Evaluation of the efficacy of oxidized cellulose (surgicel) in reducing blood loss in suprapubic simple open prostatectomy: A randomized clinical trial.

Background: Simple open prostatectomy is still the treatment of choice for removing large prostates; however, peri-surgical bleeding accompanied by this technique has always been a challenge for urologist surgeons. Therefore, the present study aimed to investigate the effect of surgicel on reducing bleeding in trans-vesical prostatectomy. Materials and Methods: The present double-blinded clinical trial included 54 patients with Benign Prostatic Hyperplasia (BPH), divided into two groups of 27, and underwent trans-vesical prostatectomy. After removing the prostate, the prostate adenoma was weighed in the first group. Then, two surgicel were inserted into the prostate loge for prostate adenomas weighing 75 g or less. For larger prostates, another surgicel was inserted for each 25 g weight higher than the limit of 75 g. However, no Surgicel was inserted in the control group. Other steps of the procedure were the same in both groups. Moreover, hemoglobin and hematocrit levels were assessed in both groups; preoperation, intra-operative, 24 h, and 48 h postoperative. In addition, all the fluid used for bladder irrigation was collected, and its hemoglobin level was assessed. Results: According to our results, no intergroup difference in hemoglobin level changes, hematocrit changes, International Prostate Symptom Score (IPSS), postoperative hospital stay, and number of packed cells received. However, the postoperative blood loss in bladder lavage fluid was significantly higher in the control group (120.83 ± 46.66 g) as compared to the surgicel group (72.56 ± 32.53 g) (P < 0.001). Conclusion: The present study concluded that using surgicel in trans-vesical prostatectomy could reduce postoperative bleeding without increasing the chance of postoperative complications.

Surgicel mimicking recurrent pelvic neuroblastoma in a 3-year-old boy.

INTRODUCTION: Surgicel is a hemostatic agent that consists of oxidized regenerated cellulose and used in surgical procedures as an aid to bleeding control. It is left in the operation site for hemostasis, could cause an operation by mimicking the recurrence of tumor, as in our patient. PATIENTS AND METHODS: A 3-year-old boy was operated by us at the age of 40 days and 2.5 years, respectively, due to pelvic neuroblastoma. He was re-operated for mimicking recurrence or residue tumor secondary to the prior placement of Surgicel within the peritoneal cavity. RESULTS: Re-laparotomy was performed and the mass approximately 2.8 × 2×1 cm in size in front of the right ureter and iliac vessels and behind the bladder was removed by blunt and sharp dissection without damaging these organs. While gelatinous content was evacuated from this mass, there was no apparent tumor appearance. Pathology report was reported as fibrotic tissue characterized by foreign body and foreign body giant cells. The postoperative period was uneventful and he was discharged on the 2nd postoperative day. CONCLUSIONS: In the light of our case, the use of hemostatic agents should be kept to a minimum and should not be left in the body unless it is difficult. Thus, unnecessary examination or recurrent surgery can be avoided.

New hemostatic technique with combined use of Hydrofit® and Surgicel®: an in vitro and in vivo study.

We developed an effective hemostatic technique using Hydrofit® and Surgicel® simultaneously. The aim of this study was to demonstrate the hemostatic efficacy of the Hydrofit® and Surgicel® combination technique through an in vitro experiment and to elucidate mid-term consequences of the combined components through an in vivo experiment. For the in vitro experiment, a closed circuit using a heparin-coated cardiopulmonary bypass circuit and a prosthetic graft was created. The amount of bleeding from the prosthetic graft was measured, and the following three hemostatic methods were applied: only gauze compression in control group, Hydrofit® application in Hydrofit group, Surgicel® spread Hydrofit® application in Hydrofit and Surgicel (HS) group, respectively. In the in vivo experiment, Hydrofit® and/or Surgicel® were implanted under skin on the back of rats (n = 10) at 4 points. In the control group, only an incision was made; in the Hydrofit, Surgicel, and HS groups, Hydrofit® and/or Surgicel® was implanted. One and three months later, each of the five rats were killed and in each section histopathologic examination was carried out. In the in vitro experiment, the amount of bleeding was 7.84 ± 1.08, 2.26 ± 1.02, and 0.87 ± 0.38 ml in the control, Hydrofit, and HS groups, respectively. The amount of bleeding in the HS group was more suppressed than in the Hydrofit group (p = 0.012). In the in vivo experiment, the maximal depth diameter of each remaining hemostatic sealant was measured. After 3 months, the diameter was 0, 2289.0 ± 768.2, 3850.3 ± 935.8 µm in Surgicel, Hydrofit and HS groups, respectively. The diameter was significantly increased in the HS group compared with the Surgicel and Hydrofit groups (p < 0.001, respectively,). In conclusion, the combination of Hydrofit® and Surgicel® was effective in achieving hemostasis. The remnants of Hydrofit® and Surgicel® were present for a long time in the tissues which could compress the surrounding tissue.

