MAUDE Adverse Event Report: ETHICON INC. PROLENE MESH 1.8INX4IN SM KEYHOLE; MESH, SURGICAL, POLYMERIC

Model Number	PMSK
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Pain (1994); Not Applicable (3189)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
(b)(4).To date, the device has not been returned.If the product is returned for evaluation, any further information derived from the evaluation will be submitted in a supplemental 3500a form.In addition, a review of the manufacturing records was performed and indicates that there were no quality concerns associated with the manufacturing process.
Event or Problem Description
It was reported by an attorney that the patient underwent inguinal hernia repair surgery on (b)(6) 2013 and mesh was implanted.It was reported that the patient underwent revision surgery on an unknown date.It was reported that the patient experienced severe pain.No additional information is provided.
Additional Manufacturer Narrative
Date sent to the fda: 5/27/2021.

• Brand Name: PROLENE MESH 1.8INX4IN SM KEYHOLE
• Common Device Name: MESH, SURGICAL, POLYMERIC
• Manufacturer (Section D): ETHICON INC.; 1000 route 202; raritan NJ 08876 0151
• MDR Report Key: 9175288
• Report Number: 2210968-2019-88120
• Device Sequence Number: 2774662
• Product Code: FTL
• UDI-Device Identifier: 10705031049055
• UDI-Public: 10705031049055
• Combination Product (Y/N): N
• Initial Reporter State: NY
• Initial Reporter Country: US
• PMA/510(K) Number: K180829
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2013
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: other
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 09/25/2019

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?: No
• Operator of Device: Health Professional
• Device Expiration Date: 01/31/2018
• Device Model Number: PMSK
• Device Catalogue Number: PMSK
• Device Lot Number: GDR498
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 09/24/2019
• Supplement Date Received by Manufacturer: 05/26/2021
• Initial Report FDA Received Date: 10/10/2019
• Supplement Report FDA Received Date: 05/27/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 53 YR