Named the details of the surgical instrument forgotten in the body of the operated woman

New Zealand woman lived for a year and a half with a plate-sized alien body

A resident of New Zealand found a surgical instrument “the size of a dinner plate”, which remained in her body after the operation. The woman suffered from abdominal pain for 18 months after her caesarean section, until a scan showed that a retractor used to widen wounds had been left inside her by mistake.

A woman who suffered from chronic pain for 18 months after a caesarean section was found to have a dinner plate-sized surgical instrument in her abdomen, writes The Guardian.

A surgical instrument called the Alexis Retractor (AWR) was “forgotten” in the body of a New Zealand mother after her baby was born at Auckland City Hospital in 2020.

After an initial investigation into the case, Te Whatu Ora Auckland, the former Auckland District Health Board, said it did not fail to show reasonable skill and care for the patient, who was in her 20s.

But on Monday, New Zealand Commissioner for Health and Disability Morag McDowell admitted that the health council was violating a patient rights code.

“There is significant precedent to conclude that when a foreign object remains inside a patient during an operation, care is below the appropriate standard,” McDowell said in the report. “This is a ‘never’ event.”

The report details that the woman had an elective caesarean section due to concerns about placenta previa.

“The Alexis Retractor (AWR), a device used to retract the edges of a wound during surgery, was left in her abdomen after a caesarean section. This resulted in the woman suffering from chronic abdominal pain until the device was accidentally discovered on a CT scan of the abdomen,” the report said.

The very large AWR, “about the size of a dinner plate” and designed to retract incisions up to 17 cm in diameter, was not detected by X-ray.

It was eventually removed from the woman’s abdomen in 2021, about 18 months after the initial procedure and several visits to her GP. One day, her pain was so severe that she went to the emergency room at Auckland City Hospital.

During the operation in 2020, a surgeon, a senior registrar, an instrumental nurse, three nurses on duty, two anesthesiologists, two anesthesiologist-resuscitator technicians and a midwife were in the operating room.

The count of all surgical instruments used in the procedure did not include AWR, possibly “due to the fact that this retractor does not enter the wound completely, since half of the retractor must remain outside the patient, and therefore there would be no risk of saving it”, – the commission nurse said.

The report notes that this case is “remarkably similar” to another case in the same health authority and recommends that hospitals’ surgical counting policies be made clearer.

The commission acknowledged that the personnel involved in the operation were genuinely concerned and apologized upon hearing of the woman’s experiences.