5 MM HARMONIC ACE INSTRUMENT (USED WITH DA VINCI IS1200 & IS2000/IS3000 SYSTEM)

K093217 · Intuitive Surgical, Inc. · NAY · Jan 21, 2010 · Gastroenterology, Urology

Device Facts

• Record ID: K093217
• Device Name: 5 MM HARMONIC ACE INSTRUMENT (USED WITH DA VINCI IS1200 & IS2000/IS3000 SYSTEM)
• Applicant: Intuitive Surgical, Inc.
• Product Code: NAY · Gastroenterology, Urology
• Decision Date: Jan 21, 2010
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 876.1500
• Device Class: Class 2
• Attributes: Therapeutic

Intended Use

The Intuitive Surgical da Vinci Harmonic ACE™ Device is intended for soft tissue incisions when bleeding control and minimal thermal injury are desired. It is designed to be used in conjunction with the da Vinci Surgical Systems (Model IS1200, IS2000 and IS3000) and the Ethicon Endo-Surgery Generator 300 (Model GEN04) and Hand Piece (Model HP054).

Device Story

Ultrasonic surgical instrument for soft tissue incision, coagulation, and transection; used with da Vinci Surgical System. Device consists of reusable instrument housing and disposable distal insert (shaft/grip assembly). Connects to Ethicon Endo-Surgery Generator 300 (GEN04) via Hand Piece (HP054). Operated by surgeon via da Vinci console; ultrasonic energy delivered to tissue at distal tip. Enables precise cutting with hemostasis; minimizes thermal injury. Used in clinical surgical settings. Output provides surgeon with controlled tissue transection and coagulation; facilitates minimally invasive procedures.

Clinical Evidence

Bench and animal lab testing conducted. No clinical data provided.

Technological Characteristics

Ultrasonic energy delivery system; 5mm and 8mm diameter configurations. Components: reusable housing, disposable shaft/grip insert. Energy source: Ethicon Endo-Surgery Generator 300 (GEN04). System integration: da Vinci Surgical Systems (IS1200, IS2000, IS3000).

Indications for Use

Indicated for soft tissue incisions in patients requiring bleeding control and minimal thermal injury. Used in conjunction with da Vinci Surgical Systems (IS1200, IS2000, IS3000) and Ethicon Endo-Surgery Generator 300.

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.

Predicate Devices

• Harmonic™ Curved Shears Instrument (K042855)
• Harmonic ACE™ with Hand Control (K042777)

Submission Summary (Full Text)

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K093217, Harmonic ACE™ Device

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# 1793217 510(k) Summary [As Required by 21 CFR 807.92(c)]

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| Date: | 12/22/09 | JAN 21 2010 |
|--------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------|
| Submitter: | Intuitive Surgical, Inc.<br>950 Kifer Road<br>Sunnyvale, CA 94086 | |
| Official Contact: | Meghna Sridharan<br>Regulatory Engineer<br>Ph: [phone]<br>Fax: [phone]<br>[e-mail] | |
| Trade Name: | da Vinci Harmonic ACE™ Device<br>• 5mm Harmonic ACE™ Instrument<br>• 8mm Harmonic ACE™ Instrument<br>• Disposable Harmonic ACE™ Insert | |
| Common Name: | Endoscopic Instrument, ultrasonic endoscopic<br>instrument | |
| Classification: | Endoscope and Accessories,<br>21 CFR 876.1500, NAY(LFL) | |
| Predicate Device: | Intuitive Surgical, Inc.<br>K042855, Harmonic™ Curved Shears Instrument<br>Ethicon Endo-Surgery, Inc.<br>K042777, Harmonic ACE™ with Hand Control | |
| Device Description: | The Intuitive Surgical Harmonic ACE™ Device is<br>used to deliver ultrasonic energy to enable<br>transection and coagulation of tissue. The<br>proximal end of the device is a re-usable<br>instrument housing and attaches to the da<br>Vinci Surgical System. The distal end is a<br>disposable insert which consists of a shaft and<br>grip assembly. The instrument housing and<br>disposable insert are assembled together,<br>attached to the da Vinci Surgical System and<br>connected to Ethicon's Endo-Surgery<br>Generator 300 (Model GEN04) using the Hand<br>Piece (Model HP054). When the Harmonic<br>ACE™ Device is activated, it delivers ultrasonic | |
| Intuitive Surgical, Inc. | Confidential | Page 3-2 |

Intuitive Surgical, Inc.

