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Description  |
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BACKGROUND OF THE INVENTION
1. Field of the Invention
This invention relates to surgical devices and a method for using the same
in endoscopic surgery (also known as closed surgery) wherein the surgeon
gains access to the surgical site via one or more portals. More
particularly, the invention relates to devices and a method for retracting
internal organs and distending the walls of a body cavity so that
structures can be seen in an adequate panoramic endoscopic view.
2 Description of the Prior Art
U.S. Pat. No. 2,202,748, (Solo) discloses a septum splint for molding the
nasal septumi straight following the operation of sub-mucous resection or
in traumatic conditions wherein it is desirable to bring into contact or
approximation the layers of the nasal septum. The splint comprises a pair
of body members, oppositely arranged screws engaging holes in the two body
members for adjusting them towards and away from each other, a stationary
blade extending from the outer side of each member, blades pivoted to each
member, a cam carried by each member and engaging parts of the pivoted
blades for moving them outwardly into a fan shape, and a screw engaging a
threaded hole in each member for moving the cam against the parts of the
blades.
U.S. Pat. No. 4,608,965, (Anspach, Jr., et al.) discloses an endoscope
retainer and tissue retracting device comprising a soft plastic
cylindrical tube slidably mountable on the probe portion of the endoscope,
the end of the soft plastic cylindrical tube having a slightly reduced
diameter to have a friction holding fit over the end of the endoscope, a
plurality of slits located around the soft plastic cylindrical tube
adjacent the end of reduced diameter, said slits forming a plurality of
flexible strips which bend to extend radially outwardly when their ends
are brought together by sliding the other end of the soft plastic
cylindrical tube along on the probe portion of the endoscope toward the
end having the friction holding fit over the end of the endoscope, and
means for fixing the other end of the soft plastic cylindrical tube to the
endoscope with the strips extending radially outward.
U.S. Pat. No. 4,654,028, (Suma) discloses an incision opening expansion
holder for inosculation comprising a cylindrical hollow elongated outer
tube having a longitudinal axis; a cylindrical elongated inner tube having
a longitudinal axis and a first end and a second end and being of a
diameter smaller than the diameter of said outer tube and slidably
inserted into said outer tube; a grip device fixed to the first end of
said inner tube; and a plurality of resilient wires, each having one end
thereof attached to the second end of the inner tube and another end
thereof having a round ball structure attached thereto, the plurality of
wires being shaped to extend radially outward from the axis in a smooth
curve. The inner tube is of sufficient length to extend said second end to
an end of the outer tube in an opened position and to retract the attached
wires to be completely within the outer tube in a closed position. The
wires are of sufficient resilience and axial length so as to be compressed
into and fit completely within the outer tube in the closed position, and
to extend completely outside of said outer tube in the opened position
with the round ball structures located at the ends of the wires being
spread out radially and with the wires being resiliently expanded to a
circular shape.
U.S. Pat. No. 3,823,709, (McGuire) discloses a table supported surgical
retractor and pelvic support which comprises an operating table supported
surgical retractor assembly for individual retracting blades which hold
the various parts of the body away from the surgical area.
U.S. Pat. No. 3,858,578, (Milo) discloses a surgical retaining device
comprising a retaining arm, the rigidity of which is controlled by a fluid
actuated operating apparatus. A surgical instrument is attached to the
retaining arm. By activating the operating apparatus, the arm can be made
flexible as the instrument is being positioned and rigid once the
instrument is in place.
U.S. Pat. No. 4,099,521, (Nestor, et al.) discloses a surgical retractor
adjustable mounting apparatus comprising an arcuate frame sized to fit
concentrically at a spaced distance about the head. Retractors, retaining
the mouth and lips in open position for vertical and lateral exposure
during mouth and jaw surgery, are adjustably suspended from the frame by
an adjustable universal connector. The frame is mounted on an upstanding
support from the operating table by connecting means providing
adjustability thereof for universal spatial orientation.
