FINE SURGICAL CIRCUMCISION CLAMP

K040052 · Fine Surgical Instrument Corp. · HFX · Apr 9, 2004 · Obstetrics/Gynecology

Device Facts

• Record ID: K040052
• Device Name: FINE SURGICAL CIRCUMCISION CLAMP
• Applicant: Fine Surgical Instrument Corp.
• Product Code: HFX · Obstetrics/Gynecology
• Decision Date: Apr 9, 2004
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 884.4530
• Device Class: Class 2
• Attributes: Therapeutic, Pediatric

Intended Use

The Fine Surgical Circumcision Clamp is intended to be used in a medical procedure to compress the foreskin of the penis during circumcision of a male infant or child.

Device Story

Gomco-style circumcision clamp; disposable manual surgical instrument. Constructed of chrome-plated brass. Used by clinicians during male infant or child circumcision procedures to compress foreskin. Sold non-sterile to distributors for final packaging and sterilization. Device provides mechanical compression; no electronic or automated components.

Clinical Evidence

No clinical data.

Technological Characteristics

Manual surgical instrument; chrome-plated brass construction; disposable; non-sterile; available in four sizes (1.1 cm, 1.3 cm, 1.45 cm, 1.6 cm).

Indications for Use

Indicated for use in male infants and children undergoing circumcision to compress the foreskin.

Regulatory Classification

Identification

An obstetric-gynecologic specialized manual instrument is one of a group of devices used during obstetric-gynecologic procedures to perform manipulative diagnostic and surgical functions (e.g., dilating, grasping, measuring, and scraping), where structural integrity is the chief criterion of device performance. This type of device consists of the following:(1) An amniotome is an instrument used to rupture the fetal membranes. (2) A circumcision clamp is an instrument used to compress the foreskin of the penis during circumcision of a male infant. (3) An umbilical clamp is an instrument used to compress the umbilical cord. (4) A uterine curette is an instrument used to scrape and remove material from the uterus. (5) A fixed-size cervical dilator is any of a series of bougies of various sizes used to dilate the cervical os by stretching the cervix. (6) A uterine elevator is an instrument inserted into the uterus used to lift and manipulate the uterus. (7) A gynecological surgical forceps is an instrument with two blades and handles used to pull, grasp, or compress during gynecological examination. (8) A cervical cone knife is a cutting instrument used to excise and remove tissue from the cervix. (9) A gynecological cerclage needle is a looplike instrument used to suture the cervix. (10) A hook-type contraceptive intrauterine device (IUD) remover is an instrument used to remove an IUD from the uterus. (11) A gynecological fibroid screw is an instrument used to hold onto a fibroid. (12) A uterine sound is an instrument used to determine the depth of the uterus by inserting it into the uterine cavity. (13) A cytological cervical spatula is a blunt instrument used to scrape and remove cytological material from the surface of the cervix or vagina. (14) A gynecological biopsy forceps is an instrument with two blades and handles used for gynecological biopsy procedures. (15) A uterine tenaculum is a hooklike instrument used to seize and hold the cervix or fundus. (16) An internal pelvimeter is an instrument used within the vagina to measure the diameter and capacity of the pelvis. (17) A nonmetal vaginal speculum is a nonmetal instrument used to expose the interior of the vagina. (18) A fiberoptic nonmetal vaginal speculum is a nonmetal instrument, with fiberoptic light, used to expose and illuminate the interior of the vagina.

Special Controls

*Classification.* (1) Class II (special controls). The device, when it is an umbilical clamp with or without a cutter, a uterine tenaculum which is sterile and does not use suction and is intended for single use, a nonmetal vaginal speculum, or a fiberoptic nonmetal vaginal speculum, is exempt from the premarket notification procedures in subpart E of part 807 of this chapter subject to the limitations in § 884.9.(2) Class I for the amniotome, uterine curette, cervical dilator (fixed-size bougies), cerclage needle, IUD remover, uterine sound, and gynecological biopsy forceps. The devices subject to this paragraph (b)(2) are exempt from the premarket notification procedures in subpart E of part 807 of this chapter, subject to the limitations in § 884.9.

Predicate Devices

• Centurion® CirClamp™ (K890897)

Submission Summary (Full Text)

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# 510(K) SUMMARY

This summary of 510(k) safety and effectiveness information is being submitted in accordance with the requirements of SMDA 1990 and 21 CFR §807.92.

The assigned 510(k) number is:

### Submitter's Identification: 1.

Fine Surgical Instruments, Inc. 741Peninsula Blvd. Hempstead, NY 11550 Tel: [phone] Fax: [phone]

Date Summary Prepared: January 9, 2004

### 2. Name of the Device:

- Proprietary: Fine Surgical Circumcision Clamp a.
- Common Name: Gomco Style Circumcision Clamp b.
- Classification Name: Circumcision Clamp C.
- d. Device Class: 21 CFR 884.4530, Class II
- Classification Panel: Obstetrical and Gynecological Panel e.
- Product Code: HFX f.

