MODIFICATION TO OPTICAL SEPARATOR SYSTEM

K041795 · Applied Medical Resources Corp. · GCJ · Sep 14, 2004 · Gastroenterology, Urology

Device Facts

Record IDK041795
Device NameMODIFICATION TO OPTICAL SEPARATOR SYSTEM
ApplicantApplied Medical Resources Corp.
Product CodeGCJ · Gastroenterology, Urology
Decision DateSep 14, 2004
DecisionSESE
Submission TypeTraditional
Regulation21 CFR 876.1500
Device ClassClass 2
AttributesTherapeutic

Indications for Use

The Optical Separator System is a sterile single use device, intended for use in conjunction with Applied's currently marketed Trocar products to establish a path of entry for endoscopic instruments for use during general, abdominal, gynecological and thoracic minimally invasive procedures or to gain access through tissue planes and/or potential spaces for endoscopic instruments. The Optical Separator System may be used with or without visualization for primary and secondary insertions, and as a means of insufflating the peritoneum prior to laparoscopic procedures.

Device Story

Sterile, single-use device used with trocar assemblies for minimally invasive surgery. Functions as a dilating tip trocar; separates tissue along natural fiber lines rather than cutting with blades. Input: manual insertion by surgeon. Transformation: mechanical dilation of tissue planes. Output: established access path for endoscopic instruments; insufflation of peritoneum. Used in OR by surgeons. Benefits: reduced trauma to vessels/abdominal wall; minimized risk of organ puncture; tissue reapproximation upon removal, leaving smaller linear defect.

Clinical Evidence

Bench testing only. Functional testing verified insertion force, device reliability, and visualization capabilities. No clinical data presented.

Technological Characteristics

Sterile, single-use, dilating tip trocar. Available in 5mm, 11mm, and 12mm diameters; lengths 55mm to 150mm. Mechanical tissue separation principle. No energy source or software components.

Indications for Use

Indicated for use in general, abdominal, and gynecological minimally invasive surgical procedures to establish a path of entry or to gain access through tissue planes and/or potential spaces for endoscopic instruments, and as a means of insufflating the peritoneum prior to laparoscopic procedures.

Regulatory Classification

Identification

An endoscope and accessories is a device used to provide access, illumination, and allow observation or manipulation of body cavities, hollow organs, and canals. The device consists of various rigid or flexible instruments that are inserted into body spaces and may include an optical system for conveying an image to the user's eye and their accessories may assist in gaining access or increase the versatility and augment the capabilities of the devices. Examples of devices that are within this generic type of device include cleaning accessories for endoscopes, photographic accessories for endoscopes, nonpowered anoscopes, binolcular attachments for endoscopes, pocket battery boxes, flexible or rigid choledochoscopes, colonoscopes, diagnostic cystoscopes, cystourethroscopes, enteroscopes, esophagogastroduodenoscopes, rigid esophagoscopes, fiberoptic illuminators for endoscopes, incandescent endoscope lamps, biliary pancreatoscopes, proctoscopes, resectoscopes, nephroscopes, sigmoidoscopes, ureteroscopes, urethroscopes, endomagnetic retrievers, cytology brushes for endoscopes, and lubricating jelly for transurethral surgical instruments. This section does not apply to endoscopes that have specialized uses in other medical specialty areas and that are covered by classification regulations in other parts of the device classification regulations.

