MAUDE Adverse Event Report: TISSUE SCIENCE LABORATORIES PERMACOL; MESH, SURGICAL

Model Number	P151020
Medical Device Problem Codes	Material Erosion (1214); Migration or Expulsion of Device (1395); Adverse Event Without Identified Device or Use Problem (2993); Patient Device Interaction Problem (4001)
Health Effect - Clinical Codes	Adhesion(s) (1695); Erosion (1750); Cellulitis (1768); Emotional Changes (1831); Fistula (1862); Unspecified Infection (1930); Inflammation (1932); Necrosis (1971); Pain (1994); Scar Tissue (2060); Scarring (2061); Seroma (2069); Discharge (2225); Hernia (2240); Injury (2348); Depression (2361); Fluid Discharge (2686); No Code Available (3191); Nodule (4551); Unspecified Tissue Injury (4559); Swelling/ Edema (4577); Appropriate Clinical Signs, Symptoms and Conditions Term/Code Not Available (4581)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
The patient¿s attorney alleged a deficiency against the device.The product was used for therapeutic treatment of an incarcerated abdominal incisional hernia.It was reported that after underlay implant, the patient experienced severe pain, hernia recurrence, inflammation, meshoma, infection, dense adhesions, enterocutaneous fistula, scarring, abdominal wall cellulitis, draining sinus, necrotic tissue, and mesh eroding into small bowel.Post-operative patient treatment included debridement and removal surgery.
Additional Manufacturer Narrative
Patient code- c64343 (mass).Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
The patient¿s attorney alleged a deficiency against the device.The product was used for therapeutic treatment of an incarcerated abdominal incisional hernia.It was reported that after underlay implant, the patient experienced severe pain, hernia recurrence, inflammation, mass, meshoma, infection, dense adhesions, enterocutaneous fistula, scarring, abdominal wall cellulitis, draining sinus, necrotic tissue, and mesh eroding into small bowel.Post-operative patient treatment included debridement of abdominal wall with partial excision of infected mesh, recurrence repair, application of wound vac and small bowel resection.
Additional Manufacturer Narrative
Additional information: a4, b5, b7, d8, e1, g1, h6 (ime, imf device codes, ime e2402: meshoma, sinus).Medtronic submits this report to comply with fda regulations 21 cfr parts 4 and 803.Medtronic has made reasonable efforts to provide as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.Medtronic will submit a supplemental report if additional relevant information becomes known.
Event or Problem Description
The patient's attorney alleged a deficiency against the device.The product was used for therapeutic treatment of an incarcerated abdominal incisional hernia.It was reported that after underlay implant, the patient experienced severe pain, hernia recurrence, inflammation, mass, meshoma, infection, dense adhesions, enterocutaneous fistula, scarring, abdominal wall cellulitis, draining sinus, necrotic tissue, mesh eroding into small bowel, mesh migration, digestive problems, depression, swelling in stomach, loss of enjoyment of life, seroma.Post-operative patient treatment included debridement of abdominal wall with partial excision of infected mesh, recurrence repair, application of wound vac, small bowel resection, wound drainage, revision surgery, hernia repair with new mesh, mesh removal.

• Brand Name: PERMACOL
• Common Device Name: MESH, SURGICAL
• Manufacturer (Section D): TISSUE SCIENCE LABORATORIES; victoria house, victoria road; aldershot, hampshire GU11 1EJ; GB GU11 1EJ
• Manufacturer (Section G): TISSUE SCIENCE LABORATORIES; victoria house, victoria road; aldershot, hampshire GU11 1EJ; GB GU11 1EJ
• Manufacturer Contact: justin ellis ; 60 middletown ave; 8200 coral sea st ne; mounds view,mn, CT 55112 ; 7635265677
• MDR Report Key: 9164420
• Report Number: 9617613-2019-00168
• Device Sequence Number: 2346837
• Product Code: FTM
• UDI-Device Identifier: 10884523000177
• UDI-Public: 10884523000177
• Combination Product (Y/N): N
• Initial Reporter State: MA
• Initial Reporter Country: US
• PMA/510(K) Number: K120605
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2010
• Device Explanted Year: 2011
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Consumer
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 06/18/2024

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 Expiration Date: 04/30/2012
• Device Model Number: P151020
• Device Catalogue Number: P151020
• Device Lot Number: 09B0709
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 09/11/2019
• Supplement Date Received by Manufacturer: 01/08/2020; 05/29/2024
• Initial Report FDA Received Date: 10/07/2019
• Supplement Report FDA Received Date: 01/20/2020; 06/18/2024
• 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
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Female
• Patient Weight: 83 KG