### 3. Predicate Device Information:

The Fine Surgical Circumcision Clamp is identical in materials, design, and intended use to the Centurion® CirClamp™ circumcision clamps marketed by Tri-State Medical Corp. (K890897). The Fine Surgical clamp differs from the predicate in that it will be offered non-sterile for further processing and a larger size will be available.

### 4. Device Description:

The Fine Surgical Gomco Circumcision Clamp is a disposable medical device that is constructed of chrome plated brass. The device will be sold non sterile for further processing (ie. Packaging and sterilization) by the final distributor. We do not intend to sell these devices directly to the end user.

### 5. Intended Use:

The Fine Surgical Circumcision Clamp is intended to be used in a medical procedure to compress the foreskin of the penis during circumcision of a male infant or child.

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| | Fine Surgical Gomco<br>Circumcision Clamp | Centurion® CirClamp™ |
|-----------------|----------------------------------------------------------------------------|-----------------------------------------------------------|
| Intended Use | Infant and Child<br>circumcision | Infant Circumcision |
| Sizes Available | Extra Small: 1.1 cm<br>Newborn: 1.3 cm<br>Infant: 1.45 cm<br>Child: 1.6 cm | Extra Small: 1.1 cm<br>Newborn: 1.3 cm<br>Infant: 1.45 cm |
| Materials | Chrome-Plated Brass | Chrome-Plated Brass |
| Re-Use | No, disposable | No, disposable |

### Comparison to Predicate Devices: 6.

## Discussion of Non-Clinical Tests Performed for Determination 7. of Substantial Equivalence are as follows:

Non-Sterile

Non Clinical testing was not performed

### Discussion of Clinical Tests Performed: 8.

Clinical testing was not performed

### 9 Conclusions:

Sterility

The Fine Surgical Gomco-Style Circumcision Clamp is safe and effective for if's intended use.

Sterile

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Food and Drug Administration 9200 Corporate Boulevard Rockville MD 20850

APR - 9 2004

Fine Surgical Instruments, Inc. c/o Ms. Carolann Kotula Official Correspondent mdi Consultants, Inc. 55 Northern Blvd. GREAT NECK NY 11021

Re: K040052

Trade/Device Name: Fine Surgical Circumcision Clamp Regulation Number: 21 CFR §884.4530 Regulation Name: Obstetric-gynecologic specialized manual instrument Regulatory Class: II Product Code: 85 HFX Dated: January 9, 2004 Received: January 12, 2004

Dear Ms. Kotula:

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. 'The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); good manufacturing practice requircments as set forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the clectronic product radiation control provisions (sections 531-542 of the Act); 21 CFR 1000-1050.

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This letter will allow you to begin marketing your device as described in your Section 510(k) premarket notification. The FDA finding of substantial equivalence of your device to a legally marketed predicate device results in a classification for your device and thus, permits your device to proceed to the market.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please contact the Office of Compliance at one of the following numbers, based on the regulation number at the top of the letter:

| 8xx.1xxx | [phone] |
|----------------------------------|----------------|
| 876.2xxx, 3xxx, 4xxx, 5xxx | [phone] |
| 884.2xxx, 3xxx, 4xxx, 5xxx, 6xxx | [phone] |
| 892.2xxx, 3xxx, 4xxx, 5xxx | [phone] |
| Other | [phone] |

Additionally, for questions on the promotion and advertising of your device, please contact the Office of Compliance at [phone]. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97) you may obtain. Other general information on your responsibilities under the Act may be obtained from the Division of Small Manufacturers, International and Consumer Assistance at its toll-free number [phone] or [phone] or at its Internet address http://www.fda.gov/cdrh/dsma/dsmamain.html.

Sincerely yours,

Nancy C. Bryden

Nancy C. Brogdon Director, Division of Reproductive, Abdominal and Radiological Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

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## ATTACHMENT 3

Page __ 1 __ of __ 1

510(k) Number (if known): _ 长0400 5 2

Device Name: Fine Surgical Instruments Gomco-Style Circumcision Clamp

Indications For Use:

A Circumcision Clamp is an instrument used in a procedure to compress the foreskin of the penis during circumcision of male infant or child.

Prescription Use _ × (Part 21 CFR 801 Subpart D) AND/OR

Over-The-Counter Use (21 CFR 807 Subpart C)

(PLEASE DO NOT WRITE BELOW THIS LINE-CONTINUE ON ANOTHER PAGE IF NEEDED)

| Concurrence of CDRH, Office of Device Evaluation (ODE) | |
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| (Division Sign-Off) | |
| Division of Reproductive, Abdominal, | |
| and Radiological Devices, | |
| K040052 | |