Special Controls

*Classification* —(1)*Class II (special controls).* The device, when it is an endoscope disinfectant basin, which consists solely of a container that holds disinfectant and endoscopes and accessories; an endoscopic magnetic retriever intended for single use; sterile scissors for cystoscope intended for single use; a disposable, non-powered endoscopic grasping/cutting instrument intended for single use; a diagnostic incandescent light source; a fiberoptic photographic light source; a routine fiberoptic light source; an endoscopic sponge carrier; a xenon arc endoscope light source; an endoscope transformer; an LED light source; or a gastroenterology-urology endoscopic guidewire, is exempt from the premarket notification procedures in subpart E of part 807 of this chapter subject to the limitations in § 876.9.(2) Class I for the photographic accessories for endoscope, miscellaneous bulb adapter for endoscope, binocular attachment for endoscope, eyepiece attachment for prescription lens, teaching attachment, inflation bulb, measuring device for panendoscope, photographic equipment for physiologic function monitor, special lens instrument for endoscope, smoke removal tube, rechargeable battery box, pocket battery box, bite block for endoscope, and cleaning brush for endoscope. The devices subject to this paragraph (b)(2) are exempt from the premarket notification procedures in subpart E of part 807of this chapter, subject to the limitations in § 876.9.

In combination with the general controls of the FD&C Act, the integrated operating table-electromechanical surgical system is subject to the following special controls: 1. (1) Premarket clinical performance testing, or a combination of premarket clinical performance testing and postmarket surveillance (in accordance with special control (2)), must include the following: 1. (i) Objective performance measures (e.g., rate and number of conversions to other surgical modalities, rate of device related adverse events (including tissue injury, hematoma, and increased blood loss), and their severity, cause, and outcomes) must be reported with relevant descriptive comparator performance measures. 2. (ii) The data must demonstrate the performance of the device for providing accurate and precise control of attached surgical instruments in range of clinical conditions relevant to the device's intended use. 3. (iii) The test dataset must include data collected from a patient population representative of the intended patient population under anticipated conditions of use. 2. (2) Data obtained from postmarket surveillance must demonstrate, in consideration of the premarket data obtained in accordance with special control (1), that the device performs in accordance with special control (1), unless FDA determines, based on the totality of the premarket data, that data from postmarket surveillance is not required to demonstrate that the device performs as intended. Such postmarket surveillance must be conducted per a protocol determined appropriate by FDA to demonstrate that the device performs as intended (in consideration of the premarket data obtained in accordance with special control (1)), and must include initiation, enrollment, and reporting requirements to ensure timely periodic updates to FDA on post-market surveillance progress and outcomes. 3. (3) Animal performance testing must evaluate the extent of port site trauma due to repositioning of table during surgical procedures when utilizing robotic minimally invasive and laparoscopic approaches 4. (4) The device manufacturer must develop, and update as necessary, a device-specific use training program that ensures proper device setup/use/shutdown, accurate control of instruments to perform the intended surgical procedures, troubleshooting and handling during unexpected events or emergencies, and safe practices to mitigate use error. 5. (5) The device manufacturer may only distribute the device to facilities that implement and maintain the device-specific use training program and ensure that users of the device have completed the device-specific use training program. (6) Human factors assessment must demonstrate that the user can correctly use the device system across all intended use environments with the provided instructions and training materials, including patient access during normal operating conditions and emergency situations, and effects arising from the integrated nature of the operating table and robotic surgical arms. (7) Labeling must include: (i) A detailed summary of clinical performance testing conducted with the device, including study population, results, adverse events, and comparisons to any comparator groups identified; (ii) A statement in the labeling that the safety and effectiveness for the representative specific procedures was based on evaluation of the device as a surgical tool and did not include evaluation of outcomes related to the treatment of the patient's underlying disease or condition, unless FDA determines that it can be removed or modified based on clinical performance data submitted to FDA; (iii) Identification of compatible devices; (iv) The list of surgical procedures for which the device has been determined to be safe with clinical justification; (v) Reprocessing instructions for reusable components; (vi) A shelf life for any sterile components; (vii) A description of the device-specific use training program; (viii) A statement that the device is only for distribution to facilities that implement and maintain the device-specific use training program and ensure that users of the device have completed the device-specific use training program; and (ix) A summary of any completed postmarket surveillance data collected as required by special control (2), including updated labeling to accurately reflect outcomes observed in postmarket surveillance. (8) Non-clinical performance testing must demonstrate that the device performs as intended under anticipated conditions of use and must include: (i) Device motion accuracy and repeatability; (ii) System testing; (iii) Instrument reliability; (iv) Crosstalk; (v) Table motion control; (vi) Thermal effects on tissue; (vii) User-device interface performance; (viii) Workspace access testing; and (ix) Performance testing with compatible devices. (9) Software verification, validation, and hazard analysis must be performed. (10) Electromagnetic compatibility and electrical, thermal, and mechanical safety testing must be performed. (11) Performance data must demonstrate the sterility of all patient-contacting device components. (12) Performance data must support the shelf life of the device components provided sterile by demonstrating continued sterility and package integrity over the labeled shelf life. (13) Performance data must validate the reprocessing instructions for the reusable components of the device. (14) Performance data must demonstrate that all patient-contacting components of the device are biocompatible. (15) Performance data must demonstrate that all patient-contacting components of the device are non-pyrogenic. (16) The device manufacturer must submit a report to the FDA annually on the anniversary of initial marketing authorization for the device, until such time as FDA may terminate such reporting, which comprises the following information: (i) Cumulative summary, by year, of complaints and adverse events since date of initial marketing authorization; and (ii) Identification and rationale for changes made to the device, labeling, or device specific use training program, which did not require submission of a premarket notification during the reporting period.

