Received: 22 January 2023 Revised: 11 June 2023 Accepted: 12 June 2023

DOI: 10.1111/vru.13281

ORIGINAL RESEARCH

Ultrasonographic appearance of retained surgical sponges and

gauzes in the acute postoperative period: a phantom and
cadaveric study

Emily M. Brand1,2 Kenneth J. Brand1,2 Jessica A. Ogden1 Chee Kin Lim1,3

Hock Gan Heng1,3

1
Department of Veterinary Clinical Sciences,
College of Veterinary Medicine, Purdue
University, West Lafayette, Indiana, USA
2
Animal Emergency and Specialty Center,
Parker, CO, USA
3
VetCT, Orlando, FL, USA
Correspondence
Emily M. Brand, Department of Veterinary
Clinical Sciences, College of Veterinary
Medicine, Purdue University, West Lafayette,
IN 47907, USA.
Email: emily.m.brand18@gmail.com
Abstract
Retained surgical sponges or gauzes (RSS) are an uncommon complication of
exploratory laparotomy surgery and pose a clinically significant risk to the patient. The
purpose of this two-part, prospective, descriptive study was to describe the previously
uncharacterized ultrasonographic appearance of RSS in phantom and cadaveric mod-
els of the acute postoperative period (24–48 h). For the first part of the study, a gelatin
phantom containing a woven gauze with a radiopaque marker (radiopaque gauze), a
woven gauze with no marker (nonradiopaque gauze), and a laparotomy sponge with a
radiopaque marker (radiopaque sponge) was evaluated with ultrasonography. For the
second part of the study, a total of 23 gauzes and sponges (of the aforementioned three
types) were placed within the peritoneal cavity of 20 cadavers in one of three ran-
domized locations during an exploratory laparotomy laboratory. The cadavers were
imaged with ultrasonography 17 h later and still images and video clips were reviewed.
The retained surgical sponges and gauzes in the gelatin phantom displayed multiple
hyperechoic layers and variable degrees of distal acoustic shadowing. In cadavers,
100% (23/23) of the retained surgical sponges and gauzes displayed a single hyper-
echoic layer of variable thickness and distal acoustic shadowing. In 95.6% (22/23)
retained sponges and gauzes, there was a thin hypoechoic layer noted superficially
to the hyperechoic layer. An improved understanding of the ultrasonographic appear-
ance of retained sponges or gauzes in the acute postoperative period may assist in the
identification of these objects.

KEYWORDS
gossypiboma, radiopaque marker, textiloma

1 INTRODUCTION ing of surgery. Two different types of responses are stimulated by

An uncommon but clinically important complication of surgery in vet-
erinary patients includes a retained surgical sponge or gauze (RSS),
also referred to as a gossypiboma or textiloma.1,2 Causes may include
a lack of intraoperative surgical gauze or sponge counts, lack of a
perioperative checklist, a change in surgical plan, or nonscheduled tim-
the body in the presence of an RSS: exudative or aseptic fibrous.3–6
The exudative response can lead to abscess formation with or with-
out secondary bacterial infection, whereas the fibrous response leads
to encapsulation and adhesions that result in granuloma forma-
tion. Due to the variability in responses, the time from the original
surgery to the detection of a RSS can vary greatly, from a few days

Vet Radiol Ultrasound. 2023;64:957–965. wileyonlinelibrary.com/journal/vru © 2023 American College of Veterinary Radiology. 957

