A surgical instrument roughly the size of a dinner plate was discovered inside a woman’s abdomen a year and a half after she underwent a cesarean section to deliver her baby, leaving doctors sutunned, according to a report from New Zealand’s Health and Disability Commissioner.
As reported by CNN, the incident took place at Auckland City Hospital in 2020, where an Alexis retractor, also known as an AWR, with a diameter of approximately 17 centimeters (equivalent to 6 inches), was inadvertently left inside the woman’s body.
The AWR is a retractable cylindrical device equipped with a translucent film, commonly used in surgical procedures to gently retract the edges of a wound. Subsequently, the woman endured several months of persistent and excruciating pain, prompting her to seek multiple medical evaluations in an attempt to diagnose the source of her suffering. X-rays conducted during these checkups failed to reveal any sign of the retained device. Eventually, the pain became unbearable, leading her to visit the hospital’s emergency department, where an abdominal CT scan in 2021 unveiled the presence of the AWR. Medical professionals promptly removed the instrument.
In a report released on Monday, New Zealand’s Health and Disability Commissioner, Morag McDowell, determined that Te Whatu Ora Auckland, the Auckland District Health Board, had violated the code of patient rights in this case. Initially, the health board attributed the error to a nurse in her twenties who had assisted during the cesarean section, alleging a failure to exercise reasonable skill and care towards the patient.
As McDowell stated in her report, the level of care provided to the woman fell significantly below the appropriate standard, resulting in prolonged distress for her. McDowell also emphasized the need for established systems to prevent such incidents from occurring in the first place.
The report clarified that the woman had undergone a scheduled C-section due to concerns related to placenta previa, a condition during pregnancy where the placenta either partially or completely obstructs the uterine opening.
During the 2020 operation, a count of all surgical instruments employed did not include the AWR, as the commission’s findings suggested that this might have been due to the fact that the Alexis Retractor did not enter the wound entirely; a portion of it remained outside the patient, supposedly reducing the perceived risk of retention, as noted by a nurse interviewed by the
