U.S. patent application number 11/725016 was filed with the patent office on 2007-07-12 for method and inflatable chamber apparatus for separating layers of tissue.
Invention is credited to Albert K. Chin, Charles Gresl, John P. Lunsford, Jeffrey A. Smith, Daniel T. Wallace.
Application Number | 20070162067 11/725016 |
Document ID | / |
Family ID | 46282144 |
Filed Date | 2007-07-12 |
United States Patent
Application |
20070162067 |
Kind Code |
A1 |
Lunsford; John P. ; et
al. |
July 12, 2007 |
Method and inflatable chamber apparatus for separating layers of
tissue
Abstract
An apparatus for tissue dissection and instrument anchoring and
methods for using such apparatus are disclosed. The apparatus
includes a cannula, a dissection balloon releasably attached to the
cannula at the distal end, an anchoring balloon disposed on the
cannula, and a means for inflating both balloons.
Inventors: |
Lunsford; John P.; (San
Calos, CA) ; Gresl; Charles; (San Francisco, CA)
; Smith; Jeffrey A.; (Sunnyvale, CA) ; Wallace;
Daniel T.; (Palo Alto, CA) ; Chin; Albert K.;
(Palo Alto, CA) |
Correspondence
Address: |
UNITED STATES SURGICAL,;A DIVISION OF TYCO HEALTHCARE GROUP LP
195 MCDERMOTT ROAD
NORTH HAVEN
CT
06473
US
|
Family ID: |
46282144 |
Appl. No.: |
11/725016 |
Filed: |
March 16, 2007 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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10392465 |
Mar 19, 2003 |
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11725016 |
Mar 16, 2007 |
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09023134 |
Feb 12, 1998 |
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10392465 |
Mar 19, 2003 |
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|
08583563 |
Jan 5, 1996 |
5779728 |
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09023134 |
Feb 12, 1998 |
|
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08542666 |
Oct 13, 1995 |
5728119 |
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08583563 |
Jan 5, 1996 |
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08405284 |
Mar 16, 1995 |
5632761 |
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08542666 |
Oct 13, 1995 |
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08365096 |
Dec 28, 1994 |
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08405284 |
Mar 16, 1995 |
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08319552 |
Oct 7, 1994 |
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08365096 |
Dec 28, 1994 |
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08282287 |
Jul 29, 1994 |
5704372 |
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08319552 |
Oct 7, 1994 |
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07911714 |
Jul 10, 1992 |
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08282287 |
Jul 29, 1994 |
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07794590 |
Nov 19, 1991 |
5309896 |
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07911714 |
Jul 10, 1992 |
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07706781 |
May 29, 1991 |
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07794590 |
Nov 19, 1991 |
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Current U.S.
Class: |
606/192 |
Current CPC
Class: |
A61B 2090/306 20160201;
A61B 17/0218 20130101; A61B 2017/3486 20130101; A61B 2017/00557
20130101; A61B 2017/22059 20130101; A61B 2017/3466 20130101; A61B
2017/00535 20130101; A61B 2017/320048 20130101; A61B 17/0281
20130101; A61B 17/3462 20130101; A61B 17/3421 20130101; A61B 90/50
20160201; A61B 17/22032 20130101; A61B 90/361 20160201; A61B
1/00082 20130101; A61B 17/3423 20130101; A61B 17/3417 20130101;
A61B 2017/00261 20130101 |
Class at
Publication: |
606/192 |
International
Class: |
A61M 29/00 20060101
A61M029/00 |
Claims
1. A surgical device comprising: an elongate tubular member having
a bore, the bore configured for receiving a surgical instrument
therethrough; a first inflatable member disposed in a distal region
of the elongate tubular member, the first inflatable member having
an inflated state and a deflated state; a collar disposed on the
elongate tubular member, the collar being compressible and capable
of engaging body tissue between the collar and the first inflatable
member when the first inflatable member is in the inflated state; a
first port fluidly coupled to the first inflatable member; and a
second port in fluid communication with the the bore.
2. The device of claim 1, wherein the balloon has a toroidal
configuration in the inflated state.
3. The device of claim 1, wherein the first port and the second
port are located in a proximal region of the device.
4. The device of claim 1, further including a first housing located
at a proximal end of the device.
5. The device of claim 4, wherein the first port and the second
port are disposed on the first housing.
6. The device of claim 3, wherein the bore of the surgical
instrument has an inner diameter of about 10 mm.
7. The device of claim 1 further including an obturator insertable
through the bore.
8. The device of claim 1 further including a second inflatable
member disposed at a distal end of a second housing.
9. The device of claim 8, wherein the second housing includes a
third port that is fluidly coupled to an interior of the second
inflatable member.
10. The device of claim 7, wherein the introduction of an inflation
medium into the second port is communicated to the distal end of
the device.
11. The device of claim 9, wherein the introduction of an inflation
medium is communicated to the interior of the second inflatable
member through the third port and causes the second inflatable
member to transition from an uninflated state towards an inflated
state.
12. The device of claim 8, wherein the second housing is releasably
attached to a first housing, the first housing located at a
proximal end of the device.
13. The device of claim 8 further including a first housing located
at a proximal end of the device and the second housing being
releasably attached to the first housing.
14. The device of claim 13 further including an obturator that is
releasably attached to the second housing.
15. The device of claim 14, wherein a distal portion of the
obturator extends into the interior of the second inflatable
member.
16. The device of claim 1, further including a valve disposed in
the bore.
17. The device of claim 1, wherein the collar includes a locking
mechanism for securing a position of the collar relative to the
elongate tubular member.
18. The device of claim 1, wherein the collar is formed from a foam
material.
