U.S. patent application number 10/810084 was filed with the patent office on 2004-12-02 for surgical retractor.
Invention is credited to Aranvi, Cathy, Farascioni, David, Hinchliffe, Peter W.J., Nicholas, David A., Ratcliff, Keith, Sherts, Charles R..
Application Number | 20040242969 10/810084 |
Document ID | / |
Family ID | 27360543 |
Filed Date | 2004-12-02 |
United States Patent
Application |
20040242969 |
Kind Code |
A1 |
Sherts, Charles R. ; et
al. |
December 2, 2004 |
Surgical retractor
Abstract
Apparatus and method for surgery is disclosed which includes a
retractor having a substantially planar base defining an opening
for overlying an operative site on a patient, and at least one
retractor blade slidably mounted to the base. The base is
positioned on the patient such that the opening therein overlies
the operative site. The operative site is percutaneously accessed,
and obstructing tissue is retracted by engaging the tissue with the
retractor blade. A surgical instrument is provided which is
engageable with the base and operable at the operative site through
the opening in the base. A surgical procedure is carried out
through the opening in the base with the surgical instrument.
Inventors: |
Sherts, Charles R.;
(Westport, CT) ; Nicholas, David A.; (Trumbull,
CT) ; Farascioni, David; (Bethel, CT) ;
Ratcliff, Keith; (Newtown, CT) ; Hinchliffe, Peter
W.J.; (New Haven, CT) ; Aranvi, Cathy;
(Easton, CT) |
Correspondence
Address: |
Mark Farber, Esq.
U.S. Surgical, A Division of
Tyco Healthcare Group, LP
150 Glover Avenue
Norwalk
CT
06856
US
|
Family ID: |
27360543 |
Appl. No.: |
10/810084 |
Filed: |
March 26, 2004 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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10810084 |
Mar 26, 2004 |
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10153385 |
May 22, 2002 |
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6733445 |
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10153385 |
May 22, 2002 |
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09779037 |
Feb 7, 2001 |
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6537212 |
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09779037 |
Feb 7, 2001 |
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09388716 |
Sep 2, 1999 |
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6213940 |
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09388716 |
Sep 2, 1999 |
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08801052 |
Feb 14, 1997 |
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5967973 |
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08801052 |
Feb 14, 1997 |
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08717591 |
Sep 23, 1996 |
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60016325 |
Apr 26, 1996 |
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Current U.S.
Class: |
600/231 |
Current CPC
Class: |
A61B 2017/00243
20130101; A61B 2217/005 20130101; A61M 1/0058 20130101; A61B
2017/2905 20130101; A61B 90/50 20160201; A61B 2217/007 20130101;
A61B 2017/0237 20130101; A61B 17/12 20130101; A61B 17/1325
20130101; A61B 2090/306 20160201; A61B 2017/0243 20130101; A61B
17/0293 20130101 |
Class at
Publication: |
600/231 |
International
Class: |
A61B 001/32 |
Claims
What is claimed:
1. An instrument for stabilizing tissue for use with an instrument
base, comprising; an articulating arm having a plurality of link
members arranged in a nested series, the link members being
concatenated by a cable passing through a bore defined through each
of the link members; a mounting assembly operatively connected at
one end of the articulating arm and a tissue engaging member
operatively connected at the opposite end of the articulating arm;
an actuator operatively associated with the mounting assembly; the
cable being selectively movable by the actuator from a first,
relaxed position which facilitates articulation of adjoining link
members of the articulating arm and facilitates relative movement
of the mounting assembly to the instrument base to a second, taut
position which limits movement of the articulating arm and locks
the mounting assembly relative to the instrument base.
2. An instrument for stabilizing tissue according to claim 1
wherein the tissue engaging member includes a suction device
operatively associated with the articulating arm.
3. An instrument for stabilizing tissue according to claim 1
wherein at least one of the link members of the articulating arm
includes a generally convex distal portion and an adjacent link
member includes a corresponding concave proximal portion which
nestingly receives the convex distal portion therein.
4. An instrument for stabilizing tissue according to claim 1
wherein the tissue engaging member includes a frame having a pair
of legs which extend therefrom, the legs being dimensioned to
position tissue therebetween.
5. An instrument for stabilizing tissue according to claim 1
wherein the tissue engaging member is selected from the group
consisting of mechanical stabilizers, organ manipulating devices,
suction devices, irrigation devices, illumination devices, and
blowing devices.
6. An instrument for stabilizing tissue according to claim 1
wherein the mounting assembly includes first and second opposed and
relatively movable mounting portions which are selectively
positionable relative to the instrument base upon activation of the
actuator.
7. An instrument for stabilizing tissue according to claim 1
wherein the actuator includes a fixed handle and a toggle handle,
the toggle handle being selectively movable relative to the fixed
handle from a first position wherein the fixed handle and the
toggle handle are disposed in spaced-apart relation relative to one
another to at least one subsequent position wherein the toggle
handle is closer to the fixed handle.
8. An instrument for stabilizing tissue according to claim 7
wherein movement of the toggle handle from the first position to
the at least one subsequent position stresses the cable which
limits movement of the articulation arm.
Description
CROSS REFERENCE TO RELATED APPLICATION
[0001] This application claims priority to U.S. Provisional
Application Ser. No. 60/016,325 filed Apr. 26, 1996.
BACKGROUND
[0002] 1. Technical Field
[0003] The subject disclosure relates to minimally invasive
surgical procedures and apparatus, and more particularly to an
instrument and method for performing surgery associated with the
thoracic cavity.
[0004] 2. Background of Related Art
[0005] The diagnosis and treatment of coronary disease and related
conditions typically requires access to the heart, blood vessels
and associated tissue. Such procedures include cardiopulmonary
bypass, valve repair and replacement, and treatment of aneurysms.
Access to the patient's thoracic cavity may be achieved by a large
longitudinal incision in the chest This procedure, referred to as a
median sternotomy, requires a saw or other cutting instrument to
cut the sternum and allow two opposing halves of the rib cages to
be spread apart U.S. Pat. No. 5,025,779 to Bugge discloses a
retractor which is designed to grip opposite sternum halves and
spread the thoracic cavity apart. The large opening which is
created by this technique enables the surgeon to directly visualize
the surgical site and perform procedures on the affected organs.
However, such procedures that involve large incisions and
substantial displacement of the rib cage are often traumatic to the
patient with significant attendant risks. The recovery period may
be extended and is often painful. Furthermore, patients for whom
coronary surgery is indicated may need to forego such surgery due
to the risks involved with gaining access to the heart U.S. Pat.
No. 5,503,617 to Jako discloses a retractor configured to be held
by the surgeon for use in vascular or cardiac surgery to retract
and hold ribs apart to allow access to the heart or a lung through
an operating window. The retractor includes a rigid frame and a
translation frame slidably connected to the rigid frame. Lower and
upper blades are rotatably mounted to the rigid frame and the
translation frame respectively.
[0006] Once access to the thoracic cavity has been achieved,
surgery on the heart may be performed. Such procedures typically
require that the heart beat be arrested while maintaining
circulation throughout the rest of the body. Cardioplegic fluid,
such as potassium chloride (KCl) is delivered to the blood vessels
of the heart to paralyze the myocardium. As disclosed in WO
95/15715 to Sterman et al. for example, cardioplegic fluid is
infused into the myocardium through the coronary arteries by a
catheter inserted into the ascending aorta. Alternatively,
cardioplegic fluid is infused through the coronary veins in a
retrograde manner by a catheter positioned in the interior jugular
vein accessed at the patient's neck. Such procedures require the
introduction of multiple catheters into the blood vessels adjacent
the heart, which is a complicated procedure requiring that the
desired vessels be properly located and accessed. The progression
of the guide wires and catheters must be closely monitored to
determine proper placement Furthermore, the introduction of
catheters forms punctures in the blood vessels that must be
subsequently closed, and there is an increased risk of trauma to
the interior walls of the vessels in which the catheters must
pass.
[0007] Therefore, a need exists for an apparatus and procedure
which provides access to the thoracic cavity without causing
extensive trauma to the patient. A procedure is needed to at least
locally stabilize a predetermined area of the heart surface that is
relatively simple to perform and incorporates instruments that are
simple and reliable. Furthermore, an apparatus and procedure is
needed which provides a stable framework for supporting additional
instruments which may be used during these procedures.
