K Number
K040948
Device Name
INTUITIVE SURGICAL ENDOPASS ENDOSCOPIC DELIVERY INSTRUMENT, MODEL P/N 400170
Date Cleared
2004-05-05

(23 days)

Product Code
Regulation Number
876.1500
AI/MLSaMDIVD (In Vitro Diagnostic)TherapeuticDiagnosticis PCCP Authorized
Intended Use
The Intuitive Surgical® Endoscopic Instrument Control System (hereinafter referred to as the " da Vinci® System") is intended to assist in the accurate control of Intuitive Surgical® Endoscopic Instruments including rigid endoscopes, blunt and sharp endoscopic dissectors, scalpels, forceps/pick-ups, needle holders, endoscopic retractors, stabilizers, electrocautery and accessories for endoscopic manipulation of tissue, including grasping, cutting, blunt and sharp dissection, approximation, ligation, electrocautery and suturing during general laparoscopic surgical procedures, general non-cardiovascular thoracoscopic surgical procedures, and thoracoscopically-assisted cardiotomy procedures. It is intended to be used by trained physicians in an operating room environment in accordance with the representative, specific procedures set forth in the Professional Instructions for Use. Intuitive Surgical® Endoscopic Instruments including scissors, scalpels, forceps/pick-ups, needle drivers and electrocautery are intended for endoscopic manipulation of tissue, including: grasping, cutting, blunt and sharp dissection, approximation, ligation, electrocautery and suturing.
Device Description
This special 510(k) is being submitted for a modification of Intuitive Surgical® Endoscopic Instruments to include the EndoPass Endoscopic Delivery Instrument. The EndoPass Endoscopic Delivery Instrument is similar to the Clip Applier instrument originally cleared by FDA in 2000 (K990144). The EndoPass Endoscopic Delivery Instrument is used with the Intuitive Surgical® Endoscopic Instrument Control System, also known as the da Vinci Surgical System. The da Vinci Surgical Systemconsists of two integrated sub-systems as follows: Intuitive Surgical® Endoscopic Instrument Control System: This subsystem is comprised of the Surgeon Console and Patient Side Cart. While seated at the Surgeon Console, the surgeon controls critical aspects of the procedure, including movement of the endoscopic instruments and endoscope, within the operative field. Endoscopic instrument and camera movements are controlled by the surgeon through use of the Master Tool Manipulators (MTM), two hand operated mechanisms residing within the Surgeon Console. The endoscopic instruments are held in a fixed position (with respect to the patient) by either two (or optionally three) unique arms known as Patient Side Manipulators (PSM), which are located on the Patient Side Cart (PSC). The endoscope is also held in a fixed position (with respect to the patient) by another arm, similar to the PSM, known as the Endoscope Camera Manipulator (ECM) and also located on the PSC. Commands from the Surgeon Console are relayed to the PSC, which is located immediately adjacent to the patient, via cables. Instrument and endoscope changes are performed by another provider positioned adjacent to the PSC. Intuitive Surgical® Stereo View Endoscopic System: The endoscopic vision system used with the da Vinci® Surgical System, also known as Intuitive Surgical® Insite™ Vision System, consists of a stereo endoscope, endoscopic camera, and various accessories, including a light source and light guides. The Insite™ Vision System provides two independent images that are relayed to the viewer located in the Surgeon Console, where they are fused to form a 3-D (or alternatively a 2-D image) image of the surgical field.
More Information

Not Found

No
The document describes a robotic surgical system controlled by a surgeon and a vision system, with no mention of AI or ML capabilities for autonomous control, image analysis, or decision support.

No
The da Vinci system is designed to assist in "accurate control of Intuitive Surgical® Endoscopic Instruments" for various surgical manipulations like grasping, cutting, and suturing. It is a tool for performing surgery rather than a device intended to treat or cure a disease or condition itself.

No

The device is described as an "Endoscopic Instrument Control System" and its purpose is to "assist in the accurate control of Intuitive Surgical® Endoscopic Instruments" for surgical procedures like "grasping, cutting, blunt and sharp dissection, approximation, ligation, electrocautery and suturing." There is no mention of the device being used for diagnosis or detection of a disease or condition.

No

The device description clearly outlines hardware components such as the Surgeon Console, Patient Side Cart, Master Tool Manipulators, Patient Side Manipulators, Endoscope Camera Manipulator, stereo endoscope, endoscopic camera, light source, and light guides. This indicates it is a hardware-based system with integrated software, not a software-only device.