Efficacy and safety of regenerated cellulose topical gauze haemostats in managing secondary haemostasis: a randomised control trial.

OBJECTIVE: To compare the efficacy and safety of HemoStyp (United Health Products, US), a neutralised oxidised regenerated cellulose (NORC) and Surgicel (Johnson & Johnson, US), an oxidised regenerated cellulose (ORC), in the management of bleeding of surgical wounds during abdominal, thoracic and vascular surgeries. METHOD: This study was a prospective, non-inferiority, multicentre, randomised, open-label trial. Surgical procedures were performed according to expected standard of care and in compliance with all relevant laws and institutional guidelines. Patients who developed Lewis Bleeding Scale grade 1 and grade 2 bleeds not controlled through conventional techniques were randomised to either the NORC or ORC treatment arms. Bleeding was measured every 30 seconds after treatment, ending at five minutes after haemostasis was achieved or at 10 minutes if haemostasis was not achieved. RESULTS: A total of 236 patients were included in the study. There was a total of seven adverse events in the study, none of which had causality related to either the NORC or ORC. For all surgical procedures, haemostasis was achieved more quickly with the NORC than the ORC (p<0.0001). In addition, haemostasis for all patients was achieved in under two minutes for the NORC compared with 81% of patients in the ORC groups. For Lewis Bleeding Scale grade 1 bleeds, the median time to control bleeding was 24 seconds in the NORC group and 51 seconds for the ORC group. For grade 2 bleeds, time to control bleeding was 76 seconds and 116 seconds, respectively. CONCLUSION: For patients in this study, haemostasis was achieved more quickly in the NORC treatment group compared with the ORC group, in patients with Lewis grade 1 or 2 bleeds caused by surgical wounds generated during abdominal, thoracic and vascular surgeries.

Gossypiboma mimicking recurrent mandibular tumor: case report.

Gossypiboma is not a commonly known surgical complication. It is a tumorous lesion usually caused by hemostatic material used in surgery. Such lesions are most commonly described after abdominal surgery. In this case report, the authors describe a case of a 17 year old female patient, operated for a mandible tumor. Histopathologically it was an ameloblastoma. The patient was treated lege artis, with the use of Surgicel® felt (Surgicel FibrillarTM Absorbable Hemostat). After two months, the young woman returned to clinics with a tumorous lesion at the same location. On the CT scan the lesion appeared to be a recurrence of the originally diagnosed ameloblastoma. Histopathologically, the lesion consisted of a foreign material with surrounding granulation tissue and massive inflamation. The foreign material had an atypical structure. Subsequent consultations and consensus at the clinic confirmed that it was a haemostatic foreign material with a surrounding hyper-inflammatory response mimicking a tumor, known in the literature under various names, most often as gossypiboma or textiloma.

Effects of quercetin and surgicel for preventing adhesions after gynecological surgery: A rat uterine horn model.

AIM: Postoperative pelvic adhesions are significant health care problems causing chronic pelvic pain, infertility and intestinal obstruction after abdominal or pelvic surgery. We investigated the effects of quercetin and Surgicel for the prevention of adhesions after gynecological surgery. METHODS: A double blind, randomized, controlled experimental study was designed. Forty female Wistar Hannover rats were divided into five groups: control, sham operated, quercetin, Surgicel, and quercetin + Surgicel. The control group received medication used for the surgical procedure only. The sham group received a laparotomy only. The quercetin group received 15 mg/kg quercetin in addition to undergoing the standard surgical procedure, and the injuries in the surgical group were covered with a single, 1 cm2 layer of Surgicel (oxidized regenerated cellulose). The quercetin + Surgicel group received both 15 mg/kg quercetin and a single, 1 cm2 layer of Surgicel. Adhesions were scored 14 days after the first surgical procedure. RESULTS: The extent, severity, degree, total adhesion, inflammation and fibrosis scores of the control group were significantly higher than those of the quercetin, Surgicel, and quercetin + Surgicel groups. There was no significant difference between the Surgicel and quercetin groups in degree, but all other parameters were significantly higher in the Surgicel than in the quercetin group. The quercetin + Surgicel group had lower adhesion scores than the quercetin group. CONCLUSIONS: Quercetin, Surgicel and quercetin + Surgicel treatment may be useful for preventing pelvic adhesions.

