BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    NA

    MDR report key: 3223178 · Received July 12, 2013

    Report

    Report Number
    0001056128-2013-00104
    Event Type
    Malfunction
    Date Received
    July 12, 2013
    Date of Event
    June 14, 2013
    Report Date
    June 14, 2013
    Manufacturer
    STRYKER SUSTAINABILITY SOLUTIONS LAKELAND
    Product Code
    NLQ
    PMA / PMN Number
    K111600
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    FL, US
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL

    Narratives

    Additional Manufacturer Narrative · 1

    THE COMPLAINT DEVICE WAS RETURNED TO STRYKER SUSTAINABILITY SOLUTIONS (SSS) FOR AN EVALUATION. THE DEVICE WAS RECEIVED WITH A DERAILED BLADE PROTRUDING FROM THE JAW, ESCHAR BUILD-UP IN THE GUIDING SLOTS, AND VISIBLE BIOLOGICAL MATERIAL ON THE JAWS, HANDLE, AND SHAFT; EVIDENCE THAT IT WAS CLINICALLY USED. THE REPORTED ISSUE WAS SUBSTANTIATED AS THE JAWS WERE UNABLE TO OPEN SINCE THE BLADE WAS DISLOCATED/NOT FULLY RETRACTED. BASED ON THE WAY THE BLADE WAS PROTRUDING, IT APPEARS THAT THE JAWS WERE CLAMPED DOWN ON THE BLADE AFTER IT WAS DISLOCATED. FUNCTIONAL INSPECTION OF THE DEVICE COULD NOT BE PERFORMED AS THE BLADE COULD NOT BE REALIGNED. BASED ON STRYKER SUSTAINABILITY SOLUTIONS ENGINEERING EVALUATIONS, THE TYPE OF FAILURE REPORTED CAN BE CAUSED BY CLAMPING ON LARGE, RIGID TISSUE. THE DESIGN OF THE LF4200 ALLOWS FOR LARGER BITES OF TISSUE THAN OTHER DEVICES. IT IS CRITICAL, HOWEVER, THAT THE USER DOES NOT PLACE TOO MUCH TISSUE IN THE JAWS DURING USE. IF THE JAWS ARE OVERFILLED, IT IS POSSIBLE FOR THE CUTTING MECHANISM TO BE DAMAGED, POTENTIALLY RESULTING IN DIFFICULTY OPENING THE JAWS OR INJURY RESULTING TO THE USER OR PATIENT. BEFORE ACTIVATING THE CUTTER, THE USER MUST VISUALLY CONFIRM THAT THE TIPS OF THE JAWS ARE FULLY CLOSED FOLLOWING THE TISSUE FUSION CYCLE. IF THE TIPS OF THE JAWS ARE NOT FULLY CLOSED, IT IS POSSIBLE FOR THE CUTTER MECHANISM TO BE DAMAGED, POTENTIALLY RESULTING IN DIFFICULTY OPENING THE JAWS OR INJURY RESULTING TO THE USER OR PATIENT. SSS INSTRUCTIONS FOR USE STATES: "KEEP THE INSTRUMENT JAWS CLEAN. BUILD-UP OF ESCHAR MAY REDUCE SEALING AND/OR CUTTING EFFECTIVENESS. WIPE JAW SURFACES AND EDGES WITH A WET GAUZE PAD AS NEEDED." "DO NOT USE THIS DEVICE ON VESSELS IN EXCESS OF 7MM IN DIAMETER." "TO ENSURE PROPER FUNCTION, ELIMINATE TENSION ON THE TISSUE WHILE SEALING AND CUTTING." "AVOID OVERFILLING THE INSTRUMENT JAWS WITH TISSUE. THIS MAY DAMAGE THE CUTTING MECHANISM OR CAUSE THE BLADE TO DEPLOY OUTSIDE OF ITS GUIDING FEATURES, POSSIBLY RESULTING IN DIFFICULTY OPENING THE JAWS OR UNINTENDED INJURY TO THE USER OR PATIENT." "VISUALLY CONFIRM THAT THE JAWS HAVE REACHED THE CLOSED POSITION PRIOR TO ACTIVATING THE CUTTER. FAILURE TO DO SO MAY DAMAGE THE CUTTING MECHANISM OR CAUSE THE BLADE TO DEPLOY OUTSIDE OF ITS GUIDING FEATURES, POSSIBLY RESULTING IN DIFFICULTY OPENING THE JAWS OR UNINTENDED INJURY TO THE USER OR PATIENT." "PRIOR TO ACTIVATING THE CUTTER, CONFIRM THAT THE JAWS ARE IN THE CLOSED POSITION. SPACING BETWEEN JAWS MUST BE LESS THAN TWO MILLIMETERS." THE DEVICE HISTORY RECORD FOR THE RETURNED DEVICE INDICATES THAT THE COMPLAINT DEVICE PASSED ALL APPLICABLE INSPECTIONS AND TESTS PRIOR TO RELEASE. THIS REPORT IS BEING FILED AS A MALFUNCTION DUE TO SSS BEING IN A 2 YEAR REPORTING CYCLE DUE TO MDR REPORT 1056128-2012-00042 WHERE THE DEVICE HAD TO BE CUT AWAY FROM THE PATIENT'S TISSUE WHEN IT BECAME STUCK EVEN THOUGH THERE WAS NO PATIENT INJURY IN THIS EVENT. THE REPORTED EVENT IS NOT OCCURRING MORE FREQUENTLY OR WITH GREATER SEVERITY THAN IS USUAL FOR THE DEVICE.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT DURING A PROCEDURE THREE LIGASURE DEVICES "FAILED TO WORK AND ONE STOPPED IN THE MIDDLE OF THE CASE." THE DEVICE WAS RETURNED WITH A DERAILED BLADE. NO PATIENT INJURY WAS REPORTED BY THE USER FACILITY.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    324361 NA NLQ NLQ STRYKER SUSTAINABILITY SOLUTIONS LAKELAND 2381151

    Patients

    Seq Age Sex Outcome Treatment
    1