Based on the provided text, this device is not an IVD (In Vitro Diagnostic).

Here's why:

  • Intended Use: The intended use clearly states that the da Vinci System and its instruments are for assisting in the accurate control of endoscopic instruments for surgical procedures on tissue. This involves physical manipulation, cutting, suturing, etc., within the body.
  • Device Description: The description details a surgical system with a surgeon console, patient side cart, robotic arms, and endoscopic instruments. It also describes a vision system for viewing the surgical field. These are all components of a surgical system used during a procedure.
  • Lack of IVD Characteristics: An IVD device is used to examine specimens from the human body (like blood, urine, tissue samples) in vitro (outside the body) to provide information for diagnosis, monitoring, or screening. The provided text does not mention any such use or components.

The da Vinci Surgical System is a surgical robot designed to assist surgeons in performing minimally invasive procedures. It is not used for testing or analyzing biological samples outside the body.

N/A

Intended Use / Indications for Use

The Intuitive Surgical® Endoscopic Instrument Control System (hereinafter referred to as the " da Vinci® System") is intended to assist in the accurate control of Intuitive Surgical® Endoscopic Instruments including rigid endoscopes, blunt and sharp endoscopic dissectors, scalpels, forceps/pick-ups, needle holders, endoscopic retractors, stabilizers, electrocautery and accessories for endoscopic manipulation of tissue, including grasping, cutting, blunt and sharp dissection, approximation, ligation, electrocautery and suturing during general laparoscopic surgical procedures, general non-cardiovascular thoracoscopic surgical procedures, and thoracoscopically-assisted cardiotomy procedures. It is intended to be used by trained physicians in an operating room environment in accordance with the representative, specific procedures set forth in the Professional Instructions for Use.

Intuitive Surgical® Endoscopic Instruments including scissors, scalpels, forceps/pick-ups, needle drivers and electrocautery are intended for endoscopic manipulation of tissue, including: grasping, cutting, blunt and sharp dissection, approximation, ligation, electrocautery and suturing.

Product codes

NAY

Device Description

This special 510(k) is being submitted for a modification of Intuitive Surgical® Endoscopic Instruments to include the EndoPass Endoscopic Delivery Instrument. The EndoPass Endoscopic Delivery Instrument is similar to the Clip Applier instrument originally cleared by FDA in 2000 (K990144). The EndoPass Endoscopic Delivery Instrument is used with the Intuitive Surgical® Endoscopic Instrument Control System, also known as the da Vinci Surgical System. The da Vinci Surgical Systemconsists of two integrated sub-systems as follows:

Intuitive Surgical® Endoscopic Instrument Control System: This subsystem is comprised of the Surgeon Console and Patient Side Cart. While seated at the Surgeon Console, the surgeon controls critical aspects of the procedure, including movement of the endoscopic instruments and endoscope, within the operative field. Endoscopic instrument and camera movements are controlled by the surgeon through use of the Master Tool Manipulators (MTM), two hand operated mechanisms residing within the Surgeon Console. The endoscopic instruments are held in a fixed position (with respect to the patient) by either two (or optionally three) unique arms known as Patient Side Manipulators (PSM), which are located on the Patient Side Cart (PSC). The endoscope is also held in a fixed position (with respect to the patient) by another arm, similar to the PSM, known as the Endoscope Camera Manipulator (ECM) and also located on the PSC. Commands from the Surgeon Console are relayed to the PSC, which is located immediately adjacent to the patient, via cables. Instrument and endoscope changes are performed by another provider positioned adjacent to the PSC.

Intuitive Surgical® Stereo View Endoscopic System: The endoscopic vision system used with the da Vinci® Surgical System, also known as Intuitive Surgical® Insite™ Vision System, consists of a stereo endoscope, endoscopic camera, and various accessories, including a light source and light guides. The Insite™ Vision System provides two independent images that are relayed to the viewer located in the Surgeon Console, where they are fused to form a 3-D (or alternatively a 2-D image) image of the surgical field.

Mentions image processing

Not Found

Mentions AI, DNN, or ML

Not Found

Input Imaging Modality

Not Found

Anatomical Site

Not Found

Indicated Patient Age Range

Not Found

Intended User / Care Setting

trained physicians in an operating room environment

Description of the training set, sample size, data source, and annotation protocol

Not Found

Description of the test set, sample size, data source, and annotation protocol

Not Found

Summary of Performance Studies

Design analysis and comparison, as well as in vitro testing, confirm that basic functional characteristics are substantially equivalent to the predicate device cited, and that design output meets the design input requirements.

