LTF-Y0009; MAJ-YOO41; XOEV-3D1

K102379 · Olympus Medical Systems Corporation · GCJ · Jan 5, 2011 · Gastroenterology, Urology

Device Facts

• Record ID: K102379
• Device Name: LTF-Y0009; MAJ-YOO41; XOEV-3D1
• Applicant: Olympus Medical Systems Corporation
• Product Code: GCJ · Gastroenterology, Urology
• Decision Date: Jan 5, 2011
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 876.1500
• Device Class: Class 2

Intended Use

This instrument has been designed for use in conjunction with light source, video system centers, 3D Video Mixer, 3D monitor, documentation equipment, hand instruments, and other ancillary equipment for endoscopy and endoscopic surgery within the peritoneal and thoracic cavity. This instrument has been designed to be used with Olympus 3D Laparo-Thoraco videoscope and Video System Center for 3D video observation. This instrument has been designed to be used with Olympus 3D Laparo-Thoraco videoscope, light source, video system center and 3D Video Mixer for endoscopic diagnosis and video observation. This instrument has been designed to be used with Olympus 3D Laparo-Thoraco videoscope, light source, video system center, 3D Video Mixer and 3D monitor for 3D video observation.

Device Story

System captures stereoscopic video via two CCDs at distal end of LTF-Y0009 videoscope; signals transmitted to video system center (CV-Y0001) for conversion; 3D Video Mixer (MAJ-Y0041) processes signals into 3D video output; Polarized 3D Monitor (XOEV-3D1) displays passive stereo image; users wear polarized 3D glasses (MAJ-Y0108) for 3D visualization. Used in clinical settings (OR/clinic) by physicians for endoscopic surgery and diagnosis. Provides depth perception to assist in surgical navigation and diagnostic visualization; benefits patient through enhanced spatial awareness during minimally invasive procedures.

Clinical Evidence

No clinical data; bench testing only.

Technological Characteristics

System includes 3D Laparo-Thoraco Videoscope, 3D Video Mixer, Polarized 3D Monitor, and 3D glasses. Uses dual CCD sensors for stereoscopic image capture. Passive stereo display technology with polarized glasses. Connectivity via video system center. Class II device.

Indications for Use

Indicated for use in endoscopy and endoscopic surgery within the peritoneal and thoracic cavity for patients requiring endoscopic diagnosis or surgical intervention.

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

• 3D Laparoscope OLYMPUS LTF Type VH (K943304, K943305, K943307)
• LTF-VH (K080948)

Submission Summary (Full Text)

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K/02379

510(k) SUMMARY LTF-Y0009, XOEV-3D1, MAJ-Y0041 3D Laparo-Thoraco Videoscope, Polarized 3D Monitor, 3D Video Mixer

JAN - 5 2011

October 21, 2010

### 1 General Information

- OLYMPUS MEDICAL SYSTEMS CORP. 1 Applicant: 2951 Ishikawa-cho, Hachioji-shi, Tokyo, Japan 192-8507 Establishment Registration No: 8010047
- Stacy Abbatiello Kluesner, M.S., RAC ■ Official Correspondent: Regulatory Affairs & Quality Assurance Olympus America Inc. 3500 Corporate Parkway PO Box 610 Center Valley, PA 18034-0610, USA Phone: [phone] FAX: [phone] Email: [e-mail]
- OLYMPUS MEDICAL SYSTEMS CORP. Hinode Plant ■ Manufacturer: 34-3 Hirai, Hinode-cho, Nishitama-gun, Tokyo, 190-0182, Japan Establishment Registration No : 3003637092

#### 2 Device Identification

- Device Trade Name: LTF-Y0009, XOEV-3D1, MAJ-Y0041
- 3D Laparo-Thoraco Videoscope, . Common Name: Polarized 3D Monitor, 3D Video Mixer
- D Regulation Number:
- 884.1720 874.4720
- Endoscope and accessories 다 Regulation Name: Gynecologic laparoscope and accessories Mediastinoscope and accessories

876.1500

- Regulatory Class: ll 1
- Gastroenterology and urology, Classification Panel: Obstetrics/Gynecology

P. 1 of 3

.

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General & Plastic Surgery

FCG, FAL, HET, GCJ, and NWB Product Code: "

# 3 Predicate Device Information

- 3D Laparoscope A5300 Urology , Ob/Gyn, General 1 Device Name: Surgery HD EndoEYE Laparo-Thoraco Videoscope OLYMPUS LTF Type VH
- . Common Name: 3D Laparoscope Laparo-Thoraco Videoscope
- Aizu Olympus Co., Ltd. . Manufacturer: 500 Aza-Muranishi, Ooaza-lidera, Monden-cho, Aizuwakamatsu-shi, Fukushima, Japan 965-8520 Establishment Registration No .: 9610595 3D Laparoscope - Urology (K943304) . 510(k) No. 3D Laparoscope - Ob/Gyn (K943305) 3D Laparoscope - General Surgery (K943307)

LTF-VH (K080948)

# 4 Device Description

3D Laparo-Thoraco Videoscope (LTF-Y0009) is a video endoscope used for endoscopy and endoscopic surgery within the peritoneal and thoracic cavity. LTF-Y0009 is basically identical to predicate device 3D Laparoscope, for the same application areas. The 3D video observation of this system is implemented with following process. The captured signals from two CCDs which correspond to left and right eye incorporated in distal end of the subject LTF-Y0009 are transferred to the MAJ-Y0041 via CV-Y0001. CV-Y0001 converts the captured signals into video image signals, and transmits them to the MAJ-Y0041. The MAJ-Y0041 converts the image signals into 3D video signal and transfers it to the XOEV-3D1. On the XOEV-3D1, 3D video image is displayed as passive stereo type which has different polarizing angle in the left and right; therefore, the MAJ-Y0108 is required to obtain 3D video image. The MAJ-Y0108's glasses have polarizing films on them which correspond to their each polarizing angle and it enables 3D observation to the users.