U.S. Pat. No. 4,457,300, (Budde) discloses a surgical retractor provided
for retaining tissue, membrane and organs in a retraced position from an
incision during a surgical procedure which includes a tiltable ring having
an outwardly extending channel to receive arm support means having a
projection captured within and movable along the channel. Retractor arms
are mounted to the arm support means such that they pass below the ring
and extend inwardly toward the incision so as to not obstruct the
surgeon's line of sight or movement of the hands along the ring.
U.S. Pat. No. 4,573,452, (Greenberg) discloses a surgical holder for a
laparoscope or the like wherein a selectively tensionable cable-type
component is released for moving the laparoscope almost into its desired
position and then tensioned into a rigid structure; and then a ball and
socket joint is rendered operational to complete the moving of the
laparoscope, if need be, to precisely position the instruments in its
required anatomy-viewing position.
U.S. Pat. No. 4,593,681, (Soni) discloses a stabilizing device for use in
arthroscopic and endoscopic surgery comprising a relatively thin, flat,
flexible plate of plastic material and adapted to be placed against a
patient's body at the area where penetration is made by the scope sheath.
The plate is formed with a predetermined sized central hole and the sheath
is slidably insertable through the hole and has an interference fit with
the surrounding plate material. The plate provides a stable base for the
scope to be slidable moved with respect to the plate to adjust the depth
of penetration.
U.S. Pat. No. 4,621,625, discloses a leg traction device for supporting the
leg and applying axial force to the leg wherein a rigid vector bar is
positioned above the knee and lower leg and a pulley system including a
cable and weight connected at one end to a leg supporting structure and at
the other end to the vector bar.
U.S. Pat. No. 4,632,458, (Brown, et al.) discloses a chair back height
adjustment mechanism for a chair having a chair back supporting standard
and a chair back bracket with a chair back or backrest mounted thereon.
The mechanism includes a rack gear on the chair back standard, a pinion
gear supported in a bearing on the chair back bracket, a worm gear coaxial
with the pinion gear, and worm threads on a dial shaft supported on the
bracket. Rotation of the dial causes the worm member to rotate the worm
gear and the pinion gear whereby the bracket supporting the pinion gear is
translated in relation to the chair back standard.
U.S. Pat. No. 4,690,647, (Dalglish) discloses an intravenous tube assembly
to supply intravenous fluid to a patient. The assembly comprises an
intravenous fluid container, held by a stand, and connected to one end of
an intravenous fluid tubing, the other end of the tubing connected to a
patient, and a mast assembly which has an elongate resilient mast and a
movable tip and a base. The base is fixed to a structure proximate the
patient, e.g., a bed frame; and the tip carries a tube holder which
releasably holds a segment of the intravenous tubing leading to the
patient. The mast permits patient movement by deflecting to follow the
patient and rebounding upon return of the patient to prevent an excess of
residual intravenous tube in the vicinity of the patient.
U.S. Pat. No. 4,809,687, (Allen) discloses a medical stirrup for supporting
a patient's limb in a desired attitude is disclosed. The limb is cradled
in a shell lined with soft material. The limb is retained in the shell by
adjustable bands. The shell is suspended from a support by adjustable
straps; and the attitude of the limb is controlled by the adjustment of
the straps and the positioning of the support.
U.S. Pat. No. 4,850,563, (Grout) discloses an adjustable desk frame
comprising a base consisting of a pair of vertically extending
transversely spaced members; a sub-frame vertically movably adjustably
supported by the base, and including a pair of vertically extending
members telescopically received within the vertical members of the base;
and a drive assembly to move the sub-frame vertically relative to the
base, the drive assembly including a rack gear attached to each vertical
member of the sub-frame, a pinion gear meshingly engaged with each rack,
with the pinion gears being rotatably supported by the base, a shaft
extending between the two pinions to transmit rotary power therebetween, a
worm gear meshingly engaged with one of the pinions, and rotatably
supported by the base, and a drive shaft fixed to the worm gear and
extending therefrom to a position manually operably by a user of the desk,
the drive shaft adapted to be supported by the sub-frame.
