According to a report released on Monday, a New Zealand woman in her 20s who underwent a cesarean section in 2020 lived with a surgical device the size of a dinner plate inside her abdomen for 18 months. Despite experiencing chronic pain after giving birth at Auckland City Hospital, X-rays failed to show the presence of the device, as reported by CNN. It was only after a visit to the emergency room in 2021 that a CT scan revealed the presence of an Alexis retractor (AWR) that had been missed by the surgeon and 10 other medical staff involved in the surgery.
The AWR is a surgical instrument consisting of two plastic rings joined by a plastic sleeve, used to retract the edges of a wound during surgery. CNN states that AWRs are typically around 6 inches wide, but this particular one was reported as being “extra large” by The Guardian. The report from Health and Disability Commissioner Morag McDowell criticized Te Whatu Ora-Auckland (formerly the Auckland District Health Board) for excluding the AWR from the count of surgical instruments used. A nurse explained that this may be because the retractor does not fully enter the wound and needs to remain partially outside the patient.
It remains unclear how the device was retained in the woman’s abdomen. According to ABC News, the report states that the AWR should have been removed after closing the uterine incision and before suturing the skin. McDowell stated that the level of care in this case fell significantly below the appropriate standard and caused prolonged distress for the woman. Measures should have been in place to prevent such an incident. The report also mentioned that this case bears striking similarities to another incident within the same health authority, as reported by The Guardian. The report recommends that the health board issue an apology to the patient and include AWRs in the count of surgical instruments. The case will now be reviewed by the commission’s prosecutor for further action. (Read more New Zealand stories.)
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