inforMED
MalfunctionJOS

ELECTRODE EXTENSION - 11"

Received Jul 8, 2009 · Event occurred Jun 9, 2009

Report 1717344-2009-00316 · MDR key 1473338

Device

Generic name

Electrosurgical Accessory

Catalog number

E1504

Lot number

101946

Product problems

  • Loose or Intermittent Connection
  • Component Missing

Patient

UNK

  • Tissue Damage

Narrative

Description of Event or Problem

THE CUSTOMER REPORTED THAT DURING A SUPRACERVICAL HYSTERECTOMY A FORCE TRIVERSE PENCIL WAS USED LAPAROSCOPICALLY WITH AN 11" EXTENDER. AFTER THE LAST ACTIVATION, THE PENCIL WAS WITHDRAWN FROM THE TROCAR AND LAID ASIDE. SHORTLY AFTERWARDS IT WAS NOTICED THAT THE ELECTRODE INSERTED IN THE EXTENDER WAS MISSING. X-RAYS SHOWED IT WAS STILL INSIDE THE PT. THE PROCEDURE WAS EXTENDED 2 HRS IN ORDER TO MAKE A MINI LAPAROTOMY INCISION TO FIND AND REMOVE THE TIP. NO OTHER COMPLICATIONS WERE NOTED IN F/U ON THE PT CONDITION. THE SITE REPORTED THAT THEY HAD NOTICED THAT THE TIP HAD BEEN LOOSE BEFORE USE BUT HAD THEN BEEN ENGAGED FULLY.

Additional Manufacturer Narrative

(B)(4). THE SITE DISCARDED THE DEVICES ASSOCIATED WITH THE COMPLAINT. IF ADDITIONAL INFO PERTINENT TO THE INCIDENT IS OBTAINED A F/U REPORT WILL BE SUBMITTED.