958
(as seen more commonly with the exudative response) to several years
later (as seen with the fibrous response).5,7 Fibrinous and hemorrhagic
inflammation has been reported to develop in association with an RSS
within the peritoneal cavity as soon as three days postoperatively; in
this case, the tissue surrounding the RSS was inflamed omentum.8
The detection of an RSS can be challenging with any imaging modal-
ity, especially if the RSS does not contain a radiopaque marker. In
patients presenting for evaluation with a history of previous surgery,
imaging modalities selected may include radiography, ultrasonogra-
phy, CT, or a combination. Radiopaque markers in RSS are easily seen
on radiographs and CT; however, not all clinicians use surgical gauze
or sponges with radiopaque markers.1 The radiographic, ultrasono-
graphic, CT, and MRI appearance of RSS have been reported in cats and
dogs.3,5,8–12 Specifically focusing on ultrasonography in the reported
veterinary cases, a hypoechoic mass with a central hyperechoic region
is the main feature with most cases also displaying distal acoustic
shadowing.3,5,9–12 In these prior studies, the time from initial surgery
to imaging was variable (ranging from 3 days to 8 years), but in all cases
when the RSS was detected there was the formation of a mass-like
structure around the RSS.7,13 Forster et al.7 describe four dogs imaged
with abdominal ultrasonography in the acute to sub-acute postoper-
ative period (5 days or less) and the ultrasonographic findings were
gas and fluid in the peritoneal cavity; the RSS was only detected dur-
ing exploratory surgery. Terrier et al.8 reported the MRI features of an
RSS detected three days after surgery in a dog, but no similar informa-
tion is available for ultrasonography. Despite ultrasound often being
a first-line modality for imaging dogs postoperatively, there is a lack
of studies reporting the ultrasonographic appearance of an RSS in the
acute postoperative period (24–48 h).
The objectives of this study were twofold. The first objective was to
evaluate the ultrasonographic appearance of RSS in a phantom model.
From this information, criteria could be developed to achieve the sec-
ond objective: to describe the ultrasonographic appearance of RSS in
a cadaveric model of the acute postoperative period. Based on pre-
viously published characteristics of RSS in the chronic postoperative
period, we hypothesized that RSS in the acute postoperative period
would have a hyperechoic layer and display distal acoustic shadowing.
2 METHODS AND MATERIALS
The study was a prospective, descriptive design and was divided into
two parts. Ethical approval by the hospital’s animal care and use
committee was not required.
2.1 Phantom study
A gelatin phantom was created using modification of a previously
described protocol.14 A total of 112 g of unflavored gelatin (The Kroger
Co., Cincinnati, OH) were dissolved into 1400 mL of just below boiling
water. After dissolution, this mixture was poured into a polypropy-
lene container. One each of the following types of gauzes and sponge
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BRAND ET AL .
were soaked in water, roughly compacted into a rounded shape, and
submerged in the gelatin: woven gauze with a radiopaque marker
(radiopaque gauze; Figure 1A), woven gauze with no marker (nonra-
diopaque gauze; Figure 1B), and laparotomy sponge with a radiopaque
marker (radiopaque sponge; Figure 1C). The gelatin was then allowed
to set in a refrigerator overnight.
The gelatin phantom was scanned using a 12 MHz linear-array
transducer (Toshiba Aplio i800, Canon Medical Systems USA, Inc.,
Tustin, CA) by the third-year imaging resident (EMB). Ultrasound gel
was used as a coupling agent. Images were saved as both still images
and video clips. Images were assessed for features including echogenic-
ity, margination, size, presence of artifacts associated with the RSS
(such as distal acoustic shadowing and reverberation), presence of
internal patterns (such as a layered or cross-hatched appearance based
on the gross appearance), and size.
2.2 Cadaveric study
2.2.1 Selection and description of subjects
The cadavers were sourced for a postmortem teaching laboratory for
third-year veterinary students learning to perform exploratory laparo-
tomy and sterilization procedures. Approval for the use of the cadavers
was granted by the veterinary teaching college. The number of cadav-
ers was limited to those available for the laboratory; however, based on
the number of dogs included in previous studies of RSS, which ranged
from 1–13 dogs, the minimum sample size was 13 cadavers.1,5,7 The
weight of the cadavers was required to be 10 kg or greater for inclusion.
Cadavers with severe autolysis were excluded from the study.
2.2.2 Cadaveric surgical sponges and gauze
placement
The same three types of surgical sponge and gauze used in the ex
vivo evaluation were used in the cadavers: radiopaque gauze, non-
radiopaque gauze, and radiopaque sponge (Figure 1). The number
of sponges and/or gauze placed in each cadaver ranged from 1 to
2 and was randomized on a computerized spreadsheet (Microsoft
Excel, Microsoft Corporation). Three sites were chosen for the place-
ment of the gauze or surgical sponge. Two of the locations were
selected based on the common sites of previously described RSS, which
included the caudal abdomen (between the bladder and descending
colon) and mid-abdomen (within omentum).1,5–7 The third site, cra-
nial to the right side of the liver, was selected based on the clinical
experience of the surgeons involved in the study. The site of gauze
or sponge placement was randomized and only one sponge or gauze
was placed per site. The cadavers used for this study were part of a
larger study of RSS, therefore the number of cadavers with each type
of gauze or sponge and the locations were not evenly distributed. How-
ever, as the current study was descriptive, all available cadavers were
utilized.