Key Metrics

Not Found

Predicate Device(s)

K990144, K002489, K011002, K013416, K021036, K022574

Reference Device(s)

Not Found

Predetermined Change Control Plan (PCCP) - All Relevant Information

Not Found

§ 876.1500 Endoscope and accessories.

(a)
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.(b)
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.

0

K040948

OC 7

Section II

MAY = 5 2004

510(k) SUMMARY

This summary of 510(k) safety and effectiveness information is submitted in accordance with the requirements of SMDA 1990 and 21 CFR 807.92.

510(k) Number:

DateApril 9, 2004
SubmitterIntuitive Surgical
950 Kifer Road
Sunnyvale, CA 94086
ER Number2955842
ContactMike Yramategui
Director, Regulatory Affairs
Telephone: (408) 523 - 2145
Fax: (408) 523 - 1390
e-mail: mike.yramategui@intusurg.com
New DeviceName: EndoPass Endoscopic Delivery Instrument
Classification Name: System, Surgical, Computer Controlled Instrument
Common Name: Endoscopic Instrument, Delivery Instrument
Predicate
DevicesIntuitive Surgical® Endoscopic Instrument Control System and Intuitive
Surgical® Endoscopic Instruments and accessories
(legally marketed under K990144 / K002489 / K011002 / K013416 / K021036 /
K022574)
Device
DescriptionThis special 510(k) is being submitted for a modification of Intuitive
Surgical® Endoscopic Instruments to include the EndoPass Endoscopic
Delivery Instrument. The EndoPass Endoscopic Delivery Instrument is
similar to the Clip Applier instrument originally cleared by FDA in 2000
(K990144).

1

Device Description (continued)

The EndoPass Endoscopic Delivery Instrument is used with the Intuitive Surgical® Endoscopic Instrument Control System, also known as the da Vinci Surgical System. The da Vinci Surgical Systemconsists of two integrated sub-systems as follows:

Intuitive Surgical® Endoscopic Instrument Control System: This subsystem is comprised of the Surgeon Console and Patient Side Cart. While seated at the Surgeon Console, the surgeon controls critical aspects of the procedure, including movement of the endoscopic instruments and endoscope, within the operative field. Endoscopic instrument and camera movements are controlled by the surgeon through use of the Master Tool Manipulators (MTM), two hand operated mechanisms residing within the Surgeon Console. The endoscopic instruments are held in a fixed position (with respect to the patient) by either two (or optionally three) unique arms known as Patient Side Manipulators (PSM), which are located on the Patient Side Cart (PSC). The endoscope is also held in a fixed position (with respect to the patient) by another arm, similar to the PSM, known as the Endoscope Camera Manipulator (ECM) and also located on the PSC. Commands from the Surgeon Console are relayed to the PSC, which is located immediately adjacent to the patient, via cables. Instrument and endoscope changes are performed by another provider positioned adjacent to the PSC.

Intuitive Surgical® Stereo View Endoscopic System: The endoscopic vision system used with the da Vinci® Surgical System, also known as Intuitive Surgical® Insite™ Vision System, consists of a stereo endoscope, endoscopic camera, and various accessories, including a light source and light guides. The Insite™ Vision System provides two independent images that are relayed to the viewer located in the Surgeon Console, where they are fused to form a 3-D (or alternatively a 2-D image) image of the surgical field.

The Intuitive Surgical® Endoscopic Instrument Control System Intended Use (hereinafter referred to as the " da Vinci Surgical System") is intended to assist in the accurate control of Intuitive Surgical* Endoscopic Instruments including rigid endoscopes, blunt and sharp endoscopic dissectors, scissors, scalpels, forceps/pick-ups, needle holders, endoscopic retractors, stabilizers, electrocautery and accessories for endoscopic manipulation of tissue, including grasping, cutting, blunt and sharp dissection, approximation, ligation, electrocautery and suturing during general laparoscopic surgical procedures, general non-cardiovascular thoracoscopic surgical procedures, and thoracoscopically-assisted cardiotomy procedures. It is intended to be used by trained physicians in an operating room environment in accordance with the representative, specific procedures set forth in the Professional Instructions for Use.

