"GossiPyboma" a retained post-operative intra-abdominal surgical sponge can lead to septicemia and septic shock: A case report

Objectives: This case report was reported as a rare case of post-surgical complication to reduce the incidence of occurrence of this near miss which can lead to sentinel event and death in such patients. Background: A retained postoperative foreign body inside the abdomen is a considered one of the common faults of the surgical team which can lead to infection and sepsis. Methods: We were working as a surgical team in a tertiary hospital and we noticed on 9th of January 2022 a retained intraabdominal sponge 4 months after an open laparotomy hernia operation with mesh repair for a 61 years old patient who admitted with infected gauze, peritonitis and septic shock due to the forgotten inflamed gauze which was diagnosed accidentally by abdominal CT as "GossiPyboma". Emergency laparotomy done, septic shock was managed and the patient condition is now stable. The case was consented for study and IRB obtained (89-45/KKJB23/89-2021). Results: We conducted a root cause analysis and recommended for Radiofrequency Detection Technique use in Operative Room to by Pass Human factors big role, save time consumed in looking for missed item & avoid extended LOS resulted from harm. Conclusion: Strict Adherence to Hospital wide policies and procedures with periodic awareness and use of modern technology is a strict requirement to reduce human errors in such patients. Also a routine abdominal CT should be done post operatively to exclude gauze retention.