Journal of Surgical Technique and Case Report
Journal of Surgical Technique and Case Report


 
  Table of Contents 
CASE REPORT
Year : 2012  |  Volume : 4  |  Issue : 1  |  Page : 24-26  

Failure to heal of thyroidectomy wound due to gossypiboma and stitch sinus: Report of two cases


1 Department of Surgery, Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu, Nigeria
2 Department of Morbid Anatomy and Pathology, Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu, Nigeria
3 Department of Medical Microbiology, Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu, Nigeria

Date of Web Publication5-Sep-2012

Correspondence Address:
Adewale A Musa
Endocrine and Biliary Surgical Unit, Olabisi Onabanjo University Teaching Hospital (OOUTH), PMB 2001, Sagamu,
Nigeria
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2006-8808.100349

Get Permissions

   Abstract 

This case series presents two females, 53 and 33 years old, with thyroidectomy wounds that failed to heal, 16 and 18 weeks, respectively, following the operation. The wounds were explored with removal of gauze and catgut suture. The patients made remarkable improvement and the wounds healed satisfactorily within seven days. Surgical materials forgotten intraoperatively, wrong use of and / or infected surgical materials should be considered when surgical wounds fail to heal.

Keywords: Gossypiboma, healing, thyroidectomy, wound


How to cite this article:
Musa AA, Banjo A, Agboola O, Osinupebi O. Failure to heal of thyroidectomy wound due to gossypiboma and stitch sinus: Report of two cases. J Surg Tech Case Report 2012;4:24-6

How to cite this URL:
Musa AA, Banjo A, Agboola O, Osinupebi O. Failure to heal of thyroidectomy wound due to gossypiboma and stitch sinus: Report of two cases. J Surg Tech Case Report [serial online] 2012 [cited 2016 Jun 10];4:24-6. Available from: http://www.jstcr.org/text.asp?2012/4/1/24/100349


   Introduction Top


During surgical procedures precautionary measures are always taken to avoid or minimize complications. [1] Despite these, complications can still occur. These may arise as a result of the type of suture used, due to its physical and natural properties, [2],[3] as well as breach in the sterile procedure. Furthermore, iatrogenic operative complications do occur when surgical materials like gauze, sponges, or surgical instruments are forgotten intraoperation – leading to various complications, such as failure of the wound to heal, sinus formation, fistulations, and abscesses. [4]

Literature is very sparse on this because most are not reported for medicolegal implications. [5] The aim of this article is to report two cases of failure of thyroidectomy wounds to heal, one as a result of 'gauzoma' (gossypiboma), and the other, a combination of gossypiboma and suture abscess, leading to a stitch sinus.


   Case Reports Top


Case 1

A 53-year-old civil servant was presented with a discharging wound that had failed to heal two-and-a-half months post thyroidectomy for a simple colloid goiter. The wound started discharging thick creamy pus postoperatively on the fifth day and this warranted wound exploration five weeks after the initial operation, in the same hospital. Despite surgical exploration and other therapeutic measures, the wound still failed to heal, and as the discharge persisted for another six weeks she was referred to our facility.

The essential findings on physical examination, at presentation in our hospital, revealed a middle-age woman, who was acutely ill-looking, febrile (Temperature 38.5°C), anicteric, and not dehydrated. There was a thyroidectomy scar with a fistula formation in the 2 cm mid-portion, discharging pus. The surrounding skin was inflamed and indurated with some degree of swelling in the lower flap of the wound. The other systems were essentially normal. An impression was formed of stitch sinus with residual abscess, keeping in view retained surgical object post thyroidectomy.

