The rf cutting loop electrode is assembled by inserting the proximal end in to the working element of resectoscope.Thereafter, the inner and outer metallic sheath is assembled, covering the rf electrode stem and distal tip.Upon application of rf energy via resectoscope connection, the cutting loop tip is energized for tissue resection.It is important that doctor activate the rf energy while the cutting loop tip is outside of the outer sheath and does activate rf energy inside the outer sheath.If for any reason the cutting loop tip comes in the contact with metallic viewing endoscope or metallic portion of the outer sheath (due to broken or missing ceramic insulation), while the rf energy is activated, resulting into short circuit and spark, causing loop wire to break.We would also live to point out that the event description states that the cutting loop broke and was attached to the (metallic) viewing endoscope, indicating potential direct contact and rf energy short circuit / spark between cutting loop and endoscope.It is also possible if the doctor used incorrect size of inner / outer sheath and cutting loop, causing loop to break.Since we did not receive info regarding instrumentation used during the procedure, it is difficult to conduct technical analysis and eval.
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The resection loop was inserted into the resectoscope, and then the scope was inserted into the urethra.The doctor activated the cutting energy, and almost immediately the stem of the resection loop broke at the distal end where it attaches to the scope.The distal tip was unable to be removed from the scope and the scope had to be sent out for repair.The procedure was eventually finished with a different scope and resection loop from another supplier.Event description update by (b)(6) on (b)(6) 2015 no harm to patient.(b)(4).
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