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An Approach to Diagnosis in the Era of Medical Tourism

Kantak, Neelesh A. M.D.; Reish, Richard G. M.D.; Slavin, Sumner A. M.D.; Lin, Samuel J. M.D.

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Plastic and Reconstructive Surgery: March 2014 - Volume 133 - Issue 3 - p 443e-444e
doi: 10.1097/01.prs.0000438499.85598.53
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The retained surgical sponge, or gossypiboma, has become a rare event with the advent of standardized surgical counting. The Association of Operating Room Nurses requires that sponge counts be performed once at the start and twice at the conclusion of every operation involving an open cavity. In addition, the World Health Organization recommends only x-ray–detectable sponges be placed in body cavities and that non–x-ray–detectable sponges only be used after skin closure.1,2 When count discrepancies cannot be reconciled, a plain radiograph should be obtained. Although retained objects typically occur in operations involving the viscera, soft-tissue procedures are not immune from retained objects.

We recently treated a 64-year-old woman who underwent bilateral breast augmentation with silicone implants in another country. She presented to our office 7 months later with a 4-cm area of firmness and associated discomfort in the upper outer quadrant of her right breast. On mammography, no abnormality was seen. An ultrasound revealed a 3-cm, hyperechoic, wavy curvilinear structure with dense posterior acoustic shadowing at the 10 o’clock position (Fig. 1). Given our suspicion of a retained foreign body, she was taken to the operating room, where a retained sponge was encountered that did not contain a radiopaque marker (Fig. 2).

Fig. 1
Fig. 1:
Ultrasound scan of the right breast over the area of palpable abnormality in the upper outer quadrant shows a hyperechoic, wavy, curvilinear structure with dense posterior acoustic shadowing suggestive of a retained foreign body.
Fig. 2
Fig. 2:
Intraoperative photograph shows retained gauze sponge in the patient’s right breast. There was no radiopaque marker present on the sponge.

Clinical suspicion for gossypiboma may be raised by the presence of a palpable mass. In cases where reports exist for the patient’s prior operation, or the facility is known, the diagnosis can be made using plain radiographs alone. However, when the facility is unknown, one cannot be certain that x-ray–detectable sponges were used intraoperatively. In such cases, a negative plain radiograph is not sufficient to rule out gossypiboma and additional imaging may be required for diagnosis. On computed tomographic scans, a gossypiboma appears as a well-circumscribed mass with an enhancing capsule, generally 2 to 8 mm thick, containing internal heterogeneous densities with a wavy or striped appearance. On ultrasound, the gossypiboma appears as an echogenic center with a hypoechoic rim and a sharply delineated acoustic shadow from attenuation of the sound waves by the sponge fibers.3,4

The need for this more complex workup may become more frequent with the rise in medical tourism. An estimated 750,000 Americans sought medical care abroad in 2007, and 648,000 did so in 2008.5 These medical tourists seek care in a variety of countries, including less-developed nations, and a variety of contexts, including cosmetic surgery. Proponents argue that medical tourism offers decreased patient cost, expedited access to care, and increased choice. Unfortunately, there are few data on patient safety and clinical outcomes.

The World Health Organization’s guidelines for the labeling and counting of sponges may be followed to varying degrees internationally, and as more patients travel abroad for cosmetic procedures but return to the United States for management of complications, the plastic surgeon must consider the possibility of retained objects. Induration, pain, or a palpable mass should prompt a diagnostic workup beginning with a radiograph. If it is unrevealing, a computed tomographic scan or ultrasound should follow, with a return to the operating room if the imaging findings suggest gossypiboma.


The authors have no financial interest to declare in relation to the content of this article. There was no internal or external financial support for this study.

Neelesh A. Kantak, M.D.

Richard G. Reish, M.D.

Harvard Plastic Surgery Combined Residency Program

Sumner A. Slavin, M.D.

Samuel J. Lin, M.D.

Division of Plastic Surgery

Beth Israel Deaconess Medical Center

Boston, Mass.


1. World Health Organization. WHO Guidelines for Safe Surgery. 2008 Geneva, Switzerland WHO Press
2. Association of Peri-Operative Registered Nurses. . Recommended practices for sponge, sharp, and instrument counts. Standards, Recommended Practices and Guidelines. 2007 Denver, Colo AORN, Inc:493–502
3. Yamato M, Ido K, Izutsu M, et al. CT and ultrasound findings of surgically retained sponges and towels. J Comput Assist Tomogr. 1987;11:1003–1006
4. Choi B-I, Kim S-H, Yu E-S, et al. Retained surgical sponge: Diagnosis with CT and sonography. AJR Am J Roentgenol. 1988;150:1047–1050
5. Turner L. News media reports of patient deaths following “medical tourism” for cosmetic surgery and bariatric surgery. Dev World Bioeth. 2012;12:21–34


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