Surgical tool the size of dinner plate found in woman 18 months after procedure

A woman suffered crippling pain after a medical device the size of a dinner plate was left in her body for 18 months after she had a caesarean section, according to an official report.

The unnamed woman – who is in her 20s – underwent the procedure in 2020 due to complications with her pregnancy, according to the report released by New Zealand’s Health and Disability Commissioner, Morag McDowell.

After the birth, the woman complained about chronic pain and doctors eventually discovered she had surgical equipment inside of her abdomen.

The physicians discovered an Alexis wound retractor – a soft, round tubular device used to hold the edges of a wound during surgery – was left inside her after the surgery.

She complained several times to doctors before the discovery, including one occasion when she went to the emergency department of Auckland Hospital.

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One reason the item went undetected for so long was because it could not be seen by x-ray, according to the report.

The Auckland health authority had failed in its duty of care to the woman, McDowell said.

The health board apologized for the distress caused but must do so again in writing within the next three weeks.

I acknowledge the stress that these events caused to the woman and her family,” McDowell said in the report.

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He added: “The woman experienced episodes of pain over a significant period of time following her surgery until the AWR was removed in 2021.

“I accept her concerns regarding the impact this had on her health and wellbeing and that of her family.”

The report said a large version of the wound retractor was used for the operation but the surgeon determined it was too small so an extra large version was brought in instead.

The second, larger device was left inside the patient and wasn’t discovered for more than a year until a CT scan was performed.

The wound retractors were not included in the routine count of medical equipment used in the surgery.

“I have little difficulty concluding that the retention of a surgical instrument in a person’s body falls well below the expected standard of care,” McDowell wrote.

The incident is not entirely isolated. In 2021, a wound retractor was left inside a man in Waitematā, an Auckland suburb.

He underwent emergency surgery for a perforated colon when a wound retractor was inserted into his abdomen. It was not removed until two weeks later after it caused him pain and nausea.

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