Plate-Sized Surgical Tool Left in Woman's Abdomen for 18 Months

A woman in New Zealand had a dinner plate-sized surgical instrument left in her abdomen after a C-section at an Auckland hospital. The instrument, an Alexis wound retractor, was used to hold open the surgical wound during the procedure. It was not removed until 18 months later when it was discovered during a CT scan.

The woman had been experiencing chronic abdominal pain for 18 months, but doctors were unable to find the source of the pain. The CT scan revealed the Alexis wound retractor, which was then removed. The woman made a full recovery.

The public hospital system in New Zealand was initially accused of failing to provide a patient with reasonable care and skill. The district health authorities, Te Whatu Ora Auckland, argued that they had not done anything wrong. However, the Health and Disability Commissioner disagreed and released findings on Monday that confirmed the patient had been failed by the system.

"It is self-evident that the care provided fell below the appropriate standard, because the [retractor] was not identified during any routine surgical checks, resulting in it being left inside the woman's abdomen," Morag McDowell said.

"Staff involved have no explanation for how the retractor ended up in the abdominal cavity, or why it was not identified prior to closure," she said.

The Alexis wound retractor is a large, transparent plastic instrument with two rings. It is used to hold open the surgical wound during a C-section. It is typically removed after the uterine incision is closed and before the skin is stitched up.

However, the Alexis wound retractor is not radio-opaque, which means it cannot be seen on X-ray scans. This is why it was not detected when the woman had a CT scan 18 months after her C-section.
The Commissioner noted it was the second time in two years that a device had been left in an Auckland hospitals' patient.
 

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