Introduction:
A retained surgical sponge in the abdomen is uncommon although it is likely that this finding is underreported in the medical literature. The intravisceral migration of retained surgical gauze is even rarer, as demonstrated by the very few cases reported.
Case presentation:
Three years after undergoing anterior resection of the rectum, a 75-year-old man presented with symptoms of small bowel obstruction. Plain abdominal radiography and CT showed a radio-opaque marker; a foreign body was suspected, probably a piece of retained surgical gauze. An ileotomy of about 5 cm. was performed to confirm this diagnosis and remove the gauze.
Conclusion:
Although rare, retained gauze in the abdomen is a complication of surgery. The authors consider that this event may be more frequent than it appears from reports in the literature, probably because of its medico-legal implications. If all such cases were reported, it would be possible to estimate their exact number, classify the occurrence as a possible surgical complication and thus modify its medico-forensic consequences.