Enhanced hemostasis with a sealant consisting of Hydrofit and Surgicel.

Bleeding is a serious concern during surgery for acute aortic dissections. We have used Hydrofit and Surgicel together to achieve hemostasis at the graft anastomotic sites during replacement of the ascending aorta and aortic arch. Complete hemostasis was achieved without further need for any additional sutures.

Effectiveness of Surgicel® (Fibrillar) in patients with colorectal endoscopic submucosal dissection.

BACKGROUND AND AIMS: Because the invasive procedure of colorectal endoscopic submucosal dissection (ESD) entails a extensive mucosal defect and submucosal exposure, the procedure may have a substantial risk of complications including delayed bleeding, perforation and bacteremia and/or endotoxemia. The aim of our study was to investigate whether Surgicel(®) would be effective in reducing complications after colorectal ESD. PATIENTS AND METHODS: Between 2012 and 2013, 52 consecutive patients who underwent a colorectal ESD were enrolled. After the removal of colorectal epithelial neoplasm, surgicel was sprayed onto the submucosal surface using the wet type of application (Surgicel(®) group). We evaluated tumor type, location, size, histology, procedure time, hospital stay and associated complication. For assessing inflammatory reaction, white blood cells and body temperature were monitored. In assessing the effectiveness of Surgicel(®) application, we retrospectively compared the clinical outcomes with 52 other consecutive large colorectal tumor patients who had previously received conventional ESD, as control group (non-Surgicel(®) group). RESULTS: Of the 52 patients, three patients were excluded. Forty-nine patients were ultimately enrolled in this study. During the follow-up period, rebleeding occurred in 0 (0% in Surgicel(®) group) patients and 4 (7.7% in non-Surgicel(®) group) patients; fever (>37.7) in 2 (4.1%) and 10 (19.2%) patients, respectively (p = 0.019); and leukocytosis in 9 (18.4%) and 16 (30.8%) patients, respectively (p = 0.172). C-reactive protein level was 0.35 ± 0.18 and 9.83 ± 2.44 (p < 0.001). The mean hospitalization period was 4.22 ± 0.94 and 5.13 ± 0.27 days, respectively (p < 0.001). The group (surgicel vs. non-surgicel, p = 0.005, odds ratio 11.114 (2.104-58.718)) was identified as independent predictor for complication such as fever or delayed bleeding by multivariated analysis. CONCLUSIONS: Surgicel(®) application after colorectal ESD may be an effective method to reduce some complications and mean hospitalization period. Therefore, surgicel application may be considered to be a valuable clinical method.

Survival of Minced Cartilage Grafts with Comparison Surgicel(®) Original and Fibrillar.

BACKGROUND: Cartilage grafts are commonly used in nasal surgery for structural and/or esthetic purposes. The viability of cartilage grafts has been investigated in many forms since the use of cartilage grafts in surgical procedures. OBJECTIVES: The objective of this study was to investigate the viability of minced cartilage grafts and whether there is a difference between grafts wrapped in Surgicel(®) Original and Surgicel Fibrillar. METHODS: A total of ten New Zealand rabbits were used for the study. Cartilage grafts were harvested from one side ear. Four groups were formed. Group 1: minced cartilage graft wrapped in Surgicel Fibrillar; Group 2: minced cartilage graft wrapped in Surgicel Original; Group 3: bare minced cartilage graft; and Group 4: bare diced cartilage graft. Four small subcutaneous pockets were made in the backs of the rabbits, and the grafts were placed in these pockets. All of the rabbits were sacrificed at the end of 3 months, and the samples were collected. The sections were stained with hematoxylin and eosin (H&E), toluidin blue, safranin-O, masson trichrome, and glial fibrillary acidic protein immunohistochemical. All specimens were assessed histopathologically under a light microscope. RESULTS: There was no statistically significant difference between the Surgicel Fibrillar and Surgicel Original groups with respect to any of the parameters. Bone formation, calcification, inflammation, fibrosis, and basophilia were similar in all groups, with no significant difference among them. In the Surgicel Fibrillar and Surgicel Original groups, a heavy chondrocyte nucleus loss accompanied by a minimal peripheral proliferation was observed. CONCLUSIONS: The viability of bare minced cartilage grafts was found to be similar to that of bare diced cartilage in this study. Minced cartilage grafts can be used in the correction of minor dorsal defects and irregularities in persons with thin nasal skins, especially in primary and revision rhinoplasty. Although there is no statistically significant difference between the Surgicel Fibrillary and Surgicel Original groups, we think that, if it is necessary to use oxidized regenerated cellulose, it should be in the fibrillar form. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Does the use of Surgicel affect postsurgical radiological follow-up of kidney tumors?

