MAUDE Adverse Event Report: MICROLINE SURGICAL INC M/L-10 MULTI-FIRE CLIP APPLIER, REUSABLE; MANUAL DETACHABLE SURGICAL INSTRUMENT

Model Number	1002
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Hernia (2240)
Date of Event	04/03/2024
Type of Reportable Event	Serious Injury
Event or Problem Description
The date of the sae onset was on (b)(6) 2024 but the site became aware of the event on 01jun2024 during the subject's 6-months follow-up, and did not consider the event as serious until 06jun2024.The sae has been described as "intestinal occlusion due to internal hernia".The subject is a 60-year-old male who underwent a laparoscopic cystectomy due to a carcinoma on (b)(6) 2023.On (b)(6) 2024 the subject suffered an episode of bowel occlusion due to an internal hernia that was confirmed with a ct scan on (b)(6) 2024 "signs of intestinal obstruction due to probable internal herniation of loops into the pelvic cavity w/ intestinal ischemia".The following day, on (b)(6) 2024, an exploratory laparotomy involving a segmental enterectomy with l-l anastomosis and the placement of a drain was performed.Due to the good peri and postoperative evolution, he was discharged from the hospital on (b)(6) 2024.According to the investigator´s criteria, the sae has been determined to be not related to neither the procedure or the device.
Additional Manufacturer Narrative
According to the investigator´s criteria, the sae has been determined to be not related to neither the procedure or the device.

• Brand Name: M/L-10 MULTI-FIRE CLIP APPLIER, REUSABLE
• Common Device Name: MANUAL DETACHABLE SURGICAL INSTRUMENT
• Manufacturer (Section D): MICROLINE SURGICAL INC; 50 dunham rd suite 1500; beverly MA 01915
• Manufacturer (Section G): MICROLINE SURGICAL INC; 50 dunham rd suite 1500; beverly MA 01915
• Manufacturer Contact: scott marchand davis ; 50 dunham rd suite 1500; beverly, MA 01915
• MDR Report Key: 19505196
• Report Number: 1223422-2024-00021
• Device Sequence Number: 4019819
• Product Code: GEI
• UDI-Device Identifier: 00811099010388
• UDI-Public: 00811099010388
• Combination Product (Y/N): N
• Initial Reporter Country: SP
• PMA/510(K) Number: K013696
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,Study
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 06/10/2024

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: 1002
• Device Catalogue Number: 1002
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/07/2024
• Initial Report FDA Received Date: 06/10/2024
• Was Device Evaluated by Manufacturer? (Y/N): No
• Is the Device Labeled for Single Use? (Y/N): No
• 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: Hospitalization; Required Intervention
• Patient Age: 60 YR
• Patient Sex: Male