inforMED
MalfunctionGET

ENDO DISSECT

Received Feb 20, 2018 · Event occurred Dec 17, 2017

Report 2647580-2018-00875 · MDR key 7283988

Device

Generic name

Motor, Surgical Instrument, Pneumatic Powered

Model number

174213

Catalog number

174213

Lot number

P7D0175X

Product problems

  • Product Quality Problem
  • Product Quality Problem

Patient

38 YR

  • No Known Impact Or Consequence To Patient
  • No Known Impact Or Consequence To Patient

Narrative

Additional Manufacturer Narrative

CORRECTION: EVALUATION SUMMARY POST MARKET VIGILANCE (PMV) LED AN EVALUATION OF ONE DEVICE. PMV FOUND SHEARING DAMAGE OF THE PLASTIC CABLE SHEATH. ENGINEERING CONFIRMED DAMAGE AND FOUND TO BE CONSISTENT WITH A MISHANDLING OF THE DEVICE. RECORDS FROM EACH MANUFACTURING LOT ARE THOROUGHLY REVIEWED TO ENSURE THAT PRODUCTS ARE RELEASED MEETING ALL QUALITY RELEASE SPECIFICATIONS AT THE TIME OF MANUFACTURE. ANALYSIS CONCLUDED THERE WERE NO ASSEMBLY COMPONENT RELATED FAILURES. REPLICATION OF THE REPORTED CONDITION MAY OCCUR WHERE AN EXCESSIVE FORCE OR LEVERAGE IS APPLIED TO THE DEVICE WHILE RETRACTING THE CLEVIS ASSEMBLY AND THE CLEVIS BOOT IS SUBSEQUENTLY DAMAGED. THIS SUBSEQUENT DAMAGE MAY RESULT IN IMPROPER RETRACTION AND DEPLOYMENT OF THE JAWS DURING ARTICULATION AND MAY CAUSE SHEARING OF THE PLASTIC CABLE SHEATH. THE ROOT CAUSE OF THE OBSERVED DAMAGE WAS MISUSE OF THE PRODUCT WHICH WOULD HAVE CAUSED OR CONTRIBUTED TO THE REPORTED INCIDENT. SHOULD NEW INFORMATION BECOME AVAILABLE, THE FILE WILL BE RE-OPENED AND THE INVESTIGATION SUMMARY WILL BE AMENDED AS APPROPRIATE. IF INFORMATION IS PROVIDED IN THE FUTURE, A SUPPLEMENTAL REPORT WILL BE ISSUED.

Additional Manufacturer Narrative

IF INFORMATION IS PROVIDED IN THE FUTURE, A SUPPLEMENTAL REPORT WILL BE ISSUED.

Description of Event or Problem

ACCORDING TO THE REPORTER: OCCURRED DURING A LAPAROSCOPIC CHOLECYSTECTOMY PROCEDURE. THE DEVICES WERE BEING USED FOR THE DISSECTION. BOTH DEVICES HAD A BURN AT THE END OF THE ROTICULATOR. BOTH DEVICES WERE ABLE TO GRASP PROPERLY AND THE HANDLES DID NOT BIND. THE PATIENT'S MEDICAL HISTORY IS SMOKING. THERE WAS NO PATIENT INJURY.