Predicate Devices

Submission Summary (Full Text)

{0}------------------------------------------------ SEP 1 4 2004 ## 510(k) SUMMARY Page 1 of 2 | 510(k) NUMBER: | PENDING K041795 | |----------------------|---------------------------------------------------------------------------------------------------------------------------------------------| | SUBMITTED BY: | Applied Medical Resources Corporation<br>22872 Avenida Empresa<br>Rancho Santa Margarita, CA-92688<br>(949) 713-8000 | | CONTACT PERSON: | Cheryl Blake<br>Vice President, Regulatory Affairs and Quality Systems | | DATE OF PREPARATION: | June 30, 2004 | | NAME OF DEVICE: | Optical Separator System | | CLASSIFICATION NAME: | Laparoscope, General & Plastic Surgery (21CFR 876.1500) | | TRADE NAME: | Optical Separator System | | PREDICATE DEVICE: | Applied Medical Optical Separator (K032889)<br>Applied Medical Insufflation Needle (K963359)<br>Applied Medical, Rancho Santa Margarita, CA | INTENDED USE: The Optical Separator System is a sterile single use device, intended for use in conjunction with Applied's currently marketed Trocar products to establish a path of entry for endoscopic instruments for use during general, abdominal, gynecological and thoracic minimally invasive procedures or to gain access through tissue planes and/or potential spaces for endoscopic instruments. The Optical Separator System may be used with or without visualization for primary and secondary insertions, and as a means of insufflating the peritoneum prior to laparoscopic procedures. DEVICE DESCRIPTION: The Optical Separator System is a sterile single use device, intended for use in conjunction with Applied's currently marketed Trocar products. A standard trocar assembly consists of an obturator, a seal and a cannula system. Traditional obturators use a blade for cutting to establish a path of entry through the several layers of tissue. The Dilating Tip Trocar dilates and separates tissue along its natural fiber lines in its path of entry. The Optical Separator System will be available in sizes of 5mm, 11mm and 12mm diameter in lengths ranging from 55mm to 150mm. {1}------------------------------------------------ Page 2 of 2 The use of the Optical Separator System, which separates tissue along its natural fibers versus cutting of tissue by traditional bladed trocars, is expected to reduce trauma to vessels and the abdominal wall and minimize the risk of organ puncture. Upon removal of the trocar at the end of the procedure the separated tissue is expected to reapproximate, leaving a smaller, linear defect. PERFORMANCE DATA SUMMARY: The performance and functional testing of the Optical Separator System included tests to verify the insertion force and tests to verify its reliability and visualization during use. The performance and functional testing demonstrated that the Optical Separator System is substantially equivalent to its predicate devices and it introduces no new safety and effectiveness issues when used as instructed. 510(k) - ODE/FDA Optical Separator June 2004 {2}------------------------------------------------ Image /page/2/Picture/1 description: The image shows the logo for the U.S. Department of Health & Human Services. The logo is a circular seal with the words "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" around the perimeter. Inside the circle is a stylized image of three human figures, possibly representing a family or community. The figures are connected and appear to be in motion. SEP 1 4 2004 Food and Drug Administration 9200 Corporate Boulevard Rockville MD 20850 Public Health Service Ms. Cheryl Blake Vice President, Regulatory Affairs and Quality Systems Applied Medical Resources Corporation 22872 Avenida Empresa Rancho Santa Margarita, California 92688 Re: K041795 Trade/Device Name: Optical