SUMMARY
[0008] The present disclosure is directed to instruments for and
methods of surgery. A retractor is provided which has a
substantially planar base defining an opening for overlying an
operative site on a patient, and at least one retractor blade
slidably mounted to the base.
[0009] The base is positioned on the patient such that the opening
therein overlies the operative site, and the operative site is
percutaneously accessed through the opening. Obstructing tissue is
retracted with one or more retractor blades to create an opening to
provide access for the surgical procedure. A surgical instrument is
provided which is engageable with the base and operable at the
operative site. A surgical procedure is carried out through the
opening in the base with the surgical instrument.
[0010] In a preferred embodiment, the retractor blade includes a
ratchet assembly, and the method includes fixing the position of
the retractor blade with respect to the base with the ratchet
assembly.
[0011] The retractor blade may also include an integral blowing,
irrigation or suction assembly operably positioned adjacent the
blade to remove blood, fluid, etc. In another embodiment, a light
assembly may be incorporated to illuminate designated portions of
the surgical field.
[0012] A heart manipulator is disclosed for use in conjunction with
the retractor and is releasably mountable on the base. The heart
manipulator assists in atraumatically holding and positioning the
heart to facilitate access thereto. In a preferred embodiment the
heart manipulator includes a loop shaped frame which supports a
mesh cradle.
[0013] A heart stabilizer instrument is also disclosed. This
instrument is preferably configured to be mounted to the base
portion and has a heart contacting surface. The heart may be
contacted with the heart contacting surface to stabilize the
position of a predetermined portion of the heart surface. A heart
stabilizer instrument may be provided which is mounted to the base
portion and movable with respect thereto. The predetermined portion
of the heart surface is substantially stabilized by applying
pressure thereto. In a preferred embodiment, the heart stabilizer
instrument includes structure configured to compress the coronary
artery, and the step of stabilizing a predetermined portion of the
heart surface includes applying pressure to the coronary artery
with the heart stabilizer instrument The position of the heart
stabilizing device may be locked with respect to the base.
[0014] The base may be provided to the hospital and/or surgeon in a
kit form including one or more retractors. The kit may also
advantageously include a heart manipulator and/or heart stabilizing
device.
[0015] The surgical method may further include providing an
actuator associated with the retractor blade and configured to
effect linear movement of the retractor blade.
[0016] These and other features of the surgical retractor and
method for heart surgery will become more readily apparent to those
skilled in the art from the following detailed description of
preferred embodiments of the subject disclosure.
BRIEF DESCRIPTION OF THE DRAWINGS
[0017] Various embodiments of the subject surgical apparatus are
described herein with reference to the drawings wherein:
[0018] FIG. 1 is a perspective view of a surgical retractor
constructed in accordance with a first embodiment of the subject
disclosure;
[0019] FIG. 2 is an enlarged perspective view with parts separated
of a retractor blade assembly of the surgical retractor of FIG.
1;
[0020] FIG. 3 is an enlarged cross-sectional view of a portion of
the retractor blade assembly, illustrating the mounting of the
retractor blade assembly on the base;
[0021] FIG. 4 is an enlarged cross-sectional view taken along line
4-4 of FIG. 1 of the retractor blade assembly mounted to the
base;
[0022] FIG. 5 is an enlarged top view, illustrating the radially
inward movement of the retractor blade with respect to the
base;
[0023] FIG. 6 is an enlarged top view, illustrating the ratchet on
the retractor blade in engagement with the pawl member associated
with the base;
[0024] FIG. 7 is an enlarged top view, illustrating the pawl member
associated with the base moved out of engagement with the retractor
blade assembly;
[0025] FIG. 8 is a perspective view of one embodiment of a heart
manipulator mounted to a base;
[0026] FIG. 9 is a perspective view of a heart manipulator mounted
to the base and constructed in accordance with another
embodiment;
[0027] FIG. 10 is an enlarged perspective view of a heart
stabilizer instrument mounted to the base;
[0028] FIG. 11 is a top view in reduced scale of the base portion
positioned on the patient's chest;
[0029] FIG. 12 is a top view, illustrating retractor blade
assemblies mounted to the base portion and retracting the patient's
ribs;
[0030] FIG. 13 is a top view, illustrating a heart manipulator in
position adjacent the patient's heart;
[0031] FIG. 14 is an enlarged side view in cross-section,
illustrating a heart manipulator mounted to the base and spaced
from the heart;
[0032] FIG. 15 is an enlarged side view in cross-section,
illustrating a heart manipulator in contact with the heart;
[0033] FIG. 16 is a top view, illustrating the heart stabilizer
instrument of FIG. 10 mounted to the base;
[0034] FIG. 17 is a perspective view of the heart stabilizer
instrument of FIG. 10 mounted to the base and spaced from the
heart;
[0035] FIG. 18 is a perspective view of the heart stabilizer
instrument of FIG. 10 in contact with the heart;
[0036] FIG. 19 is a perspective view of a surgical retractor
assembly and base constructed in accordance with another embodiment
of the subject disclosure;
[0037] FIG. 20 is an enlarged perspective view with parts separated
of the retractor blade assembly,
[0038] FIG. 21 is an enlarged perspective view from below of the
retraction knob, illustrating the pinion gearing disposed
thereon;
[0039] FIG. 22 is an enlarged cross-sectional view of the retractor
blade assembly mounted to the base;
[0040] FIG. 23 is an enlarged cross-sectional view of the retractor
blade assembly in the process of being mounted to the base;
[0041] FIG. 24 is an enlarged top view illustrating the radially
outward translation of the retractor blade;
[0042] FIG. 25 is an enlarged top view of the pawl member
associated with the base in engagement with the retractor
blade;
[0043] FIG. 26 is an enlarged top view, illustrating the pawl
member moved out of engagement with the retractor blade;
[0044] FIG. 27 is a perspective view of a heart manipulator
constructed in accordance with yet another embodiment of the
subject disclosure;
[0045] FIG. 28 is an enlarged cross-sectional view of the mounting
assembly for the heart manipulator of FIG. 27;
[0046] FIG. 29 is a perspective view of a heart stabilizer
instrument constructed in accordance with another embodiment of the
subject disclosure;
[0047] FIG. 30 is an enlarged cross-sectional view of the mounting
assembly of the heart stabilizer instrument of FIG. 29 in an
unlocked position;
[0048] FIG. 31 is an enlarged cross-sectional view of the mounting
assembly of the heart stabilizer instrument of FIG. 29 in a locked
position;
[0049] FIG. 32 is a cross-sectional view taken along line 32-32 of
FIG. 31 illustrating the mounting assembly;
[0050] FIG. 33 is a top view of the surgical retractor positioned
on the patient's chest, illustrating retractor blade assemblies, a
heart manipulator and a heart stabilizer instrument mounted to the
base;
[0051] FIG. 34 is a perspective view of a surgical retractor
constructed in accordance with another embodiment of the subject
disclosure;
[0052] FIG. 35 is a perspective view with parts separated of a
retractor blade assembly of the surgical retractor of FIG. 34;
[0053] FIG. 36 is an enlarged side cross-sectional view of the
retractor blade assembly, illustrating the positioning adjacent a
rib and the mounting of the retractor blade assembly on the
base;
[0054] FIG. 37 is an enlarged side cross-sectional view of the
retractor blade assembly mounted to the base and in the process of
retracting a rib;
[0055] FIG. 38 is a perspective view, illustrating the pawl member
and the retractor blade in engagement;
[0056] FIG. 39 is an enlarged cross-sectional view taken along line
39-39 of FIG. 37, illustrating the ratchet on the retractor blade
in engagement with the pawl member,
[0057] FIG. 40 is an enlarged cross-sectional view, illustrating
the pawl member associated with the base moved out of engagement
with the retractor blade;
[0058] FIG. 41 is a perspective view of another embodiment of a
heart stabilizer instrument mounted to the base of FIG. 34;
[0059] FIG. 42 is a perspective view with parts separated of the
heart stabilizer instrument of FIG. 41;
[0060] FIG. 42A is a perspective view of the toggle member,
illustrating the cable mounting configuration;
[0061] FIG. 42B is a perspective view from below of the heart
stabilizer instrument of FIG. 41;
[0062] FIG. 43 is a side cross-sectional view of the heart
stabilizer instrument of FIG. 41;
[0063] FIG. 44 is a side view in partial cross-section of the heart
stabilizer instrument in an unlocked configuration;
[0064] FIG. 45 is an enlarged cross-sectional view of the toggle
mechanism in an unlocked configuration;
[0065] FIG. 46 is an enlarged cross-sectional view of a portion of
the articulating arm, illustrating the cable in a loose
configuration corresponding to the unlocked configuration of FIGS.
