← Product Code [KCT](/productcode/KCT) · K152745

# ReNew Sterilization Trays(Catalog #3708 and #3709) (K152745)

_Microline Surgical, Inc. · KCT · May 12, 2016 · General Hospital · SESE_

**Canonical URL:** https://fda-staging.innolitics.com/device/K152745

## Device Facts

- **Applicant:** Microline Surgical, Inc.
- **Product Code:** [KCT](/productcode/KCT.md)
- **Decision Date:** May 12, 2016
- **Decision:** SESE
- **Submission Type:** Traditional
- **Regulation:** 21 CFR 880.6850
- **Device Class:** Class 2
- **Review Panel:** General Hospital

## Indications for Use

Microline Surgical ReNew Sterilization Trays (Catalog #3708 and #3709) are intended to protect the ReNew Reusable Tips (Scissors, Graspers and Dissectors) and to facilitate the sterilization process by allowing steam penetration and air removal. When used in conjunction with 2 layers of FDA-cleared 1-ply polypropylene sterilization wrap, sterility of the enclosed sterilization trays (Catalog #3708 and #3709) is maintained until used.

## Device Story

ReNew Sterilization Trays (Catalog #3708, #3709) are reusable plastic containers designed to hold and protect ReNew Reusable Tips (scissors, graspers, dissectors) during transport, steam sterilization, and storage. Trays consist of a base, lid, and biomedical-grade silicone brackets to secure instruments. Trays feature an evenly distributed hole pattern to facilitate steam penetration and air removal. Used in hospital/OR settings by clinical staff. Trays are wrapped in 2 layers of FDA-cleared 1-ply polypropylene sterilization wrap before processing. Validated for prevacuum and gravity steam sterilization cycles. Output is a sterilized, protected instrument set ready for surgical use. Benefits include organized instrument handling, protection of delicate tips, and validated sterilization efficacy.

## Clinical Evidence

Bench testing only. Validation included cleaning (automated/manual) and steam sterilization cycles (prevacuum: 132°C for 4 min; gravity: 121°C for 30 min or 132°C for 15 min). Sterility assurance level (SAL) of 10-6 achieved using biological indicators. No clinical data.

## Technological Characteristics

Materials: Radel® Polyphenylsulfone (base/lid) and biomedical grade silicone (brackets). Dimensions: Catalog #3708 (7.8"x4.31"x1.22"), Catalog #3709 (6.32"x3.32"x1.21"). Energy: Steam sterilization. Connectivity: None. Sterilization: Steam only. Form factor: Perforated plastic tray with locking lid.

## Regulatory Identification

A sterilization wrap (pack, sterilization wrapper, bag, or accessories, is a device intended to be used to enclose another medical device that is to be sterilized by a health care provider. It is intended to allow sterilization of the enclosed medical device and also to maintain sterility of the enclosed device until used.

## Predicate Devices

- PolyVac Surgical Instrument Delivery System ([K012105](/device/K012105.md))

## Submission Summary (Full Text)

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

May 12, 2016

Microline Surgical, Inc. Anu Gaur, Ph.D., MBA, MSRA, RAC Regulatory Affairs Manager 50 Dunham Road. Suite 1500 Beverly, MA 01915

Re: K152745

Trade/Device Name: ReNew Sterilization Trays [Catalog #3708 and #3709] Regulation Number: 21 CFR 880.6850 Regulation Name: Sterilization Wrap Regulatory Class: Class II Product Code: KCT Dated: April 01, 2016 Received: April 04, 2016

Dear Dr. Anu Gaur:

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

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Page 2 - Dr. Anu Gaur

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 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/Resourcesfor You/Industry/default.htm. 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 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,

*Tejashri Purohit-Sheth, M.D.*

Tejashri Purohit-Sheth, M.D. Clinical Deputy Director DAGRID/ODE/CDRH FOR

Erin I. Keith, M.S. Director Division of Anesthesiology, General Hospital, Respiratory, Infection Control and Dental Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

{2}------------------------------------------------

# Indications for Use

510(k) Number (if known) K152745

Device Name

ReNew Sterilization Trays (Catalog #3708 and #3709)

#### Indications for Use (Describe)

Microline Surgical ReNew Sterilization Trays (Catalog #3708 and #3709) are intended to protect the ReNew Reusable Tips (Scissors, Graspers and Dissectors) and to facilitate the sterilization process by allowing steam penetration and air removal. When used in conjunction with 2 layers of FDA-cleared 1-ply polypropylene sterilization wrap, sterility of the enclosed sterilization trays (Catalog #3708 and #3709) is maintained until used.

