MAUDE Adverse Event Report: LUMENIS LTD SLIMLINE SIS EZ; POWERED LASER SURGICAL INSTRUMENT

Model Number	0644-018-01
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	08/15/2023
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that during a ureter stone procedure, the fiber broke into two pieces.The procedure was completed with another device.There were no patient complications.
Additional Manufacturer Narrative
(b)(6).
Additional Manufacturer Narrative
Correction made to d3 manufacture name, manufacture address, manufacturer city, manufacturer zip/postal code, manufacturer country, manufacturer email, g1 mfr site facility name, mfr site address 1, mfr site city, mfr site state, mfr site zip, mfr site country, mfr site phone, h6 conclusion code.
Event or Problem Description
It was reported that during a ureter stone procedure, the fiber broke into two pieces.The procedure was completed with another device.There were no patient complications.
Event or Problem Description
It was reported that during a ureter stone procedure, the fiber broke into two pieces outside of the patient body.The procedure was completed with another device.There were no patient complications and there was not any extra medical intervention needed.
Additional Manufacturer Narrative
Upon receipt of this fiber at our quality assurance laboratory, this device was thoroughly analyzed.Visual analysis identified that the that the fiber was broken in two pieces, confirming the reported event.The product analysis indicates that it is probably that procedural handling of the device during set-up and use could contributed to the fiber breaks.A partial body break or kink could have occurred during use and when it was inserted into the scope and fired it and that could lead to a fiber break.It is likely that procedural handling and procedural conditions of the device during set-up and use contributed to the fiber body break in two pieces, leading to the reported event.Based on review of all information available and analysis results, a conclusion code of cause traced to component failure was assigned to this investigation.Correction made to d3 manufacture name, manufacture address, manufacturer city, manufacturer zip/postal code, manufacturer country, manufacturer email, g1 mfr site facility name, mfr site address 1, mfr site city, mfr site state, mfr site zip, mfr site country, mfr site phone, h6 conclusion code.
Additional Manufacturer Narrative
Upon receipt of this fiber at our quality assurance laboratory, this device was thoroughly analyzed.Visual analysis identified that the that the fiber was broken in two pieces, confirming the reported event.The product analysis indicates that it is probably that procedural handling of the device during set-up and use could contributed to the fiber breaks.A partial body break or kink could have occurred during use and when it was inserted into the scope and fired it and that could lead to a fiber break.It is likely that procedural handling and procedural conditions of the device during set-up and use contributed to the fiber body break in two pieces, leading to the reported event.Based on review of all information available and analysis results, a conclusion code of cause traced to component failure was assigned to this investigation.
Event or Problem Description
It was reported that during a ureter stone procedure, the fiber broke into two pieces.The procedure was completed with another device.There were no patient complications.

• Brand Name: SLIMLINE SIS EZ
• Common Device Name: POWERED LASER SURGICAL INSTRUMENT
• Manufacturer (Section D): LUMENIS LTD; hakidma 6; yokneam AZ 20692 04; IS 2069204
• Manufacturer (Section G): MOLEX LLC; 18019 n 25th ave; phoenix AZ 85023
• Manufacturer Contact: farshad fahimi ; 4100 hamline avenue north; building c; saint paul, MN 55112
• MDR Report Key: 17653509
• Report Number: 2124215-2023-46670
• Device Sequence Number: 6331338
• Product Code: GEX
• UDI-Device Identifier: 17290109147038
• UDI-Public: 17290109147038
• Combination Product (Y/N): N
• Initial Reporter Country: HK
• 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
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup,Followup
• Report Date (Section B): 12/06/2023

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 Model Number: 0644-018-01
• Device Catalogue Number: 0644-018-01
• Device Lot Number: 0004481022
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 08/15/2023
• Supplement Date Received by Manufacturer: 09/21/2023; 11/20/2023; 12/01/2023
• Initial Report FDA Received Date: 08/30/2023
• Supplement Report FDA Received Date: 10/03/2023; 11/21/2023; 12/06/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 10/02/2022
• 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: Male