44-45;
[0066] FIG. 47 is an enlarged cross-sectional view of the toggle
mechanism in an locked configuration;
[0067] FIG. 48 is a reduced scale side view in partial
cross-section of the heart stabilizer instrument in an locked
configuration;
[0068] FIG. 49 is an enlarged cross-sectional view of a portion of
the articulating arm, illustrating the cable in a tightened
configuration corresponding to the locked configuration of FIGS.
47-48;
[0069] FIG. 50 is an perspective view of a heart stabilizer
instrument mounted to the base in accordance with another
embodiment of the present disclosure;
[0070] FIG. 50A is an enlarged perspective view of the link members
of the heart stabilizer instrument of FIG. 50;
[0071] FIG. 50B is an enlarged perspective view of the link members
of the heart stabilizer instrument of FIG. 50;
[0072] FIG. 51 is a perspective view of a surgical retraction
system in accordance with another embodiment of the subject
disclosure incorporating a variety of retractors, a heart
manipulator and a heart stabilizer, all positioned on a base;
[0073] FIG. 52 is a top view of the base of FIG. 51 illustrating
suture mounts positioned thereabout;
[0074] FIG. 53 is an enlarged perspective view of the suture mounts
of FIG. 52;
[0075] FIG. 54 is a perspective view of a surgical retractor in
accordance with the subject disclosure incorporating an integral
blowing structure;
[0076] FIG. 55 is a reverse perspective view of the surgical
retractor of FIG. 54;
[0077] FIG. 56 is an enlarged perspective view with parts separated
of the surgical retractor of FIG. 54;
[0078] FIG. 57 is a perspective view of a surgical retractor in
accordance with the subject disclosure incorporating a light;
[0079] FIG. 58 is a reverse perspective view of the surgical
retractor of FIG. 57;
[0080] FIG. 58A is a top plan view in partial cross-section of a
surgical retractor mounted to the base of FIG. 52;
[0081] FIG. 58B is a top plan view in partial cross-section of the
surgical retractor in FIG. 58A pulled proximally relative to the
base;
[0082] FIG. 58C is a top plan view in partial cross-section of the
surgical retractor in FIG. 58A released from engagement with the
rack;
[0083] FIG. 59 is a perspective view of another embodiment of a
heart stabilizer instrument in accordance with the subject
disclosure;
[0084] FIG. 60 is an enlarged perspective view of a portion of the
heart stabilizer instrument of FIG. 59, illustrating a positioning
flange formed thereon;
[0085] FIG. 61 is a perspective view with parts separated of the
heart stabilizer instrument of FIG. 59;
[0086] FIG. 62 is a perspective view of the mounting flange member
of the heart stabilizer instrument of FIG. 59;
[0087] FIG. 63 is a perspective view of the movable handle of the
heart stabilizer instrument of FIG. 59;
[0088] FIG. 64 is a top plan view in partial cross-section of the
heart stabilizer instrument of FIG. 59 with the movable handle in
the unlocked unstressed position;
[0089] FIG. 65 is a cross-sectional view taken along line 65-65 of
FIG. 64, illustrating the relative position of the handle spring
member,
[0090] FIG. 66 is a top plan view in partial cross-section of the
heart stabilizer instrument of FIG. 59 with the movable handle in
the locked unstressed position;
[0091] FIG. 67 is a cross-sectional view taken along line 67-67 of
FIG. 66, illustrating the relative position of the handle spring
member,
[0092] FIG. 68 is a top plan view in partial cross-section of the
heart stabilizer instrument of FIG. 59 with the movable handle in
the locked and stressed position;
[0093] FIG. 69 is a cross-sectional view taken along line 69-69 of
FIG. 68, illustrating the relative position of the handle spring
member,
[0094] FIG. 70 is a perspective view of another embodiment of a
heart manipulator,
[0095] FIGS. 71A and 71B are front and back perspective views of
the rib elevator,
[0096] FIG. 72 is a perspective view of a kit assembly having a
base, three retractors, a retraction knob, a heart manipulator and
a heart stabilizer instrument; and
[0097] FIG. 73 is a perspective view of a kit assembly having a
base, a retraction knob and three retractors.
DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS
[0098] The preferred embodiments of the apparatus disclosed herein
will be discussed in terms of procedures and apparatus for heart
surgery. However, the subject disclosure should not be limited to
an apparatus for use in conjunction with such heart surgery, but
may find application in surgery wherein access to the surgical site
is achieved through a small incision and retraction of the
surrounding tissues and/or bone is desired.
[0099] Referring now in detail to the drawings in which like
reference numerals identify similar or identical elements, a first
embodiment of the surgical retractor of the subject disclosure is
illustrated in FIG. 1, and is designated generally by reference
numeral 10. Surgical retractor 10 has base 12 and retractor blade
assembly 14, including mounting assembly 16 and retractor blade 18.
As will be described below, base 12 in this embodiment is
configured to be placed on the chest of a patient surrounding an
incision. Retractor blade 18 includes hook 20 configured for
atraumatically engaging a rib. Strap 22 assists the surgeon in
drawing the retractor blade 18 radially outward and retracting a
rib therewith. One-way ratchet assembly 23 on mounting assembly 16
retains retractor blade 18 in position. Base 12 is also configured
to receive surgical instruments for mounting thereon, as will be
described below.
[0100] Base 12 preferably has a closed shape, such as an oval
configuration as shown, or a circle, polygon, or the like. Base 12
is sized sufficiently large in order to enclose sufficient area to
provide access to the operative site. The bottom portion of base 12
is preferably configured to permit placement directly on the skin
of the patient with the base substantially flush with the patient's
skin. Suture mounts 24a, 24b, 24c may be provided at several
locations on the base 12 to permit suture tie down of internal
tissue structures such as the pericardial sac. Outer periphery 26
of base 12 includes a series of outwardly extending teeth 27 formed
thereon to provide additional stability to the positioning of
mounting assembly 16 and other instruments on base 12. Base 12 also
includes a beveled inner surface 28 with an inner lip 30, and top
surface 32. Base 12 has a low profile when placed on the body. Base
12 is rigidly supported by pressure from retractor blade assembly
14 on the ribs in three or four locations. Preferably, three
retractor blade assemblies are disposed on base 12 at 120.degree.
apart Retractor blade assemblies may be disposed 90.degree.
apart.
[0101] Turning now to FIG. 2, mounting assembly 16 permits quick
and stable mounting of the retractor blade assembly to base 12.
Mounting assembly 16 includes mounting bracket 34, retainer block
36, and retainer spring 38. Gripping flange 40 on mounting bracket
34 is configured to engage inner lip 30 of base 12 (FIGS. 3 and 4).
Sleeve 42 forms an open-sided channel 44 for sliding reception of
retractor blade 18. Pawl member 46 is formed on mounting bracket 34
and has a series of engaging teeth 48 which communicate with the
open side of channel 44 for engaging retractor blade 18, as will be
described below. Mounting bracket 34 defines a cavity 49 for
mounting retainer block 36 therein. Cavity 49 is partially defined
by outer retainer wall 50 with upper flange 51 and by inner wall 52
having aperture 53. Retainer block 36 is radially slidable within
cavity 49 and is biased inward by retainer spring 38 such that
engagement teeth 54 on retainer block 36 protrude through aperture
53, to engage teeth 27 provided on periphery 26 of base 12.
Retainer block 36 also includes handle 56 which permits the surgeon
to move retainer block 36 towards retainer wall 50 against the bias
of retainer spring 38, in order to disengage teeth 54 from base
12.
