Vacuum assisted closure therapy is widely used in the management of complex wounds. Negative pressure in a closed environment promotes healing, with a reduction of wound colonisation and an acceleration of ingrowth of the granulation tissue. Vacuum therapy was originally devised for use in secondary care, but technological advancements mean it is now used in primary care too. Although the retention of surgical instruments and swabs inside body cavities after surgery is well recognised, the retention of foam dressings used in vacuum therapy has not been widely reported. Outside of the ordered theatre environment, however, dressing counts may be overlooked, and with such foam this can have serious consequences because it is radiolucent.

We report a case where foam dressings were retained in a surgical wound leading to chronic wound sepsis and further surgery.