IS4000 8mm Harmonic ACE Curved Shears

K143132 · Intuitive Surgical, Inc. · NAY · Apr 2, 2015 · Gastroenterology, Urology

Device Facts

Record IDK143132
Device NameIS4000 8mm Harmonic ACE Curved Shears
ApplicantIntuitive Surgical, Inc.
Product CodeNAY · Gastroenterology, Urology
Decision DateApr 2, 2015
DecisionSESE
Submission TypeTraditional
Regulation21 CFR 876.1500
Device ClassClass 2
AttributesTherapeutic

Indications for Use

The IS4000 8 mm Harmonic ACE™ Curved Shears 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 IS4000 (da Vinci Xi) Surgical System and a compatible Ethicon Endo-Surgery Generator and Hand Piece.

Device Story

Single-use, sterile ultrasonic surgical instrument; delivers ultrasonic energy for tissue transection and coagulation. Operated by surgeon via da Vinci Xi (IS4000) Surgeon Console; integrates with Ethicon Endo-Surgery Generator (G11) and Hand Piece (HP054). Used in surgical environments for soft tissue procedures. Provides precise cutting and hemostasis; minimizes thermal injury to surrounding tissue. Benefits patient through controlled, minimally invasive tissue management.

Clinical Evidence

No human clinical data. Evidence consists of bench testing (dimensional, mechanical, electrical, functional, cleaning/sterilization, packaging, labeling) and animal testing using simulated clinical models. Reliability testing included simulated use cycling, mechanical stressing, and RFID functional testing. All tests passed.

Technological Characteristics

Single-use ultrasonic surgical instrument; compatible with Ethicon G11 generator and HP054 hand piece. Features RFID for equipment interface. Designed for integration with da Vinci Xi (IS4000) robotic system. Sterilized device.

Indications for Use

Indicated for soft tissue incisions requiring bleeding control and minimal thermal injury. Used in conjunction with the da Vinci Xi Surgical System.

