Name of procedure being performed: tatme case.
Hospital: [name}.
Gelpoint point path was used for a tatme case.
During the case, surgeon tried to remove a grasper from the 10mm sleeve, it also drags out the plastic instrument guide.
A 4th piece was introduced.
Half way through the surgery, the surgeon tried to remove the grasper again for cleaning but the plastic instrument guide was dragged out again.
In the end, circulating nurse had to open another piece of sleeves from [name] (new box).
Additional information received via email on 06apr2021 from [name]: patient status: no patient injury.
Type of intervention: a new piece was opened.
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