MAUDE Adverse Event Report: APPLIED MEDICAL RESOURCES CTB71, KII 12X150MM SHLD BLD Z-THR, 6/BX; GCJ

Model Number	CTB71
Medical Device Problem Codes	Bent (1059); Fracture (1260)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	09/08/2016
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
No product is being returned for evaluation but lot # is provided.A device history report is to be reviewed by engineering.A follow up report will be sent once the results have been analyzed.In accordance to 21 cfr 803.56, if we obtain additional information, which was not known or was not available when the initial report was submitted, then the supplemental report will be submitted to the fda.
Event or Problem Description
Robotic hysterectomy - "when doctor went to insert the trocar, it bent at the shaft and slightly cracked.It was still intact and no particulation occurred.They were not able to put camera down and used new trocar.Pictures are attached.".
Additional Manufacturer Narrative
Additional information was requested and provided.The event product was not returned to applied medical for evaluation.This is consistent with the initial intake of the complaint which detailed that the product would not be returned.A review of the manufacturing records indicates this lot passed all manufacturing and quality inspections.In the absence of the subject device, it is difficult to determine the root cause of the incident.During the manufacturing process, all trocars are thoroughly inspected for functionality and performance prior to packaging.Applied medical continuously seeks to improve the form, function and ease of use of its products.As such, applied medical has opened a corrective and preventative action (capa) to further elevate and track this investigation and implement appropriate corrective actions to mitigate this type of event.In accordance with 21 cfr 803.56, if additional information is obtained which was not known or was not available when this report was submitted, then a supplemental report will be submitted to the fda.
Event or Problem Description
Additional info received via email on october 12, 2016 - the trocar cracked 2/3 of the way down the shaft.The location of the camera port being used was at the umbilicus.The trocar was inserted directly entry bladed.

• Brand Name: CTB71, KII 12X150MM SHLD BLD Z-THR, 6/BX
• Common Device Name: GCJ
• Manufacturer (Section D): APPLIED MEDICAL RESOURCES; 22872 avenida empresa; rancho santa margarita CA 92688
• MDR Report Key: 5995583
• Report Number: 2027111-2016-00670
• Device Sequence Number: 94624
• Product Code: GCJ
• UDI-Device Identifier: 00607915125066
• UDI-Public: (01)00607915125066(17)190316(30)01(10)1267279
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: K072674
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 12/09/2016

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: Other
• Device Expiration Date: 03/16/2019
• Device Model Number: CTB71
• Device Catalogue Number: 101066301
• Device Lot Number: 1267279
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/08/2016
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 10/03/2016
• Supplement Report FDA Received Date: 12/09/2016
• Patient Sequence Number: 1