Apparently, a surgical tool the size of a dinner plate was discovered inside a woman's abdomen 18 months after she had given birth. The woman had been experiencing extreme lower stomach pain for months following the surgery, and even after numerous x-rays, the device was never detected. It wasn't until an emergency visit to the ER that a CT scan finally revealed the presence of the Alexis retractor, or AWR device, in her abdomen.
From CNN:
An Alexis retractor, or AWR, which can measure 17 centimeters (6 inches) in diameter, was left inside the mother’s body following the birth of her baby at Auckland City Hospital in 2020.
The AWR is a retractable cylindrical device with a translucent film used to draw back the edges of a wound during surgery.
The woman suffered months of chronic pain and went for several checkups to find out what was wrong, including X-rays that showed no sign of the device. The pain got so severe that she visited the hospital’s emergency department and the device was discovered on an abdominal CT scan and removed immediately in 2021.
New Zealand’s Health and Disability Commissioner, Morag McDowell, found Te Whatu Ora Auckland – the Auckland District Health Board – in breach of the code of patient rights, in a report released on Monday.
The health board initially claimed that a nurse, who was in her 20s, attending to the woman during the cesarean had failed to exercise reasonable skill and care towards the patient.
“As set out in my report, the care fell significantly below the appropriate standard in this case and resulted in a prolonged period of distress for the woman,” McDowell said. “Systems should have been in place to prevent this from occurring.”
The report explained that the woman had a scheduled C-section because of concerns about placenta previa, a problem during pregnancy when the placenta completely or partially covers the opening of the uterus.
During the operation in 2020, a count of all surgical instruments used in the procedure did not include the AWR, the commission report found. This was possibly “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,” a nurse told the commission.
I'm certainly no medical professional, but I have a really hard time understanding how a device that size got haphazardly left in a woman's body.
This isn't the first or the last time we've heard of medical devices being left inside people after surgery, and you really have to question why this keeps happening.
