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Figure 1.25. Sponge marker. X-ray image of the barium-impregnated thread used as a marker for a surgical sponge.

Chorvat et al. reported that more than 50% of sponges were discovered more than 5 years postoperatively [82]. At least one third of these patients were asymptomatic, and the sponges were found and removed incidental to other reasons for reexploration. These findings must be tempered by the observation that Chorvat's work predates the use of abdominal CT, modern ultrasound techniques, or MR imaging.

As already noted, sponges used in the operating room contain a barium-impregnated thread that makes them readily identifiable on postoperative plain films [83]. Lap pads have a wide radiopaque tape and often a large metallic ring attached (Fig. 1.26). With a rare exception of thoracotomy dressings and those used in vaginal packing [personal experience of one of the authors (BJ)], the detection of a marker should be presumed to represent a retained sponge [83]. Unfortunately, if the marker has been distorted, it may not appear as a curvilinear density in sponges that have been folded or otherwise compressed. A marker that has deteriorated over time may not be readily detectable [84]. A cadaver study revealed a 25% false negative rate of detecting the markers on plain films [85].

Liessi described the following three different presentations of retained sponges on plain films [86]: the detection of the marker, a calcified mass, and a "whirl-like" pattern due to the sponge itself (Figs. 1.27-1.32).

Figure 1.26. Lap pad marker. X-ray image of the radiopaque lap pad marker.
Figure 1.27. Gossypiboma. Supine (A) and lateral (B) plain films of the abdomen demonstrate the marker for a lap pad surrounded by a soft tissue mass (best seen on the lateral film). A specimen radiograph (C) demonstrates the retained lap pad encompassed by a large fibrous mass.
Figure 1.28. Retained lap pad. Supine film of the abdomen demonstrates a retained lap pad in the right midabdomen. The multiplicity of surgical clips serves as a visual distractor, making the diagnosis more difficult.
Figure 1.29. Retained lap pad. Frontal film from an upper GI series shows a retained lap pad projecting into the duodenal "C" loop.
Figure 1.30. Retained lap pad that is difficult to see. Supine film of the abdomen reveals a hard-to-find lap pad marker superimposed over the lumbar spine.

Figure 1.31. Remote retained lap pad. Upright film of the abdomen reveals a lap pad marker in the left upper quadrant. Lap pads may often be found far from the actual site of the surgical procedure. When used to pack the bowel out of the surgeon's way, they may be forgotten and overlooked when the abdomen is being closed.

Figure 1.31. Remote retained lap pad. Upright film of the abdomen reveals a lap pad marker in the left upper quadrant. Lap pads may often be found far from the actual site of the surgical procedure. When used to pack the bowel out of the surgeon's way, they may be forgotten and overlooked when the abdomen is being closed.

Figure 1.32. Multiple retained lap pads. Supine film of the abdomen showing multiple lap pads. The sheer number of markers should not dissuade one from reporting the possibility of retained implements.

On CT examination, many different patterns have also been described [80,81,84,86]. One sign is that of a cystic mass with high density contents representing a hematoma containing a retained sponge [81]. A second pattern is that of a well-defined mass containing multiple gas bubbles [80,81]. Another possible appearance is that of a cystic mass (with or without a calcified rim) that contains multiple thin linear densities in an folded or zigzag configuration [81]. This represents the folded nature of a "lap" pad or towel. A variant on this appearance is a whorled or spokelike configuration of the cyst contents [69,80,84,86]. When these appearances are noted, it can be very difficult to differentiate a gossypiboma from an abscess [80,87] (Fig. 1.33). At times, differentiation from other intra-abdominal masses, including recurrent or even primary neoplasms, may also be difficult [69,71,77,86,88].

Although this effect is rarely encountered, the inflammatory response to a retained surgical sponge may cause erosion into adjacent bowel. When a barium enema is performed in that instance, the irreg-

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