Patient admitted for robotic laparoscopic fulguration with excision of lesion.A small tip rumi was placed in the uterus.At a specific point in the procedure, the surgeon instructed the surgical tech to instill methylene blue into the dye port on the rumi.Robotic surgeries are often done in the dark and the cooper surgical rumi ports have no differentiation.They look exactly the same with universal connectivity which caused the tech to choose the wrong port.She tried to instill the dye and when she met resistance, she escalated to the surgeon.The surgeon instructed her to try again.She met resistance a second time after which the assistant surgeon entered the surgical arena.He attempted to instill the dye and it went into the uterine balloon causing it to rupture the uterus.A 3cm rent was notice after deflating the rumi.It was noted at the time and subsequent to the procedure that the two ports do not differentiate in color or connectivity which lends itself to confusion during the procedure.Fda safety report id# (b)(4).
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