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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: ARTHREX, INC. 4K LAPAROSCOPE, 0, 5.5MM X 300MM; LAPAROSCOPE, GENERAL & PLASTIC SURGERY

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ARTHREX, INC. 4K LAPAROSCOPE, 0, 5.5MM X 300MM; LAPAROSCOPE, GENERAL & PLASTIC SURGERY Back to Search Results
Model Number 4K LAPAROSCOPE, 0°, 5.5MM X 300MM
Device Problem Adverse Event Without Identified Device or Use Problem (2993)
Patient Problem Burn, Thermal (2530)
Event Date 10/08/2019
Event Type  malfunction  
Manufacturer Narrative
The contribution of the device to the reported event could not be determined as the device was not returned for evaluation.The root cause of the event could not be determined from the information available and without device evaluation.
 
Event Description
It was reported that during a diagnostic laparoscopy procedure, the patient got burned.The burn was discovered by the patient after the surgery.The following devices were used during the procedure: ss9-gyw50w108 / batch wo155094, ar-3210-0030, s/n (b)(4), ar-3210-0006, s/n (b)(4), ar-3351-5500, s/n (b)(4).No further information has been made available.
 
Manufacturer Narrative
No problem found.The evaluation did not identify any issues relevant to the reported event for ar-3351-5500/1279082.
 
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Brand Name
4K LAPAROSCOPE, 0, 5.5MM X 300MM
Type of Device
LAPAROSCOPE, GENERAL & PLASTIC SURGERY
Manufacturer (Section D)
ARTHREX, INC.
1370 creekside boulevard
naples FL 34108 1945
MDR Report Key10422432
MDR Text Key203454485
Report Number1220246-2020-02062
Device Sequence Number1
Product Code GCJ
UDI-Device Identifier00888867029774
UDI-Public00888867029774
Combination Product (y/n)N
PMA/PMN Number
K941541
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type foreign,health professional,u
Type of Report Initial,Followup
Report Date 08/10/2021
1 Device was Involved in the Event
1 Patient was Involved in the Event
Is this an Adverse Event Report? Yes
Is this a Product Problem Report? No
Device Operator Health Professional
Device Model Number4K LAPAROSCOPE, 0°, 5.5MM X 300MM
Device Catalogue NumberAR-3351-5500
Device Lot Number10205539
Was Device Available for Evaluation? Yes
Initial Date Manufacturer Received 07/27/2020
Initial Date FDA Received08/18/2020
Supplement Dates Manufacturer Received07/27/2020
Supplement Dates FDA Received08/10/2021
Patient Sequence Number1
Patient Outcome(s) Other;
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