The Microline Surgical ReNew Sterilization Trays (Catalog #3709) are used to secure the ReNew Reusable Tips (Scissors, Graspers and Dissectors). Catalog #3708 measures at 7.8" length , 4.31" width, and 1.22" height , in dimensional measurements, as intended load during the transport, sterilization and storage between their intended use. Similarly, Catalog #3709 measures at 6.32" length, 3.32" width, and 1.21" height, in dimensional measurements as intended load during the transport, sterilization and storage between their intended use.

The ReNew Sterilization Tray (Catalog #3708 & 3709) have been validated with the ReNew Reusable Tips (Scissors,Graspers and Dissectors) wrapped in 2 layers of FDA-cleared 1-ply polypropylene wrap weighing a calculated total weight of 280.52 grams, for Catalog number 3708, and 148.195 grams for Catalog #3709. The validation included Cleaning Validation (Automated and Manual) Testing and Steam Sterilization Cycles. The validated prevacuum cycle parameters are as follows: time: 4 minutes at temperature 132 ℃, with a dry time of 30 minutes. The validated gravity cycle parameters are as follows: Time: 30 minutes at 121 ℃ with a dry time of 20 minutes, as well as time: 15 minutes at temperature 132 ℃ with a dry time of 20 minutes.

| Type of Use (Select one or both, as applicable) |
|-------------------------------------------------|
|-------------------------------------------------|

| <span></span> Prescription Use (Part 21 CFR 801 Subpart D) | <span></span> Over-The-Counter Use (21 CFR 801 Subpart C) |
|------------------------------------------------------------|-----------------------------------------------------------|
|------------------------------------------------------------|-----------------------------------------------------------|

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Image /page/3/Picture/0 description: The image shows the logo for Microline Surgical. The word "MICROLINE" is written in gray, with a teal circle containing a four-leaf clover design in the middle of the word. Below "MICROLINE" is the word "SURGICAL" in a smaller, gray font.

# Traditional 510(k) Summary [As Required by 21 CFR § 807.92]

| 510(k) Submitter:                  | Microline Surgical, Inc.<br>50 Dunham Road, Suite 1500<br>Beverly, MA 01915<br>USA                        |
|------------------------------------|-----------------------------------------------------------------------------------------------------------|
| Establishment Registration Number: | 1223422                                                                                                   |
| Contact Representative:            | Anu Gaur, Ph.D., MBA, MSRA, RAC<br>Regulatory Affairs Manager<br>Phone: 978-867-1726<br>Fax: 978-922-9209 |
| Date Prepared:                     | May 12, 2016                                                                                              |
| Trade Name:                        | ReNew Sterilization Trays<br>[Catalog #3708 and #3709]                                                    |
| Common Name(s):                    | Sterilization Tray                                                                                        |
| Classification:                    | Class II, in accordance to 21 CFR § 880.6850<br>Sterilization Wrap.                                       |
| Classification Product Code(s):    | KCT                                                                                                       |
| Regulation Medical Specialty:      | General Hospital                                                                                          |
| Predicate Device(s):               | PolyVac Surgical Instrument Delivery System (K012105)                                                     |

### Device Description:

Microline Surgical ReNew Sterilization Trays (Catalog #3708 and #3709) intended purpose is to secure the ReNew Tips (Graspers, Dissectors, and Scissors) devices during its transportation, and storage purposes.

Microline Surgical ReNew Sterilization Trays (Catalog #3708 and #3709) consist of a base, a lid and device holding brackets. The lid can be fastened to the base by means of a locking tab, which is designed as a part of the lid. The brackets are constructed from biomedical grade silicone material. These brackets are used to secure the intended devices during their transport, sterilization and storage purpose. The ReNew Sterilization Trays (Catalog #3708 and #3709) are intended to be used for ReNew Tips sterilization purpose which are non-porous devices including graspers, dissectors, and scissors.

## ReNew Sterilization Tray (Catalog #3708)

The subject device ReNew Sterilization Tray (Catalog #3708) consists of a case, a cover and brackets. The Lid is 7.80" (Length) x 4.31" (Width) x 0.46" (Height) in dimensions; and the Base is 7.60" (Length) x 4.12" (Width) x 0.76" (Height).

