MAUDE Adverse Event Report: KARL STORZ SE & CO.KG CLICKLINE OUTER SHEATH/FORCEPS INSERT

Model Number	30310ULS
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	08/12/2025
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The device will be forwarded to the manufacturer for further investigation.Should relevant additional information / investigation results become available, a supplemental medwatch report will be submitted unsolicited.This event is filed under internal complaint id (b)(4).
Event or Problem Description
It was reported that during a laparoscopic surgery; surgeon saw a black object adherer internally in the patient which was retained from a previous surgery.Scar tissue had begun to form around it.The object was removed.Staff and surgeon determined it was a shaving from the outer sheath of the clickline instrument and likely caused by dragging in or out of trocar cannula.Both ks and disposable trocars were used.Pictures attached.The hospital is reporting it as a sentinel event.Other than scar tissue formation, patient was unharmed.

• Brand Name: CLICKLINE OUTER SHEATH/FORCEPS INSERT
• Common Device Name: CLICKLINE OUTER SHEATH/FORCEPS INSERT
• Manufacturer (Section D): KARL STORZ SE & CO.KG; dr.karl-storz-strasse 34; tuttlingen, deu 78523 2; GM 785232
• MDR Report Key: 22906067
• Report Number: 2020550-2025-01490
• Device Sequence Number: 9089487
• Product Code: GCJ
• UDI-Device Identifier: 04048551121924
• UDI-Public: 04048551121924
• Combination Product (Y/N): N
• Initial Reporter State: CO
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Importer
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 08/27/2025
• Report Date (Section F): 08/27/2025

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?: Yes
• Operator of Device: Health Professional
• Device Model Number: 30310ULS
• Device Catalogue Number: 30310ULS
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 08/12/2025
• Event Location: Hospital
• Date Report to Manufacturer: 08/27/2025
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 08/27/2025
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other
• Patient Sex: Unknown