It was reported that during a total laparoscopic hysterectomy procedure, co2 air leak (causing abdomen deflated).Six types of suspected causes -- a) ports, b) vaginal cup, c) gas tubing, d) gas tubing adaptor, e) low level of gas tank, f) defect of karl storz's spies camera system (newly purchases by hospital), and g) didn't close harmonic jaw while removing it through working ports.Event chronology: air leaked only towards the end of surgery (during colpotomy).Didn't suspect leak from trocars initially.The doctor checked vaginal cup - problem persisted.Changed gas tubing.Problem persisted.Changed one of the three working ports (cb5lt).Didn't change main camera port (2b5lt).Noticed gas tank level was at low levels - changed to new gas tank.Air pressure still low and it fluctuated from 0-9.Changed adaptor tubing (a metal fastener that fastens the rubber gas tubing).) changed one more pc of cb5lt.Air leakage persisted - air pressure cannot be maintained and continue to fluctuate but a t low levels of 0-9.Changed to older version of karl storz's camera system set.Problem persisted.The doctor aborted surgery and proceeded to finish colpotomy trans-vaginally.Audible air hissing from ports were detected after a few minutes.Problem occurred laparoscopically.Delay of two hours.
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(b)(4).When additional information is received and/or the device analysis has been completed, a supplemental medwatch will be sent.The following information was requested, but unavailable: did they close the stopcock when the procedure was converted to vaginal? what model of the karl storz camera system was utilized? (what is the diameter?) was air hissing only noticed when a device was in the trocar or was it also noticed with no device was in the trocar? when did they notice air leaking; was it after noticing the insufflation levels were low?.
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