MAUDE Adverse Event Report: APPLIED MEDICAL RESOURCES CTR73, 12X100 KII OPT ZTHR 6/BX; LAPAROSCOPE, GENERAL & PLASTIC SURGERY

Model Number	CTR73
Medical Device Problem Code	Material Fragmentation (1261)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	12/19/2022
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The event unit is anticipated to return to applied medical for evaluation.A follow-up report will be sent upon completion of investigation.
Event or Problem Description
Procedure performed: retroperitoneoscopic total nephroureterectomy.Event description: complaint 1 of 2: 2023-000150, complaint 2 of 2: 2023-000151.Report from the sales rep: one of the wing tabs of the cannula was broken when the seal was removed and a suction or something was performed.Instead of replacing the trocar, the seal part was fixed with tape, and the procedure was completed.It has also occurred with another ctr73 used in the same patient.Initial investigation report: the event unit was returned to us and visually inspected.One of the wing tabs of the cannula was broken.The area around the broken tab was scratched as if it had been rubbed.The unit will be returned to amr for further evaluation.Intervention: instead of replacing the trocar, the seal part was fixed with tape, and the procedure was completed.Patient status: no patient injury.
Event or Problem Description
Procedure performed: retroperitoneoscopic total nephroureterectomy.Event description: complaint 1 of 2: 2023-000150, mfr report # 2027111-2023-00325.Complaint 2 of 2: 2023-000151, mfr report # 2027111-2023 00326.Report from the sales rep one of the wing tabs of the cannula was broken when the seal was removed and a suction or something was performed.Instead of replacing the trocar, the seal part was fixed with tape, and the procedure was completed.It has also occurred with another ctr73 used in the same patient.Initial investigation report the event unit was returned to us and visually inspected.One of the wing tabs of the cannula was broken.The area around the broken tab was scratched as if it had been rubbed.The unit will be returned to amr for further evaluation.Intervention: instead of replacing the trocar, the seal part was fixed with tape, and the procedure was completed.Patient status: no patient injury.
Additional Manufacturer Narrative
The event unit was returned to applied medical for evaluation, with the fractured cannula tab.Applied medical has reviewed the details surrounding the event and related products and is unable to determine the cause of the reported event based on the evaluation of the returned unit.

• Brand Name: CTR73, 12X100 KII OPT ZTHR 6/BX
• Common Device Name: LAPAROSCOPE, GENERAL & PLASTIC SURGERY
• Manufacturer (Section D): APPLIED MEDICAL RESOURCES; 22872 avenida empresa; rancho santa margarita CA 92688
• Manufacturer Contact: aaron fulcher ; 22872 avenida empresa; rancho santa margarita, CA 92688 ; 9497135765
• MDR Report Key: 16269490
• Report Number: 2027111-2023-00325
• Device Sequence Number: 17629702
• Product Code: GCJ
• UDI-Device Identifier: 00607915123680
• UDI-Public: (01)00607915123680(17)250501(30)01(10)1447897
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K060096
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,User Facility,Distributor
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 03/29/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 05/01/2025
• Device Model Number: CTR73
• Device Catalogue Number: 101219401
• Device Lot Number: 1447897
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/18/2023
• Supplement Date Received by Manufacturer: 01/18/2023
• Initial Report FDA Received Date: 01/30/2023
• Supplement Report FDA Received Date: 03/29/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 05/02/2022
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Unknown