BRAND ET AL .
F I G U R E 1 A, Woven gauze with radiopaque marker (radiopaque gauze) and arrow pointing to radiopaque part of the gauze. B, Woven gauze
with no marker (nonradiopaque gauze). C, Laparotomy sponge with a radiopaque marker (radiopaque sponge). The black arrow is pointing to the
radiopaque marker and the white arrowhead is pointing to the string of the sponge. [Color figure can be viewed at wileyonlinelibrary.com]
2.2.3 Cadaver protocol
The cadavers were previously frozen and were thawed at room tem-
perature for 48–96 h prior to usage in the laboratory. A routine ventral
abdominal approach for exploratory laparotomy was performed. The
gauzes and sponges were first soaked in water and then roughly com-
pacted into a rounded shape prior to placement. The gauzes or sponges
were placed into the abdomen according to the randomization chart.
The abdomen was closed in three layers (body wall, subcutaneous fat,
and skin). The cadavers were stored at room temperature or in a cooler
until they were used for radiographic and CT imaging studies approx-
imately 5 h later (as a part of a separate study). The cadavers were
stored in a cooler overnight until the ultrasonography procedure (17 h
after the exploratory laparotomy).
2.2.4 Imaging protocol and evaluation
All cadavers were scanned by an ECVDI and ACVR board-certified vet-
erinary radiologist (HGH), with the majority also being scanned by the
third-year imaging resident (EMB). The cadavers were positioned in
dorsal recumbency and any remaining fur on the abdomen was clipped.
A combination of ultrasound gel and alcohol was used for coupling. The
ultrasonographer was permitted to tilt the cadaver as needed for com-
plete imaging. A large convex array probe (4 MHz), microconvex array
probe (7 MHz), and linear array probe (12 MHz) were used for scan-
ning. Gain and depth were adjusted as needed by the ultrasonographer.
The abdomen was scanned in a zigzag pattern scanning in sagittal plane
from lateral to lateral and then again in transverse plane from cranial
to caudal. Images were saved as both still images and video clips. The
amount of gas present in the abdomen was recorded and subjectively
graded on a scale of 1–4: (1) scant, entire peritoneal cavity can be eval-
uated, and only a scant volume or no gas is detected; (2) mild, majority
of the peritoneal cavity can be evaluated, but up to 25% of the abdomen
cannot be assessed due to the volume of gas; (3) moderate, a large por-
tion of the peritoneal cavity can be evaluated, but between 25% and
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959
50% of the abdomen cannot be assessed due to the volume of gas; or (4)
severe, 50% or more of the of the peritoneal cavity cannot be assessed
due to the volume of gas.
The ultrasonographic appearance was described using retrospec-
tive review of still images and video clips by the third-year imaging
resident for the imaging features. Imaging features that were evaluated
included echogenicity, margination, presence of artifacts associated
with the RSS (such as distal acoustic shadowing and reverberation),
and presence of internal patterns (such as a layered or cross-hatched
appearance as seen in the gross appearance of the gauzes and sponge).
The echogenicity was classified into hypoechoic, isoechoic (to adjacent
peritoneal fat), or hyperechoic. If a layered appearance was noted, the
echogenicity of the layer, subjective thickness (thick or thin), and length
of the layer were recorded. Margination was classified into smooth or
irregular as well as continuous or discontinuous.
2.3 Data analysis
Data were analyzed following consultation with a statistician and using
commercial statistical software (STATA/SE 15.1; College Station, TX).
Frequencies and percentages were used for reporting categorical data.
Continuous variables were assessed for normality using a Shapiro-
Wilk test. For parametric continuous variables, means and standard
deviations were reported, and for nonparametric continuous variables,
medians and ranges were reported.
3 RESULTS
3.1 RSS ultrasound appearance in phantoms
The radiopaque gauze and nonradiopaque gauze were indistinguish-
able from one another in appearance with multiple layers of fine linear
hyperechoic striations (some of which had a cross-hatching pattern)
and anechoic gelatin between layers (Figure 2A–C). A few regions with
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960 BRAND ET AL .

