During an unspecified procedure, the subject device was used.The loop of the subject device could not be released, and the handle broke.The user severed the insertion portion of the subject device.The user withdrew the endoscope from the patient while leaving the subject device inside the patient.The user inserted the endoscope into the patient again and cut off the loop.The user withdrew the subject device from the patient.There was no patient injury reported.No further information was provided.This is the report regarding the failure of releasing the loop.
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This is a supplemental report to provide additional information.The subject device was not returned to olympus medical systems corp.(omsc) for evaluation.Therefore, the exact cause of the reported event could not be conclusively determined.The manufacturing record was reviewed and found no irregularities.Based on the past similar cases, it was known that this event occurred since the loop was caught between the hook and the coil sheath after the loop was released in the tube sheath for unspecified reason.The above device handling has warned in the instruction manual as follows.Do not try to forcibly withdraw the instrument from the endoscope when the loop cannot be detached from the instrument.Forcibly withdrawing the instrument could cause patient injury such as punctures, hemorrhages or mucous membrane damage.If the loop cannot be detached from the instrument, follow the procedures described in this section.If there are any deviations or crushed sections on the distal end of the coil sheath, it may not be possible to detach the loop from the instrument.Do not remove the loop from the hook while the coil sheath is not extended from the tube sheath.Otherwise, the loop may be tangled with the hook and become impossible to be removed.
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