MAUDE Adverse Event Report: MEDLINE INDUSTRIES, LP Medline Industries, Inc.; GENERAL LAPAROSCOPY

Model Number	DYNJ903234C
Medical Device Problem Code	Appropriate Device Problem Term/Code Not Available (3191)
Health Effect - Clinical Code	Foreign Body In Patient (2687)
Date of Event	11/11/2022
Type of Reportable Event	Serious Injury
Event or Problem Description
According to the facility on (b)(6) 2022 during a laparoscopic procedure, 'the raytec gauze are being used to wipe the trocar sites out and leaving fibers in the surgical site'.
Additional Manufacturer Narrative
According to the facility on (b)(6) 2022 during a laparoscopic procedure, 'the raytec gauze are being used to wipe the trocar sites out and leaving fibers in the surgical site'.Per the facility the 'strings are removed with a grasper from the surgical site without serious injury or impact to the patient.Per the facility there was no reported adverse outcome and the procedure was completed without issue.The sample was returned for evaluation, but a definitive root cause could not be determined at this time.No additional information is available at this time.Due to the reported incident and in an abundance of caution, this medwatch is being filed.If any further relevant information is identified or obtained, a supplemental medwatch will be submitted.

• Brand Name: Medline Industries, Inc.
• Common Device Name: GENERAL LAPAROSCOPY
• Manufacturer (Section D): MEDLINE INDUSTRIES, LP; three lakes drive; northfield IL 60093
• Manufacturer Contact: justin herrmann ; three lakes drive; northfield, IL 60093
• MDR Report Key: 15914849
• Report Number: 1423395-2022-00041
• Device Sequence Number: 19948217
• Product Code: FDE
• UDI-Device Identifier: 10195327187828
• UDI-Public: 10195327187828
• Combination Product (Y/N): N
• Initial Reporter State: PA
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 12/05/2022

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
• Operator of Device: Health Professional
• Device Model Number: DYNJ903234C
• Device Catalogue Number: DYNJ903234C
• Device Lot Number: 22GBB562
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/18/2022
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 11/11/2022
• Initial Report FDA Received Date: 12/05/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Unknown
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Unknown