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Image /page/4/Picture/0 description: The image shows the logo for Microline Surgical. The logo consists of the word "MICROLINE" in gray, with a teal-colored four-pointed star in the middle of the word. Below the word "MICROLINE" is the word "SURGICAL" in a smaller, gray font. The logo is simple and modern, and the colors are calming and professional.

The ReNew Sterliization Tray (Catalog #3708) Id and base are designed using Radel® Polyphenylsulfone material, which can be reused with steam sterilization methods. The brackets are constructed from biomedical grade silicone material. To support steam sterilization Tray and Lid have an evenly distributed hole pattern in relation to its size for penetration of steam during sterilization process.

## ReNew Sterilization Tray (Catalog #3709)

The subject device ReNew Sterilization Tray (Catalog #3709) consists of a cover and brackets. The Lid is 6.32" (Length) x 3.32" (Width) x 0.44" (Height) with ±0.02 in dimensions; and the Base is 6.15" (Length) x 3.14" (Width) x 0.77" (Height) with ±0.02 in dimensions. The ReNew Sterilization Tray (Catalog #3709) lid and base are designed using Radel® Polyphenylsulfone material. which steam sterilization methods. The brackets are constructed from biomedical grade silicone material. To support steam sterilization Tray and Lid have an evenly distributed hole pattern in relation to its size for penetration of steam during sterilization process.

Microline Surgical ReNew Sterilization Trays (Catalog #3709) are non-patient and non-blood/fluid contact devices during their intended use. Microline Surgical ReNew Sterilization Trays (Catalog #3709) are primarily packaged in a foam wrap (Polyethylene foam sheet) and a plastic Bag (Poly-bag) and Bubble), and single wall, 32lbs/inch edge, crushed corrugated white cardboard shipping box, which does not need any special handling requirements during shipment.

### Statement of Intended Use:

### Indications for Use:

Microline Surgical ReNew Sterilization Trays (Catalog #3709) are intended to protect the ReNew Reusable Tips (Scissors, Graspers and Dissectors) and to facilization process by allowing steam penetration and air removal. When used in conjunction with 2 layers of FDA-cleared 1-ply polypropylene sterilization wrap, sterility of the enclosed sterilization trays (Catalog #3708 and #3709) is maintained until used.

The Microline Surgical ReNew Sterilization Trays (Catalog #3709) are used to secure the ReNew Reusable Tips (Scissors, Graspers and Dissectors). Catalog #3708 measures at 7.8" width, and 1.22" height, in dimensional measurements, as intended load during the transport, sterilization and storage use. Similarly, Catalog #3709 measures at 6.32" length, 3.32" width, and 1.21" height, in dimensional measurements as intended load during the transport, sterilization and storage between their intended use.

The ReNew Sterilization Tray (Catalog #3708 & 3709) have been validated with the ReNew Reusable Tips (Scissors, Graspers and Dissectors) wrapped in 2 layers of FDA-cleared 1-ply polypropylene wrap weighing a calculated total weight of 280.52 grams, for Catalog number 3708, and 148.195 grams for Catalog #3709. The validation included Cleaning Validation (Automated and Manual) Testing and Steam Sterilization Cycles. The validated prevacum cycle parameters are as follows: time: 4 minutes at temperature 132 °C, with a dry time of 30 minutes. The validated gravity cycle parameters are as follows: Time: 30 minutes at 121 °C with a dry time of 20 minutes, as well as time: 15 minutes at temperature 132 °C with a dry time of 20 minutes.

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Image /page/5/Picture/0 description: The image shows the logo for Microline Surgical. The word "MICROLINE" is written in gray, with a teal circle in the middle of the word. The word "SURGICAL" is written in gray below the word "MICROLINE".

#### Comparison to Predicate Device:

Microline Surgical. Inc., has determined substantial equivalence of the subject devices ReNew Sterlization Trays (Catalog #3708 and #3709) with their legally marketed predicate device, PolyVac Surgical Instrument Delivery System (K012105); based on the principles of safety and effectiveness applicable to the 510(k) review including the applicable standard and the least burdensome approach.

