Introduction: Surgical instrument retention continues to occur despite considerable preventive efforts. The resulting infection can be asymptomatic or demonstrate variable clinical presentations, such as intestinal obstruction, malnutrition, gastrointestinal bleeding, peritonitis, adhesions, fistulas, abscesses, erosion and/or intestinal perforation. In this case report, we present a patient whose last surgical event occurred 22 years prior with appendicular symptoms and a palpable abdominal mass.
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