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'Dinner Plate-Sized' Surgical Tool Used During C-Section Left Inside Mom For 18 Months

A new mom in New Zealand complained to her doctor about abdominal pain after delivering her child via C-section.

After welcoming her baby via C-section in 2020, a new mom in New Zealand complained to her doctor about abdominal pain. For quite some time, that pain went unexplained. Until 18 months after the fact, when she had a “dinner plate-sized” surgical tool removed from her abdomen. A surgical tool that had been left inside her during her C-section.

An Alexis wound retractor (AWR), which is a round soft-tubular device used in surgery to draw back the edge of wounds, was left inside the unnamed woman in her 20s, according to a report by New Zealand’s Health and Disability Commissioner, Morag McDowell. The woman had been reporting abdominal discomfort to her doctor for several months and even went to the emergency room in Aukland Hospital to find a reason for her pain, but the surgical tool went undetected by X-ray because it was “non-opaque.” The extra large AWR measures 17 inches in diameter, and was accidentally left inside the woman after the surgeon decided to use a different size of AWR and was therefore not included in a routine count before she was stitched back up after her C-section, according to the report.

The surgical tool went undetected for more than a year, when the woman finally had a CT scan and it was finally seen by medical professionals. It was immediately removed, but New Zealand Health Commissioner McDowell has issued a public acknowledgment about the failure of Aukland Hospital to provide duty of care in this situation.

“I acknowledge the stress that these events caused to the woman and her family. The woman experienced episodes of pain over a significant period of time following her surgery until the AWR was removed in 2021,” McDowell said in the report. “I accept her concerns regarding the impact this had on her health and wellbeing and that of her family.”

An image of an Alexis retractor used in C-sections. SURGICAL TECH GEEK/ YouTube

Mike Shepard, director of operations for Auckland Hospital, said in a statement to the media: “I would like to say how sorry we are for what happened to the patient, and acknowledge the impact that this will have had on her and her whānau [family]. For ethical and privacy reasons we can’t comment on the details of individual patient care.”

Sadly, this is not the first incident of a surgical tool being left inside a patient in the Aukland area. In 2021, a man went to a hospital in an Aukland suburb and also had an AWR left inside after surgery to correct a perforated colon. This landed him in the Intensive Care Unit for two months.