EVA15 insufflator

K232902 · Palliare , Ltd. · HIF · May 2, 2024 · Obstetrics/Gynecology

Device Facts

• Record ID: K232902
• Device Name: EVA15 insufflator
• Applicant: Palliare , Ltd.
• Product Code: HIF · Obstetrics/Gynecology
• Decision Date: May 2, 2024
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 884.1730
• Device Class: Class 2
• Attributes: Therapeutic

Intended Use

The EVA15 Insufflator is intended for use in diagnostic and/or therapeutic endoscopic and laparoscopic procedures to distend the abdomen, rectum, colon, esophagus, stomach or thoracic cavity with up to 25 mmHg pressure, by filling it with gas and to evacuate surgical smoke.

Device Story

EVA15 Insufflator is a microprocessor-controlled device for endoscopic/laparoscopic procedures; performs cavity distension via CO2 insufflation and surgical smoke evacuation via venturi vacuum. Used in OR or endoscopy suites by clinicians. Input: compressed CO2 (50 psi) and air; output: gas flow (up to 40 SLPM) and smoke evacuation. New AutoEvac accessory enables automatic smoke evacuation activation/deactivation by sensing electrical energy from electrosurgical tools; replaces manual pneumatic foot pedal. Device benefits include automated smoke management, improving visualization and safety during surgery. System includes reusable insufflator unit and sterile, single-use tube set.

Clinical Evidence

Bench testing only. Performance testing verified the ability of the AutoEvac accessory to activate/deactivate smoke evacuation in response to electrosurgical energy. Compliance with IEC 60601-1 (safety) and IEC 60601-1-2 (EMC) was demonstrated.

Technological Characteristics

Microprocessor-controlled insufflator; digital pressure regulation; venturi-based smoke evacuation. Powered by 100-240V AC; uses 50 psi CO2/air. Dimensions: 160x130x330mm; weight: 5.5kg. Sterile, single-use tube set (EtO sterilized). AutoEvac accessory is battery-operated with antenna for energy sensing. No software in AutoEvac accessory.

Indications for Use

Indicated for patients undergoing laparoscopic or endoscopic procedures requiring cavity distension (up to 25 mmHg) and surgical smoke evacuation. No specific age or gender contraindications provided.

Regulatory Classification

Identification

A laparoscopic insufflator is a device used to facilitate the use of the laparoscope by filling the peritoneal cavity with gas to distend it.

Predicate Devices

• Palliare EVA15 (K222901)

Reference Devices

• Buffalo Filter VISICLEAR (K131402)

Submission Summary (Full Text)

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May 2, 2024

Palliare Ltd. % Paul Dryden President ProMedic Consulting LLC 131 Bay Point Dr. NE St. Petersburg, Florida 33704

Re: K232902

> Trade/Device Name: EVA15 insufflator Regulation Number: 21 CFR 884.1730 Regulation Name: Laparoscopic Insufflator Regulatory Class: II Product Code: HIF Dated: April 24, 2024 Received: April 24, 2024

Dear Paul Dryden:

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 (the 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. Although this letter refers to your product as a device, please be aware that some cleared products may instead be combination products. The 510(k) Premarket Notification Database available at https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm identifies combination product submissions. 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.

Additional information about changes that may require a new premarket notification are provided in the FDA guidance documents entitled "Deciding When to Submit a 510(k) for a Change to an Existing Device"

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(https://www.fda.gov/media/99812/download) and "Deciding When to Submit a 510(k) for a Software Change to an Existing Device" (https://www.fda.gov/media/99785/download).

Your device is also subject to, among other requirements, the Quality System (QS) regulation (21 CFR Part 820), which includes, but is not limited to, 21 CFR 820.30. Design controls; 21 CFR 820.90. Nonconforming product; and 21 CFR 820.100, Corrective and preventive action. Please note that regardless of whether a change requires premarket review. the OS regulation requires device manufacturers to review and approve changes to device design and production (21 CFR 820.30 and 21 CFR 820.70) and document changes and approvals in the device master record (21 CFR 820.181).

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 of medical device-related adverse events) (21 CFR Part 803) for devices or postmarketing safety reporting (21 CFR Part 4, Subpart B) for combination products (see https://www.fda.gov/combination-products/guidance-regulatory-information/postmarketing-safety-reportingcombination-products); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820) for devices or current good manufacturing practices (21 CFR Part 4, Subpart A) for combination products; and, if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR Parts 1000-1050.

Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21 CFR 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to https://www.fda.gov/medical-device-safety/medical-device-reportingmdr-how-report-medical-device-problems.

For comprehensive regulatory information about mediation-emitting products, including information about labeling regulations, please see Device Advice (https://www.fda.gov/medicaldevices/device-advice-comprehensive-regulatory-assistance) and CDRH Learn (https://www.fda.gov/training-and-continuing-education/cdrh-learn). Additionally, you may contact the Division of Industry and Consumer Education (DICE) to ask a question about a specific regulatory topic. See

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the DICE website (https://www.fda.gov/medical-device-advice-comprehensive-regulatoryassistance/contact-us-division-industry-and-consumer-education-dice) for more information or contact DICE by email ([e-mail]) or phone [phone] or 301-796-7100).