Remaining Surgicel in the body can be mistaken for complications such as hematoma, abscess, or tumor recurrence in paraclinical examinations after surgery. We have presented the case of kidney cancer who underwent radical nephrectomy. In radiological follow-ups, hematoma was reported in the surgery site. The typical appearance of Surgicel on a postoperative CT scan is characterized by air trapped bubbles. Surgicel exhibits a short relaxation time on T2-weighted images. It is important to differentiate the remaining Surgicel from cases such as hematoma, abscess and tumor recurrence. T2MRI images will be most accurate in the correct diagnosis of Surgicel.

A contemporary systematic review of the complications associated with SURGICEL.

BACKGROUND: This review aims to summarize the findings from recent literature (2010-2022) reporting on complications that resulted from the surgical use of SURGICEL for intraoperative hemostasis. METHODS: A literature search was conducted using the MEDLINE (OVID), Embase, and Cochrane Central Register of Controlled Trials - CENTRAL (OVID) databases. The studies were sorted into case reports and other study types for data extraction. Covidence was used for data extraction and statistics were descriptive. RESULTS: Of the total 560 articles screened, 73 papers were selected for a full-text review and 70 studies were included in this review. A total of 7,242 participants were included in the studies (case studies n = 93, others n = 7149). 67/70 of the included studies reported complications when SURGICEL was used intraoperatively. Reported complications included: SURGICEL induced masses (granulomas, abscesses, hematomas, cysts) (n = 25), hemorrhagic complications (n = 12), masses misdiagnosed as tumors, cardiovascular, nervous system, and hepatobiliary complications, pain, and infections. Other complications included: fistulas, erectile dysfunction, chorioamnionitis, swelling, urinary leak, renal failure, and anaphylaxis. CONCLUSIONS: Publications reporting on complications associated with the use of SURGICEL intraoperatively have continued to emerge. Future studies should compare how the types and rates of complications compare between SURGICEL and alternative hemostatic agents.

Surgicel plug technique versus endoclose technique for port-site closure post minimally invasive (robotic and laparoscopic) surgeries: Retrospective cohort study.

OBJECTIVES: To compares the endoclose technique (ET) techniques and surgicel plug technique (SPT) in terms of port-site related complications. Minimally invasive surgeries (MIS) are widely performed nowadays, nonetheless, port-site closure technique plays a role in the prevention of port-site related complications. METHODS: This retrospective study was carried out at general surgery and urology departments of King Fahad Medical City, Saudi Arabia. Variables that were collected include age, gender, height, weight, body mass index, co-morbidities, type and date of surgery, intraoperative visceral injury or bleeding, technique cost, and port-site post-operative complications (hernia, infection, bleeding, dehiscence, and hypertrophic scarring). Data was collected from electronic medical records. Patients included are whom underwent any minimally invasive procedure from the beginning of 2014 until the end of September 2020. Follow up period was at least for 2 years. RESULTS: We analyzed 397 patients. Surgicel plug technique was more of having hernia (2.3%) than of ET (0%). While ET was more on infection (0.9%) than in SPT, but no significant difference being observed (p=0.064). CONCLUSION: There is no significant difference between the ET and the novel SPT in terms of port-site related complications.

The Efficacy of BloodSTOP iX, Surgicel, and Gelfoam in Vascular Operations: First-in-Human Head-to-Head Study.