Microline Surgical ReNew Sterilization Trays (Catalog #3709) are substantially equivalent to their predicate device, PolyVac Surgical Instrument Delivery System (K012105) including the following criteria;

- Selection of the applicable predicate device; O
- Similarities in the intended use and indication for use; O
- Similarities in materials for construction of device; O
- Similarities in performance testing criteria; O
- Similarities in the technological characteristics and fundamental technology. O
- Does not raise new questions of safety and effectiveness; and O
- Demonstrates at least as safe and effective as its legally marketed predicate device. O

The differences between the subject devices ReNew Applier Sterilization Trays (Catalog #3708 and #3709) are the following;

- Internal configuration of the ReNew Sterilization Tray (Catalog #3708) to secure and hold eighteen (18); and O ReNew Sterlization Tray (Catalog #3709) to secure and hold nine (9) ReNew Tips (Graspers, Dissectors and Scissors) devices.
In summary, the subject devices ReNew Sterilization Trays (Catalog #3709) are similar in design, materials, manufacturing, performance, safety, effectiveness, labeling, sterilization, and fundamental technological characteristics as applicable to their legally marketed predicate device, PolyVac Surgical Instrument Delivery System (K012105).

#### Summary of Technological Characteristics:

Microline Surgical ReNew Sterlization Trays (Catalog #3708 and #3709) intended purpose is to secure the ReNew Tips (18 and 9 configuration arrangements) device during its transportation and storage purposes. The subject devices ReNew Sterilization Trays (Catalog #3708) are technologically similar to their legally marketed predicate device, PolyVac Surgical Instrument Delivery System (K012105). The following pertains to the technological characteristics comparison presented in a tabular format.

| Characteristics       | Predicate Device                                                        | Subject Device<br>(Proposed)                                            |
|-----------------------|-------------------------------------------------------------------------|-------------------------------------------------------------------------|
| Trade Name            | PolyVac Surgical Instrument<br>Delivery System                          | Microline Surgical ReNew Sterilization<br>Tray (Catalog #3708)          |
| 510(k) Number         | (K012105)                                                               | This Submission                                                         |
| 510(k) Clearance Date | Aug 02, 2002                                                            | Not Applicable                                                          |
| Classification        | Class II<br>21 CFR § 880.6850                                           | Class II<br>21 CFR § 880.6850                                           |
| Classification Name   | Sterilization Wrap Containers, Trays,<br>Cassettes & other Accessories. | Sterilization Wrap Containers, Trays,<br>Cassettes & other Accessories. |

### ReNew Sterilization Trav (Catalog #3708)

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Image /page/6/Picture/0 description: The image shows the logo for Microline Surgical. The word "MICROLINE" is written in gray, with a teal circle containing a four-pointed star in the middle. Below "MICROLINE" is the word "SURGICAL" in a smaller, gray font.

| Classification Product<br>Code        | KCT                                                                                                                                                                                                                                                                                                                              | KCT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |
|---------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Common Name                           | Sterilization Wrap                                                                                                                                                                                                                                                                                                               | Sterilization Tray                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      |
| Regulation Medical<br>Specialty       | General Hospital                                                                                                                                                                                                                                                                                                                 | General Hospital                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
| Environment of Use                    | Hospital, Operating Room (OR) Use<br>(not specified).                                                                                                                                                                                                                                                                            | Hospital, Operating Room (OR) Use<br>only.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              |
| Intended Use<br>(indications for Use) | PolyVac Delivery Systems are intended<br>to protect medical device instrumentation<br>and to facilitate the sterilization process<br>by allowing steam penetration and air<br>removal. When used in conjunction with<br>an approved sterilization wrap, sterility of<br>the enclosed medical device is<br>maintained until used. | Microline Surgical ReNew Sterilization<br>Trays (Catalog #3708 and #3709) are<br>intended to protect the ReNew<br>Reusable Tips (Scissors, Graspers and<br>Dissectors) and to facilitate the<br>sterilization process by allowing steam<br>penetration and air removal. When<br>used in conjunction with 2 layers of<br>FDA-cleared 1-ply polypropylene<br>sterilization wrap, sterility of the<br>enclosed sterilization trays (Catalog<br>#3708 and #3709) is maintained until<br>used.<br>The Microline Surgical ReNew<br>Sterilization Trays (Catalog #3708 and<br>#3709) are used to secure the ReNew<br>Reusable Tips (Scissors, Graspers and<br>Dissectors). Catalog #3708 measures<br>at 7.8" length, 4.31" width, and 1.22"<br>height, in dimensional measurements,<br>as intended load during the transport,<br>sterilization and storage between their<br>intended use. Similarly, Catalog #3709<br>measures at 6.32” length, 3.32" width,<br>and 1.21" height, in dimensional<br>measurements as intended load during<br>the transport, sterilization and storage<br>between their intended use.<br>The ReNew Sterilization Tray (Catalog<br>#3708 & 3709) have been validated<br>with the ReNew Reusable Tips<br>(Scissors, Graspers and Dissectors)<br>wrapped in 2 layers of FDA-cleared 1-<br>ply polypropylene wrap weighing a<br>calculated total weight of 280.52 grams,<br>for Catalog number 3708, and 148.195<br>grams for Catalog #3709. The<br>validation included Cleaning Validation<br>(Automated and Manual) Testing and<br>Steam Sterilization Cycles. The |

