AJR 2005; 184:S75-S77
© American Roentgen Ray Society
CT Appearance of a Retained "Fish" in the Abdomen
Gabriela Gayer1,2,
Tamar Karni2,3 and
Margarita Vasserman1
1 Department of Diagnostic Imaging, Assaf Harofeh Medical Center, Zrifin 70300,
Israel.
2 Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
3 Department of Surgery, Assaf Harofeh Medical Center, Zrifin 70300,
Israel.
Received March 23, 2004;
accepted after revision June 17, 2004.
Address correspondence to G. Gayer.
Introduction
Diagnosing a retained foreign body in the peritoneal cavity after
laparotomy is a challenge for the radiologist. Several reports have described
the appearance of retained surgical sponges on conventional radiographs, CT,
and MRI. There is, however, to the best of our knowledge, no report about the
CT appearance of a viscera retainer (a "fish") that remained in
the abdomen after closure. This "fish" is a device used by
surgeons to retain the omentum and viscera during closure of the peritoneal
cavity.
We present a patient in whom a clinically unsuspected viscera retainer was
diagnosed on CT 4 months after extensive thoracoabdominal surgery. The
peculiar appearance of the foreign body on CT, mainly on reformatted images,
is shown and discussed.
Case Report
A 30-year-old woman underwent elective CT as a baseline for oncologic
follow-up. She had undergone resection of a recurrent gastric carcinoma in a
combined abdominal and thoracic approach 4 months earlier. A jejunostomy was
fashioned after esophagojejunal anastomosis. The patient was asymptomatic.
CT was performed after the administration of contrast material both orally
and IV. Some of the contrast material for opacification of the
gastrointestinal tract was instilled through a jejunostomy tube because the
patient had difficulty swallowing the oral contrast material. CT revealed a
dense linear structure along the anterior abdominal wall abutting the fascia,
extending from the level of the umbilicus down to the pelvis, and curving
posteriorly in its caudal aspect (Figs.
1A and
1B). Coronal reformation
clearly delineated the elliptic shape of the structure
(Fig. 1C). The nature of this
dense linear structure was uncertain. It was not present on the CT scans
obtained shortly before surgery. The differential diagnosis included, in the
first place, a foreign body, but the structure did not resemble any familiar
retained sponge or other retained foreign body. The possibility of
extravasated contrast material was also raised; however, it was dismissed for
two reasons: First, the structure, on an image obtained using bone window
settings, was more dense than oral contrast material within the bowel
(Fig. 1D); and second, the
extravasated contrast material would spread in the peritoneal space and not
retain a linear shape.
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Fig. 1A. —30-year-old woman 4 months after resection of recurrent
gastric carcinoma in combined abdominothoracic approach. Elective CT was
performed as baseline for oncologic follow-up. Patient was asymptomatic. CT
scans obtained at level of mid abdomen (A) and at level of iliac fossa
(B) show dense flat structure abutting fascia along anterior abdominal
wall (arrows). Intrauterine contraceptive device is present in center
of uterus.
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Fig. 1B. —30-year-old woman 4 months after resection of recurrent
gastric carcinoma in combined abdominothoracic approach. Elective CT was
performed as baseline for oncologic follow-up. Patient was asymptomatic. CT
scans obtained at level of mid abdomen (A) and at level of iliac fossa
(B) show dense flat structure abutting fascia along anterior abdominal
wall (arrows). Intrauterine contraceptive device is present in center
of uterus.
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Fig. 1C. —30-year-old woman 4 months after resection of recurrent
gastric carcinoma in combined abdominothoracic approach. Elective CT was
performed as baseline for oncologic follow-up. Patient was asymptomatic.
Volume rendering image shows elliptic shape of retained foreign body
(arrows) that is typical of "fish" (SurgiFish Viscera
Retainer, Greer Medical).
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Fig. 1D. —30-year-old woman 4 months after resection of recurrent
gastric carcinoma in combined abdominothoracic approach. Elective CT was
performed as baseline for oncologic follow-up. Patient was asymptomatic. CT
image obtained using bone window settings shows foreign structure is much
denser than contrast material within bowel loops (arrows).
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The patient underwent repeat CT 1 week after the initial follow-up CT
examination. This time, CT was performed without either oral or IV contrast
material in the hope to gain more information about the dense structure. The
CT scans showed no change at all in the linear structure. At this point, the
diagnosis of a foreign body in the abdominal cavity was certain, but its exact
nature was established only after another conference with the surgeons in
which the multiplanar reformations were again reviewed. The surgeons finally
recognized the elliptic form of the foreign body to be compatible with a
"fish" (SurgiFish Viscera Retainer, Greer Medical)
(Fig. 1E). The foreign body was
removed from the peritoneal cavity through a small opening several days later.
