6-inch surgical tool accidentally left inside mom’s body for 18 months after cesarean section
A woman made a horrifying discovery about her body when a surgical tool "about the size of a dinner plate" was accidentally left inside of her for 18 months after she underwent a cesarean section to deliver her baby.
According to a report by New Zealand’s Health and Disability Commissioner, Morag McDowell, the unnamed woman gave birth via c-section at an Auckland in 2020. Doctors used a device called an "Alexis wound retractor" (AWR) to draw back the edges of a wound during surgery.
The device is described as a "round, soft tubal instrument of transparent plastic fixed on two rings" that is "about the size of a dinner plate." Usually, it would be removed after closing the uterine incision and before the skin is sutured.
While the report did not specify the size of the tool, it mentioned that the surgeon had used an extra-large AWR, which the National Institutes of Health detailed measures 17 centimeters (6 inches) in diameter.
After the c-section was accomplished, the staff present during the surgery—a surgeon, a senior registrar, an instrument nurse, three circulating nurses, two anesthetists, two anesthetic technicians, and a theater midwife—failed to notice that they had accidentally left the tool inside the woman's abdomen.
This resulted in the new mom suffering episodes of chronic abdominal pain over a significant period. Despite several visits to the hospital for consultation, the device went unnoticed even when it was subjected to X-rays.
The tool was finally discovered and removed in 2021 after the woman underwent an abdominal CT scan. The X-rays weren't effective as the AWR is "a non-radio-opaque item."
According to one of the nurses present in the operation, the tool was left inside the woman's body as "AWRs were not included as part of the surgical count."
“[A]s far as I am aware, in our department no one ever recorded the Alexis Retractor on the count board and/or included in the count. This may have been due to the fact that the Alexis Retractor doesn’t go into the wound completely as half of the retractor needs to remain outside the patient and so it would not be at risk of being retained," they said.
Highlighting the importance of the counting policy, McDowell stressed that the hospital's system was flawed and that it should be clearer to maintain "an awareness of all surgical items and their location when on the surgical field."
"I acknowledge the stress that these events caused to the woman and her family," McDowell said in the report. "I accept her concerns regarding the impact this had on her health and wellbeing and that of her family."
The case has since been referred to the Director of Proceedings to determine whether any further proceedings should be taken.