inforMED
InjuryFSO

OPMI VARIO

Received Oct 21, 2015 · Event occurred Sep 12, 2015

Report 9615010-2015-00011 · MDR key 5164381

Device

Generic name

Microscope, Surgical, General & Plastic Surgery

Model number

NA

Catalog number

6629321351

Lot number

NA

Product problems

  • Failure to Conduct
  • Disconnection
  • Electrical /Electronic Property Problem

Patient

37 YR

  • No Code Available

Narrative

Additional Manufacturer Narrative

THE MANUFACTURER EVALUATED THE ILLUMINATION SYSTEM AND FOUND THAT THE CONNECTOR BETWEEN LIGHT POWER SUPPLY IN THE LAMP HOUSING AND THE INSERT-ABLE LAMP MODULE CARRIER MALFUNCTIONED. ONE PIN OF THE CONNECTOR IN THE LAMP HOUSING WAS PUSHED BACK LEADING TO A POOR ELECTRICAL CONNECTION. THIS CAUSED HIGHER ELECTRICAL RESISTANCE AND/OR AN ELECTRIC ARC RESULTING IN OXIDATION OF THE PIN OVER THE TIME. AS A RESULT, THE ELECTRICAL CONNECTION GOT INTERRUPTED DURING THE CASE, AND NONE OF BOTH LAMPS WAS FUNCTIONING. THE MOST LIKELY ROOT CAUSE THAT THE PIN WAS PUSHED BACK IS AN ALIGNMENT ISSUE OF BOTH CONNECTORS, WHEN THE LAMP MODULE CARRIER WAS INSERTED INTO THE LAMP HOUSING. THIS COULD HAVE CAUSED MECHANICAL FORCE ON THE PIN, AND PUSHED IT BACKWARDS. HOW TO REPLACE A LAMP AND INSERT THE LAMP MODULE CARRIER INTO THE LAMP HOUSING IS DESCRIBED IN THE USER MANUAL, G-30-1607-EN, PAGE 22. THE USER MANUAL ALSO ADVISES ON PAGE 174 ABOUT "LIKE ANY TECHNICAL DEVICE USED IN THE OR, THIS ILLUMINATION MAY FAIL. IT IS THUS RECOMMENDED TO HAVE A SUITABLE BACKUP LAMP, SUCH AS AN OR ILLUMINATOR, READY AT HAND DURING SURGERY." IT CANNOT BE DETERMINED DEFINITIVELY, IF THE UNSUCCESSFUL RECONSTRUCTION OF THE FINGER WAS A RESULT OF THE REPORTED DEVICE PROBLEM, BECAUSE THERE WERE ALSO OTHER FACTORS LIKE KIND OF AMPUTATION, TIME, STATE AND CONDITION OF SEPARATED BODY LIMB, ETC., PLAYING AN IMPORTANT ROLE, AND WHICH ARE NOT KNOWN. (B)(4).

Description of Event or Problem

THE HEALTHCARE PROVIDER INITIALLY REPORTED THE FOLLOWING: THE LIGHT OF THE OPMI VARIO MICROSCOPE WENT OUT DURING A FINGER RECONSTRUCTION SURGERY AND THE BACKUP LAMP DID NOT WORK. THE SURGEON DECIDED TO FINISH THE CASE WITHOUT THE MICROSCOPE. NO DELAY NOR OTHER PROBLEMS WERE REPORTED. THE HEALTH CARE PROVIDER SUBSEQUENTLY REPORTED THE FOLLOWING: THE FINGER HAD TO BE AMPUTATED IN SECOND SURGERY DUE TO POOR CONNECTION OF BLOOD VESSELS AND NERVES.

Remedial action

  • Repair