Separator System Regulation Number: 21 CFR 876.1500 Regulation Name: Endoscope and accessories Regulatory Class: II Product Code: GCJ Dated: June 30, 2004 Received: July 2, 2004 Dear Ms. Blake: We have reviewed your Section 510(k) premarket notification of intent to market the device we nave reviewed your bection of the device is substantially equivalent (for the indications felerenced above and nave dotenmined in arketed predicate devices marketed in interstate 101 use stated in the encreativent of the enactment date of the Medical Device Amendments, or to comments proc to May 20, 1976, the occordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). allu Costiette Troty that to neview, subject to the general controls provisions of the Act. The I ou may, dicierore, market the act include requirements for annual registration, listing of general controls providers a ractice, 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 If your device is classified (see acero) also Existing major regulations affecting your device can may be subject to satin address, legulations, Title 21, Parts 800 to 898. In addition, FDA may oc found in the Oour of reants concerning your device in the Federal Register. Please be advised that FDA's issuance of a substantial equivalence determination does not mean 1 Toase be advised that I Dris assumes syour device complies with other requirements of the Act that I Dri has made a coulations administered by other Federal agencies. You must of any I cuchar statutes and regalations and limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); good manufacturing practice requirements as set CI IC rut 0075, labeling (21 (QS) regulation (21 CFR Part 820); and if applicable, the electronic forth in the quand by of trol provisions (Sections 531-542 of the Act); 21 CFR 1000-1050. {3}------------------------------------------------ Page 2 - Ms. Cheryl Blake This letter will allow you to begin marketing your device as described in your Section 510(k) I mis letter wif anow you to organization of substantial equivalence of your device to a legally premaired 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 If you desire specific as not as (301) 594-4659. 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 from the Division of Small other general micronational and Consumer Assistance at its toll-free number (800) 638-2041 or (301) 443-6597 or at its Internet address http://www.fda.gov/cdrh/dsma/dsmamain.html Sincerely yours, Miriam C. Provost Celia M. Witten, Ph.D., M.D. Director Division of General, Restorative and Neurological Devices Office of Device Evaluation Center for Devices and Radiological Health Enclosure {4}------------------------------------------------ ## INDICATIONS FOR USE Applied Medical Resources is providing this separate cover page for the Optical Separator System "Indications for Use" as required. 510(k) Number: Not assigned k041795 Optical Separator System Device Name: Indications for Use: The Optical Separator System is indicated for use in general, abdominal, muncations for Ose. The Opinimally invasive surgical procedures to establish a path of entry or to gain access through tissue planes and/or potential spaces for endoscopic instruments, and as a means of insufflating the peritoneum prior to laparoscopic procedures. Signature: Title: Vice President RA and Quality Systems Date:6/30/2004 Prescription Use (Per 21 CFR 801.109) X OR Over-The -Counter Use - - - (Optional Format 1-2-96) 510(k) - ODE/FDA Optical Separator June 2004 27 (PLEASE DO NOT WRITE BELOW THIS LINE - CONTINUE ON ANOTHER PAGE IF NEEDED) Concurrence of CDRH, Office of Device Evaluation (ODE) Miriam C. Provost Division of General, Restorative, and Neurological Devices **510(k) Number** K041795
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