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Image /page/7/Picture/0 description: The image shows the logo for Microline Surgical. The logo has the word "MICROLINE" in large, gray, sans-serif font. In the middle of the word, there is a teal-colored symbol that looks like four leaves coming together to form a diamond shape. Below the word "MICROLINE", there is the word "SURGICAL" in a smaller, gray, sans-serif font.

| Technological Characteristics       |                                                                                                                                                                                                                                                                                                                                                                                                                  |                                                                                                                                                                                                                                                                                                                                                      |
|-------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
|                                     |                                                                                                                                                                                                                                                                                                                                                                                                                  | validated prevacuum cycle parameters<br>are as follows: time: 4 minutes at<br>temperature 132 °C, with a dry time of<br>30 minutes. The validated gravity cycle<br>parameters are as follows: Time: 30<br>minutes at 121 °C with a dry time of 20<br>minutes, as well as time: 15 minutes at<br>temperature 132 °C with a dry time of<br>20 minutes. |
| Primary Configuration               | Plastic Tray                                                                                                                                                                                                                                                                                                                                                                                                     | Plastic Tray                                                                                                                                                                                                                                                                                                                                         |
| Primary Materials<br>(Construction) | Polyphenylsulphone (Radel® R-5500)<br>and Biomedical Grade Silicone.                                                                                                                                                                                                                                                                                                                                             | Identical                                                                                                                                                                                                                                                                                                                                            |
| Dimensions                          | Lid:<br>7.80" (Length) x 4.31” (Width) x 0.46"<br>(Height) inches.<br><br>Base:<br>7.60" (Length) x 4.12" (Width) x 0.76"<br>(Height) inches.                                                                                                                                                                                                                                                                    | Identical                                                                                                                                                                                                                                                                                                                                            |
| Air Permeability                    | Yes                                                                                                                                                                                                                                                                                                                                                                                                              | Yes                                                                                                                                                                                                                                                                                                                                                  |
| Intended for Reuse                  | Yes                                                                                                                                                                                                                                                                                                                                                                                                              | Yes                                                                                                                                                                                                                                                                                                                                                  |
| Material Thickness                  | 0.0625"                                                                                                                                                                                                                                                                                                                                                                                                          | Identical                                                                                                                                                                                                                                                                                                                                            |
| Hole Size                           | Ø 0.188"                                                                                                                                                                                                                                                                                                                                                                                                         | Identical                                                                                                                                                                                                                                                                                                                                            |
| Hole Pattern                        | Lid:<br>Five (5)X in two (2) rows on bottom and<br>top edges, Four (4)X – one (1) in each<br>corner, Two(2)X – two(2) rows centrally<br>aligned with bottom and top edge rows.<br><br>Base:<br>Five (5)X in Two (2) rows on bottom and<br>top edges, Four (4)X – one (1) in each<br>corner, Seven (7)X central row evenly<br>spaced.<br>[Centrally the lid includes the printed<br>Company Logo and Trade Name]. | Identical                                                                                                                                                                                                                                                                                                                                            |
| Brackets                            | Two (2) rows - (.74) x (.29) with taper.                                                                                                                                                                                                                                                                                                                                                                         | Identical                                                                                                                                                                                                                                                                                                                                            |
| Feet                                | Four (4) on base, to align with the 4<br>holes in lid corners (0.1405" height)                                                                                                                                                                                                                                                                                                                                   | Identical                                                                                                                                                                                                                                                                                                                                            |
| Weight                              | 270 grams                                                                                                                                                                                                                                                                                                                                                                                                        | Identical                                                                                                                                                                                                                                                                                                                                            |
| Sterilization Method(s)             | Steam Sterilization<br>& Ethylene Oxide (EtO)                                                                                                                                                                                                                                                                                                                                                                    | Steam Sterilization only                                                                                                                                                                                                                                                                                                                             |

