Surgical Device Found In Woman's Abdomen 18 Months After Operation

A woman in New Zealand suffered from a chronic stomach ache after undergoing a caesarean 18 months ago. She was found to have a surgical instrument as large as a dinner plate inside her abdomen.

The Alexis retractor, or AWR, was left inside her abdomen after her baby was delivered at Auckland City Hospital in 2020. Te Whatu Ora Auckland, formerly known as Auckland District Health Board, investigated the case and claimed that it had not failed to exercise reasonable skill and care towards the patient.

Surgical Device Left In Abdomen After Caesarean

However, on Monday, the New Zealand and Disability Commissioner, Morag Madwell, found the organisation to have breached the code of patient rights. It was a substantial precedent to infer that when a foreign object is left inside the patient’s body during an operation, the care falls below appropriate standards, as stated in McDowell’s report. The report also mentioned that the woman underwent a scheduled caesarean as a result of placenta previa.

The AWR, which was left inside the woman’s abdomen, is a device used to draw back the edges of a wound during surgery. This has resulted in chronic abdominal pain for the woman until the device was found through an abdominal CT scan. The extra-large AWR is reported to be about the size of a dinner plate and designed to retract incisions up to 170 cm in diameter. The device was initially not detectable in an X-ray and was incidentally discovered only through a CT scan. It was then removed from the woman’s abdomen in 2021, about 18 months after the initial procedure and several visits to the gynaecologist.

During the surgery in 2020, a surgeon, a senior registrar, an instrument nurse, three circulating nurses, two anaesthetists, two anaesthetic technicians, and a theatre midwife were present in the operation theatre.

A nurse told the commission that during the count of all surgical instruments, the AWR possibly was not included because "it doesn’t go into the wound completely as half of the retractor needs to remain outside the patient so it would not be at risk of being retained."

Noting that the case is "remarkably similar to another instance in the same health authority, the report advised that the hospital surgical count policies should be clearer. The commissioner also acknowledged that the theatre staff were genuinely concerned and apologetic for hearing the woman’s experience.

However, they were devastated by her response to Te Whatu Ora’s claims, which pointed out the lack of expert evidence to support the conclusion that the code had been breached and referenced known error rates.

In a statement, Dr Mike Shpherd, Te Whatu Ora Group Director of Operations, apologised for the error on behalf of the Women’s Health Service at Te Toka Tumai Auckland and Te Whatu Ora.

For ethical reasons, the details of the woman have not been disclosed. However, the doctor stated that they have reviewed the patient’s care and confirmed that it has resulted in improvements in their systems and processes, which will reduce the chance of similar incidents happening again. He added that the hospital acknowledges the commissioner's report, which they have either implemented or are in the process of implementing.

Similar Incident In Kerala

Last month, a similar incident happened in Kerala’s Eluru government hospital. The doctors who performed a caesarean on a woman left surgical forceps in the woman’s stomach. The medical negligence came to light after the woman complained of severe stomach pain since the surgery and underwent an ultrasonography at another hospital.

The surgical forceps were removed through surgical intervention. The Eluru district collector took note of the incident and directed the district medical and health officials to form a committee, investigate the issue, and submit a report.

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