[0102] Retractor blade 18 includes curved hook 20 on a distal end
portion and slot 57 on a proximal end portion to receive flexible
assist strap 22 therethrough. A series of ratchet teeth 58 are
provided on an edge of retractor blade 18 and engage teeth 48 of
pawl member 46 when retractor blade 18 is disposed in channel 44 of
mounting bracket 34.
[0103] As illustrated in FIGS. 3-4, mounting assembly 16 is mounted
to base 12 in a simple, one-handed operation. FIG. 3 illustrates
retainer block 36 displaced towards retainer wall 50 against the
normal bias of retainer spring 38. Handle 56 of retainer block 36
facilitates approximation of retainer wall 50 with flange 51 of
retainer wall 50. Mounting assembly 16 is lowered onto base 12 at
an angle as shown such that gripping flange 40 engages inner lip 30
of base 12. Engagement teeth 54 are angled to permit camming over
outer lip 60. FIG. 4 illustrates mounting assembly 16 into position
with respect to base 12, upon which retainer block 36 is released,
which thereby returns inward towards base 12 under the normal bias
of spring 38. Engagement teeth 54 pass under outer lip 60 and
engage teeth 27 on periphery 26 of base 12.
[0104] Turning to FIGS. 5-7, the progression of retractor blade 18
with respect to mounting bracket 34 is illustrated. Ratchet
assembly 23 includes pawl 46 on mounting bracket 34 and teeth 58 on
retractor blade 18. Pawl 46 is normally biased towards retractor
blade 18. Pawl teeth 48 and retractor blade teeth 58 are each
configured with a sloping portion and a straight portion. This
permits retractor blade 18 to be progressively displaced in a
radially outward direction as indicated by arrow "O" in FIG. 5. As
illustrated in FIG. 6, radially inward displacement of retractor
blade 18 is prevented by engagement of pawl teeth 48 and retractor
blade teeth 58 under the normal bias of pawl 46. The arrangement of
teeth, as shown in FIGS. 5-6 permits retraction of a rib or other
body structure and prevents slipping of or loss of retraction force
exerted by retractor 18. As illustrated in FIG. 7, retractor blade
18 is permitted to displace radially inward as indicated by arrow
"I" when pawl tab 62 is rotated clockwise causing it to move away
from retractor blade 18 against its normal bias by actuation of tab
62. Unrestricted movement of retractor blade 18 is permitted in
both radially inward and radially outward directions when tab 62 is
moved to the position of FIG. 7.
[0105] FIG. 8 illustrates a heart manipulator 64 for use in
conjunction with surgical retractor 10 and for mounting on base 12.
Heart manipulator 64 includes loop shaped frame 66 that supports
mesh surface 68. Frame 66 and mesh surface 68 together form a heart
contacting surface for manipulating the heart therewith.
Preferably, frame 66 includes upright portion 70, generally
horizontally extending portion 72 and atraumatic curved end portion
74, which provide a surface for engaging and manipulating the
heart. Frame 66 is supported by mounting bar 76 which is slidably
received in support bracket 78 for height adjustment. Set screw 80
secures mounting bar 76 with respect to support bracket 78. Radial
positioning of support bracket 78 and heart manipulator 64 is
achieved by slidable mounting of support bracket 78 on mounting
assembly 82 which mounts to base 12 in a manner substantially
similar to that of mounting assembly 16 described above with
respect to FIG. 3-4. Set screw 84 secures the radial position of
heart manipulator 64 with respect to mounting assembly 82. More
particularly, support bracket 78 has an elongated slot 79 formed
therein which enables bracket 78 to slide radially with respect to
set screw 84 and mounting assembly 82. As shown in FIG. 14,
mounting assembly 82, like mounting assembly 16, has a mounting
bracket 83 which engages inner lip 30 of base 12, retainer block
81, and retainer spring 87. Handle 89 of retainer block 81 enables
the engagement and disengagement of mounting assembly 82 in the
same manner as mounting assembly 16 described above.
[0106] Turning to FIG. 9, a heart manipulator 90 is shown in
accordance with another preferred embodiment. Loop frame 66 and
mounting assembly 82 are substantially as described above with
respect to heart manipulator 64 in FIG. 8. Mounting bar 92 supports
frame 66 and has a substantially right angled bend 94 for slidable
insertion in support bracket 96. Radial position of heart
manipulator 90 is achieved by sliding mounting bar 92 with respect
to support bracket 96 and secured thereto by set screw 98. Although
height adjustment of heart manipulator 90 is not provided, access
to the operative site is enhanced by the one-piece design of
mounting bar 92.
[0107] FIG. 10 illustrates a heart stabilizer instrument 100,
configured to apply pressure to the coronary artery to reduce blood
flow in the artery to allow anastomosis to the coronary artery and
to reduce movement of the heart muscle between legs 104a, 104b in
order to enable the surgeon to perform cardiovascular surgery.
Heart stabilizer instrument 100 is mounted to base 12 by mounting
assembly 82, substantially as described above. Heart stabilizer
instrument 100 includes frame 102 supporting legs 104a and 104b and
transverse bars 106a and 106b. Protrusion 108a is formed on
transverse bar 106a, and protrusion 108b is formed on transverse
bar 106b. Protrusions 108a and 108b have an atraumatic convex heart
contacting surface and permit the exertion of localized pressure on
the coronary artery when frame 102 is compressed on the surface of
the heart. Mounting bar 110 is slidably received in support bracket
78 and secured with respect thereto by set screw 80. Radial
positioning of heart stabilizer instrument 100 with respect to
mounting assembly 82 is secured by a coupling means, such as set
screw 84.
[0108] Turning now to FIG. 11, the operation of the surgical
retractor 10 will now be described. Conventional surgical
techniques are used to determine the location of the incision I
accessing the chest cavity C. Base 12 is placed on the chest of the
patient with the opening overlying the operative site. Incision I
is made, exposing several ribs R.sub.1, R.sub.2, and R.sub.3.
[0109] As illustrated in FIG. 12, retractor assemblies 14a, 14b,
and 14c are mounted to base 12 at various locations. Hook 20a is
positioned around a rib R.sub.1. Assist strap 22a is used to
provide a grip for the surgeon to deflect and retract rib R.sub.1
by pulling retractor blade 18 radially outward. One way ratchet
assembly 23a maintains retractor blade 18 and consequently rib
R.sub.1 in position. Rib R.sub.2 is retracted in a substantially
identical manner by hook 20b on retractor assembly 14b. Additional
retractors are mounted and used to retract ribs until a
sufficiently large opening O in chest cavity C is defined in order
to provide access to the heart. Although three retractors are
shown, it is contemplated that a fewer number or a grater number of
retractors could be utilized, and these retractors can be mounted
anywhere along base 12 in order to perform their function. For
example, the sternum and the fourth and fifth ribs can be spread
apart to create a window. Alternatively, the fourth and fifth ribs
are cut from the sternum and spread to create a larger window.
Alternatively, a fifth rib can be cut, and the sternum and the
fourth and sixth ribs are spread.
[0110] Base 12 is at least partially held in position over the
operative site by tension created in retracting the ribs by
retractor blades 18. Internal tissue structures may be tied down
utilizing sutures passing through securement points 24a, 24b, 24c
and 24d.
[0111] Turning now to FIG. 13, heart manipulator 64 is mounted to
base 12 in order to manipulate the position of heart H to
facilitate the surgery. With reference to FIG. 14, heart
manipulator 64 is positioned in the chest cavity adjacent heart H.
Frame 66 and mounting bar 76 can be lowered and fixed by set screw
80 such that horizontal portion 72 and curved end portion 74 are
positioned slightly underneath heart H. As illustrated in FIG. 15,
heart manipulator 64 is displaced radially inward and against heart
H by loosening set screw 84 and sliding mounting bar 92 in the
direction of the arrow. When sufficient pressure is placed on the
heart to substantially fix its position, heart manipulator 64 is
secured by the tightening of set screw 84.
[0112] With the heart manipulated to the desired position, FIG. 16
illustrates the mounting of heart stabilizer instrument 100 to base
12. As illustrated in FIG. 17, heart stabilizer instrument 100 is
positioned over heart H and more particularly, over coronary artery
A. The radial positioning of instrument 110 is accomplished by
relative movement of support bracket 78 with respect to mounting
assembly 82.