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Image /page/8/Picture/0 description: The image shows the logo for Microline Surgical. The word "MICROLINE" is written in gray, with a teal-colored symbol in the middle of the word. Below the word "MICROLINE" is the word "SURGICAL" in a smaller, gray font. The logo is simple and modern, and it is likely used to represent a medical device company.

| Sterilization Cycle<br>Parameters                                               | Prevacuum Steam:<br>132°C - 4 Mins<br>Dry for 20 - 40 mins (as needed)                                                                                                                                                    | Prevacuum Steam:<br>132°C - 4 minutes<br>Dry for 30 minutes                                                                                |
|---------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------|
|                                                                                 | Gravity Air Displacement Cycle:<br>132°C - 30 Mins                                                                                                                                                                        | Gravity Steam:<br>121°C - 30 minutes<br>Dry for 20 minutes                                                                                 |
|                                                                                 | Gravity Steam:<br>121°C - 55 Mins<br>Dry for 20 - 50 mins (as needed)                                                                                                                                                     | Gravity Steam:<br>132°C -15 minutes<br>Dry for 20 minutes                                                                                  |
| Sterility<br>(Disposable or Multiple Use)                                       | Multiple Use                                                                                                                                                                                                              | Multiple Use                                                                                                                               |
| Patient Contact                                                                 | No                                                                                                                                                                                                                        | No                                                                                                                                         |
| Blood/Fluid Contact                                                             | No                                                                                                                                                                                                                        | No                                                                                                                                         |
| Special Conditions<br>(Shipping and Handling)                                   | No                                                                                                                                                                                                                        | No                                                                                                                                         |
| Manufacturer                                                                    | Contract Manufacturer:<br>Symmetry Medical, Inc.<br>253 Abby Road,<br>Manchester, NH 03103<br>USA<br>(Registration Number: 1221053)<br>(Symmetry Medical OEM Solutions<br>acquired by Tecomet, Inc.,<br>December 5, 2014) | Identical                                                                                                                                  |
| Proposed Brand Labeling<br>(Relabeling, Repackaging<br>and Market Distribution) | Not Applicable                                                                                                                                                                                                            | Microline Surgical, Inc.<br>50 Dunham Road, Suite 1500<br>Beverly, MA 01915<br>USA                                                         |
| Differences in Technological Characteristics                                    |                                                                                                                                                                                                                           |                                                                                                                                            |
| Tray Internal Configuration                                                     | Not Applicable                                                                                                                                                                                                            | ReNew Sterilization Tray (Catalog<br>#3708) internal configuration to secure<br>the ReNew Tips (18 Tips configuration<br>arrangement) only |

# ReNew Sterilization Tray (Catalog #3709)

| Characteristics       | Predicate Device                      | Subject Device                         |
|-----------------------|---------------------------------------|----------------------------------------|
|                       |                                       | (Proposed)                             |
| Trade Name            | PolyVac Surqical Instrument Delivery  | Microline Surqical ReNew Sterilization |
|                       | System                                | Tray (Catalog #3709)                   |
| 510(k) Number         | (K012105)                             | This Submission                        |
| 510(k) Clearance Date | Aug 02, 2002                          | Not Applicable                         |
| Classification        | Class II                              | Class II                               |
|                       | 21 CFR § 880.6850                     | 21 CFR § 880.6850                      |
| Classification Name   | Sterilization Wrap Containers, Trays, | Sterilization Wrap Containers, Trays,  |
|                       | Cassettes & other Accessories.        | Cassettes & other Accessories.         |

{9}------------------------------------------------

Image /page/9/Picture/0 description: The image shows the logo for Microline Surgical. The logo consists of the word "MICROLINE" in gray, with a teal four-leaf clover symbol in the middle. Below the word "MICROLINE" is the word "SURGICAL" in a smaller, gray font.

