GREENLIGHT MOXY FIBER OPTIC
Report
- Report Number
- 2937094-2013-00597
- Event Type
- Malfunction
- Date Received
- May 20, 2013
- Date of Event
- April 8, 2013
- Report Date
- April 8, 2013
- Manufacturer
- AMERICAN MEDICAL SYSTEMS
- Product Code
- GEX
- PMA / PMN Number
- K120870
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- AZ, US
- Reporter Occupation
- NOT APPLICABLE
Narratives
(B)(4). FIBER ANALYSIS: A CIRCUMFERENTIAL FRACTURE OF THE GLASS CAP WAS FOUND, PROXIMAL TO THE FIBER/CAP FUSION ZONE; THE GLASS CAP/FIBER PROXIMAL TO THE FRACTURE WAS FOUND TO ROTATE INDEPENDENTLY OF THE METAL CAP. BURNT ON DETRITUS AND DEVITRIFICATION OF THE GLASS CAP OUTPUT WINDOW WAS ALSO OBSERVED. THE IDENTIFIED ISSUES MAY ACTIVATE THE FIBERLIFE FUNCTION WHICH WOULD MODULATE THE POWER SHOWING A PULSING BEAM AND DECREASED TISSUE VAPORIZATION EFFICIENCY, OR THE SYSTEM WOULD BE PLACED INTO STANDBY MODE. THE CIRCUMFERENTIAL FRACTURE MAY ALSO CAUSE FORWARD-FIRING OF THE SIDE-FIRING SURGICAL FIBER. THE MOST PROBABLE ROOT CAUSE OF THE DEVICE FAILURE WAS DETERMINED TO BE HEAT ACCUMULATION/USER HANDLING DUE TO TISSUE CONTACT AND OR TECHNIQUE AND ANATOMICAL/PROCEDURAL FACTORS ENCOUNTERED DURING THE PROCEDURE, LIMITING THE PERFORMANCE OF THE FIBER.
IT WAS REPORTED THAT WHILE USING THE SURGICAL FIBER DURING A PROSTATE PROCEDURE, THE FIBER FAILED AT 4,583 JOULES OF USE; NO OTHER DETAILS WERE PROVIDED. THE CASE WAS COMPLETED USING A SECOND FIBER. THERE WAS NO REPORT OF INJURY.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 223230 | GREENLIGHT MOXY FIBER OPTIC | POWERED SURGICAL LASER INSTRUMENT | GEX | AMERICAN MEDICAL SYSTEMS | 10-2400 | 308A |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 |