An Alexis wound retractor (AWR) “about the size of a dinner plate” was accidentally left in a woman’s abdomen after giving birth via c-section in 2020
A surgical device “about the size of a dinner plate” was accidentally left inside of a woman’s abdomen for 18 months after delivering her baby via cesarean section, according to a report by New Zealand’s Health and Disability Commissioner, Morag McDowell.
The unnamed woman, who’s in her 20s, gave birth via c-section at Auckland City Hospital in 2020. During the procedure, an Alexis wound retractor (AWR), a device used to draw back the edges of a wound during surgery, was left in her abdomen.
An extra-large AWR can measure 17 centimeters (6 inches) in diameter, according to the National Institutes of Health.
The report, which was released Monday, states that the woman suffered chronic abdominal pain but the device went unnoticed during several checkups — including visits where she received X-rays.
However, 18 months later, in 2021, the AWR was discovered and immediately removed after the woman visited the hospital’s emergency department and received an abdominal CT scan. The AWR wasn’t detected in the X-rays because it is “a non-radio-opaque item,” McDowell states.
During the c-section, McDowell said the staff present included a surgeon, a senior registrar, an instrument nurse, three circulating nurses, two anesthetists, two anesthetic technicians, and a theater midwife.
According to the report, the surgeon stated that the typical large wound retractor for the c-section was too small, so they opted for an extra-large retractor instead. Therefore, a count of all the surgical devices used during the procedure did not include the AWR.
“The Case Review found that it was this second AWR (size XL) that was retained,” the report states. “It should be noted that the retractor, a round, soft tubal instrument of transparent plastic fixed on two rings, is a large item, about the size of a dinner plate. Usually, it would be removed after closing the uterine incision (and before the skin is sutured).”
"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," McDowell said in the report. "I accept her concerns regarding the impact this had on her health and wellbeing and that of her family."
In the report, McDowell found that Te Whatu Ora Auckland — the Auckland District Health Board — was in breach of the code of patient rights.
He also recommended that the Auckland District Health Board provide a written apology to the woman and revise its policies to ensure the surgeon and surgical assistant are “maintaining an awareness of all surgical items and their location when on the surgical field,” including the retractors.
In a statement, Mike Shepard, Te Whatu Ora Group director of operations for Auckland, apologized to the woman.
“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],” Shepard said. “However, we have reviewed the patient’s care and this has resulted in improvements to our systems and processes which will reduce the chance of similar incidents happening again.”
“We acknowledge the recommendations made in the Commissioner’s report, which we have either implemented, or are working towards implementing,” the statement continued. “We would like to assure the public that incidents like these are extremely rare, and we remain confident in the quality of our surgical and maternity care.”
The case has since been referred to the Director of Proceedings, who will determine whether any further disciplinary action will be taken.
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