MAUDE Adverse Event Report: AIZU OLYMPUS CO., LTD. VISERA LAPARO-THORACO VIDEOSCOPE

Model Number LTF-VP

Device Problem Poor Quality Image (1408)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Type  malfunction  

Manufacturer Narrative

The device was returned and evaluated by olympus.In addition to the findings in b5, evaluation found the white glue at the distal end body joint was missing, the bending section cover was cracked, the light guide lens was cracked, and the video connector case and printed circuit board were cracked.A review of the device history record found no deviations that could have caused or contributed to the reported issue.The foggy image was likely due to water invasion; however, a definitive root cause of the foggy image could not be determined.The customer may be able to reduce and prevent occurrence of the event by handling device in accordance with the instructions for use (ifu).If additional information becomes available at a later date, this report will be supplemented.Olympus will continue to monitor the field performance of this device.

Event Description

The customer reported the laparo-thoraco videoscope had poor quality image.The issue occurred during a procedure.The customer noted there may be a possible internal issue and there was condensation forming on the inside of the tip of the scope.There was no reported patient harm or impact due to this event.During device evaluation at olympus, it was found the scope image failed a fog test.The report is being submitted due the defect found during evaluation.

• Brand Name: VISERA LAPARO-THORACO VIDEOSCOPE
• Type of Device: LAPARO-THORACO VIDEOSCOPE
• Manufacturer (Section D): AIZU OLYMPUS CO., LTD.; 3-1-1 niiderakita; aizuwakamatsu-shi, fukushima 965-8 520; JA 965-8520
• Manufacturer (Section G): AIZU OLYMPUS CO., LTD.; 3-1-1 niiderakita; aizuwakamatsu-shi, fukushima 965-8 520; JA 965-8520
• Manufacturer Contact: todd brill ; 800 west park drive; westborough, MA 01581 ; 5082077661
• MDR Report Key: 19211959
• MDR Text Key: 341375713
• Report Number: 9610595-2024-08885
• Device Sequence Number: 1
• Product Code: GCJ
• UDI-Device Identifier: 04953170382673
• UDI-Public: 04953170382673
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K955403
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: User Facility,Company Representative
• Reporter Occupation: Other
• Type of Report: Initial
• Report Date: 04/30/2024

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 04/30/2024
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: LTF-VP
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 02/24/2021
• Was the Report Sent to FDA?: No
• Date Manufacturer Received: 02/24/2021
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 06/28/2006
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1