[0113] As illustrated in FIG. 18, frame 102 and mounting bar 110
are lowered with respect to support bracket 78 such that frame 102
applies direct pressure on heart H. Protrusions 108a and 108b
localize this pressure to substantially restrict the flow of blood
from coronary artery A and 104a and 104b reduce movement of the
surface of the heart muscle to facilitate the surgery. Heart
movement is restricted by virtue of the leg pressure and the
anti-slip texture of the legs 104a and 104b. The position of
instrument 100 may be locked with respect to the base as set forth
in detail below.
[0114] Turning now to FIGS. 19-33, another preferred embodiment of
the surgical retractor is disclosed at reference numeral 200.
Instrument 200 operates substantially as described above with
regard to instrument 10, with the differences described
hereinbelow. In particular, FIG. 19 illustrates surgical retractor
200 having base 212 and retractor blade assembly 214, which
includes mounting bracket 216, retractor blade 218 and retraction
knob 220. The provision of retraction knob 220 enables the surgeon
to achieve additional mechanical advantage in retracting a rib.
[0115] Base 212 includes suture mounting portions 224a, 224b, 224c
and 224d for securing base 212 adjacent the surgical site. Base 212
further includes beveled inner surface 228 with inner lip 230 and
top surface 232 in which a series of cylindrical recesses or
openings 240 are defined.
[0116] As illustrated in FIG. 20, mounting bracket 216 includes
sleeve 242 defining open-sided channel 244 for sliding reception of
retractor blade 218. Pawl member 246 has a series of ratchet teeth
248 configured to engage ratchet teeth 258 on retractor blade 218
when blade 218 is slidably inserted in channel 244.
[0117] Retraction knob 220 is rotatably positioned in aperture 236
in mounting bracket 216. With reference to FIG. 20 in conjunction
with FIG. 21, retraction knob 220 includes pinion gear 260 which
cooperates with rack 262 provided on retractor blade 218. As will
be described below, rotation of knob 220 provides additional
mechanical advantage in cooperation with one-way ratchet mechanism
23 to retract and/or advance retractor blade 218.
[0118] As illustrated in FIGS. 22-23, retractor blade assembly 214
is mounted to base 212 in a simple, one-handed motion. Mounting
bracket 216 includes pin 264 on a bottom portion thereof
dimensioned to be received in one of cylindrical recesses 240 in
base portion 212. The length of pin 264 is preferably substantially
equivalent to the depth of recess 240 to provide stability to
mounting bracket 216. In addition, wedge shaped inner portion 266
of mounting bracket 216 cooperates with beveled inner surface 228
of base 212 to facilitate positioning and to provide resistance
against tilting of retractor blade 218. Mounting bracket 216 is
further secured in position by tab 270 which includes a flange 272
which engages outer rim 274 of base 212. As illustrated in FIG. 23,
removal and placement of mounting bracket 216 is accomplished by
deflecting flange 272 of tab 270 clear of outer rim 274. Tab 220
includes rigid lever arm 276 which facilitates such deflection of
tab 270.
[0119] Turning to FIGS. 24-26, the interaction of retractor blade
218 with respect to mounting bracket 216 is illustrated. Ratchet
assembly 223, which includes pawl 246 and sloping teeth 258
function substantially as described above with respect to FIG. 5,
and permits retractor blade 218 to be progressively displaced
radially outwardly while preventing radially inward displacement
Initially, assist straps 22 (See, FIG. 19) are used by the surgeon
to retract a rib. Retracting blade 218 is displaced radially
outwardly as far as possible given the strength of the surgeon.
Subsequently, additional retraction force can be applied to the rib
by rotation of retraction knob 220. Pinion gear 260 disposed on
knob 220 engages rack 262 on retraction blade 218 and provides
additional leverage to the surgeon. As illustrated in FIG. 25, pawl
246 is normally biased against retraction blade 218 such that
ratchet teeth 258 on blade 218 and ratchet teeth 248 on pawl 246
engage to prevent radially inward movement. It should be
appreciated that knob 220 is optionally removable so it can be used
to retract each retractor blade 218.
[0120] FIG. 26 illustrates that pawl 246 may be rotated away from
retraction blade 218 by pivoting lever 262 to disengage teeth 258
and 248. Unrestricted radial movement of retraction blade 218 is
facilitated thereby.
[0121] FIGS. 27-28 illustrated another embodiment of a heart
manipulator instrument designated by reference numeral 300. Heart
manipulator 300 is used to manipulate the position of the heart and
operates substantially as described above with regard to heart
manipulator 64, with the differences described below. In
particular, heart manipulator 300 includes frame member 302, formed
in a modified "U" configuration having an upright portion wherein
the bars are parallel, including closely spaced mounting portions
304a and 304b, more widely spaced mesh supporting portions 306a and
306b, and a curved horizontally extending portion 308. Mesh
supporting portions 306a and 306b and horizontally extending
portion 308 support a mesh surface 310 therebetween. Mounting
portions 304a and 304b are snap fit within bores formed in support
bracket 320. It is contemplated that members 304a and 304b may be
slidable with respect to bracket 320 and secured with set screws
(not shown). Radial positioning of support bracket 320 is achieved
by slidable mounting of support bracket 320 on mounting bracket
322. Set screw 324 is used to secure the radial positioning of
heart manipulator 300. Elongated slot 330 allows movement of
support bracket 320 with respect to set screw-324 and mounting
bracket 322.
[0122] Turning now to FIG. 28, mounting bracket 322 is configured
to mount on base 212 substantially as described with respect to
mounting bracket 216 in FIGS. 22-23. Pin 364 of bracket 322 is
received in one of openings 240 in base 212. Tab 370 includes
flange 372 which removably engages outer rim 274 of base 212 and is
disengaged by lever arm 376. Support bracket 320 is slidably
mounted on mounting bracket 322 such that a portion of slot 330 is
aligned over threaded bore 332. Set screw 324 extends through slot
330 into bore 332 and includes collar 334 which abuts a top surface
of support bracket 320 to secure it against radial movement.
[0123] FIGS. 29-32 illustrate a heart stabilizer instrument 350 in
accordance with another preferred embodiment of the subject
disclosure. With reference to FIG. 29, heart stabilizer instrument
350 includes frame 102 and mounting bar 110. Frame 102 includes
legs 104a and 104b and transverse bars 106a and 106b having
protrusions 108a and 108b substantially as described with respect
to FIG. 10, above. Mounting bar 110 is slidably received in a bore
in support bracket 352 and secured with respect thereto by set
screw 354. Support bracket 352 is slidable with respect to mounting
bracket 356.
[0124] As illustrated in FIGS. 30-31, mounting bracket 356 is
removably mounted on base portion 212 substantially as described
with respect to mounting bracket 216 in FIGS. 22-23. Pin 358 is
received in one of cylindrical recesses or openings 240 in base
212. Tab 360 includes flange 362 for removably engaging outer rim
274 of bore 212. Flange 362 is disengaged by actuation of lever arm
364. With reference to FIG. 32 in conjunction with FIGS. 30-31,
support bracket 352 includes a pair of vertical walls 364a and 364b
and a pair of horizontal walls 366a and 366b which rest on a top
surface of mounting bracket 356. A lever mounting rod 368 extends
upwardly from mounting bracket 356 between horizontal walls 366a
and 366b. A pair of hinge pins 370a and 370b extend from rod 368
and are received in a clevis portion 372 of lever arm 374.
Horizontal walls 366a, 366b of support bracket 352 are disposed
between mounting bracket 356 and clevis portion 372 of lever arm
374.
[0125] With continued reference to FIGS. 30-31, clevis portion 372
is substantially circular or elliptical in lateral cross-section
and is eccentrically mounted to hinge pins 370a and 370b. As
illustrated in FIG. 30, when lever arm 374 is in a released
position, clevis portion 372 is spaced from horizontal walls 366a
and 366b and unrestricted radial movement of support bracket 352 is
enabled thereby. As illustrated in FIG. 31, pivoting of lever arm
374 causes clevis portion 372 to apply a compressive force on
horizontal walls 366a and 366b on top of mounting bracket 356 to
thereby fix the radial position of support bracket 352 with respect
to mounting bracket 356.
