An instrument, used to hold open surgical wounds, was left inside the abdomen of a woman in New Zealand after she underwent a caesarean section at a hospital. The retractor was not removed until 18 months after her delivery.
According to the report, the woman suffered severe pain for 18 months and the retractor, the size of a dinner plate, was only found during a CT scan. Health regulators have said that the public hospital system had failed her.
“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,” said Health and Disability Commissioner Morag McDowell
“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 instrument is an Alexis wound protector-retractor which is widely used in surgical procedures.
A team of surgeons at Auckland City Hospital replaced the first Alexis wound retractor with a larger one, but the second retractor was inadvertently left in the woman’s abdomen, the Commissioner’s report said.
The retractor could not be found through X-ray scans because it is a “non-radiopaque item” but was eventually traced through a CT scan.
According to the commissioner, it was the second time in two years that a medical device had been left inside a patient at an Auckland hospital.