In 2020, a woman in her twenties underwent a scheduled Caesarean section (C-section) at 36 weeks plus 3 days’ gestation in Auckland, New Zealand. The C-section was planned because of concerns about placenta previa and placenta accreta.
An Alexis wound retractor (AWR), a device used to draw back the edges of a wound during surgery, was left in her abdomen following her C-section. This resulted in the woman suffering chronic abdominal pain until the device was discovered incidentally on an abdominal CT scan. In 2021, approximately 18 months after the woman’s C-section, the AWR was removed from her abdomen.
The surgeon had performed a midline laparotomy, and initially used a large-sized AWR. However, the surgeon stated that this was too small for the incision, so it was removed and replaced with an extra-large AWR. The senior registrar also referred to the replaced AWR. She stated: “A midline incision was made and an Alexis retractor was inserted, however it was too small for the incision.” This was therefore removed and replaced with a larger Alexis retractor, which provided the visualization required. The Case Review found that it was this second AWR (size XL) that was retained. The retractor, a round, soft tubal instrument of transparent plastic fixed on two rings, is a large item, about the size of a dinner plate. Usually, it would be removed after closing the uterine incision (and before the skin is sutured).
At the time of the surgery in 2020, AWRs were not included as part of the surgical count. This understanding of not including AWRs in the surgical count was confirmed by the nursing staff involved in the woman’s surgery: “[A]s far as I am aware, in our department no one ever recorded the Alexis Retractor on the count board and/or included in the count. This may have been due to the fact that the Alexis Retractor doesn’t go into the wound completely as half of the retractor needs to remain outside the patient and so it would not be at risk of being retained.”
The woman presented to her GP a number of times in the 18 months after the C-section, and on one occasion she presented to the Emergency Department at Auckland City Hospital with severe pains in her abdomen.
The Health and Disability Commissioner concluded: “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 — and I do not consider it necessary to have specific expert advice to assist me in reaching that conclusion. This is a consistent approach to the precedent cases, as well as the nursing and surgical advice in opinion 19HDC00159 (as reported in that opinion), which concluded that retention of the AWR, of itself, constituted a serious deviation from the standard of care. In reaching this conclusion, I have also formed the view that while individuals hold some measure of accountability in this respect, this is a systems failure for which Te Whatu Ora Te Toka Tumai Auckland holds responsibility. I therefore find Te Whatu Ora Te Toka Tumai Auckland in breach of Right 4(1) of the Code.”
If you or a loved one may have been injured as a result of an object left in after surgery in the United States, you should promptly find a medical malpractice lawyer in your state who may investigate your retained object medical malpractice claim for you and represent you or your loved one in a retained surgical instrument medical malpractice case, if appropriate.
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