Sincerely,

# Jason Roberts -S

Jason R. Roberts, Ph.D. Assistant Director DHT3B: Division of Reproductive, Gynecology and Urology Devices OHT3: Office of Gastrorenal, ObGyn, General Hospital, and Urology Devices Office of Product Evaluation and Quality Center for Devices and Radiological Health

Enclosure

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| Date Prepared: | 2-May-24 |
|----------------------------|-----------------------------------------------------------------------------------------------------------------------------------|
| Official Contact: | John O'Dea, Ph.D., CEO<br>Palliare Ltd.<br>Galway Business Park,<br>Dangan Galway H91 P2DK, Ireland<br>Telephone - [phone] |
| Submission Correspondent: | Paul Dryden<br>ProMedic, LLC |
| Proprietary or Trade Name: | EVA15 Insufflator |
| Common/Usual Name: | CO2 insufflator |
| Regulation Number: | 21 CFR 884.1730 |
| Regulation Name: | Laparoscopic insufflator |
| Product Code: | HIF |
| Predicate Device: | K222901 - Palliare EVA15 |
| Reference Device: | K131402 – Buffalo Filter VISICLEAR |

#### Modifications:

We have provided an accessory, Auto-Evac, as an alternative to the pneumatic foot pedal used by the predicate - K222901 to activate and de-activate the EVA15 smoke evacuation functionality.

#### Device Description:

The EVA15 insufflator is intended for use in diagnostic and/or therapeutic endoscopic and laparoscopic procedures to distend a cavity by filling it with gas and to evacuate surgical smoke. It is indicated to facilitate the use of various endoscopic instruments by filling the abdominal cavity or rectum with gas to distend it, and by evacuating surgical smoke. The EVA15 Insufflator is used in an operating room or endoscopic suite. It consists of the following major components: (1) a micro-processor-controlled insufflation and smoke evacuation unit, and (2) a disposable tube set.

The laparoscopic tube set is a sterile, single-use product. The EVA15 Insufflator is an active medical device, nonsterile and reusable and is intended to insufflate a body cavity up to 25 mmHg and with up to 40 SLPM instantaneous flow. The EVA15 is powered by AC and uses compressed 50 psi CO2 and air gas supply the pneumatic circuitry for insufflation and smoke evacuation respectively.

#### Principle of Operation:

The operating principle employs 2 methods. A) A digital insufflation pressure regulation system using compressed CO2 gas to deliver CO2 into the patient cavity to be insufflated at the direction and control of the physician and B) The use of a venturi method to create a vacuum to evacuate any smoke created during the procedure. Smoke evacuation in the predicate is activated/deactivated by sequentially pressing a pneumatic foot-pedal. AutoEvac comprises a battery-operated pneumatic pump along with an antenna to detect when an electrical energy system has been activated. Using the same pneumatic connection as used in the predicate, when energy is activated the pump turns on, causing the smoke evacuator to switch on, and when energy is de-activated the pump turns off up to 5 seconds later which turns off the smoke evacuator.

#### Indications for Use:

The EVA15 Insufflator is intended for use in diagnostic and/or therapeutic endoscopic and laparoscopic procedures to distend the abdomen, rectum, colon, esophagus, stomach or thoracic cavity with up to 25 mmHg pressure, by filling it with gas and to evacuate surgical smoke.

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# Patient Population:

Patients undergoing laparoscopic or endoscopic procedures in which insufflation may be helpful.

#### Environments of use:

Operating room or endoscopy suite.

Table 1 is a comparison - Subject Device vs. the Predicate, K222901 - Palliare EVA15.

# Substantial Equivalence Discussion

The EVA15 insufflator has the identical intended use and indications, technological characteristics, and principles of operation as the predicate Palliare EVA15, K222901. There has been no change to the EVA15 system, but an additional accessory is made available to activate/de-activate smoke evacuation.

## Intended Use/ Indications for Use

Unchanged from the predicate

# Technological Characteristics

The modification does not change the technological characteristics of the EVA 15 insufflator and smoke evacuation system. The AutoEvac accessory provides an alternative means of turning on and off smoke evacuation. Both AutoEvac and the foot pedal accessories activate/deactivate smoke evacuation using the same pneumatic tube. The AutoEvac accessory does not employ software.

## Principles of Operation

The EVA 15 Insufflator principle of operation remains unchanged to the predicate.

# Non-clinical Testing

Performance testing of the insufflator has demonstrated the ability to activate and de-activate smoke evacuation when electrosurgical energy is switched on and off. including testing to IEC 60601-1:2005/AMD1:2012 / AMD 2:2020 (Edition 3.2) - Medical Electrical Equipment - Part 1: General Requirements For Safety and IEC 60601-1-2:2014 / A1:2020 (Edition 4.1) – Medical electrical equipment - Part 1-2: General requirements for basic safety and essential performance - Collateral Standard: Electromagnetic disturbances - Requirements and tests.

