Forgotten gauze piece will not be forgiven always.

A 49-year-old female presented with persistent leakage of urine through vagina following hysterectomy for dysfunctional uterine bleeding. Vaginal and cystoscopic examination revealed 1 cm supra-trigonal vesico-vaginal fistula on the right posterior aspect of the bladder. She underwent laparoscopic repair of vesico-vaginal fistula. Vaginal packing was done at the end of the procedure. Her postoperative period was uneventful. Follow-up cystogram done at 2 weeks revealed wavy radio-opacity in the pelvis [Figure 1]. Oblique view during cystogram revealed that the radio-opaque marker was posterior to the bladder [Figure 2]. Her abdominal examination was normal. Her vaginal examination revealed a packed gauze piece in the vaginal apex. The forgotten gauze piece was removed from the vagina, and trial voiding was successful. We report this case to stress the need for a postoperative checklist and to question the routine use of vaginal packing.

Figure 1

Plain X-ray KUB shows wavy radio-opaque marker in the pelvis suggestive of retained gauze piece

Figure 2

Cystogram (oblique view) shows the location of gauze piece posterior to bladder

Intravaginal packing after vaginal reconstructive surgery is traditionally kept up to 24–48 h postoperatively.[1] Recent studies have contradicting recommendations regarding the continued practice of vaginal packing in the postoperative period.[12] Vaginal packing helps in reducing postoperative pain but may not reduce the incidence of hematoma formation.[1] Vaginal packing can be safely omitted in most of the cases unless hemostasis is not satisfactory.[2] There is a high incidence of under-reporting of forgotten gauze piece because of the fear of litigation.[3] Gossypiboma in the pelvis may be located in the retrovesical space, bladder, or vagina.[3] Computerized tomography is indicated for accurate location of the forgotten gauze piece as X-ray and ultrasound might miss one which does not have a radio-opaque marker. Luckily in our case, as the gauze piece had a radio-opaque marker, it could be diagnosed on X-ray and removed before any complications could occur. Gossypiboma can be prevented by a meticulous count of surgical instruments and by use of gauze pieces with radio-opaque markers.[4] Although WHO surgical safety list is the standard of care,[5] postoperative checklist for removing vaginal pack before discharging the patient and thorough vaginal examination during immediate follow-up may help in reducing the incidence of a forgotten gauze piece.

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The authors certify that appropriate patient consent was obtained.

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Conflicts of interest

There are no conflicts of interest.