Recovery was uneventful.
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Fig. 1E. —30-year-old woman 4 months after resection of recurrent
gastric carcinoma in combined abdominothoracic approach. Elective CT was
performed as baseline for oncologic follow-up. Patient was asymptomatic.
Photograph shows fish-shaped viscera retainer (SurgiFish Viscera Retainer,
Greer Medical).
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Reviewing the scanogram of the studies, the "fish," although
dense on cross sections, did not have a radiopaque marker and was not visible
on the scanogram, except for its superior and inferior right borders that were
retrospectively discernible (Fig.
1F).
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Fig. 1F. —30-year-old woman 4 months after resection of recurrent
gastric carcinoma in combined abdominothoracic approach. Elective CT was
performed as baseline for oncologic follow-up. Patient was asymptomatic.
Scanogram of repeated study obtained without oral contrast material vaguely
shows superior and inferior borders of the fish (SurgiFish Viscera Retainer,
Greer Medical) (arrows) in right and middle lower abdomen and pelvis.
Intrauterine contraceptive device is present in pelvis.
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Retrospective analysis of the course of the surgery that led to the
inadvertent retention of the "fish" revealed that the surgical
intervention had been complex. The patient initially underwent a laparotomy,
followed by a temporary closure of the abdomen using the "fish."
Then a thoracotomy was performed for anastomosis between the esophagus and the
jejunum. Only after the esophagojejunal anastomosis was successfully completed
through the thoracic approach was the abdomen permanently closed—leaving
the "fish" inadvertently in the abdominal cavity.
Discussion
A retained foreign body in the abdominal cavity (including sponges, swabs,
and instruments) after surgery is, despite precautions, a persisting problem
that may lead to complications including adhesions, perforation, and abscess
or fistula formation [1,
2]. The exact incidence of a
retained foreign body has not been determined, but it is estimated to occur in
one of every 1,000-1,500 intraabdominal operations
[1,
2]. Although many sponges will
become symptomatic in the early postoperative period, it is possible for the
foreign body to remain unnoticed for months or years
[1,
3]. Risk factors for a retained
foreign body include emergency surgery, unplanned change of procedure, and
patient obesity [1].
The "fish" (SurgiFish Viscera Retainer, Greer Medical) is a
device used by surgeons to retain omentum and viscera during closure of the
peritoneal cavity. The device is a latex-free thermoplastic rubber viscera
retainer that has an oval body portion joined by a relatively narrow waist
region to a small "tail" portion. It is imprinted with a series of
contour lines that can be cut along, should a smaller size be needed. It is
inserted when the surgical procedure has been finished—just before
closure of the abdominal wall—to prevent inadvertent puncture of the
bowel during closure of the peritoneum and fascia and is removed just before
the last stitches in the fascia.
The high elasticity of the "fish" enables it to fold and to be
easily removed, even through a small aperture. The device is not molded to
conform to the peritoneal cavity, but because it is smooth and elastic, it can
attain the configuration of the space available for it. We assume that the
configuration it attained in our patient occurred naturally over the course of
the 4-month postoperative period. The relative radiolucency of the device can
be attributed to its rubbery composition, which like various drains composed
of rubber, is better seen on CT than on conventional radiography.
In the patient described, the "fish" was left in situ while
closing the abdomen temporarily, leaving the option to continue the surgical
procedure through the laparotomy if the planned surgical procedure through the
thoracic approach failed.
Imaging plays an important role in the diagnosis of a retained foreign
body. It is often an unexpected finding and not necessarily related to the
patient's symptoms. Since the advent of CT, foreign bodies have been
recognized more easily and more frequently than previously when one had to
rely on conventional abdominal radiographs. The "fish" under
discussion has, to our knowledge, never been described before on CT.
Retrospectively, it could easily be diagnosed after the specimen had been
shown to us. While appearing on axial images as a linear density, the
reformatted images showed clearly its flat and elliptic form, virtually
pathognomonic, enabling us to suggest the correct diagnosis before
reoperation.
The possibility of a retained foreign body should be considered when
unfamiliar findings cannot be otherwise explained.
Acknowledgments
We thank Marjorie Hertz for her help in preparing this manuscript.
References
- Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk
factors for retained instruments and sponges after surgery. N Engl
J Med 2003;348:229
-235[Abstract/Free Full Text]
- Kaiser CW, Friedman S, Spurling KP, Slowick T, Kaiser HA. The
retained surgical sponge. Ann Surg1996; 224:79
-84[Medline]
- Roumen RM, Weerdenburg HP. MRI features of a 24-year-old
gossypiboma: a case report. Acta Radiol1998; 39:176
-178[Medline]
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Introduction
Case Report
