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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 45-47

Textiloma mimicking an intra-abdominal tumor: A case report from a medicolegal point of view


1 Department of General Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
2 Department of Surgery, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Date of Submission05-Nov-2021
Date of Decision12-Nov-2021
Date of Acceptance10-Dec-2021
Date of Web Publication12-May-2022

Correspondence Address:
Ibtihal Oudah AlGhamdi
Department of Surgery, King Abdulaziz University Hospital, P.O. Box: 23454, Jeddah 7951
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_91_21

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  Abstract 


Textiloma is a pseudotumor arising from a nonabsorbable retained cotton matrix, incidentally left behind during surgery, which has triggered an inflammatory reaction. This study describes a case of intra-abdominal textiloma, which mimicked a small bowel tumor on preoperative assessment. A 24-year-old asymptomatic female patient, who had undergone open appendectomy at the age of 20, presented to our institution with incidental finding of a large solid mass in the small bowel, covered by the omentum. Abdominal computed tomography showed an enhanced tumoral mass occupying the right intraperitoneum. During the laparoscopic exploration, the tumor was identified attached to the small bowel loop; small bowel en bloc resection was performed. Pathology results were compatible with a piece of gauze surrounded by reactive changes adherent to the small bowel (textiloma). The patient had a good recovery, and postoperative follow-ups were uneventful. The case offers a medicolegal perspective of this not uncommon, yet avoidable, problem and assesses the difficulties of assigning the responsibility for its occurrence to surgical team members and operating room staff.

Keywords: Foreign body granuloma, medicolegal, surgical sponge, textiloma


How to cite this article:
AlHarthi M, AlGhamdi IO, Aljiffry M. Textiloma mimicking an intra-abdominal tumor: A case report from a medicolegal point of view. Saudi Surg J 2021;9:45-7

How to cite this URL:
AlHarthi M, AlGhamdi IO, Aljiffry M. Textiloma mimicking an intra-abdominal tumor: A case report from a medicolegal point of view. Saudi Surg J [serial online] 2021 [cited 2022 May 27];9:45-7. Available from: https://www.saudisurgj.org/text.asp?2021/9/2/45/345196




  Introduction Top


Textiloma is a pseudotumor that arises from a nonabsorbable retained cotton matrix. The reported frequency of this incident varies between 1 in 1000 and 1 in 10,000 interventions.[1],[2] The first report of a retained surgical sponge appeared in the medical literature in 1884 by Wilson.[3]

The study describes a case of intra-abdominal textiloma, which mimicked a small bowel tumor on preoperative assessment. The case illustrates the medicolegal perspectives of this not uncommon, yet avoidable, problem and assesses the difficulties involved in assigning the responsibility of its occurrence to surgical team members and operating room (OR) staff.


  Case Report Top


A 24-year-old asymptomatic female patient underwent an open appendectomy at the age of 20 years. Four years later, the patient was pregnant, and during the third-trimester follow-up, the patient complained of decreased fetal movement and clear vaginal discharge. She underwent cesarean section, during which an incidental finding of a large solid mass on the antimesenteric side of the small bowel was found, covered by the omentum. The patient was transferred to the ward in good condition.

Basic laboratory investigations were normal. An abdominal computed tomography scan showed a right intraperitoneal mass, oval-shaped with central and peripheral necrotic tissue. The mass, which has a solid-enhancing component within an internal linear serpentine high-density structure, is occupying the anterior abdominal wall. Adjacent to the ileal loop and uterine fundus, it measured 4.4 cm × 8.5 cm [Figure 1]. The differential diagnosis included gastrointestinal stromal tumor, desmoid tumor, or neuroendocrine tumor. Tumor marker were normal.

Surgery to remove the tumor was carried out under a minor risk with American Society of Anesthesiologists I. The patient underwent elective laparoscopic exploration, and the tumor was identified attached to a small bowel loop. After complete mobilization, a small midline laparotomy incision was performed to extract the mass. An en bloc small bowel resection anastomosis was performed [Figure 2]. The histological evaluation was compatible with a piece of gauze surrounded by reactive changes adherent to the small bowel (i.e., textiloma) [Figure 3]. The patient had a good recovery and was discharged on the 4th postoperative day. Postoperative follow-up was uneventful.
Figure 1: Abdominal computed tomography image showing a mass that is occupying the anterior abdominal wall and adjacent to the ileal loop and uterine fundus

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Figure 2: The resected specimen

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Figure 3: Gross histological evaluation of the small bowel mass showed piece of gauze surrounded by reactive changes adherent to the small bowel (textiloma)

