| Brand Name | HF-RESECTION ELECTRODE "PLASMALOOP", LOOP, MEDIUM, 24 FR., 12°/16°, ESG TURIS |
| Common Device Name | ENDOSCOPIC ELECTROSURGICAL ELECTRODE, BIPOLAR, SINGLE-USE |
| Manufacturer (Section D) |
| OLYMPUS MEDICAL PRODUCTS CZECH, SPOL. S R.O. |
| telickova 457/29 |
| prerov 75124 |
| EZ 75124 |
|
| Manufacturer (Section G) |
| OLYMPUS MEDICAL PRODUCTS CZECH, SPOL. S R.O. |
| telickova 457/29 |
|
| prerov 75124 |
|
EZ
75124
|
|
| Manufacturer Contact |
|
todd
brill
|
| 801 west park drive |
| westborough, MA 01581
|
|
5082077661
|
|
| MDR Report Key | 25236517 |
| Report Number | 3007960282-2026-00110 |
| Device Sequence Number | 10289847 |
| Product Code |
FAS
|
| UDI-Device Identifier | 14042761085325 |
| UDI-Public | 14042761085325 |
| Combination Product (Y/N) | N |
| Initial Reporter State | MI |
| Initial Reporter Country | US |
| PMA/510(K) Number | K171965 |
| Number of Events Summarized | 1 |
| Summary Report (Y/N) | N |
| Serviced by Third Party (Y/N) | Unknown |
| Reporter Type |
Manufacturer
|
| Report Source |
Health Professional,User Facility |
| Initial Reporter Occupation |
Administrator/Supervisor
|
| Type of Report
| Initial,Followup |
| Report Date (Section B) |
06/30/2026 |
| 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 | WA22702S |
| Device Lot Number | 1000221804 |
| Was Device Available for Evaluation? |
No
|
| Type of Report(Section G) | Follow-Up |
| Initial Date Received by Manufacturer | 05/12/2026 |
| Supplement Date Received by Manufacturer | 06/26/2026
|
| Initial Report FDA Received Date | 05/20/2026 |
| Supplement Report FDA Received Date | 06/30/2026
|
| Was Device Evaluated by Manufacturer? (Y/N) |
No
|
| Date Device Manufactured | 09/16/2025 |
| 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 |
|
|