Surgical Tool Found Inside Woman’s Abdomen 18 Months After C-Section
In a shocking medical mishap, a surgical tool the size of a dinner plate was discovered inside a woman’s abdomen a year and a half after she gave birth via cesarean section. According to a report by New Zealand’s Health and Disability Commissioner, the incident occurred at Auckland City Hospital in 2020.
The tool, known as an Alexis retractor or AWR, measures 17 centimeters (6 inches) in diameter. It is a retractable cylindrical device with a translucent film used to draw back the edges of a wound during surgery. It was mistakenly left inside the woman’s body following the birth of her baby.
The woman suffered from chronic pain for several months and went for multiple checkups to determine the cause. X-rays did not show any signs of the device. Eventually, the pain became so severe that she visited the hospital’s emergency department. An abdominal CT scan finally revealed the presence of the AWR, and it was promptly removed in 2021.
New Zealand’s Health and Disability Commissioner, Morag McDowell, conducted an investigation into the incident and found Te Whatu Ora Auckland, the Auckland District Health Board, in breach of the code of patient rights. McDowell released a report on Monday stating that the care provided to the woman fell significantly below the appropriate standard, resulting in a prolonged period of distress for the patient.
The health board initially blamed a nurse in her 20s, who was attending to the woman during the cesarean, for failing to exercise reasonable skill and care. McDowell emphasized the need for proper systems in place to prevent such incidents from occurring.
The woman had a scheduled C-section due to concerns about placenta previa, a condition where the placenta partially or completely covers the opening of the uterus. During the operation, a count of all surgical instruments used did not include the AWR. It was explained that the retractor does not go into the wound completely, with half of it remaining outside the patient, which may have contributed to the oversight.
McDowell recommended that the Auckland District Health Board issue a written apology to the woman and revise its policies to include AWRs as part of the surgical count. The case has also been referred to the director of proceedings, who will determine if further action should be taken.
Dr. Mike Shepherd, Te Whatu Ora Health New Zealand group director of operations for Te Toka Tumai Auckland, issued a statement apologizing for the error and expressing sympathy for the patient and her family. He reassured the public that incidents like these are extremely rare and affirmed confidence in the quality of their surgical and maternity care.
While medical mistakes are unfortunate, incidents like this emphasize the importance of thorough procedures and protocols to ensure patient safety during surgical procedures.