F I G U R E 2 B-mode ultrasound images of the gelatin phantom acquired with a linear array probe (12 MHz). A, Radiopaque gauze with multiple
variable thickness hyperechoic layers. B, Radiopaque gauze at the level of the marker with variable distal acoustic shadowing. C, Nonradiopaque
gauze within a gelatin phantom showing the cross-hatching pattern (bracket). D, Radiopaque sponge with multiple thick hyperechoic layers and
distal acoustic shadowing. E, Radiopaque sponge at the level of the string. F, Radiopaque sponge at the level of the radiopaque marker. Distal
acoustic shadowing is seen on the right side of the image and reverberation artifact is present on the left side of the image (arrow).

distal acoustic shadowing were present in areas where the gauze was
thicker; however, most of the gauze remained well-defined in the far
field (Figure 2A, B). No difference was noted in the appearance of
the hyperechoic layers or in the degree of shadowing when scanning
over the region of the radiopaque marker of the radiopaque gauze
(Figure 2B). The radiopaque sponge had thicker hyperechoic layers that
lacked the fine linear striations seen in both the radiopaque and non-
radiopaque gauze (Figure 2D). Greater distal acoustic shadowing was
seen within the sponge and hampered the evaluation of the deep por-
tions of the sponge (Figure 2D). The ribbon of the sponge was a sharply
marginated hyperechoic curvilinear line that produced no distal acous-
tic shadowing (Figure 2E). The region of the radiopaque marker had a
sharply marginated, long, thin hyperechoic line with clean, strong distal
acoustic shadowing and areas of reverberation artifact (Figure 2F). The
sponge was larger in size than both types of gauze.
3.2 Cadaver study sampled subjects
A total of 20 cadavers were included. The mean weight of the cadav-
ers was 25.9 kg (+/− 7.1 kg). Two cadavers were female and 18 were
male; as the cadavers had undergone sterilization surgery as part of
the preceding laboratory, reproductive status during life was unknown.
Eighteen of 20 cadavers were mixed breed dogs and two of 20 were
purebred (one each, Dobermann, and Siberian Husky). Fourteen cadav-
ers had a single sponge or gauze and six cadavers had two sponges or
gauzes. A total of six radiopaque gauzes, nine nonradiopaque gauzes,
and eight radiopaque sponges were used in the cadavers. The location
of the sponges and gauze were as follows: nine in the caudal abdomen,
seven in the mid-abdomen, and seven in the cranial abdomen. The large
convex array probe was used in 19 of 20 cadavers for initial scanning.
The microconvex probe was used solely for one cadaver and was used
in conjunction with the large convex in another. The linear array probe
was used in conjunction with the large convex probe in four of 20
cadavers. The amount of gas in the abdomen was a median grade of 3
(range, 1–4).
3.3 RSS ultrasound appearance in cadavers
A hyperechoic layer was present in 23 of 23 (100%) RSS (Figure 3).
The hyperechoic layer extended the entire length of the RSS so the
exact size could not be measured as it extended beyond a single field
of view. The hyperechoic layer was irregular in margination in most
RSS (19 of 23 RSS, 82.6%) and smooth in margination in four of 23
RSS (17.4%; Figure 3A, B). However, both smooth and irregular regions
were present in seven of 23 RSS (30.4%). The margination was contin-
uous in one of 23 RSS (4.3%) and discontinuous in 22 of 23 RSS (95.6%,
Figure 3C, D). The subjective thickness was classified as thick in 14
of 23 RSS (60.9%) and thin in nine of 23 RSS (39.1%) (Figure 3E, F).
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BRAND ET AL . 961

F I G U R E 3 B-mode ultrasound images of the cadavers and features of the hyperechoic layer. Images A–C, E, and F were acquired with a large
convex array probe (4 MHz), and image D was acquired with a linear array probe (12 MHz). A, Radiopaque gauze with a thick, irregularly
marginated hyperechoic layer. B, Radiopaque sponge with a thin, smoothly marginated hyperechoic layer. C, Nonradiopaque gauze with a thick,
smoothly marginated, continuous hyperechoic layer. D, Radiopaque sponge with a thin, irregularly marginated, discontinuous hyperechoic layer.
Arrow is pointing to the region of discontinuity. E, Nonradiopaque gauze with a thin, smoothly marginated hyperechoic layer. F, Radiopaque gauze
with a thick, irregularly marginated hyperechoic layer. [Color figure can be viewed at wileyonlinelibrary.com]