2

| Intended Use
(continued) | Intuitive Surgical® Endoscopic Instruments including scissors, scalpels,
forceps/pick-ups, needle drivers and electrocautery are intended for
endoscopic manipulation of tissue, including: grasping, cutting, blunt and
sharp dissection, approximation, ligation, electrocautery and suturing. |
|--------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Comparison to
Predicate
Device | The Intuitive Surgical® EndoPass Endoscopic Delivery Instrument
described herein is essentially identical in terms of shape, function,
activation, and use to the predicate Class II endoscopic instrument cited
The primary difference is that the predicate device is intended to deliver
and apply a surgical clip to ligate vessels; the subject device is intended to
deliver general accessories, such as suture, needles and clamps, to the
surgical site under the direct control of the console surgeon. |
| Technological
Characteristics | The technological characteristics of the subject devices are the same as or
the predicate devices. |
| Performance
Data | Design analysis and comparison, as well as in vitro testing, confirm that
basic functional characteristics are substantially equivalent to the
predicate device cited, and that design output meets the design input
requirements. |
| Conclusion | Based upon the product technical information, intended use, and
performance information provided in this pre-market notification, the
Intuitive Surgical® EndoPass Endoscopic Delivery Instrument describe is
herein has been shown to be substantially equivalent to the current legally
marketed predicate device, and the results of the design control process
confirm that the design output meets the design input requirements. |

3

DEPARTMENT OF HEALTH & HUMAN SERVICES

Image /page/3/Picture/2 description: The image shows the seal of the Department of Health & Human Services - USA. The seal is circular and contains the text "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" around the perimeter. In the center of the seal is a stylized graphic of an eagle.

Food and Drug Administration 9200 Corporate Boulevard Rockville MD 20850

MAY - 5 2004

Mr. Michael H. Yramategui Director, Regulatory Affairs Intuitive Surgical, Inc. 950 Kifer Road Sunnyvale, California 94086

Re: K040948

Trade/Device Name: Intuitive Surgical® Endoscopic Instrument, EndoPass Endoscopic Delivery Instrument

Regulation Number: 21 CFR 876.1500 Regulation Name: Endoscope and accessories Regulatory Class: II Product Code: NAY Dated: April 9, 2004 Received: April 12, 2004

Dear Mr. Yramategui

We have reviewed your Section 510(k) premarket notification of intent to market the device wt have reviewed four becaren broker is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate for use stated in the encreations of the enactment date of the Medical Device Amendments, or to conimeres pro. to 1125 2012 11:45 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). and Costiete . I've (110) that the device, subject to the general controls provisions of the Act. The I ou may, aroney animas 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 r your de rise to such additional controls. Existing major regulations affecting your device can may or balyeet to decir was a 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 or carf i with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); 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.

4

Page 2 - Mr. Michael H. Yramategui

This letter will allow you to begin marketing your device as described in your Section 510(k) I ma reter nations on. The FDA finding of substantial equivalence of your device to a legally premated 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 contact the Office of Compliance at (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 Manufacturers, International 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,

Muriam C. Provost

Fed Celia M. Witten, Ph.D., M.D. I)irector Division of General, Restorative and Neurological Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

5

Indications for Use

510(k) Number (if known): K040948

Device Name: Intuitive Surgical® Endoscopic Instrument, EndoPass Endoscopic Delivery Instrument

Indications For Use:

The Intuitive Surgical® Endoscopic Instrument Control System (hereinafter referred to as the " da Vinci® System") is intended to assist in the accurate control of Intuitive Surgical® Endoscopic Instruments including rigid endoscopes, blunt and sharp endoscopic dissectors, scalpels, forceps/pick-ups, needle holders, endoscopic retractors, stabilizers, electrocautery and accessories for endoscopic manipulation of tissue, including grasping, cutting, blunt and sharp dissection, approximation, ligation, electrocautery and suturing during general laparoscopic surgical procedures, general non-cardiovascular thoracoscopic surgical procedures, and thoracoscopically-assisted cardiotomy procedures. It is intended to be used by trained physicians in an operating room environment in accordance with the representative, specific procedures set forth in the Professional Instructions for Use.

Intuitive Surgical® Endoscopic Instruments including scissors, scalpels, forceps/pick-ups, needle drivers and electrocautery are intended for endoscopic manipulation of tissue, including: grasping, cutting, blunt and sharp dissection, approximation, ligation, electrocautery and suturing.

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

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)

Muriam C. Provost

(Division Sign-Off) Division of General, Restorative, and Neurological Devices

Page 1 of ____________________________________________________________________________________________________________________________________________________________________

510(k) Number_Ko40948