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  Discussion Top


The documented risk factors include emergency surgery, increased body mass index, unexpected changes in surgery, and changing the nursing staff during the procedure. In addition, the most common locations of textiloma are the abdomen (56%), pelvis (18%), and thorax (11%). In addition, the time it takes to discover a retained surgical item (RSI) varies; it may be detected during the early postoperative period or weeks to years after the surgery.[4],[5] Patients are usually asymptomatic, and textilomas are difficult to diagnose, even when a patient is symptomatic. Their presentations are usually nonspecific gastrointestinal symptoms, and they do not typically arouse any suspicion of RSI. Retained sponges may appear as a mass, as in our case, and are often interpreted as a tumor, cyst, abscess, or blood collection. In an attempt to reduce the number of cases of RSI, the World Health Organization (WHO) launched the World Alliance for Patient Safety program in 2004, followed by the Second Global Patient Safety Challenge, titled Safe Surgery Saves Lives, in 2008. Participants discussed, among other objectives, how to prevent sponges or other instruments in the surgical wound from being inadvertently retained. This was later included in the WHO Surgery Safety Checklist (2009) and the WHO Surgery Checklist Implementation Manual (2009). However, RSI cases continue to occur, despite the implementation of surgical count policies and documented steps to prevent them.

The impact of RSI is increasing the patients' mortality and morbidity; these cases raise numerous medicolegal questions regarding the responsibility of the OR team. This event is a part of medical error, which is defined as “a preventable adverse effect of medical care, whether or not it is evident or harmful to the patient.”[6] Given the various different roles of members of the OR team, medicolegal evaluation of an error attempts to sign out the OR team member responsible for the error. Here, it is essential to distinguish between the primary role of the OR nurses, who perform the actual sponge count and control, and that of the surgeon, who is responsible for observation of the surgical field and identification of possible sponges in a body cavity.

From a medicolegal point of view, surgical specialties are the main source of litigated potential medical errors, yet there are differences in charges and awarded compensations depending on the country's law, legal guidelines, and regulations. For example, in Italy, OR staff can be accused criminally or civilly. Under criminal law, the subsequent damage to the patient's psychophysical integrity, whether it was temporary or permanent, could result in charges being made against the responsible OR staff. In addition, OR staff can be required to compensate patients for patrimonial and nonpatrimonial damage under civil law.[5] On the other hand, in Saudi Arabia (SA), there are fewer clinical claims compared to other countries. A previous study compared SA to the UK on the process of litigation for medical errors,[7] and showed that the Saudi system did not include formal procedures for mediation and conciliation, which leads to an increase in the length of the process of litigation in SA compared to other countries. In fact, the litigation is done in a context that is more like a judicial committee meeting than a court proceeding. This issue, along with the Saudi culture of insufficient awareness about litigation and compensation, is among the many reasons why these cases are kept hidden with no further regulation, which raises the need for more transparency in documentation and publication and an increase in patient awareness of the rights of patients to complain and litigated medical errors in SA.

It is important that the patients understand their rights and are given space to make a claim. Prevention of this problem can easily be achieved by adherence to the implemented policies of a systematic count of surgical items in the OR. Hence, OR staff should realize the consequences of this medical claim and the importance of everyone's duty to prevent it from happening.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mouhsine E, Garofalo R, Cikes A, Leyvraz PF. Leg textiloma. A case report. Med Princ Pract 2006;15:312-5.  Back to cited text no. 1
    
2.
Serghini I, El Fikri A, Salim Lalaoui J, Zoubir M, Boui M, Boughanem M. Abdominal textiloma: Report of a case. Pan Afr Med J 2011;9:10.  Back to cited text no. 2
    
3.
Hyslop JW, Maull KI. Natural history of the retained surgical sponge. South Med J 1982;75:657-60.  Back to cited text no. 3
    
4.
Fouelifack FY, Fouogue JT, Fouedjio JH, Sando Z. A case of abdominal textiloma following gynecologic surgery at the Yaounde Central Hospital, Cameroon. Pan Afr Med J 2013;16:147.  Back to cited text no. 4
    
5.
Gualniera P, Scurria S. Retained surgical sponge: Medicolegal aspects. Leg Med (Tokyo) 2018;31:78-81.  Back to cited text no. 5
    
6.
Carver N, Gupta V, Hipskind J. Medical Error; 2021. Available from: https://Ncbi.nlm.nih.gov. [Last accessed on 2021 Aug 09].  Back to cited text no. 6
    
7.
Alkhenizan AH, Shafiq MR. The process of litigation for medical errors in Saudi Arabia and the United Kingdom. Saudi Med J 2018;39:1075-81.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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