A hypoechoic layer was present superficial to the hyperechoic layer
in 22 of 23 (95.6%; Figure 4). The hypoechoic layer was thinner than
or the same thickness as the hyperechoic layer in all cases (100%,
22/22). The length of the hypoechoic layer was variable and mea-
sured less than 1 cm in length in one of 22 (4.5%), between 1 and
3 cm in length in 14 of 22 (63.6%), and greater than 3 cm in length
in seven of 22 (31.8%) (Figure 4B–D). The hypoechoic layer was con-
tinuous along the entire length of the hyperechoic layer in one RSS
(4.5%, 1/22). In the remainder of RSS (21 of 22), the hypoechoic
layer was discontinuous (95.5%). All RSS (100%, 23/23) displayed dis-
tal acoustic shadowing (Figure 5). Reverberation artifact was present
in four of 23 (17.4%) of RSS (Figure 5B); of these four RSS, one of
four (25%) was a radiopaque gauze and three of four (75%) were
radiopaque sponges. A cross-hatching pattern was not present in any
RSS (0%, 0 of 23). A linear hyperechoic striation was present in two
of 23 RSS (8.7%), one was a radiopaque gauze and the other was
a nonradiopaque gauze (Figure 5C). When comparing the features
of nonradiopaque gauze, radiopaque gauze, and radiopaque sponges,
there was a large amount of overlap of the features between the groups
(Table 1).
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962 BRAND ET AL .

F I G U R E 4 B-mode ultrasound images of the cadavers and features of the hypoechoic layer. Images were acquired with a large convex array
probe (4 MHz). A. Radiopaque gauze with an absent hypoechoic layer. B, Radiopaque sponge with a short (< 1 cm) hypoechoic layer (arrow). C,
Nonradiopaque gauze with a moderate length (>1 cm to <3 cm) hypoechoic layer (arrow). Calipers (+) are indicating the width of the RSS. D,
Radiopaque sponge with a long (> 3 cm) hypoechoic layer (arrow). [Color figure can be viewed at wileyonlinelibrary.com]

F I G U R E 5 B-mode ultrasound images of the cadavers and additional ultrasonographic features. Images were acquired with a large convex
array probe (4 MHz). A, Radiopaque gauze with distal acoustic shadowing (white bracket). This feature is also present in B and C (white bracket). B,
Radiopaque gauze with reverberation artifact (arrow). C, Nonradiopaque gauze with linear striation (arrow).

TA B L E 1 Ultrasonographic features of nonradiopaque gauze, radiopaque gauze, and radiopaque sponge in cadavers.

Hyperechoic layer features Hypoechoic layer length

Short Moderate Long
Smooth Irregular Thick Thin (<1 cm) (>1 cm to <3 cm) (>3 cm) Reverberation
Nonradiopaque gauze 3 6 6 3 0 7 2 0
Radiopaque gauze 1 5 5 1 0 2 3 1
Radiopaque sponge 0 8 3 5 1 5 2 3