This study aims to compare the efficacy and safety of 3 different hemostatic agents in vascular surgeries in humans. Twenty-four patients were enrolled in the present study with 40 vascular anastomoses including 16 aortic and 24 femoral. The patients were randomized (computer-based) to either BloodSTOP iX, Gelfoam, or Surgicel. The hemostatic agent was applied at the site of the vascular anastomosis before declamping. The site of anastomosis was then observed for bleeding from the suture line for 2 min. If any bleeding was detected, blood was then collected for 5 min, and the time needed to stop bleeding was measured. A suction drain was fixed in the surgical bed to collect serous fluid postoperatively more than 48 h afterward. The volume of blood collected in 5 min was significantly lower in the BloodSTOP group compared with the other 2 hemostatics. There was a significant reduction in the mean time needed to stop bleeding from the anastomotic surface in the BloodSTOP group compared with the Surgicel and Gelfoam groups. In addition, Surgicel showed the highest rate of complication (46.2%) compared with BloodSTOP (7%). BloodSTOP iX dramatically reduced bleeding volume and time compared with the other hemostatic agents. Furthermore, it showed a lower complication rate and did not interfere with the healing process at the application sites.

Oxidized cellulose-based reaction mimicking thyroidal recurrence of disease: a case report and literature review.

Oxidized cellulose is a hemostatic agent currently used in surgery. Foreign body reactions have been described after its use. This paper describes a foreign body reaction caused by oxidized cellulose in a young woman who underwent thyroid surgery. A patient underwent two thyroid surgeries for treatment of papillary carcinoma. Five years after the last surgery, an asymptomatic mass was detected with a routine ultrasound in the left thyroid cavity. After surgical removal, the mass turned out to be a foreign body granuloma based on oxidized cellulose sheets used in the previous surgery. The patient was discharged from the hospital without complications. The follow-up period was uneventful. Oxidized cellulose is a useful tool in surgery to control and prevent intra and post-operative bleeding. Even if it is a biodegradable material, sometimes it persists in the human body causing foreign body reactions that can be misdiagnosed. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03556-0.

Evaluation of postoperative bleeding control employing Surgicel: a clinical trial.

INTRODUCTION: Various techniques have been developed for the rapid control of bleeding as a potential surgical complication. Research shows that the Surgicel has a significant effect on reducing bleeding in most surgeries; however, in our experimental observations on patients undergoing open prostatectomy, not only no significant reduction was seen in the amount of bleeding, but in some cases, Surgicel led to infection. Therefore, in this study, the effect of the Surgicel on infection and bleeding in open prostatectomy was investigated. MATERIALS AND METHODS: Thirty patients undergoing open prostatectomy were randomly divided into two groups. To control bleeding after suturing the bladder neck, the Surgicel was installed in the first group, while it was not in the second group. Hemoglobin, hematocrit, PT, PTT, INR, bleeding rate, and postoperative complications were evaluated in all patients. RESULTS: In the studied groups, hemoglobin level and hematocrit percentage before surgery and on the first and second days after surgery, along with coagulation status, were compared in terms of PT, PTT, and INR. There were no significant differences between the studied variables and baseline variables. CONCLUSION: The present study revealed that the Surgicel in open prostatectomy was ineffective in controlling bleeding and can lead to infection.

Using Surgicel-wrapped Merocel to reduce pain during the removal of nasal packing.

BACKGROUND: Merocel is a commonly used material for nasal packing; nevertheless, the majority of patients experience pain when the nasal packing is removed.Aims/Objectives: This study aims to introduce a novel technique for nasal packing using Surgicel-wrapped Merocel. MATERIAL AND METHODS: Patients who underwent septoplasty received either Merocel or Surgicel-wrapped Merocel as nasal packing. Clinical complications related to bleeding and subjective symptoms associated with the packing materials were assessed. RESULTS: Between 2018 and 2021, a total of thirty-three patients with a deviated nasal septum underwent septoplasty. Among them, eight patients received Merocel nasal packing, while twenty-five patients were treated with the new nasal packing technique involving Surgicel-wrapped Merocel. We observed a significant reduction in pain during removal in the Surgicel-wrapped Merocel group compared to the Merocel group (p = .008). However, no significant differences were noted in other discomforts related to packing or bleeding after removal between these two groups.Conclusions and Significance:Using Surgicel-wrapped Merocel as nasal packing following septoplasty is an effective method to alleviate pain during removal.

Surgicel® Granuloma Mimicking Recurrent Thyroid Tumor After Thyroidectomy: A Case Report and Literature Review.

