OLYMPUS WINTER & IBE GMBH HF-RESECTION ELECTRODE, LOOP, 24 FR., 0.35 WIRE, 12°; ENDOSCOPIC ELECTROSURGICAL ELECTRODE, MONOPOLAR, REUSABLE
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Model Number A22201A |
Device Problem
Thermal Decomposition of Device (1071)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 06/28/2023 |
Event Type
malfunction
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Event Description
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The customer reported that a spark emitted from a monopolar high-frequency cable during a therapeutic total laparoscopic hysterectomy.Smoke appeared and the wire was disconnected with an explosion sound.The hf-resection electrode, loop, 24 fr., 0.35 wire, 12° was energized during the operation, but the output was weak, and after disconnection, about 3 centimeters from the electrode part at the tip to the proximal side was burnt and darkened.The procedure was completed using similar devices.The doctor had a light burn on their hand, which they treated by cooling it down, and had not taken any medication since then.There was no harm or user injury reported due to the event.This mdr is being submitted for the reportable malfunction on the hf-resection electrode loop.
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Manufacturer Narrative
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The suspect device has been returned to olympus.The allegation of burning was confirmed.A piece of burnt tissue was found adhering to the electrode at the tip and rust was observed throughout.The failure location was identified to be the burnt electrode and rust.Upon checking the continuity with a tester, no energization failure was found.Therefore, the reported phenomenon alleging weak output could not be confirmed.Since rust occurred on the surface of the equipment, it was not considered to be the cause of poor conduction.Disconnection of the "a code", which is a combined device, is considered to be the cause of the current failure.The effects of reprocessing (insufficient rinsing after cleaning, chemical residue, insufficient drying, storage environment, etc.) are considered to be factors contributing to rust formation.The investigation is ongoing.A supplemental report will be submitted upon completion of the investigation or if additional information is received.
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Manufacturer Narrative
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This report is being supplemented to provide additional information based on the legal manufacturer's final investigation.A review of the device history record found no deviations that could have caused or contributed to the reported issue.Based on the results of the investigation, the root cause of the event was unable to be identified.The event likely occurred due to the usage of a defective high frequency cable.Olympus will continue to monitor field performance for this device.
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