A repeat microscopy, culture, and sensitivity of the discharge in our hospital yielded atypical coliforms, sensitive to levofloxacin and Augmentin. There was no clinical or laboratory evidence of immunosuppressive illness in the patient. She was placed on two antimicrobial agents and she improved significantly within one week of admission. She subsequently had wound re-exploration, with the finding at operation revealing a strip of gauze (gauzoma) well tucked (encapsulated) into the lower flap, with some strands extruding into the subcutaneous layer [Figure 1]. The histology of biopsy of the cavity was consistent with chronic granuloma formation.
Figure 1: Extraction of the gauze in case 1

Click here to view


Case 2

A 33-year-old civil servant developed a wound infection on the fourth day post thyroidectomy performed in a private hospital for a simple multinodular goiter. Culture of the discharge from the wound yielded heavy growth of Staphylococcus aureus, which was sensitive to chloramphenicol and erythromycin. The wound, however, failed to heal, and there was recurrent discharge 10 weeks after surgery, despite antimicrobial treatment. A wound exploration and drainage of abscess was performed a week later. A repeat microscopy, culture, and sensitivity yielded Pseudomonas aeruginosa, which was sensitive to floxacillin and gentamycin. There was some degree of success as the wound started healing with exuberant granulation tissue, although the discharge persisted for another eight weeks until a stitch sinus eventually developed.

She was referred to our institution on account of persistent wound discharge. At presentation she was found to be clinically stable, with a discharging sinus over the surgical scar. There was no clinical or laboratory evidence of immunosuppressive illness in the patient.

The wound was re-explored in our hospital four weeks after presentation. A deep-seated abscess, with some free chromic catgut sutures were encountered extruding from encapsulated surgical gauze left on the right side [Figure 2]. The wound was copiously irrigated with saline and the wound closed primarily. She did well postoperatively and was discharged after 10 days of admission, without any residual problem. She has been followed up in the clinic for six months and has remained stable since.
Figure 2: Shows the extracted gauze in case 2

Click here to view



   Discussion Top


Thyroidectomy is considered a clean operation, but when the wound fails to heal in the expected period of time, especially with purulent discharge or abscess formation, pyogenic infection is often primarily implicated. Usually the discharge from the wound is cultured and appropriate antimicrobials are used. However, when the wound still fails to heal, retained surgical material or infected suture material (due to poor surgical technique or nature of suturing material used) are often ignored because of the medicolegal implication. [1] For the same reason, these are not often published. [5],[6]

Although, gauze and sponges are usually used to achieve hemostasis, as well as in dissection, during surgery, they are still forgotten intraoperation, despite measures taken to avoid this. [7] This also applies to other surgical materials and equipments like gelfoam, surgicel, artery forceps, and so on. [8]

There are quite a few causes for operative loss of gauze, sponges, and surgical instruments. [9] Notable among these are serious emergency procedures that might not allow initial sponge count, severe hemorrhagic procedures, time consuming operations, and no sponge counting while closing. Others include, the nature of surgical materials like cotton pads that might break into pieces, lack of tags on the sponges, towels and gauze, inaccessible operation sites, poor surgical techniques, change of theater personnel, as well as lack of good rapport and understanding among the operating team (assistant nurses, anesthetists, surgeons). [10]

The course of events, when they occur, are extrusion, elicitation of an exudative reaction leading to abscess, cellulitis, septic syndrome, or remaining inert with encapsulation and formation of a lot of adhesions. [11] In our patients, severe cellulitis with abscess formation and copious pus discharge were elicited, as previously documented. [12] An attempt at extrusion into the outside also occurred, as some of the chromic catgut used was seen projecting into the wound surface and some strands of the cotton gauze (gauzoma) were detected in the subcutaneous layer of the wound of the first patient.

The radiological features of gossypiboma, textilioma, as well as others, are well known, including the use of ultrasonography and magnetic resonance imaging (MRI). [13] The first patient started discharging pus on the fifth day, while the second started discharging pus on the fourth day post the operation (both were accompanied with classical clinical features of acute pyogenic infection). We believed that the 'explorations' that were done from the referring hospitals were just laying open the skin down to the platysma level, as the wounds continued to discharge despite the 'explorations'. The wounds were thoroughly explored under general anesthesia in our hospital. These eventually yielded the forgotten gauze in the first patient, [Figure 1]. In the second patient the chromic catgut used was trying to extrude, while a gauze was found on the right side, fully encapsulated [Figure 2].

Suture materials are known to cause adverse effect on tissues and increase susceptibility to infection. [14] The types of suture material used and the surgical technique also play some role in wound infection. This is further encouraged by the presence of devascularized tissue and hematoma dead space from tissue damage. [15] The severity of infection elicited, depends on the physical and chemical configuration of the sutures. [16] Bacteria are known to adsorb into the strands of multifilament sutures such as silk and catgut (especially plain catgut), hence, these should be taken into consideration when planning surgical procedures.


