A new mother in New Zealand who underwent a Cesarean section in 2020 recently experienced severe abdominal pain that persisted for several months. Her discomfort remained unexplained until an alarming discovery 18 months later when medical professionals found a “dinner plate-sized” surgical tool inside her abdomen. The surgical instrument, an Alexis wound retractor (AWR), is a soft-tubular device utilized in surgical procedures to draw back the edges of wounds.
According to a report by New Zealand’s Health and Disability Commissioner, Morag McDowell, the AWR had inadvertently been left inside the woman in her twenties. She had reported abdominal discomfort to her healthcare provider and even sought help in the emergency room at Auckland Hospital. Unfortunately, the surgical tool went undetected during X-rays due to its “non-opaque” nature. The exceptionally large AWR, measuring 17 inches in diameter, had been unintentionally retained after the surgeon opted for a different size AWR during the C-section, resulting in a failure to include it in the routine surgical instrument count before closing the incision.
The presence of the surgical tool remained undetected for over a year until the woman finally underwent a CT scan, which revealed the foreign object. Medical professionals promptly removed it. However, Health Commissioner McDowell publicly acknowledged Auckland Hospital’s failure to fulfill its duty of care in this incident.
“I acknowledge the stress that these events caused to the woman and her family. The woman experienced episodes of pain over a significant period of time following her surgery until the AWR was removed in 2021,” stated McDowell in the report. “I accept her concerns regarding the impact this had on her health and wellbeing and that of her family.”
Mike Shepard, the director of operations for Auckland Hospital, expressed his regret in a media statement, saying, “I would like to say how sorry we are for what happened to the patient and acknowledge the impact that this will have had on her and her whānau [family]. For ethical and privacy reasons, we can’t comment on the details of individual patient care.”
Regrettably, this is not an isolated incident in the Auckland region. In 2021, another patient in an Auckland suburb underwent surgery to correct a perforated colon and subsequently had an AWR left inside, resulting in a two-month stay in the Intensive Care Unit. The repeated occurrence of such incidents raises concerns about patient safety and surgical procedures in the area.