| Classification Product Code                                                     | KCT                                                                                                                                                                                                                                                                                                                                 | KCT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |
|---------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Common Name                                                                     | Sterilization Wrap                                                                                                                                                                                                                                                                                                                  | Sterilization Tray                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      |
| Regulation Medical Specialty                                                    | General Hospital                                                                                                                                                                                                                                                                                                                    | General Hospital                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
| Environment of Use                                                              | Hospital, Operating Room (OR) Use<br>(not specified).                                                                                                                                                                                                                                                                               | Hospital, Operating Room (OR) Use<br>only.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              |
| Intended Use<br>(Indications for Use)                                           | PolyVac Delivery Systems are<br>intended to protect medical device<br>instrumentation and to facilitate the<br>sterilization process by allowing steam<br>penetration and air removal. When<br>used in conjunction with an approved<br>sterilization wrap, sterility of the<br>enclosed medical device is maintained<br>until used. | Microline Surgical ReNew Sterilization<br>Trays (Catalog #3708 and #3709) are<br>intended to protect the ReNew<br>Reusable Tips (Scissors, Graspers and<br>Dissectors) and to facilitate the<br>sterilization process by allowing steam<br>penetration and air removal. When<br>used in conjunction with 2 layers of<br>FDA-cleared 1-ply polypropylene<br>sterilization wrap, sterility of the<br>enclosed sterilization trays (Catalog<br>#3708 and #3709) is maintained until<br>used.<br><br>The Microline Surgical ReNew<br>Sterilization Trays (Catalog #3708 and<br>#3709) are used to secure the ReNew<br>Reusable Tips (Scissors, Graspers and<br>Dissectors). Catalog #3708 measures<br>at 7.8" length, 4.31" width, and 1.22"<br>height, in dimensional measurements,<br>as intended load during the transport,<br>sterilization and storage between their<br>intended use. Similarly, Catalog #3709<br>measures at 6.32" length, 3.32" width,<br>and 1.21" height, in dimensional<br>measurements as intended load during<br>the transport, sterilization and storage<br>between their intended use.<br><br>The ReNew Sterilization Tray (Catalog<br>#3708 & 3709) have been validated<br>with the ReNew Reusable Tips<br>(Scissors, Graspers and Dissectors)<br>wrapped in 2 layers of FDA-cleared 1-<br>ply polypropylene wrap weighing a<br>calculated total weight of 280.52 grams,<br>for Catalog number 3708, and 148.195<br>grams for Catalog #3709. The<br>validation included Cleaning Validation<br>(Automated and Manual) Testing and<br>Steam Sterilization Cycles. The<br>validated prevacuum cycle parameters |
|                                                                                 |                                                                                                                                                                                                                                                                                                                                     | temperature 132 °C, with a dry time of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  |
|                                                                                 |                                                                                                                                                                                                                                                                                                                                     | 30 minutes. The validated gravity cycle                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 |
|                                                                                 |                                                                                                                                                                                                                                                                                                                                     | parameters are as follows: Time: 30                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |
|                                                                                 |                                                                                                                                                                                                                                                                                                                                     | minutes at 121 °C with a dry time of 20                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 |
|                                                                                 |                                                                                                                                                                                                                                                                                                                                     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
|                                                                                 |                                                                                                                                                                                                                                                                                                                                     | minutes, as well as time: 15 minutes at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 |
|                                                                                 |                                                                                                                                                                                                                                                                                                                                     | temperature 132 °C with a dry time of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   |
|                                                                                 |                                                                                                                                                                                                                                                                                                                                     | 20 minutes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             |
|                                                                                 | Technological Characteristics                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| Primary Configuration                                                           | Plastic Tray…

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**Source:** [https://fda-staging.innolitics.com/device/K152745](https://fda-staging.innolitics.com/device/K152745)

**Published by [Innolitics](https://innolitics.com)** — a medical-device software consultancy. We help companies design, build, and clear FDA-regulated software and AI/ML devices. If you're preparing [a 510(k)](https://innolitics.com/services/510ks/), [a De Novo](https://innolitics.com/services/regulatory/), [a SaMD](https://innolitics.com/services/end-to-end-samd/), [an AI/ML medical device](https://innolitics.com/services/medical-imaging-ai-development/), or [an FDA regulatory strategy](https://innolitics.com/services/regulatory/), [get in touch](https://innolitics.com/contact).

**Cite:** Innolitics at https://innolitics.com