[0126] Turning to FIG. 33, operation of surgical retractor 200 in
conjunction with heart manipulator and heart stabilizer instrument
proceeds substantially as described with respect to FIGS. 11-18. As
noted above, mounting bracket 216a of retractor blade assembly 214
is placed on base 212 by actuation of lever arm 276a (not shown).
Heart manipulator 200 and heart stabilizer instrument 350 are
mounted to base 212 in a substantially identical manner as
described above. The surgical procedure is carried out
substantially as described above. Ribs R.sub.1, R.sub.2 and R.sub.3
are retracted by the pulling of assist straps 22 and by the
rotation of retraction knob 220. The position of heart H is
stabilized by heart manipulator 300. Heart stabilizer instrument
350 is positioned and lowered onto heart H to apply pressure to the
coronary artery and thereby substantially reduce movement (motion)
of the heart within the legs. The instrument 350 may be locked with
respect to the base. At this time, other surgical procedures, such
as coronary bypass or valve surgery may be performed.
[0127] Turning now to FIGS. 34-52, another embodiment of the
surgical retractor is disclosed at reference numeral 400.
Instrument 400 operates substantially as described with regard to
instrument 200, with the differences noted hereinbelow. In
particular, FIG. 34 illustrates surgical retractor 400 having base
412 and retractor blade assembly 414, which includes mounting
bracket 416, retractor blade 418, and retraction knob 420. The
provision of retraction knob 420 enables the surgeon to achieve
additional mechanical advantage in retracting a rib.
[0128] Base 412 includes suture mounting portions 424 for suture
tie down of internal tissue structures. Base 412 further includes
beveled inner surface 428 with inner lip or rim 430 and top surface
432, which forms an outer lip or rim 434. A channel or groove 436
is formed in top surface 432. Outer periphery 438 of base 412
includes a series of teeth 440 formed thereon.
[0129] As illustrated in FIG. 35, mounting bracket 416 includes
housing 442 and mounting plate 444 which are connected and allow
retractor blade 418 to slide within channel 446 defined in a lower
surface of housing 442.
[0130] Retractor blade 418 includes body portion 448 and rib
engaging portion 450. Body portion 448 defines a T handle 452
configured to be grasped by the surgeon in order to slide retractor
blade 418 within channel 446. Body portion 448 defines a rack
gearing 454 and a series of sloping ratchet teeth 456. Preferably,
such gearing 454 and ratchet teeth 456 are respectively disposed
along elongated channel 458 defined within body portion 448.
[0131] Ratchet teeth 456 are releasably engaged by pawl 460.
Mounting plate 444 defines first channel 462 and second channel 464
for receiving pawl 460. Preferably, pawl 460 is a resilient member
having a modified U-shaped configuration including crown portion
466, first leg 468 defining cut-out portion 470, and second leg
472. Second leg 472 is fixedly retained within second channel 464
having an elbow configuration. The junction of second leg 472 and
crown 466 acts as a hinge or pivot such that first leg 468 is
slidable within first channel 462. Pawl 460 is normally biased at
this junction of second leg 472 and crown 466 such that first leg
468 is partially disposed in first channel 462. Crown 466 may be
pressed by the user towards mounting plate 444 against the normal
bias to slide first leg 468 further along first channel 462.
Retractor blade 418 is positioned adjacent mounting plate 444, and
pawl 460 is placed on top of blade 418 such that cut-out portion
470 of first leg 468 straddles a portion of blade 418 adjacent
ratchet teeth 456. (See, FIG. 38) As will be described below, pawl
460 is normally biased such that first leg 468 is in engagement
with one of ratchet teeth 456. Pawl 460 and ratchet teeth 456
together define a one-way ratchet mechanism 474.
[0132] Rack gearing 454 is engaged by pinion gearing 476 formed on
retraction knob 420, which is positioned in aperture 478 defined in
housing 442. As will be described below, rotation of retraction
knob 420 provides additional mechanical advantage when used in
cooperation with ratchet mechanism 474 to retract and/or advance
retractor blade 418.
[0133] Rib engaging portion 450 is connected to body portion 448
with a dovetail joint and secured thereto with pins 480a and 480b.
Alternatively, retractor blade 418 may be constructed of a single
part Rib engaging portion 450 includes a horizontal portion 482,
angularly depending portion 484, and tip portion 486. Angularly
depending portion 484 forms an acute angle with horizontal portion
482 to securely engage the rib. Strengthening rib or beading 488 is
formed on the outside of rib engaging portion 450 to provide
additional strength and to resist bending.
[0134] Referring to FIG. 35 in conjunction with FIGS. 36-37,
mounting plate 444 includes a gearing 490 on a forward portion
thereof to engage peripheral gear teeth 440 on base 412 (See, FIG.
34).
[0135] As illustrated in FIG. 36, base 412 is placed at the
operative site on patient's chest. Rib engaging portion 450 is
positioned adjacent rib R, such that angularly depending portion
484 and tip portion 486 at least partially surround rib R. Housing
442 has a flat bottom portion and is placed on upper surface 432 of
base 412.
[0136] FIG. 37 illustrates the simultaneous mounting of mounting
bracket 416 to base 412 and retraction of rib R towards base 412 as
indicated by the arrows. Retractor blade 418 is moved radially
outward with respect to base 412 while rib engaging portion 450
engages rib R Mounting plate 444 is spaced from the bottom portion
of housing 442 in order to permit mounting plate 444 to slide under
outer rim 434 of base 412, and to allow teeth 490 engage teeth 440
on base 412. Mounting bracket 416 is secured on base 412 by the
compression force created between rib engaging portion 450 against
rib R and mounting plate 444 against outer rim 434 of base 412.
Removal of retractor blade 418 from rib R occurs by sliding
retractor blade 418 radially inward, thereby releasing compression
sufficiently to allow mounting plate 444 to be released from outer
rim 434.
[0137] One-way ratchet mechanism 474 enables retractor blade 418 to
be incrementally moved in one direction, i.e. radially outwardly to
retract a rib, while resisting movement in an opposite direction,
i.e. radially inward. FIG. 38 illustrates pawl 460 normally biased
such that first leg 456 is in engagement with ratchet teeth 456. As
shown in FIG. 39, sloping portions 490 of teeth 456 permit
retractor blade 418 to incrementally move in a radially outward
motion while transverse slopes 492 of teeth 456 inhibit radially
inward motion to hold retractor blade 418 and the rib in position.
As described above with respect to retractor 200, additional
retraction force can be applied to the rib by rotation of
retraction knob 420. Pinion gear 476 disposed on retraction knob
420 engages rack 454 on retraction blade 418 to provide additional
leverage to the surgeon. After retracting the rib to create
sufficient access for the surgeon, rotation knob 420 may be removed
from aperture 478 in housing 442 (See, FIG. 35) and thereby provide
greater visibility and access for the surgeon.
[0138] Pawl 460 may be moved against its normal bias by depressing
crown 466 towards mounting plate 444, which causes first leg 468 to
disengage from ratchet teeth 456 as shown in FIG. 40. Cut-out
portion 470 as aligned such that blade 418 may slide therethrough,
such that unrestricted radial movement of retraction blade 418 is
enabled.
[0139] FIGS. 41-49 illustrate a heart stabilizer instrument 500 in
accordance with another preferred embodiment of the subject
disclosure. With reference to FIG. 41, heart stabilizer instrument
500 includes frame 502, articulating arm 504, and mounting assembly
506. Articulating arm 504 is configured to allow frame 502 to be
positioned at the precise location and orientation with respect to
the heart of the patient Mounting assembly 506 secures articulating
arm 504 and frame 502 in a fixed configuration, as will be
described below.
[0140] Frame 502 is configured to contact the heart and applies
pressure to the heart without touching the coronary artery. Frame
502 includes a pair of legs 508a and 508b, each having teeth 510
for atraumatically contacting the heart. Frame 502 is mounted to
frame mount 512 by pin 514. The distal end of cable 516 is mounted
to frame 502, and passes into frame mount 512 at opening 513.
