented for high-risk procedures, with some institutions obtaining routine postoperative radiographs or CT scans before patient departure from the operating room [44]. While this approach requires significant resources, the cost-effectiveness may be justified given the substantial expenses associated with missed gossypibomas.
Quality assurance programs should monitor diagnostic accuracy for gossypiboma detection, with regular review of missed cases to identify opportunities for improvement [33,34]. Multidisciplinary conferences can facilitate knowledge sharing and improve overall diagnostic performance.
The radiological diagnosis of gossypiboma carries significant economic and medicolegal implications. Delayed or missed diagnosis can result in substantial malpractice claims [45].
The quality of radiological interpretation becomes critical evidence in legal proceedings, emphasizing the importance of thorough image evaluation and appropriate documentation. Radiologists should be aware that gossypibomas have been designated as "never events" by the National Quality Forum, creating heightened scrutiny around these cases [46].
Advances in CT technology continue to improve gossypiboma detection capabilities. Higher resolution imaging, improved contrast resolution, and advanced reconstruction algorithms enhance sensitivity for detecting small retained fragments or subtle architectural features.
Artificial intelligence and machine learning applications show promise for automated gossypiboma detection [29]. These systems could serve as decision support tools, alerting radiologists to potential findings and reducing oversight risk in busy clinical environments.
Dual-energy CT and spectral imaging techniques may provide additional discrimination between retained textile materials and surrounding tissues, potentially improving diagnostic accuracy in challenging cases.
Gossypiboma diagnosis in pediatric patients requires special consideration of radiation exposure and age-appropriate imaging protocols. The ALARA principle should guide technique selection, with consideration of alternative modalities when appropriate.
When CT is necessary, low-dose pediatric protocols should be employed while maintaining diagnostic image quality. The smaller body habitus in children may actually improve diagnostic sensitivity due to reduced tissue depth and better contrast resolution [33,34].
Conclusions
Computed tomography serves as the primary imaging modality for gossypiboma diagnosis, offering superior sensitivity and specificity compared to other imaging techniques. The key to successful diagnosis lies in radiologists awareness of the polymorphic CT appearances and maintenance of appropriate clinical suspicion based on surgical history.
The characteristic imaging features include radiopaque markers when present, spongiform patterns in chronic cases, cystic transformations, and various inflammatory patterns in acute presentations. Understanding these appearances and their differential diagnosis is crucial for accurate interpretation.
Complications such as transmural migration, fistula formation, and bowel obstruction require careful evaluation and may significantly impact patient management. The role of CT extends beyond simple detection to include complication assessment and treatment planning.
As surgical procedures become increasingly complex and patient populations more diverse, the radiologist's role in gossypiboma diagnosis becomes increasingly important. Continued education, quality assurance programs, and technology advancement will help optimize diagnostic accuracy and patient outcomes.
The ultimate goal remains the prevention of gossypibomas through improved surgical protocols and safety measures. However, when prevention fails, accurate and timely radiological diagnosis provides the foundation for optimal patient care and outcomes. Radiologists must remain vigilant for these preventable complications while contributing to quality improvement initiatives aimed at their elimination from modern surgical practice.
Data Availability Statement
Articles did not analyze any data of patients
Funding Statement
The authors declare no financial relationships with any organizations that could be perceived to influence the work reported in this manuscript.
Conflict of Interest Disclosure
The authors declare that they have no competing interests.
Ethics Approval Statement
This study no needs ethical approval.
Patient Consent Statement:
Informed consent (written) was obtained from publication of patient images.
Permission to Reproduce Material from Other Sources: No reproducible materials.
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