Delayed Retroperitoneal Textiloma 10 Years after Varicocelectomy:
A Case Report and Literature Review
Elissa Mahfouz 1, MD, Shaza Mortada 1, MD, Perla Audi 2, MD, Georges Boustany 1, MD
*Correspondence to: Dr. Georges Boustany, MD, General Surgery, Lebanese American University Medical Center, Beirut, Lebanon.
Copyright.
© 2026 Dr. Georges Boustany, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 16 October 2026
Published: 01 November 2026
DOI: https://doi.org/10.5281/zenodo.23906728
Abstract
Introduction and Importance:
Textiloma, also known as gossypiboma, is a rare yet significant surgical complication involving a retained surgical textile material. These foreign bodies can incite chronic inflammation or present as mass lesions long after the index surgery.
Presentation of Case:
We report a case of a 51-year-old male presenting with right-sided abdominal discomfort 10 years after undergoing a right varicocelectomy. Imaging revealed a 10 cm retroperitoneal mass. Laparoscopic exploration and excision confirmed a cystic lesion containing two retained surgical gauzes. Pathology identified a fibrous-walled cyst containing foreign body granulomatous inflammation. This case has been reported in line with the SCARE criteria.
Clinical Discussion:
Retroperitoneal textilomas are uncommon and may mimic other cystic or tumoral pathologies, including hydatid cysts or neoplasms, leading to diagnostic uncertainty. Imaging findings are often non-specific, and a history of prior surgery may be the only clue to diagnosis. Surgical exploration is frequently required for both confirmation and treatment. This case emphasizes the importance of maintaining a high index of suspicion in patients presenting with atypical abdominal masses and a remote surgical history.
Conclusion:
This case highlights the diagnostic challenge of retroperitoneal textiloma and underscores the importance of preventive strategies. Surgical resection remains the mainstay of treatment for definitive diagnosis and management.
Keywords:
Gossypiboma, Textiloma, Retroperitoneal mass, Varicocelectomy, Case report.
Highlights
Introduction
Textiloma, also referred to as gossypiboma or gauzoma, describes a retained surgical textile material left inadvertently after a surgical procedure. It triggers a foreign body reaction that may present acutely or remain clinically silent for years.¹
Although rare, this complication carries significant morbidity and medico-legal implications. Retroperitoneal textilomas are particularly uncommon and often pose a diagnostic challenge due to their nonspecific presentation and resemblance to malignancy.
We present a case of delayed retroperitoneal textiloma occurring 10 years after varicocelectomy, emphasizing diagnostic difficulty and management strategies.
This case report has been reported in line with the SCARE checklist.
Case Presentation
This is the case of a 51-year-old male patients who presented to our institution for abdominal discomfort and right flank pain for a few months prior to presentation. The patient has no past medical history; however, he has undergone a right varicocelectomy 10 years prior to presentation. He reports experiencing abdominal discomfort, not associated with fever or chills, nor any weight loss or change in bowel movements. An abdominal CT scan was performed and revealed a right suspicious retroperitoneal mass, 10 cm in size, containing calcifications (Figure 1). After consulting a general surgeon, the decision of laparoscopic resection of the retroperitoneal mass was taken.
After administration of general anesthesia, the patient was placed in supine position. After scrubbing and draping in the usual sterile manner, 4 trocars were inserted, one 10mm trocar and two 5mm trocars in the left lateral abdominal wall. An additional 5 mm trocar was inserted in the right hypochondriac region.
Insufflation of the abdomen was performed until reaching a pneumoperitoneum of 13 mmHg. Upon inspection of the abdominal cavity, a large cystic structure was noted attached to the cecum and the right lateral abdominal wall, extending posteriorly into the retroperitoneum. During dissection of the large mass to free it from its attachments, an area of extensive fibrosis was observed posterior to the cecum. Further dissection revealed an old gauze with blue threads completely enclosed in the cystic wall (Figure 2). As the surgery progressed, a second gauze was discovered. The large cyst was completely dissected, removed with an endobag, along with the 2 gauzes found, and sent to pathology. Hemostasis was achieved. Finally, closure of the trocar sites and skin was completed.
Post operatively, the patient recovered smoothly without any complications. Pathology results of the surgical specimen revealed a 10x7x5 cm cyst with a wall thickness measuring 0.2 to 0.5 cm, containing fragmented gauze, with fibrous tissue with inflammation and foreign body giant cells, negative for malignancy (Figure 3).
This case has been reported in line with the SCARE criteria.
Discussion
Textilomas are rare surgical complications characterized by retained surgical sponges or other textile materials. The first reported case dates back to 1884 by Wilson. Despite strict surgical counting protocols, their incidence persists, occurring most frequently in abdominal (52%) and gynecological (22%) procedures, followed by urologic, vascular (10%), and orthopedic surgeries (6%).¹?² Retroperitoneal textilomas are even less common, with an estimated incidence ranging from 1 in 1,000 to 1 in 1,500 intra-abdominal operations, although the true prevalence is likely underestimated due to underreporting and asymptomatic cases.³??
The retention of textile material induces a foreign body reaction, leading to the formation of fibrous tissue and granulomas.??? Clinically, this may manifest as either an acute exudative response with abscess formation and sepsis, or a delayed aseptic fibrotic reaction resulting in encapsulated mass lesions.¹ The latter was observed in our patient, who presented 10 years after the initial procedure with a large cystic retroperitoneal mass, highlighting the potential for prolonged asymptomatic evolution.
Imaging plays a central role in evaluation; however, findings are often nonspecific. Radiographs, ultrasound, CT, and MRI may aid in diagnosis.? The characteristic spongiform pattern on CT is considered suggestive of gossypiboma, although it is not consistently present. In our case, the lesion appeared as a large calcified retroperitoneal mass without definitive features of a retained foreign body, raising suspicion for malignancy. This emphasizes the diagnostic challenge associated with such presentations.
The use of radio-opaque markers in surgical sponges has improved detection; however, these markers may become distorted or fragmented over time, limiting their reliability.? Additionally, textilomas may increase in size and develop calcifications over time, further complicating radiological interpretation.?
Reported sizes of retroperitoneal textilomas vary widely, ranging from a few centimeters to up to 25 cm.¹? The size observed in our case (10 cm) falls within this spectrum and likely reflects the long interval since the initial surgery.
The differential diagnosis of retroperitoneal masses includes sarcoma, lymphoma, chronic abscess, and other cystic or inflammatory lesions. Given the inability of imaging modalities to reliably distinguish these entities, surgical exploration and resection remains both diagnostic and therapeutic.
Surgical removal is the mainstay of management and may be technically challenging due to dense adhesions and surrounding fibrosis. In selected cases, minimally invasive approaches can be successfully employed. In our case, laparoscopic resection was feasible despite the lesion size and adhesions, allowing complete excision with an uneventful recovery.
Prevention remains the most effective strategy. Although standard sponge counts are routinely performed, they are not infallible. Additional measures such as radio-opaque markers, barcode systems, and radiofrequency identification technologies have been introduced to further reduce the risk of retained surgical items, particularly in complex or prolonged procedures.
Conclusion
Retroperitoneal textiloma is a rare but important differential diagnosis for retroperitoneal masses, particularly in patients with a history of prior surgery. Its delayed presentation and nonspecific imaging findings make diagnosis challenging. Surgical excision remains essential for definitive diagnosis and treatment. Strict adherence to preventive measures is critical to avoid this complication.
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
Assistance with the study: none.
Financial support and sponsorship: none.
Conflicts of interest: none.
Presentation: none..
Reference