BRAND ET AL .
4 DISCUSSION
The ultrasonographic features of RSS in the gelatin phantom subjec-
tively differed from those observed in cadavers. In the gelatin phantom,
the RSS displayed multiple hyperechoic layers, and, in the gauzes,
fine linear hyperechoic striations (some with a cross-hatching pattern)
were also noted. Distal acoustic shadowing was present in some areas
but was not the predominant feature. This occurred more with the
radiopaque sponge than with either the radiopaque gauze or nonra-
diopaque gauze. In the cadavers, findings supported our hypothesis
in that only a single hyperechoic layer was visible in all cases and a
superficial hypoechoic layer was present in 95.6% of cases. All RSS
in the cadavers displayed distal acoustic shadowing as a predominant
feature.
The subjective difference in the appearance of the RSS in a gelatin
phantom as compared with the cadavers highlights the usefulness of
in vivo and/or cadaveric imaging in addition to ex vivo imaging. In the
gelatin phantom, the gelatin was able to soak into and surround all
the recesses and cavities within the RSS. This appearance has been
reported in a dog with an RSS (surgery performed 6 months prior) that
was surrounded by a fluid-filled cavitated mass.10 A similar appearance
may also be noted in dogs with large volumes of peritoneal effusion.
In the cadaver, though the RSS was first soaked in water and roughly
compacted into a rounded shape, gas and scant residual peritoneal fluid
could surround the recesses and cavities of the RSS. The cadavers thus
more closely mimicked the postoperative imaging appearance of a liv-
ing patient, as there would be no way to effectively exclude gas from a
postoperative peritoneal cavity.
The presence of reverberation artifact in four RSS (one radiopaque
gauze and three radiopaque sponges) may be due to gas trapped
within the RSS or could be due to the presence of a radiopaque
marker within these RSS. Reverberation artifact was seen when the
radiopaque sponge was imaged in the gelatin phantom at the level of
the radiopaque marker. When present, this feature may suggest an RSS
with a radiopaque marker, and radiographs may be able to confirm the
presence of an RSS. However, when absent, an RSS with a radiopaque
marker could still be present as several radiopaque gauzes and sponges
did not display this feature. The lack of reverberation artifact from the
metal markers may be due to the location within the sponge, such as if it
were in the deep portion of the RSS within the region of distal acoustic
shadowing, or if the marker was oriented on the edge of the RSS.
The predominant features identified in the RSS in cadavers in the
simulated acute postoperative period (hyperechoic and hypoechoic
layers with distal acoustic shadowing) subjectively differ from the fea-
tures previously reported for RSS in dogs and cats. In the literature,
RSS are described to be a hypoechoic mass with a central irregularly
shaped hyperechoic area and distal acoustic shadowing.5,11,12,15 In the
human medical literature, Barriga and Garcia described a mass in addi-
tion to distal acoustic shadowing in patients greater than four months
since the original surgical procedure.15 In contrast, in the patients who
underwent surgery 1–7 days before the diagnosis of an RSS there were
either no significant findings or a structure with only distal acoustic
shadowing.15 Similar findings were noted in the acute cases reported
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963
F I G U R E 6 B-mode ultrasound image of a cadaver. Image was
acquired with a large convex array probe (4 MHz). A nonradiopaque
gauze is positioned in the caudal abdomen adjacent to a segment of
colon (red brackets). The colon wall has a normal five-layered or
seven-layered appearance whereas the gauze (white bracket) has only
a two-layered appearance (thin outer hypoechoic layer and thick inner
hyperechoic layer) with distal acoustic shadowing. [Color figure can be
viewed at wileyonlinelibrary.com]
by Forster et al.7 where of the four patients presenting 5 days or less
from the initial surgery, abdominal ultrasonography did not diagnose
any mass-like structure nor identify an RSS. This may be due to the vol-
ume of gas within the peritoneal cavity postoperatively or could be due
to a lack of knowledge of the appearance of RSS in the acute postoper-
ative period. As seen in our current study, an additional confounding
factor may have been the hypoechoic and hyperechoic layering that
was identified in 95.6% of cases which gave the impression of intesti-
nal wall layering (Figure 6). When combined with the presence of distal
acoustic shadowing in all RSS, this appearance could mimic the appear-
ance of gas and/or formed feces within the colon. We hypothesized that
the cause of the hypoechoic layer may be due to a scant amount of fluid
or adhered peritoneal tissue.
A limitation of ultrasonography in the acute postoperative period
is the presence of gas within the peritoneal cavity. The volume of
gas within the peritoneal cavity postoperatively varies greatly and the
amount and location of gas could hamper evaluation of portions of the
abdomen. In our study, the median amount of gas in the cadavers was
graded moderate, corresponding to 25%–50% of the abdomen could
not be evaluated due to the presence of gas. Given the impact of gas
in the abdomen on ultrasound and the ease of detection of RSS with a
radiopaque marker, abdominal radiography may be a better first-line
imaging modality. However, in cases of an RSS without a radiopaque
marker, detection via radiography is difficult at best. Additionally in the
experience of the authors, ultrasound is often selected as the first-line
imaging modality when it is available in clinical practice. The features of
this paper may therefore aid in the detection of an RSS with ultrasound.
Alternative imaging modalities, such as CT, may also provide more
information and more definitive information than ultrasonography.
Cadavers were selected in the present study based on their avail-
ability and the inherent ethical limitations of knowingly leaving a
surgical sponge and/or gauze in a live patient. There are several lim-
itations to the use of cadavers. First, in a living patient, the presence