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### K093217, Harmonic ACE™ Device

Intended Use:

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energy and enables transection and coagulation of tissue. The instrument is available in 5mm and 8mm diameters and in two configurations: one for use with the da Vinci (IS1200); and the other for the da Vinci Surgical ર /ડાં (122000/123000) Systems, respectively. The same disposable insert is used with all configurations of the instrument.

The Intuitive Surgical da Vinci Harmonic ACE™ Device is intended for soft tissue incisions when bleeding control and minimal thermal injury are desired. It is designed to be used in conjunction with the da Vinci Surgical Systems (Model IS1200, IS2000 and IS3000) and the Ethicon Endo-Surgery Generator 300 (Model GEN04) and Hand Piece (Model HP054).

Technological Characteristics: The subject device is equivalent in intended use, design and technology as compared to the predicate devices.

Performance Data: Performance tests (bench and animal lab tests) were conducted to demonstrate that the device is substantially equivalent to the predicate devices and that the design output meets the design input requirements. The results of the testing did not raise any new issues of safety or efficacy as compared to Intuitive Surgical's currently cleared Harmonic™ Curved Shears (K042855).

Summary: Based on the technical characteristics. intended use and performance test data, the Intuitive Surgical Harmonic ACE™ Device has been determined to be equivalent in safety, efficacy, and performance to the predicate devices.

Confidential

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Image /page/2/Picture/1 description: The image shows the logo for the U.S. Department of Health and Human Services. The logo consists of a circle with the text "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" arranged around the circumference. Inside the circle is a stylized image of an eagle.

Food and Drug Administration 10903 New Hampshire Avenue Document Control Room W-O66-0609 Silver Spring, MD 20993-0002

JAN 2 1 2010

Intuitive Surgical, Inc. % Ms. Meghna Sridharan Regulatory Engineer 950 Kifer Road Sunnyvale, California 94086

Re: K093217

Trade/Device Name: da Vinci Harmonic ACE™ Device Regulation Number: 21 CFR 876-1500 Regulation Name: Endoscope and accessories Regulatory Class: Class II Product Code: NAY Dated: December 22, 2009 Received: December 23, 2009

Dear Ms. Sridharan:

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); medical device reporting (reporting of medical

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#### Page 2 - Ms. Meghna Sridharan

device-related adverse events) (21 CFR 803); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please go to http://www.fda.gov/AboutFDA/CentersOffices/CDRH/CDRHOffices/ucm1.15809.htm for the Center for Devices and Radiological Health's (CDRH's) Office of Compliance. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to http://www.fda.gov/cdrl/mdr/ for the CDRH's Office of Surveillance and Biometrics/Division of Postmarket Surveillance.

You may obtain other general information on your responsibilities under the Act 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/industry/support/index.html.

Sincerely yours.

erely yours,

Mark N. Melkerson Director Division of Surgical, Orthopedic and Restorative Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

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# Indications for Use

1093217 510(k) Number if known:

Device Name: da Vinci Harmonic ACE™ Device

## INDICATION FOR USE:

The Intuitive Surgical da Vinci Harmonic ACE™ Device is intended for soft tissue incisions when bleeding control and minimal thermal injury are desired. It is designed to be used in conjunction with the da Vinci Surgical Systems (Model IS 1200, IS2000 and IS3000) and the Ethicon Endo-Surgery Generator 300 (Model GEN04) and Hand Piece (Model HP054).

Prescription Use _ X (Per 21 CFR 801 Subpart D)

AND/OR

Over-the-Counter Use (Per 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 Surgical, Orthopedic, and Restorative Devices

510(k) Number k09347