# Substantial Equivalence Conclusion

The EVA15 with the AutoEvac accessory has the same intended use, indications, technological characteristics and principles of operation as the predicate.

This difference does not raise different questions of safety or effectiveness as compared to the predicate device because smoke evacuation is activated/de-activated using the same pneumatic principle.

The AutoEvac accessory uses energy sensing to activate and de-activate smoke evacuation in a similar manner to the reference device, Buffalo Filter Visiclear - K131402, which has an accessory called the EZLink automatic activation device. The results of non-clinical performance testing demonstrate that the subject device is as safe and effective as the predicate device to support a substantial equivalence determination.

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| | Subject Device:<br>EVA15 Insufflator with AutoEvac | Predicate:<br>EVA15 Insufflator - K222901 | Comparison |
|-----------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------|
| Manufacturer | Palliare | Palliare | |
| Classification | 21 C.F.R. § 884.1730 (Laparoscopic Insufflator)<br>Product Code HIF (Class II) | 21 C.F.R. § 884.1730 (Laparoscopic Insufflator)<br>Product Code HIF (Class II) | Same |
| Fundamental<br>scientific<br>technology | Digital insufflation pressure regulation system using<br>compressed CO2 gas. Venturi smoke evacuation. | Digital insufflation pressure regulation system using<br>compressed CO2 gas. Venturi smoke evacuation. | Same |
| Patient<br>connection | Standard Trocar luer connection | Standard Trocar luer connection | Same |
| Indications for<br>Use | The EVA15 Insufflator is intended for use in diagnostic<br>and/or therapeutic endoscopic and laparoscopic<br>procedures to distend the abdomen, rectum, colon,<br>esophagus, stomach or thoracic cavity with up to 25<br>mmHg pressure, by filling it with gas and to evacuate<br>surgical smoke. | The EVA15 Insufflator is intended for use in diagnostic<br>and/or therapeutic endoscopic and laparoscopic<br>procedures to distend the abdomen, rectum, colon,<br>esophagus, stomach or thoracic cavity with up to 25<br>mmHg pressure, by filling it with gas and to evacuate<br>surgical smoke. | Same |
| Gas Deliverv<br>Modes | Intermittent Pressure (Standard) Insufflation<br>Continuous Pressure Insufflation | Intermittent Pressure (Standard) Insufflation<br>Continuous Pressure Insufflation | Same |
| Smoke<br>Evacuation | Available in all modes. Operates continuously or may be<br>activated on/off using foot pedal or automatically using<br>the AutoEvac accessory. | Available in all modes. Operates continuously or may be<br>activated on/off using foot pedal. | Alternative accessory<br>provided for automatic<br>activation and deactivation<br>of smoke evacuation |
| Technology of<br>energy sensing | Activates which surgical energy is sensed | Not available, but use of a reference<br>Buffalo Filter Visiclear - K131402 EZLink automatic<br>activation device when surgical energy is sensed. | Buffalo Filter Visiclear -<br>K131402 EZLink<br>automatic activation<br>device when surgical<br>energy is sensed. |

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K232902 Page 4 of 4

# 510(k) Summary Page 4 of 4

| | Subject Device: | Predicate: | Comparison |
|-------------------------------|--------------------------------------------------------|-----------------------------|------------|
| | EVA15 Insufflator | EVA15 Insufflator - K222901 | |
| Flow Range | 0-40 SLPM | 0-40 SLPM | Same |
| Pressure Range | Up to 25 mmHg | Up to 25 mmHg | Same |
| Accessories | Tubeset | Tubeset | Same |
| Use limitation of<br>tube set | 48 hours due to ID Chip | 48 hours due to ID Chip | Same |
| Dimensions | 160x130x330mm | 160x130x330mm | Same |
| Weight | 5.5kg | 5.5kg | Same |
| Power Source | 100-240V | 100-240V | Same |
| Tubeset<br>Sterilization | EtO | EtO | Same |
| User Interface | Membrane Panel | Membrane Panel | Same |
| Testing | IEC 60601-1 Electrical safety<br>IEC 60601-1-2 - - EMC | Similar | Similar |

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# Indications for Use

510(k) Number (if known) K232902

Device Name EVA15 Insufflator

Indications for Use (Describe)

The EVA15 Insufflator is intended for use in diagnostic and/or therapeutic endoscopic procedures to distend the abdomen, rectum, colon, esophagus, stomach or thoracic cavity with up to 25 mmHg pressure, by filling it with gas and to evacuate surgical smoke.

| Type of Use (Select one or both, as applicable) | |
|----------------------------------------------------------------------------------|----------------------------------------------------------------------|
| <input checked="" type="checkbox"/> Prescription Use (Part 21 CFR 801 Subpart D) | <input type="checkbox"/> Over-The-Counter Use (21 CFR 801 Subpart C) |

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