ABSTRACT
Unintentional retention of a surgical gauze following a surgical intervention is uncommon but the complications can sometimes be life-threatening. Its diagnosis is challenging due to varied clinical presentations and inconclusive radiographic findings. We put forth a case which reported to us complaining of pain, swelling, pus discharge and sinus opening prejudicing our clinical and radiographic diagnosis to be a residual cyst but turned out to be unintentionally retained surgical gauze with encapsulation. The use of relatively bigger sized surgical gauze and ensuring a correct surgical gauze count intraoperatively in addition to checking the surgical site thoroughly before initiating surgical site closure is a gold standard to prevent such mishaps.
