According to the reporter, during the closure of the gallbladder artery in a laparoscopic cholecystectomy procedure, after one clip was closed, the inner clip did not separate from the outer clip.Both were taken out together.It was also stated that another clip was damaged and could not be used.A new device was used to complete the procedure.There was no patient injury.
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Additional information: d10, g4, h3, h6 h3 evaluation summary: post market vigilance (pmv) led an evaluation of one device.The visual inspection of the first cartridge noted that the clip was fully formed but not completely deployed from the cartridge.The visual inspection of the second cartridge noted it was received fully applied, the clip body was broken in half, and was missing the other half.The tracks were received.The clinical instrument was not received.No other visual abnormalities were observed.Functional evaluation could not be performed on the damaged clip.Since the clinical instrument was not received the loading unit was loaded into a pmv representative instrument and fired; the pusher advanced properly and deployed the clip.Records from each manufacturing lot are thoroughly reviewed to ensure that products are released meeting all quality release specifications at the time of manufacture.The investigation concluded there were no abnormalities that would have caused or contributed to the reported condition.Replication of the clip body fracture may occur if the clip is applied over indicated tissue or an obstruction that exceeds the clip capacity.Replication of the clip not fully deployed condition may occur if the trigger of the instrument is not fully actuated releasing the clip from the cartridge.The root cause of the observed damage was due to the product not being used as indicated which caused or contributed to the reported condition.No further actions have been deemed necessary at this time.If information is provided in the future, a supplemental report will be issued.
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