MAUDE Adverse Event Report: Cook Inc MODIFIED NOVY CORNUAL CANNULATION SET; MOV, Catheters, Salpingography

Model Number	G17558
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	07/24/2026
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that the distal end of the inner catheter from a modified novy cornual cannulation set broke upon entering the opening of the fallopian tube during a hysteroscopy procedure.The edges of the fractured catheter wall exhibited elongation, thinning, and curling.Photos of the broken device were provided.All device fragments were successfully retrieved.The procedure was completed using by using another same-like device.As reported, the patient did not experience any adverse effects or require any additional procedures due to this occurrence.
Additional Manufacturer Narrative
E1: phone number: (b)(6).H3: device has been returned and preliminary evaluation has been performed, however, our investigation is ongoing and device evaluation summary will be included in our follow up report once our investigation has been completed.This report includes information known at this time.A follow-up report will be submitted should additional relevant information become available.This report is required by the fda under 21 cfr part 803.This report is based on unconfirmed information submitted by others.Neither the submission of this report nor any statement made in it is intended to be an admission that any cook device is defective or malfunctioned; that a death or serious injury occurred; or that any cook device caused or contributed to; or is likely to cause or contribute to a death or serious injury if a malfunction occurred.

• Brand Name: MODIFIED NOVY CORNUAL CANNULATION SET
• Common Device Name: MOV, Catheters, Salpingography
• Manufacturer (Section D): Cook Inc; 750 daniels way; bloomington IN 47404
• Manufacturer Contact: jason crouch ; 750 daniels way; bloomington, IN 47404 ; +1(812)339-2235
• MDR Report Key: 50304607
• Report Number: 1820334-2026-00864
• Device Sequence Number: 10247511
• Product Code: MOV
• UDI-Device Identifier: 00827002175587
• Combination Product (Y/N): N
• Initial Reporter Country: CH
• PMA/510(K) Number: K180552
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Other,Foreign,Distributor
• Type of Report: Initial
• Report Date (Section B): 08/18/2026

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: G17558
• Device Catalogue Number: J-NCS-504070
• Device Lot Number: 16584205
• Was Device Available for Evaluation?: Yes
• Date Returned to Manufacturer: 08/15/2026
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/29/2026
• Initial Report FDA Received Date: 08/18/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 05/01/2025
• 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 Age: 28 YR
• Patient Sex: Female
• Patient Weight: 121 LB