[0141] Articulation arm 504 consists of a plurality of link members
518a, 518b, 518c, 518d, each of which has hemispherical convex
distal portion 520, cylindrical body portion 522 including
peripheral step 523, and concave proximal end 524. Bore 526 extends
longitudinally through each link 518 from convex distal portion 520
to concave proximal end 524. Link members 518 are aligned such that
convex distal portion 520 is received in concave proximal end 524
in a ball-and-socket type connection to permit a wide range of
pivoting motion between adjoining link members 518. Link members
518 are concatenated by cable 516 passing through each bore 526,
and the distalmost link member 518a is fitted adjacent frame mount
512. Articulation arm 504 can be used to mount a light cable to
illuminate the surgical site, a suction and/or irrigation device, a
blowing device to disperse blood or any other instrument to
facilitate the surgery:
[0142] Mounting assembly 506 is mounted adjacent proximalmost link
member 518d and includes mounting flange member 530, mounting base
532, toggle housing 534, and toggle 536. As shown in FIG. 42B,
mounting base 532 has a flat bottom surface 538 to rest on top
surface 432 of base 412 and a protrusion or peg 540 configured and
dimensioned to be received in flange 436 of base 412. With
continued reference to FIG. 42, mounting flange member 530 and
toggle housing 534 are slidably mounted with respect to mounting
base 532 and are normally biased in a spaced-apart configuration
from mounting base 532 by springs 542 and 544, respectively.
Mounting flange member 530 has flange 546 for engaging inner rim
430 of base 412. Toggle housing 534 has flange 548 for engaging
outer rim 434 of base 412.
[0143] Toggle 536 includes cylindrical mounting portion 550 and
toggle arm 552. Cylindrical mounting portion 550 is configured to
be received within cylindrical recess 554 defined within toggle
housing 534 and to be pivotably movable therein. Cable 516 extends
through link members 518 and through mounting flange member 530,
spring 542, mounting base 532, spring 544, and into cylindrical
recess 554 of toggle housing 534. The distal end portion of cable
516 is pinned to toggle 536 by pin 556. As illustrated in FIG. 42A,
cylindrical mounting portion 550 defines a laterally offset
pie-shaped or arc-section recess 558 to define an "over-center"
type locking mechanism, as will be described below.
[0144] As illustrated in FIG. 43, heart stabilizer instrument 500
is configured such that cable 516 extends through instrument 500
from frame 502 to toggle 536. Bore 526 in each link member 518 has
a tapering diameter which is larger adjacent convex distal portion
520 and is narrower adjacent concave proximal portion 524. This
configuration permits relative articulation of link members 518
while cable 516 extends therethrough.
[0145] FIGS. 44-46, illustrate heart stabilizer instrument 500 with
cable 516 in a relaxed unstressed configuration. As illustrated in
FIG. 44, instrument 500 is placed on base 412 such that peg 540 is
disposed in groove 436, and mounting flange member 530 and toggle
housing 534 are spaced apart sufficiently to allow flanges 546 and
548 to clear inner rim 430 and outer rim 434, respectively.
[0146] As illustrated in FIG. 45, toggle 536 is disposed in toggle
housing 534 in an unlocked configuration, such that toggle arm 552
and fixed arm 535 are spaced apart. Eccentrically mounted pin 556
is disposed such that cable 516 is loose. FIG. 46 illustrates that
cable 516 loosely disposed in tapered bores 526 of link member 518
permit articulation of adjoining link members 518.
[0147] FIGS. 47-49 illustrate instrument 500 with cable 516 in a
taut, stressed configuration. As depicted in FIG. 47, toggle 536 is
pivoted with respect to toggle housing 534 such that toggle arm 552
is approximated with fixed arm 535. Simultaneously, the distal end
of cable 516 connected to pin 556 moved into an "over-center"
position, thereby stressing cable 516 and locking surgical
instrument 500 in position. The surgeon is permitted to perform
other procedures without maintaining pressure on the heart.
[0148] Another embodiment of the heart stabilizer instrument is
illustrated in FIG. 50 and disclosed at reference numeral 600.
Instrument 600 is constructed and operates substantially as
described above with regard to instrument 500, with the differences
described below. Heart stabilizer instrument 600 includes frame
502, articulating arm 606 and mounting assembly 506. Articulating
arm 606 permits fame 502 to be placed at the appropriate height and
angle with respect to the heart. Articulating arm 606 is composed
of link members 608, and 610 having a series of intermeshing
teething to positively engage adjoining link members together.
[0149] As illustrated in FIGS. 50A and 50B, link members 608 are
positioned adjacent link member 610. Link member 608 has generally
cylindrical body portion 612. A pair of rows of concave gearing
614a and 614b is disposed on one axial end 616 of link member 608.
A second pair of rows of concave gearing 618a and 618b is disposed
on the second axial end 620 of link member 608. Gearing 614a and
614b is disposed 90.degree. out of alignment with gearing 616a and
616b. Longitudinal bore 622' extends through link member 608 from
axial end 616 to axial end 620 between each pair of gearing.
[0150] Link member 610 has body portion 624, to which first pair of
gearing 626a and 626b having a convex profile and second pair of
convex gearing 628a and 628b are attached to opposite sides
thereof. First pair of gearing 626a and 626b is disposed 90' out of
alignment with second pair of gearing 628a and 628b. A longitudinal
bore (not shown) extends through body portion 624 and between each
pair of gearing 626a and 626b and gearing 628a and 628b.
[0151] Link member 610 is placed adjacent link member 608. Cable
516 extends through longitudinal bore 622 in link member 608 and
longitudinal bore (not shown) in link member 610. When toggle 552
is moved to the "over center" position (See, FIG. 47), thereby
tightening cable 516, ink members' 608 and 610 are approximated
such that convex gearing 626a, 626b or 628a, 628b of link member
610 engages concave gearing 614a, 614b and 618a, 618b of link
member 608.
[0152] FIG. 51 illustrates another preferred embodiment of the
surgical retractor in accordance with the subject disclosure. This
surgical retractor, designated generally at 700, includes a base
702 and any one or more of the instruments shown including:
retractor blade assembly 704; retractor blade assembly with
suction/irrigation structure 706; retractor blade assembly with
light 708; heart manipulator 710; and heart stabilizer instrument
712. These instruments are discussed in greater detail
hereinbelow.
[0153] Base 702 is configured in accordance with the other bases
discussed above and provides a low profile mount for
instrumentation used in the surgical procedure being performed. A
plurality of suture mounts 714 are defined in an upper peripheral
portion 716 of base 702 and serve as attachment and anchor points
for suture ends 718 from the surgical field. Referring to FIGS. 52
and 53, suture mounts 714 include a tightly wound coil spring 720
positioned in a cavity 722 with the coils oriented substantially
transverse to the radians of the base 702. A triangular ramp 724 is
formed on an inner radial surface of suture mount 714. A slot 726
is formed on an outer radial surface of suture mount 714 beyond
coil spring 720 and in axial alignment with ramp 724. This
ramp/slot configuration facilitates easy access to position suture
end 718 in coil spring 720.
[0154] The balance of base 702 is configured in substantially the
same manner as previously described bases and includes teeth 728,
beveled inner peripheral surface 730 and inner lip 732.
[0155] Surgical retractor blade assembly with blowing structure 706
is shown in FIGS. 54-56. Structure 706 can also be used for suction
or for irrigation to remove fluids from the surgical site. The
retractor blade assembly 704 is similar to the retractor blade
assembly 414 discussed in detail above. Retractor blade assembly
704 includes mounting bracket 734, retractor blade 736 and
removable retraction knob 738.
[0156] As illustrated in FIG. 56, mounting bracket 734 includes
housing 740 and mounting plate 742 which together form a channel
through which retractor blade 736 is reciprocally slidable.
[0157] Retractor blade 736 includes body portion 744 and rib
engaging portion 746. Body portion 744 defines a flanged gripping
handle 748 configured to be grasped by the surgeon in order to
slide retractor blade 736 relative to mounting bracket 734. Body
portion 744 further defines longitudinally oriented rack gearing
750 and a series of sloping teeth 752. Rack gearing 750 and teeth
752 are disposed along elongated cavity 754 defined in body portion
744.
[0158] Teeth 752 are releasably engaged by pawl 756 mounted in
housing 740. Operation of this pawl 756 is substantially the same
as pawl 460 described above in connection with retractor blade
assembly 414.
[0159] Rib engaging portion 746 extends distally from body portion
744 and includes an angularly depending portion including one or
more strengthening ribs 758 to provide additional strength.