U.S. Pat. No. 4,867,404, (Harrington, et al.) discloses a flexible holder
for a cytoscope or the like which is equipped with a clamping assembly
which permits the holding of various sized instrument shafts. The clamping
assembly comprises a vertically adjustable spring-biased C-shaped
open-sided region, which is telescopically movable in a tubular housing
and releasably urged to an open position. The instrument shaft is received
sideways into the C-shaped jaw and retained between the jaw and a pair of
circumferentially opposing notches of the tubular housing.
U.S. Pat. No. 4,926,849, (Downey) discloses an apparatus for separating
vertebrae, i.e. adjacent first and second vertebrae, during surgery
comprising: a support; first and second grips associated with the support
and being sized and structured to grip the first and second vertebrae,
respectively; a first movement assembly, associated with the first grip,
capable of moving the first grip to a desired location relative to the
second grip; and a second movement assembly, associated with the second
grip, capable of moving the second grip to a desired location relative to
the first grip.
U.S. Pat. No. 4,932,395, (Mehdizadeh) discloses a hemi-laminectomy
retractor attachment device, adapted for use with prior art retractors,
including two hook-shaped members that are joined together by a length of
strong flexible cord. The hook-shaped members are narrow enough to fit
between spinal bones to brace against the spinal ligaments, and the cord
is engagable with the retractor arm.
U.S. Pat. No. 4,945,896, (Gade) discloses a surgical retractor having a
generally flat malleable blade with a miniature metabolic parameter sensor
embedded or removably inset into the blade to monitor tissue viability of
the tissue underlying the retractor.
U.S. Pat. No. 5,003,967, discloses a traction support member for holding an
individual's arm and hand in elevated position. The traction support
member includes an upright member which is disposed between first and
second transverse members. The upright member is movable about a vertical
axis universal positioner; and the first transverse member is movable
about a horizontal axis through an attachment coupling at which the first
transverse member is attached to the upright member.
U.S. Pat. No. 5,065,739, (Forrest, et al.) discloses a retractor support
assembly comprising a rocking arm, means for flexibly connecting the
retractor to the rocking arm and weight means, connected to the rocking
arm, for pulling the retractor in a generally upward direction.
As may be readily ascertained, few of the aforementioned devices refer to
endoscopic surgery. By endoscopic surgery is understood surgery during
which the surgeon gains access to the surgical site via one or more
portals. Through these portals, endoscopes, instruments and the like are
inserted. The endoscopic surgical procedures include, but are not limited
to, arthroscopy, laryngobronchoscopy, laparoscopy (pelviscopy),
gastroenteroscopy, and laparoscopic surgery of the female reproductive
organs.
Endoscopic surgery would be preferred over open surgery for most procedures
because it greatly reduces trauma and risk of general anesthesia-related
complications to the patient and saves the costs associated with
performing the surgical procedures. However, the below outlined
disadvantages had not allowed full expansion in the areas in which this
type of surgery could be competently performed.
To date, it is necessary to infuse the body cavity with CO.sub.2 or N.sub.2
O in order to achieve sufficient expansion of the cavity in order to
obtain proper panoramic viewing. A major drawback of the present
technique, as explained in the example of laparoscopy, is the necessity to
maintain an air-tight boundary between the inside and outside of the body
cavity, i.e., the abdomen, in order to obtain proper visualization of
structures. Another important handicap is the fact that in spite of the
floating effect created by the gas, it is still not possible to reach
deep-seated areas. Other disadvantages include image distortion and
patient discomfort.
SUMMARY OF THE INVENTION
Accordingly, a primary objective of the present invention is to provide a
system particularly useful in distending the anterior wall of a body
cavity and in retracting all superficial organs in order to obtain a good
panoramic view of the body cavity when performing closed surgery,
preferably arthroscopic, thoracoscopic or laparoscopic surgery, more
preferably deep laparoscopic surgery or selective large bowel, pancreatic,
splenic gastric, hepatic laparoscopic surgery or laparoscopic surgery of
the female reproductive organs.