964
of an inflammatory response may alter the ultrasonographic appear-
ance of the tissues surrounding the RSS, though this was not reported
by Forester et al.7 Mass-like structures are described in other papers
of RSS, but even in a living patient, granuloma formation would not
be expected within 17 h after the initial surgery so it was determined
that the cadaver still more closely mimicked what would be seen in
an acutely postoperative patient as compared with a phantom model.
Additionally, in the study by Terrier et al.,8 inflamed omentum was
the only finding associated with the RSS after three days. Another
limitation of the cadavers was the presence of autolysis, which could
not be controlled for. Cadavers with severe autolysis were excluded
from the study to avoid additional confounding factors due to the
presence of organ decomposition or excessive intraperitoneal gas. To
prevent worsening autolysis, cadavers were only allowed to be stored
at room temperature for less than 5 h to avoid the postmortem changes
that can occur rapidly in cadavers between 8–16 h at ambient room
temperature.16
In conclusion, the ultrasonographic features of RSS in a canine
cadaver model of the acute postoperative period include a thin hypoe-
choic superficial layer of variable length, a long hyperechoic layer of
variable thickness, and distal acoustic shadowing. Additional features,
such as reverberation artifacts and linear hyperechoic striations were
seen in only a few RSS. Due to the overlap in features of the gauzes
and sponges, there were no defining features to suggest a radiopaque
gauze, nonradiopaque gauze, or radiopaque sponge. The hypoechoic
and hyperechoic layers combined with distal acoustic shadowing could
mimic the normal appearance of gas distended and/or feces-filled
colon, leading to misdiagnosis. While this paper provides a description
of the ultrasound findings to improve the ability of ultrasound to diag-
nose RSS, the ease of diagnosis of an RSS with a radiopaque marker
using radiography as a first-line imaging modality must be acknowl-
edged and advocated. However, in cases where the type of RSS is
unknown or ultrasound is selected as the first line imaging modality for
a postoperative patient, evaluating the abdomen for the presence of a
structure with distal acoustic shadowing and a thin hypoechoic layer
noted superficially to a hyperechoic layer will aid in the diagnosis of an
RSS.
ACKNOWLEDGMENTS
The authors acknowledge the contribution of Dr. George E. Moore for
assisting with the statistical analysis of the study.
LIST OF AUTHOR CONTRIBUTIONS
Category 1
a. Conception and design: Brand, Brand, Ogden, Lim, Heng
b. Acquisition of data: Brand, Heng
c. Analysis and interpretation of data: Brand
Category 2
a. Drafting the article: Brand
b. Revising article for intellectual content: Brand, Ogden, Lim, Heng
17408261, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vru.13281 by Cochrane Mexico, Wiley Online Library on [10/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
BRAND ET AL .
Category 3
a. Final approval of the completed article: Brand, Brand, Ogden, Lim,
Heng
Category 4
a. Agreement to be accountable for all aspects of the work in ensur-
ing that questions related to the accuracy or integrity of any part of
the work are appropriately investigated and resolved: Brand, Brand,
Ogden, Lim, Heng
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.
PREVIOUS PRESENTATION OR PUBLICATION
DISCLOSURE
Portions of this study were presented at the Purdue Resident Seminar
Series on September 17, 2021. Portions of this study were presented
as an abstract presentation for the 2022 ACVR conference on October
20, 2022.
DATA AVAILABILITY STATEMENT
The data acquired during this study is available from the corresponding
author upon reasonable request.
REPORTING CHECKLIST DISCLOSURE
No reporting checklists were used.
ORCID
Emily M. Brand https://orcid.org/0000-0002-5970-0963
Chee Kin Lim https://orcid.org/0000-0002-8041-0645
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How to cite this article: Brand EM, Brand KJ, Ogden JA, Lim
CK, Heng HG. Ultrasonographic appearance of retained
surgical sponges and gauzes in the acute postoperative period:
a phantom and cadaveric study. Vet Radiol Ultrasound.
2023;64:957–965. https://doi.org/10.1111/vru.13281