[0160] Blowing structure 760 is integrally formed into the
retractor blade assembly shown in FIGS. 54-56. This structure
includes a tube 762 which extends the length of the retractor blade
assembly and exits the ring engaging portion 764 to access the
surgical site. A tube connector 764 is positioned at a proximal end
of tube 762 and connects to an appropriate source such as a vacuum
or pressure source (not shown) depending on whether structure 760
is used for blowing, irrigation or suction. Forming wire 766 is
positioned adjacent tube 762 and is deformable to configure tube
762 in a desired angular orientation. Alternatively, tube 762 may
be remotely oriented or rotated from body portion 744 using known
structure.
[0161] FIGS. 57 and 58 illustrate a retractor blade assembly with
an integral light shown generally at 708. The basic configuration
and operation of this assembly is identical to that described above
with the difference that a light 768 has been substituted for
suction/irrigation structure. A wide variety of lights can be
accommodated. In the illustrated embodiment, a fiber optic bundle
is disposed within a longitudinally extending sheath 770. A fiber
optic coupler 772 is positioned adjacent the proximal end of the
assembly and can be connected to an appropriate light source (not
shown). It is also envisioned that a wide variety of divergent and
focusing lenses may be used to tailor the light as required by the
surgeon.
[0162] The one-way ratchet mechanism used in these embodiments of
the retractor blade assembly is shown in FIGS. 58A-C. This ratchet
mechanism operates in the same manner as the ratchet mechanism
discussed above with respect to FIGS. 39-40. Note that as shown in
FIG. 58B, the retractor blade 736 can be pulled in the direction of
the arrow to retract the bone and tissue. However, to move the
retractor blade 736 in the opposite direction, i.e. the direction
of the arrow of FIG. 58C, pawl 756 must be pressed in.
[0163] FIGS. 59-63 illustrate another embodiment of a heart
stabilizer instrument 800 in accordance with the subject
disclosure. Heart stabilizer instrument 800 is substantially the
same as heart stabilizer instrument 500 discussed in detail above.
The instrument includes frame 802, articulating arm 804 and
mounting assembly 806.
[0164] Frame 802 is configured in the same manner as frame 502 and
includes a pair of legs 808a and 808b, each having teeth 810 for
atraumatically contacting the surface of the heart.
[0165] Frame 802 is connected to articulating arm 804 by connector
812. A positioning flange 814 is formed on connector 812 and
facilitates positioning of frame 802 on the heart surface either by
manually grasping the flange 814 or by affixing a grasping
instrument (not shown) to the flange 814 and positioning the frame
in a desired location.
[0166] Mounting assembly 806 is mounted adjacent the articulating
arm 804 and includes mounting flange member 830, mounting base 832,
toggle housing 834, and toggle 836. As shown in FIGS. 61-62,
mounting base 832 has a flat bottom surface 838 to rest on the top
of base 702. Mounting flange member 830 and toggle housing 834 are
slidably mounted with respect to mounting base 832. Mounting flange
member 830 has flange 846 for engaging inner rim of base 702.
Toggle housing 834 has flange 848 for engaging outer rim of base
702.
[0167] Toggle 836 includes cylindrical mounting pins 850 and finger
loop 852. Cylindrical mounting pins 850 are configured to be
received within recess 854 defined within toggle housing 834 and to
be pivotably movable therein. Cable 816 extends through
articulating arm 804. The distal end portion of cable 816 is pinned
to toggle 836 by clip 856. Biasing spring 858 is positioned in
toggle housing 834 and serves to normally bias mounting flange
member 830 distally relative to toggle housing 834.
[0168] Handle spring member 0.860 is integrally formed on toggle
836 and is configured to operatively interact with protrusion 862
formed in cavity 854 of toggle housing 834, as toggle 836 is moved
into and out of approximation with toggle housing 834.
[0169] FIGS. 64-66, illustrate heart stabilizer instrument 800 with
cable 816 in an unlocked, unstressed configuration. As illustrated
in FIG. 64, instrument 800 is placed on base 702 with mounting
flange member 830 and toggle housing 834 spaced apart sufficiently
to allow flanges 846 and 848 to clear inner rim 830 and outer rim
833, respectively.
[0170] Toggle 836 is disposed in toggle housing 834 in an unlocked
configuration, such that finger loop 852 and finger loop 853 are
spaced apart Cable 816 is loose to permit manipulation of
articulating arm 804.
[0171] FIG. 65 illustrates the relative position of handle spring
860 relative to protrusion 862 within toggle housing 834.
[0172] FIGS. 66-67 illustrate instrument 800 with cable 816 in a
first taut, locked, unstressed configuration. As depicted in FIG.
66, toggle 836 is pivoted with respect to toggle housing 834 such
that finger loop 852 is moved toward finger loop 853. The distal
end of cable 816 is stressed to approximate mounting flange member
832 and mounting base 832 locking surgical instrument 500 in
position on base 702
[0173] FIG. 67 shows the progression of toggle 836 relative to
toggle housing 834 into the locked, unstressed configuration. In
this position, articulating arm 804 can still be manipulated.
[0174] The final, locked and stressed configuration is shown in
FIGS. 68-69. In this configuration, finger loops 852 and 853 have
moved into close approximation simultaneously, further stressing
cable 816 to maintain a preset configuration desired by the
surgeon, e.g. to lock articulating arm 804 in place. Once locked
into this locked-stressed configuration, the surgeon is permitted
to perform other procedures without having to manually apply
pressure on the heart via the heart stabilizer instrument.
[0175] Another preferred embodiment of the heart manipulator 900 in
accordance with the subject disclosure is shown in FIG. 70. The
heart manipulator includes a manipulator portion 902, an
articulating arm 904 and a mounting assembly 906. The structure and
operation of mounting assembly 906 and articulating arm 904 are
substantially the same as the heart stabilizer 800 discussed
above.
[0176] The manipulator portion 902 includes a frame 908 supporting
mesh 910 and is preferably provided with a curved section adjacent
a distal end thereof to assist in manipulation of the heart.
[0177] FIGS. 71A and 71B illustrate a rib elevator 980 which can be
mounted to the aforedescribed bases to enable the patient's rib to
be lifted. Rib elevator 980 includes a set of tabs 982 which engage
inner lip 732 for attachment to the base. Reinforcement ribs 984a,
984b formed on the rear surface 981, increase the rigidity of rib
elevator 980 and also provide a gripping surface fur the user to
flex the rib elevator 980 to facilitate attachment and removal from
the base. Teeth 986 function in the same manner as the teeth 728 of
base 702, i.e. for mounting one or more of retractor assemblies
704, 706, 708. As can be appreciated, when rib elevator 980 is
mounted to base 702, the mounted retractor assembly will be angled
towards the rib so that a retraction force will be applied to the
rib partially in an upward direction. This is advantageous, for
example, for access and severing of the IMA. The rib elevator 980
can subsequently be removed and a retractor assembly mounted
directly to the base 702 in the manner described above.
[0178] FIGS. 71 and 72 illustrate two preferred kit configurations
in accordance with the subject disclosure. Kit 950 (FIG. 71) is
formed to accommodate a basic blade retractor assembly 704, a blade
retractor assembly with suction irrigation 706, a blade retractor
assembly with light 708, a base 702, a retraction knob 738, a heart
stabilizer instrument 800 and/or a heart manipulator 900 therein.
Cavities 952, 954, 956, 958 and 960 are formed in cover 962 to
accommodate these elements. Cover 962 may be fixed to bottom 964 by
adhesive, ultrasonic welding, heating, etc.
[0179] Kit 970 is substantially similar to kit 950 except that the
heart stabilizer instrument 800 and the heart manipulator 900 are
excluded. Cover 972 includes cavities 952, 958 and 960 to
accommodate retractors 704, 706, 708, base 702 and retraction knob
738. Cover 972 and bottom 974 may be joined in the same manner as
disclosed for kit 950 above.
[0180] Rib elevator 980 can optionally be included in the kits.
[0181] It will be understood that various modifications may be made
to the embodiments shown herein. Therefore, the above description
should not be construed as limiting, but merely as exemplifications
of preferred embodiments. Those skilled in the art will envision
other modifications within the scope and spirit of the claims
appended hereto.
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