   Conclusion Top


In conclusion, gossypiboma should be given a high index of suspicion in the presence of a persistently discharging wound post operation, post-thyroidectomy wound inclusive. The routine gauze and instrument count prior to and after surgical procedure cannot be over-emphasized.

 
   References Top

1.Okten A, Adam M, Gezercan Y. Textilioma: A case of foreign body mimicking a spinal mass. Eur Spine J 2006;15(Supp 5):626-9.  Back to cited text no. 1
    
2.Katz S, Izhar M, Mirelman D. Bacterial adherence to surgical sutures: A possible factor in suture induced infection. Ann Surg 1981;194:35-41.  Back to cited text no. 2
[PUBMED]    
3.Alexander JW, Jerold Z, Kaplan BS, Altemeier WA. Role of suture materials in the development of wound infection. Ann Surg 1967;165:192-9.  Back to cited text no. 3
    
4.Abdul-Karim FW, Benevenia J, Pahtria MN, Makley JT. Case report 736: Retained surgical sponge (gossypiboma) with a foreign body reaction and remote and organizing hematoma. Skeletal Radiol 1992;21:466-9.  Back to cited text no. 4
    
5.Turgut M, Akyuz O, Ozsunar Y, Kacar F. Sponge-induced granuloma ("gauzoma") as a complication of posterior lumber surgery. Neurol Med Chir (Tokyo) 2005;45:209-11.  Back to cited text no. 5
    
6.Gifford RR, Plaut MR, Mc Leary RD. Retained surgical sponge following laminectomy. JAMA 1973;223:1040.  Back to cited text no. 6
    
7.Rappaport W, Haynes K. The retained surgical sponge following intra-abdominal surgery: A continuing problem. Arch Surg 1990;125:405-7.  Back to cited text no. 7
[PUBMED]    
8.Slim K, Ben Slimane T, Dziri C, Mzabi R. Les corps étrangers textiles oublies dans l'abdomen. Ann Radiol (Paris) 1990;33:280-3.  Back to cited text no. 8
[PUBMED]    
9.Lauwers PR, Van Hee RH. Intraperitoneal gossypibomas: The need to count sponges. World J Surg 2000;24:521-7.  Back to cited text no. 9
    
10.Serra J, Matias-Guiu X, Calabuig R, Garcia P, Sancho FJ, La Calle JP. Surgical gauze pseudotumor. Am J Surg 1988;155:235-7.  Back to cited text no. 10
    
11.Furukawa H, Hara T, Taniguchi T. Two cases of retained foreign bodies after cholecystectomy: Diagnosis by sonography, CT, angiography and MRI. Jpn J Surg 1991;21:556-70.  Back to cited text no. 11
    
12.Klein J, Farman J, Burrell M, Demeter E, Frosina C. The forgotten surgical foreign body. Gastrointest Radiol 1988;13:173-6.  Back to cited text no. 12
    
13.Leppaniemi AK. Intravesical foreign body after inguinal herniorrhaphy: Case report. Scand J Urol Nephrol 1991;25:87-8.  Back to cited text no. 13
    
14.Elek SD, Conen PE. The virulence of staphylococcus pyogenes for man. A study of the problems of wound infection. Br J Exp Pathol 1957;38:573-86.  Back to cited text no. 14
    
15.Edlich RF, Tsung MS, Rogers W, Rogers P, Wangensteen OH. Studies in the management of the contaminated wound infection. Technique of closure of such wounds together with a note on reproducible model. J Surg Res 1968;8:585-92.  Back to cited text no. 15
    
16.Edlich RF, Panek PH, Rodeheaver GT, Turnbull VG, Kurtz LD, Edgerton MT. Physical and chemical configuration of sutures in the development of surgical infection. Ann Surg 1973;177:679-88.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Case Reports
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed2552    
    Printed103    
    Emailed0    
    PDF Downloaded49    
    Comments [Add]    

Recommend this journal