MAUDE Adverse Event Report: COVIDIEN SURGICAL TRI-STAPLE 2.0; STAPLE, IMPLANTABLE

Model Number	SIG60CTAVM
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Failure to Anastomose (1028)
Date of Event	06/05/2025
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that post-operatively of a segmental small bowel resection, there were issues with the devices, resulting in an anastomotic leak 13 days after surgery.It was noted that the patient had emergent surgery and non-elective.
Additional Manufacturer Narrative
D10 concomitant product: egia60avm, egia60avm egia 60 artic vasc med sulu (lot#p4j1078); egia60avm, egia60avm egia 60 artic vasc med sulu (lot#p4j1078); egia60avm, egia60avm egia 60 artic vasc med sulu (lot#p4j1078); egia60avm, egia60avm egia 60 artic vasc med sulu (lot#p4j1078); egia60avm, egia60avm egia 60 artic vasc med sulu (lot#p4j1078); egia60avm, egia60avm egia 60 artic vasc med sulu (lot#p4j1078); sig60ctavm, tri 2.0 sig60ctavm 60 ct vsclr med 12mm (lot#n3m1643y); sig60ctavm, tri 2.0 sig60ctavm 60 ct vsclr med 12mm (lot#n3m1643y).Medtronic submits this report to comply with fda regulations 21 cfr parts 4 and 803.Medtronic has made reasonable efforts to provide as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.Medtronic will submit a supplemental report if additional relevant information becomes known.

• Brand Name: TRI-STAPLE 2.0
• Common Device Name: STAPLE, IMPLANTABLE
• Manufacturer (Section D): COVIDIEN SURGICAL; 60 middletown ave; north haven CT 06473
• Manufacturer (Section G): COVIDIEN SURGICAL; 60 middletown ave; north haven CT 06473
• Manufacturer Contact: mike bocchino ; 8200 coral sea st ne; mounds view, MN 55112-4391 ; 8006464633
• MDR Report Key: 22575362
• Report Number: 1219930-2025-03167
• Device Sequence Number: 13171146
• Product Code: GDW
• UDI-Device Identifier: 10884521543690
• UDI-Public: (01)10884521543690(17)280430(10)N3E0510Y
• Combination Product (Y/N): N
• Initial Reporter State: NY
• Initial Reporter Country: US
• PMA/510(K) Number: K160176
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 07/23/2025

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: SIG60CTAVM
• Device Catalogue Number: SIG60CTAVM
• Device Lot Number: N3E0510Y
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/28/2025
• Initial Report FDA Received Date: 07/23/2025
• Date Device Manufactured: 05/18/2023
• 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
• Concomitant Medical Products and Therapy/Usage Dates: PLEASE SEE NOTE ON H11
• Patient Sex: Female