Oxidized regenerated cellulose, commonly known by the brand name Surgicel®, is a hemostatic agent widely used in various surgical procedures. While it is generally considered safe and effective, there have been reports of complications associated with its use, including the formation of pseudotumoral lesions. This article presents a case of a patient who developed a Surgicel® granuloma in the thyroid bed, mimicking a recurrent tumor. Surgicel® is known to cause a chronic inflammatory reaction, leading to foreign body giant cell formation and fibroblastic proliferation. Fine-needle aspiration (FNA) cytology is a valuable diagnostic tool for identifying pseudotumoral lesions caused by oxidized cellulose. The characteristic appearance of oxidized cellulose fragments and the presence of a granulomatous reaction can help distinguish these lesions from tumor recurrence or abscesses. To prevent Surgicel® granuloma, it is recommended to use the minimal amount necessary to achieve hemostasis. It is also important to document its use in the operative report. In cases where a recurrent mass lesion is suspected postoperatively, a comprehensive medical history, imaging studies, and FNA are essential for accurate diagnosis and management. This case report highlights the importance of considering Surgicel®-induced granuloma in the differential diagnosis of recurrent thyroid-bed tumors. A correct diagnosis can help avoid unnecessary aggressive interventions, particularly in cancer patients.

Safety and Hemostatic Effectiveness of SURGICEL® Powder in Mild and Moderate Intraoperative Bleeding.

This postmarket clinical study evaluated the safety and effectiveness of the novel adjunctive topical hemostat SURGICEL® Powder (SURGICEL®-P), a powdered form of oxidized regenerated cellulose. In a prospective, open-label, single-arm multicenter trial, adult surgical subjects with mild-to-moderate bleeding for which conventional hemostatic methods were impractical/ineffective were treated with SURGICEL®-P. Descriptive analyses included hemostatic success rate at 3, 5, and 10 min, rebleeding and thromboembolic events, SURGICEL®-P-related serious adverse events requiring surgical intervention, and SURGICEL®-P ease of use (questionnaire). In 8 centers, 103 subjects were enrolled with a median (range) age of 64.0 (33.0-88.0) years. Surgeries were open (53.4%) or laparoscopic/thoracoscopic (46.6%) and mostly urological (37.9%) and abdominal (32.0%) procedures. Bleeding sites included various tissue types, with a median (range) surface area of 4 (0.02-72.0) cm2. Hemostatic success rates were 77.7%, 87.4%, and 92.2% at 3, 5, and 10 min, respectively. In 7 subjects (6.8%), investigators reverted to standard of care. No safety signals were identified. Two deaths occurred with causes unrelated to SURGICEL®-P. Investigators favorably evaluated the ease of use of the SURGICEL®-P device. SURGICEL®-P is safe and effective in controlling mild-to-moderate bleeding in a broad range of surgical procedures. The trial was registered at https://clinicaltrials.gov as NCT03762200.

Intracranial gossypiboma 9 years after intracranial pressure bolt insertion: illustrative case.

BACKGROUND: Resorbable hemostatic agents left behind postoperatively occasionally result in granulomatous space-occupying lesions known as "gossypibomas." The authors report a case of an intracranial gossypiboma, which is exceedingly rare and frequently radiologically indistinguishable from other lesions. OBSERVATIONS: A 35-year-old woman presented with a generalized tonic-clonic seizure and subsequent left-sided hemiparesis. Magnetic resonance imaging showed an enhancing lobulated lesion subjacent to a right frontal burr hole, surrounded by vasogenic edema with mass effect and midline shift. Nine years earlier, she had had a triple bolt inserted to monitor intracranial pressure after sustaining a traumatic brain injury. Surgicel was used to control bleeding during insertion. Colocation of the lesion with the position of triple bolt 9 years earlier raised suspicion for gossypiboma. However, the minor nature of the surgery and the length of time since surgery to presentation placed this case well outside the range of cases reported in the literature. The lesion was resected en bloc with no recurrence 18 months later. Histological examination revealed the presence of foreign material. However, given its minute size, confirming its nature was not possible. Lessons: The authors show that gossypibomas can occur following a relatively minor procedure and remain clinically and radiologically silent for much longer than previously reported.

Cochlear Implant in Klippel-Feil Syndrome: Challenges and Concerns.

Cochlear implantation (CI) can be safely performed in patients with syndromic hearing loss. Here we present a case of CI in a child with Klippel-Feil syndrome with various skeletal, extraskeletal, cochleovestibular and Arnold-Chiari malformations. Multidisciplinary approach and good preoperative imaging play a key role in planning for surgery.