Using the system of this invention, substantial improvement can be obtained
in the efficacy of treatment since the operating surgeon can easily pull
the anterior wall of the body cavity far enough away so as to be able to
obtain an adequate panoramic endoscopic view while not worrying about
maintaining adequate intro-cavital pressure. This greatly enhances the
potential for developing more advanced surgical techniques. The system
allows the retraction of internal organs, especially those located in the
abdominal cavity such as bowels, to the sides of the body cavity to allow
access to such structures like, for instance, the retro-peritoneum or
selected intro-abdominal structures. This second step must be performed
endoscopically.
It is a further object to provide a lateral suspension device consisting of
means for attaching the device to the side of the table, means for holding
one end of one or more wires and a sliding assembly for adjusting the
suspending force of the wires. Optionally, the lateral suspension device
may comprise a malleable arm, a shaft for holding the malleable arm, and a
portion comprising means for fixing the position of the retractor.
Still another object to this invention is to provide a novel retractor
comprising a plurality of blades for retracting internal organs, said
blades being slidably moved to adjust the span of the blades. A retractor
according to the invention, can therefore be used generally, in endoscopic
surgical procedures, so that it can be located in the body cavity and
pulling means can easily pull the desired internal organ to the side,
selectively exposing thereby the body structure to be viewed. The
retractor can be used as a stand alone device, or in conjunction with one
or more lateral suspension device.
A suspension and retraction system comprising at least one lateral
suspension deice operably connected with an overhead device and a
retractor is also encompassed by the present invention.
The present invention is further generally characterized in a method of
exposing any desired portion of body cavity during endoscopic surgical
procedures comprising the steps of (a) locating at least one lateral
suspension device on each side of the patient; (b) passing a wire through
a muscular layer into a body cavity, along a predetermined distance under
the anterior wall of the body cavity, and out of the body cavity through a
muscular layer; (c) connecting each end of said wire to a lateral
suspension device on opposite sides of the patient; (d) repeating steps
(a)-(c), as needed, to form a mesh sufficient to support said anterior
wall of the body cavity; and (e) tensioning said wire to support said
anterior wall of the body cavity.
These and other advantages and objects of the invention will be apparent
from the following description of the preferred embodiments taken in
conjunction with the accompanying drawings and the appended claims.
BRIEF DESCRIPTION OF THE DRAWING FIGURES
FIG. 1A shows a side view of an embodiment of a complete suspension and
retractin system in its operable mode.
FIG. 1B is a plan view of FIG. 1A.
FIG. 2 shows a sliding assembly utilizable with the suspension system of
FIGS. 1A and 1B.
FIG. 3 is a sectional view of a retractor according to the present
invention in a "closed" position.
FIG. 4 is a sectional view of the retractor of FIG. 3 in an "open"
position.
FIG. 5 is a side sectional view of the retractor of FIG. 3.
FIG. 6 is an exploded view of a preferred embodiment of the retractor of
the present invention.
FIGS. 7A and 7B illustrate different activation mechanisms for the
retractor of FIG. 6.
FIGS. 8A, 8B and 8C illustrate different blade configurations usable with
the retractor of FIG. 6.
FIG. 9 is a perspective view of the lateral suspension device according to
the present invention.
FIGS. 10A and 10B illustrate the utilization of the lateral suspension
device of the present invention.
FIGS. 11A and 11B illustrate the utilization of the lateral suspension
device of the present invention in conjunction with the preferred
retractor of the present invention.
DETAILED DESCRIPTION OF THE INVENTION
The invention will now be explained by way of examples of the devices,
system and method designed fo ruse in deep laparoscopic surgery.
