MAUDE Adverse Event Report: OLYMPUS WINTER & IBE GMBH HF-CABLE, BIPOLAR; ELECTROSUGRICAL RESECTION AND VAPORIZATION ELECTRODE SERIES

Model Number WA00014A

Device Problems Mechanical Problem (1384); Sparking (2595); Communication or Transmission Problem (2896)

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

Event Date 09/06/2023

Event Type  malfunction  

Manufacturer Narrative

The device was returned to olympus for evaluation, and the customer¿s allegation was confirmed.The evaluation found the following reportable issues: the cable was broken around the control part side cap 2 (l-shaped connector).Traces of melting and black discoloration that appeared to be scorching were seen at the fractured part.The investigation is ongoing and a supplemental report will be submitted upon completion of the investigation or if any additional information is provided by the user facility.

Event Description

The customer reported to olympus that during a therapeutic trans-urethral resection in saline (turis) urological procedure, the hf bipolar cable, while being used with the esg-400/hf generator displayed error message e006.A spark appeared near the break stop of the hf bipolar cable, causing the wire to break.The opinion from the doctor in charge stated that the damage was caused by continued output with the a cord disconnected.High-frequency output settings were 200w for electrolyte solution cut and 120w for electrolyte solution cut.There was no reported damage or effect on the patient or the hospital staff.The intended procedure was completed with a similar device.

Manufacturer Narrative

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 age-related wear and tear in combination with improper handling by the user like application of mechanical force, stress, bending and pulling.The event can be detected/prevented by following the instructions for use which state: "the service life of the cable is limited to 12 months.After this time, the cable should no longer be used.Furthermore, the cable must be checked for a damage prior to each use and after reprocessing.By gently pulling on the plug (with a maximum of 20 n) the user can determine if there is pre-existing damage to the stranded copper wire of the cable.If the cable does not buckle but remains firm, the cable is most likely fine in this place.Finally, in order not to increase the service life of the cable, the cable should not be wound up with a loop diameter of less than 10 cm, and the user should pull on the connector and not on the cable when unplugging the cable." olympus will continue to monitor field performance for this device.

• Brand Name: HF-CABLE, BIPOLAR
• Type of Device: ELECTROSUGRICAL RESECTION AND VAPORIZATION ELECTRODE SERIES
• Manufacturer (Section D): OLYMPUS WINTER & IBE GMBH; kuehnstrasse 61; hamburg, hamburg 22045 ; GM 22045
• Manufacturer (Section G): OLYMPUS WINTER & IBE GMBH; kuehnstrasse 61; hamburg
• Manufacturer Contact: todd brill ; 800 west park drive; westborough, MA 01581 ; 5082077661
• MDR Report Key: 17856937
• MDR Text Key: 324785876
• Report Number: 9610773-2023-02789
• Device Sequence Number: 1
• Product Code: FAS
• UDI-Device Identifier: 04042761076449
• UDI-Public: 04042761076449
• Combination Product (y/n): N
• Reporter Country Code: JA
• PMA/PMN Number: K120418
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Other,Foreign,Health Professional,User Facility
• Reporter Occupation: Nurse
• Type of Report: Initial,Followup
• Report Date: 01/13/2024

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 10/02/2023
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: WA00014A
• Device Lot Number: 185W-2633
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/13/2023
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Date Manufacturer Received: 01/05/2024
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 05/01/2018
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Reuse
• Patient Sequence Number: 1
• Treatment: ESG-400/HF GENERATOR