### 5 Indications for Use

- LTF-Y0009 (3D Laparo-Thoraco Videoscope)
This instrument has been designed for use in conjunction with light source, video system centers, 3D Video Mixer, 3D monitor, documentation equipment, hand instruments, and other ancillary equipment for endoscopy and endoscopic surgery within the peritoneal and thoracic cavity.

P.2/3

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### - MAJ-Y0041 (3D Video Mixer)

This instrument has been designed to be used with Olympus 3D Laparo-Thoraco videoscope and Video System Center for 3D video observation.

### - XOEV-3D1(Polarized 3D Monitor)

This instrument has been designed to be used with Olympus 3D Laparo-Thoraco videoscope, light source, video system center and 3D Video Mixer for endoscopic diagnosis and video observation.

#### - MAJ-Y0108 (3D glasses)

This instrument has been designed to be used with Olympus 3D Laparo-Thoraco videoscope, light source, video system center, 3D Video Mixer and 3D monitor for 3D video observation.

# 6 Comparison of Technological Characteristics

The LTF-Y0009, XOEV-3D1. MAJ-Y0041 is basically identical to the predicate device in intended use, and similar in specifications except for the optical system of the subject LTF-Y0009.

# 7 Conclusion

When compared to the predicate device, the LTF-Y0009, XQEV-3D1, MAJ-Y0041 do not incorporate any significant changes in intended use, method of operation, material, or design that could affect the safety or effectiveness of the device.

P3/3

: 222222

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Image /page/3/Picture/0 description: The image shows the seal of the Department of Health & Human Services (HHS) of the United States of America. The seal features a stylized depiction of an eagle with its wings spread, symbolizing protection and care. The words "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" are arranged in a circular pattern around the eagle, indicating the department's name and national affiliation.

Food and Drug Administration 10903 New Hampshire Avenue Document Control Room -WO66-G609 Silver Spring, MD 20993-0002

Olympus Medical Systems Corporation % Olympus America. Inc. Stacy Abbatiello Kluesner, M.S., RAC 3500 Corporate Parkway P.O. Box 610 Center Valley, Pennsylvania 18034-0610

JAN - 5 2011

Re: K102379

Trade/Device Name: 3D Laparo-Thoraco Videoscope: Polarized 3D Monitor: 3D Video Mixer: 3D Glasses Regulation Number: 21 CFR 876.1500 Regulation Name: Endoscope and accessories Regulatory Class: Class II Product Code: GCJ Dated: December 28, 2010 Received: December 29, 2010

Dear Ms. Kluesner:

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.

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Page 2 - Stacy Abbatiello Kluesner, M.S., RAC

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 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/AboutlFDA/CentersOffices/CDRH/CDRHOffices/ucm115809.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/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 Small Manufacturers, International and Consumer Assistance at its toll-free number [phone] or [phone] or at its Internet address http://www.fda.gov/MedicalDevices/Resourcesfor You/Industry/default.htm.

Sincerely 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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510(k) Number (if known):K102379

JAN - 5 2011

Device Name: 3D Laparo-Thoraco Videoscope

Indications For Use:

This instrument has been designed for use in conjunction with light source, video system centers, 3D video mixer, 3D monitor, documentation equipment, hand instruments, and other ancillary equipment for endoscopy and endoscopic surgery within the peritoneal and thoracic cavity.

Prescription Use_ > AND/OR (Part 21 CFR 801 Subpart D)

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)

Page 1 of _4

Nitrogen for min

Division Sign-Division of Surgical, Orthopedic, and Restorative Devices

510(k) Number. K102379

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510(k) Number (if known): K102379 Device Name: 3D VIDEO MIXER

JAN - 5 2011

Indications For Use:

This instrument has been designed to be used with Olympus 3D Laparo-Thoraco videoscope and video system center for 3D video observation.

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

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)

Page 2 of _ 4

Nid R.P. Dahlen ferson
(Print Name)

(Division Sign-Off) Division of Surgical, Orthopedic, and Restorative Devices

510(k) Number_ K102379

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JAN - 5 2011

# 510(k) Number (if known):K102379 Device Name: POLARIZED 3D MONITOR

Indications For Use:

This instrument has been designed to be used with Olympus 3D Laparo-Thoraco videoscope, light source, video system center and 3D video mixer for endoscopic diagnosis and video observation.

AND/OR Prescription Use_ > (Part 21 CFR 801 Subpart D)

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)

Page 3 of 4

Phil REDden Lir MKM
(Division Chief of Staff)

(Division Sign-Off) Division of Surgical, Orthopedic, and Restorative Devices

510(k) Number K102379

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510(k) Number (if known):K102379 Device Name: 3D glasses

JAN - 5 2011

Indications For Use:

This instrument has been designed to be used with Olympus 3D Laparo-Thoraco videoscope, light source, video system center, 3D Video Mixer and 3D monitor for 3D video observation.

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

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)

Page 4 of 4

Ndlke Dule for mkm
Division Sign-Off

(Division Sign-Off) Division of Surgical, Orthopedic, and Restorative Devices

510(k) Number_K102379