As illustrated in FIGS. 1A, 1B and 2, the lateral suspension device 17
comprises a clamp 1 which attaches to the side, preferably a rail, of the
surgical table 2, bed or any other kind of furniture in close proximity to
the patient. The clamp 1 is in fact the distal section of a sliding
assembly 6 which supports a vertical rod 15 which is preferably about 85
centimeters long. The sliding assembly has an excursion of about 10
centimeters to and from the side of the table, and this excursion is
obtained by turning, preferably manually, a nut 4, which is preferably
knurled, which rotates a screw 5. The screw 5 meshes with rack 3 attached
to rod clamp 13, the rod clamp being slidably retained in the sliding
assembly 6. The above described sliding assembly is an example of means
for adjusting the suspending force of the wires. These means may vary
without affecting the concept of the invention. As an alternative, the
vertical rod 15 may have teeth (not shown) along its internal side and its
movements up or down are controlled with a ratchet (not shown) located on
the sliding assembly 6. The axial advancement of the vertical rod would
then determine the amount of suspending force. The vertical rod 15 may
have an angle 14, preferably of about 80 degrees, located preferably about
35 centimeters from its distal end 16. This distal end 16 has a portion 18
for securing one or more wires directly or for holding at least one means
for attachment to one end of the one or more wires. An example of such
means for holding wires is a clamp. The means of wire-attachment may vary
without affecting the concept of the invention. Optionally, the lateral
suspension device may comprise a malleable arm, a shaft for holding the
malleable arm, and a portion comprising means for fixing the position of
the retractor. The complete unit (with exception of the wires) is made of
rigid material which is conventionally used for manufacturing surgical
devices. Preferably, stainless steel is used.
The wires can be made from any materials which are conventionally used for
manufacture of needles and wires suitable for use in surgical procedures.
Stainless steel is illustrative of such suitable materials that may be
used in manufacturing the wires for use in the lateral suspension device
17 of this invention. The configuration, diameter or cross-section along
the length of the wires can be varied depending upon the endoscopic
procedure. For instance, wires can be tapered throughout their length to a
sharp tip. The configuration of the wires can be of any conventional shape
and can range from, but is not limited to, solid, hollow, circular,
semi-circular, oval, rectangular, hexagonal or polygonal configuration.
The wires are not designed to remain in the tissue after the surgical
procedure is completed. The wires can be conventionally sterilized for
reuse, if necessary, although it is preferable to discard them since the
unit cost is low and disposal avoids any subsequent sterilization and
storage problems.
The lateral suspension device 17 of the present invention can be any size
from micro to macro depending on the type of the endoscopic procedure for
which it is designed for use without effecting the concept of the
invention. All components of the lateral device (with exception of the
wires) are intended for indefinite reuse.
In one embodiment of the invention, as shown in FIGS. 3-5, a retractor 7
comprises a cylindrical tube 8, a plunger 9, slidably received within the
tube 8, and blades 10. Various mechanisms can be accommodated on the tube
8 to hold one or more, preferably four to eight, blades 10. The blades can
be made from any suitable rigid material, preferably stainless steel.
Optionally, they may be covered with a teflon coating and the like. The
tube 8 provides a stable cover for the plunger 9 holding the blades 10 to
be slidably moved with respect to the sheath to adjust the span of the
blades and the depth of penetration. The blades can vary in length and
thickness.
After the retractor 7 has been inserted, the blades can be pushed out and
locked din place by lock screw 12.
After the retractor 7 has been inserted and its blades 10 have been put in
traction, retracting organs, the top of the retractor is attached to the
distal end 16 of the suspension device. In this fashion, the retractor
becomes autostatic and can still be adjusted from time to time by the
surgeon. As mentioned already, the retractor can be used as stand alone
device, or in conjunction with one or more lateral suspension devices, or
combination of both.
In the construction of a working model of the retractor 7, the blades 10
were in length from 12 to 20 centimeters and in thickness up to about 1
mm, and had a span of 7 to 9 cm.
A system for retracting any internal organs and distend | | |
