Unintentionally retained lap sponge mimicking an ovarian cyst two years after Caesarean section in a 37-year old patient: case report of a rare "never event" in Sudan.

To the best of our knowledge, this is the first reported case of gossypiboma in Sudan in 2024, highlighting diagnostic challenges and the need for preventive protocols. Root cause analysis of accidents, enhanced training, application of advanced technologies and a collaborative culture in the operating room can prevent the occurrence of such incidents. This case underscores the importance of meticulous surgical protocols and continuous improvement in safety measures to prevent retained surgical items, ensuring patient safety and optimal outcomes.