Surgical hemostatic material is used to control bleeding intraoperatively and is hence frequently voluntarily left in the operative bed, not to be confused with a gossypiboma which is caused by foreign material left behind in error. It can mimic an abscess on imaging studies. Various types are available, the most common type being composed of oxidised regenerated cellulose.
Oxidized regenerated cellulose or Surgicel® (Ethicon, part of Johnson & Johnson) 7 is a bioabsorbable sterile knitted fabric prepared by the controlled oxidation of regenerated cellulose.
The mechanism of action whereby Surgicel® accelerates clotting is not completely understood, the effect appears to be physical rather than an alteration to the physiological clotting mechanism.
Surgicel® combines with blood into a brownish gelatinous mass which aids in the formation of a clot, as it is bioabsorbable it can be left in the surgical bed with almost no local tissue reaction. Retained Surgicel® is normally reabsorbed within 7-14 days.
Surgicel can absorb a large amount of blood and fluid, expanding in volume as it does so, with potential deleterious effects on surrounding structures 8.
Differentiating hemostatic material from abscess
The most important factor is accurate clinical information on the use of surgical hemostatic material. If in doubt, discuss with the operating surgeon who should be able to advise whether surgical hemostatic material was used.
There are a number of appearances that can help to differentiate between surgical hemostatic material and an abscess 6:
- gas pockets are packed tightly, not discrete, and lined up in a linear fashion
- gas-fluid levels, commonly seen in abscess are usually not seen with surgical hemostatic material
- rim enhancement is generally not seen around surgical hemostatic material
- surgical hemostatic material ‘collections’ tend to be organized in geometric shapes
Oxidised cellulose is seen as an echogenic mass with posterior reverberation artifact from the gas, mimicking a gas-containing abscess 4. There may be surrounding free fluid.
A well-defined "collection" comprised of mixed gas and soft tissue is seen, often surrounded by free fluid and adjacent to other collections. An enhancing margin typical of abscesses is usually not present.
Be cautious about labeling well-defined clusters of admixed gas and soft tissue without definable marginal enhancement as abscesses. Check with the operating surgeon whether surgical hemostatic material was used.
- 1. Gayer G, Petrovitch I, Jeffrey RB. Foreign objects encountered in the abdominal cavity at CT. Radiographics : a review publication of the Radiological Society of North America, Inc. 31 (2): 409-28. doi:10.1148/rg.312105123 - Pubmed
- 2. Arnold AC, Sodickson A. Postoperative Surgicel mimicking abscesses following cholecystectomy and liver biopsy. Emergency radiology. 15 (3): 183-5. doi:10.1007/s10140-007-0665-2 - Pubmed
- 3. Young ST, Paulson EK, McCann RL, Baker ME. Appearance of oxidized cellulose (Surgicel) on postoperative CT scans: similarity to postoperative abscess. AJR. American journal of roentgenology. 160 (2): 275-7. doi:10.2214/ajr.160.2.8424333 - Pubmed
- 4. Melamed JW, Paulson EK, Kliewer MA. Sonographic appearance of oxidized cellulose (Surgicel): pitfall in the diagnosis of postoperative abscess. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine. 14 (1): 27-30. Pubmed
- 5. Tam T, Harkins G, Dykes T, Gockley A, Davies M. Oxidized regenerated cellulose resembling vaginal cuff abscess. JSLS : Journal of the Society of Laparoendoscopic Surgeons. 18 (2): 353-6. doi:10.4293/108680813X13693422518597 - Pubmed
- 6. Sandrasegaran K, Lall C, Rajesh A, Maglinte DT. Distinguishing gelatin bioabsorbable sponge and postoperative abdominal abscess on CT. AJR. American journal of roentgenology. 184 (2): 475-80. doi:10.2214/ajr.184.2.01840475 - Pubmed
- 7. Ethicon Inc. Johnson & Johnson. Somerville, New Jersey. Available at: http://www.ethicon.com/healthcare-professionals/products/biosurgery/surgicel-family-of-absorbable-hemostats/surgicel-original-absorbable-hemostat
- 8. Arora ND, Varghese R, Pavithran S, Kothandam S. The pressures of surgicel(®) in cardiac surgery. (2015) Annals of pediatric cardiology. 8 (2): 167-9. doi:10.4103/0974-2069.157040 - Pubmed