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}------------------------------------------------ Image /page/0/Picture/1 description: The image is a black and white logo for the U.S. Department of Health & Human Services. The logo features the department's name in a circular arrangement around a symbol. The symbol is a stylized representation of three human profiles facing right, with flowing lines above them that could be interpreted as hair or wings. Food and Drug Administration 10903 New Hampshire Avenue Document Control Center - WO66-G609 Silver Spring, MD 20993-0002 April 2, 2015 Intuitive Surgical Incorporated Ms. Nadine Nasr Senior Regulatory Affairs Specialist 1266 Kifer Road Sunnyvale, California 94086 Re: K143132 Trade/Device Name: IS4000 8mm Harmonic ACETM Curved Shears Regulation Number: 21 CFR 876.1500 Regulation Name: Endoscope and Accessories Regulatory Class: Class II Product Code: NAY Dated: February 23, 2015 Received: February 25, 2015 Dear Ms. Nasr. 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. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading. 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 device-related adverse events) (21 CFR 803); good manufacturing practice requirements as set {1}------------------------------------------------ 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 contact the Division of Industry and Consumer Education at its toll-free number (800) 638-2041 or (301) 796-7100 or at its Internet address http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm. Also, please note the regulation entitled. "Misbranding by reference to premarket notification" (21 CFR 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/MedicalDevices/Safety/ReportaProblem/default.htm 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 Industry and Consumer Education at its toll-free number (800) 638-2041 or (301) 796-7100 or at its Internet address http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm. Sincerely yours, # Jennifer R. Stevenson -S For Binita S. Ashar, M.D., M.B.A., F.A.C.S. Director Division of Surgical Devices Office of Device Evaluation Center for Devices and Radiological Health Enclosure {2}------------------------------------------------ # Indications for Use 510(k) Number (if known) K143132 Device Name IS4000 8mm Harmonic ACETM Curved Shears Indications for Use (Describe) The IS4000 Harmonic ACE™ Curved Shears 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 IS4000 (da Vinci Xi) Surgical Systems and a compatible Ethicon Endo - Surgery Generator and Hand Piece. | Type of Use (Select one or both, as applicable) | | |------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------| | <span style="font-size:16px">☒</span> Prescription Use (Part 21 CFR 801 Subpart D) | <span style="font-size:16px">☐</span> Over-The-Counter Use (21 CFR 801 Subpart C) | #### CONTINUE ON A SEPARATE PAGE IF NEEDED. This section applies only to requirements of the Paperwork Reduction Act of 1995. #### *DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF EMAIL ADDRESS BELOW.* The burden time for this collection of information is estimated to average 79 hours per response, including the time to review instructions, search existing data sources, gather and maintain the data needed and complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden, to: > Department of Health and Human Services Food and Drug Administration Office of Chief Information Officer Paperwork Reduction Act (PRA) Staff PRAStaff@fda.hhs.gov "An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB number." {3}------------------------------------------------ ### 510(k) Summary | 510(k) Owner: | Intuitive Surgical, Inc. | |-------------------------|---------------------------------------------------------------------------------------| | | 1266 Kifer Road | | | Sunnyvale, CA 94086 | | Contact: | Nadine Nasr | | | Regulatory Affairs | | | Phone Number: 408-523-7093Fax Number: 408-523-8907 | | | Email: Nadine.nasr@intusurg.com | | Date Summary Prepared: | March 31, 2015 | | Trade Name: | IS4000 8 mm Harmonic ACE™ Curved Shears | | Common Name: | System, Surgical, Computer Controlled Instrument (instrument,<br>ultrasonic surgical) | | Classification: | Class II | | | 21 CFR 876.1500, Endoscope and Accessories | | Product Codes: | NAY (System, Surgical, Computer Controlled Instrument) | | Classification Advisory | | | Committee: | General and Plastic Surgery | | Predicate Device: | da Vinci 8 mm Harmonic ACE™ device, cleared under K112584 | ## Device Description The IS4000 8 mm Harmonic ACE Curved Shears is a single-use, sterile instrument used to deliver ultrasonic energy to enable transection and coagulation of tissue. The movement and function of the IS4000 8 mm Harmonic ACE Curved Shears are controlled by the surgeon from the Surgeon Console of the da Vinci Xi Surgical System (model IS4000). The instrument is compatible with the Ethicon Hand Piece (model HP054) and Ethicon Endo-Surgery Generator (model G11). ## Intended Use/Indications for Use: The IS4000 8 mm Harmonic ACE™ Curved Shears 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 IS4000 (da Vinci Xi) Surgical System and a compatible Ethicon Endo-Surgery Generator and Hand Piece. Image /page/3/Picture/8 description: The image shows the logo for Intuitive Surgical. The word "INTUITIVE" is in all caps and in a light gray color. Below that, the words "SURGICAL" and the registered trademark symbol are also in light gray. {4}------------------------------------------------ ## Technological Characteristics: In terms of intended use, indications for use, and technological characteristics, the IS4000 8 mm Harmonic ACE Curved Shears are substantially equivalent to the currently marketed da Vinci 8 mm Harmonic ACE device, cleared under K112584. ## Performance Data: Performance test data (bench and animal tests) demonstrate that the subject device is substantially equivalent to the predicate device and that the design output meets the design input requirements for the IS4000 8 mm Harmonic ACE Curved Shears. The testing conducted consisted of design verification, reliability, and animal testing. ### Design Verification: The testing provided in this submission consisted of dimensional measurements, mechanical, and functional verification. | Test | Results | |--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------| | Design Verification –<br>The purpose of this test was to verify that the<br>instrument met the dimensional, mechanical,<br>functional, and electrical requirements and<br>specifications. Test methods were based on<br>pre-defined test procedures, and objective<br>pass/fail criteria were defined in the protocol<br>and used. Sample sizes up to six units were<br>used. The following design verification tests<br>were performed:<br>- Dimensional<br>- Mechanical<br>- Electrical<br>- User/Equipment Interface<br>- Cleaning and Sterilization<br>- Packaging<br>- Labeling | - All final tests PASSED | Image /page/4/Picture/9 description: The image shows the logo for Intuitive Surgical. The word "INTUITIVE" is in all caps and in a light gray color. Below that, the word "SURGICAL" is also in all caps and in a smaller font size, also in light gray. There is a yellow dot above the word "INTUITIVE". {5}------------------------------------------------ ## Reliability: The testing provided in this submission consisted of simulated use cycling test articles through their typical use environment, including sterilization. The evaluation method included visual inspections as well as functional testing. | Test | Results | |---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------| | Design Verification, Life –<br>The purpose of this test was to verify that the<br>instrument was robust when exposed to a<br>typical use environment. A sample size of six<br>was used. Test articles were cycled through<br>simulated clinical use, including the following:<br>- Surgical Maneuvers and Tasks<br>- Visual Inspection<br>- Mechanical Stressing<br>- Equipment Interface<br>- RFID Functional Test | - All final tests PASSED | ## Animal Testing: The testing provided in this submission was performed using simulated clinical models (animal) to confirm that the IS4000 8 mm Harmonic ACE Curved Shears meets the user needs and intended use. | Test | Summary | |----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------| | Design Validation –<br>The purpose of this testing was to confirm that<br>the IS4000 8 mm Harmonic ACE™ Curved<br>Shears meets the user needs and intended use<br>as documented in the Product Requirements<br>document. Test methods were based on pre-<br>defined test procedures and objective pass/fail<br>criteria were defined in the protocol and used. | All final tests PASSED | # Human Factors and Usability Testing: After review of IS1200, and IS3000 da Vinci Harmonic instruments data (e.g., field actions, MDRs, etc.), an analysis of predicate device comparison, and formative usability testing of the IS4000 Harmonic ACE instrument, it was concluded that the usability of the IS4000 Harmonic ACE instrument, when used by the intended users in the intended use environment in foreseeable use scenarios, is safe and effective. {6}------------------------------------------------ # Summary: Based on the intended use, indications for use, technological characteristics, and the results of the verification and validation testing, the IS4000 8 mm Harmonic ACE Curved Shears meets all verification and validation requirements and is considered substantially equivalent to the predicate device. Image /page/6/Picture/4 description: The image shows the logo for Intuitive Surgical. The word "INTUITIVE" is in large, sans-serif, gray letters. Below that, in smaller letters, is the word "SURGICAL" also in gray. Above the word "INTUITIVE" is a small, yellow circle.
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