Introduction:

Never events are medical errors that should never happen. Retained foreign bodies are uncommon but serious never events in surgery that may lead to the agony of undergoing another major surgery and medicolegal problems. The most common surgically retained foreign body is the laparotomy sponge.

Methods:

The authors report five cases of gossypiboma to highlight the varied presentation of this condition and the need for proper count of surgical items.

Results:

All the five cases were females in the age range of 25–55 years. The index surgery in four patients was caesarean section. One patient had hysterectomy and cholecystectomy in the same sitting. The average duration of symptoms was 5 months. Two of these patients presented with an abdominal lump. One patient presented with an enterocutaneous fistula and the other with pus discharge from the drain site. The fifth patient with lower abdominal pain radiating to the back. Preoperative diagnosis of gossypiboma was clinched in only two patients while the other two pateints were misdiagnosed as ovarian teratoma and abdominal koch’s respectively. In one patient diagnosis remained a dilemma and she was planned for diagnostic laparoscopy. Surgery was done with retained laparotomy sponge in four patients. One patient passed the sponge per rectally while awaiting surgery.

Discussion:

Gossypiboma is a classic example of medical negligence in which the presence of a foreign body inside the patient can be easily proved. The possibility of this condition should be kept if any patient postoperatively presents with a lump abdomen, infection or pain. The best approach to manage this condition is prevention.