Gossypiboma, the Never Event; a Case Report

Introduction and importance: In the surgical field, we utilize gauze and surgical instruments daily, and the complications can be divided into avoidable versus nonavoidable. The term Gossypioma in the literature indicates a retained surgical sponge or gauze. It can be there for years and be dormant or discovered within days as the patient starts to reveal symptoms. This makes diagnosing challenging pre-operatively as the radiological findings might not be as specific. Case presentation: A 75 male Moroccan patient with Normal Body mass index, Medically free. His main complaint was Abdominal pain in the epigastric area. His past surgical history was positive for a left open inguinal hernia repair with mesh three months ago that went uneventfully And an open appendectomy before 20 years. The Abdomen X-ray: multiple air-fluid levels with dilated small bowel as well as perfectly rounded calcifications at the right lower quadrant. Conclusion: It’s a devastating medical error, but it can be avoidable. Communication between the surgical team and operation staff is a crucial and straightforward tactic to prevent these complications. As the sequel will reveal itself at any time and the patient will pay the price.