19. The device of claim 1, wherein the collar has a substantially
planar distal face adapted for contacting tissue.
20. The device of claim 1, wherein the collar is slidable with
respect to the elongate tubular member.
21. The device of claim 1, wherein a distal face of the collar
conforms to a surface of body tissue located between the first
inflatable member and the collar.
22. A method of accessing a space comprising the steps of: making
an incision through body tissue; inserting a device through the
incision, the device including: an elongate tubular member having a
bore, the bore configured for receiving a surgical instrument
therethrough, a first inflatable member disposed in a distal region
of the elongate tubular member, the first inflatable member having
an inflated state and a deflated state, a collar disposed on the
elongate tubular member, the collar being compressible and capable
of engaging body tissue between the collar and the first inflatable
member when the first inflatable member is in the inflated state, a
first port fluidly coupled to the first inflatable member, and a
second port in fluid communication with the bore; and introducing
an inflation medium to the first port such that the first
inflatable member transitions from an uninflated state to an
inflated state.
23. The method of claim 22, wherein the device further includes a
valve disposed in the bore.
24. The method of claim 22, further comprising the step of:
inserting a surgical instrument through the bore of the device.
25. The method of claim 24, further comprising the step of:
performing a procedure using the surgical instrument.
26. The method of claim 22, further comprising the step of:
insufflating the space by introducing an inflation medium through
the bore of the device.
27. The method of claim 22, wherein the collar of the device is
formed from a foam material.
28. The method of claim 22, wherein the collar has a substantially
planar distal face adapted for contacting tissue.
29. The method of claim 22, wherein the collar is slidable with
respect to the elongate tubular member.
30. The method of claim 22, wherein a distal face of the collar
conforms to a surface of body tissue located between the first
inflatable member and the collar.
31. The method of claim 29, further comprising the step of: sliding
the collar distally towards the first inflatable member such that
at least a portion of the collar contacts skin of the patient.
Description
[0001] This application is a continuation of co-pending application
Ser. No. 10/392,465, filed Mar. 19, 2003, which is a continuation
of application Ser. No. 09/023,134, filed Feb. 12, 1998, now
abandoned, which is a continuation of application Ser. No.
08/583,563, filed Jan. 5, 1996, now U.S. Pat. No. 5,779,728 which
is a continuation-in-part (C.I.P.) of Ser. No. 08/542,666, filed
Oct. 13, 1995, now U.S. Pat. No. 5,728,119 of inventors Jeffrey A.
Smith, Daniel T. Wallace, Edwin J. Hlavka, Charles Gresl, John P.
Lunsford, and Albert K. Chin, which is a C.I.P. of U.S. application
Ser. No. 08/405,284, filed Mar. 16, 1995, now U.S. Pat. No.
5,632,761 of inventors Jeffrey A. Smith, Albert K. Chin, and
Frederic H. Moll, which is a C.I.P. of Ser. No. 08/365,096, filed
Dec. 28, 1994, now abandoned, of inventors Albert K. Chin and Todd
Thompson, which is a C.I.P. of Ser. No. 08/319,552, filed Oct. 7,
1994, now abandoned, of inventors Albert K. Chin, Jeffrey A. Smith,
John P. Lunsford and Frederic H. Moll, which is a C.I.P. of Ser.
No. 08/282,287, filed Jul. 29, 1994, now U.S. Pat. No. 5,704,372 of
inventors Frederic H. Moll, Jeffrey A. Smith, John P. Lunsford and
Albert K. Chin, which is a C.I.P. of Ser. No. 07/911,714, filed
Jul. 10, 1992, now abandoned, of inventors Albert K. Chin and John
P. Lunsford, which is a C.I.P. of Ser. No. 07/794,590, filed Nov.
19, 1991, now issued as U.S. Pat. No. 5,309,896, of inventors
Frederic H. Moll, Charles Gresl, Jr., Albert K. Chin, and Philip K.
Hopper, which is a C.I.P. of Ser. No. 07/706,781, filed May 29,
1991, now abandoned, of inventors Frederic H. Moll, Albert K. Chin,
Diane E. Caramore, and Frank T. Watkins III. The specifications of
the above-referenced applications, which are commonly owned with
present application, are incorporated by reference into the
specification of the present application.
FIELD OF THE INVENTION
[0002] The invention pertains to inflatable tissue separation and
retraction devices and methods of using such devices. The apparatus
and methods of the invention are useful in any procedure requiring
dissection and/or retraction of tissue planes throughout the body
including inguinal hernia repair, pelvic lymphadenectomy and
bladder neck suspension in the preperitoneal space; renal, adrenal,
aortic and anterior spinal access in the retroperitoneal space;
penile prosthetic reservoir placement in the anterior abdominal
wall; plastic surgery; and augmentation mammaplasty prosthetic
placement. By way of example only, use of such devices and methods
for hernia repair will be described.
BACKGROUND OF THE INVENTION
[0003] A hernia is the protrusion of part of a body part or
structure through a defect in the wall of a surrounding structure.
Most commonly, a hernia is the protrusion of part of abdominal
contents, including bowel, through a tear or weakness in the
abdominal wall, or through the inguinal canal into the scrotum.
[0004] An abdominal hernia is repaired by suturing or stapling a
mesh patch over the site of the tear or weakness. The mesh patch
has a rough surface that can irritate the bowel and cause
adhesions. It is therefore preferred to install the patch
properitoneally (the terms properitoneal and preperitoneal are used
as synonyms). The mesh patch is preferably attached to the
properitoneal fascia of the abdominal wall and covered by the
peritoneum. To attach the mesh patch to the properitoneal fascia,
the peritoneum must be dissected from the properitoneal fascia.
This is a difficult process which involves the risk of puncturing
the peritoneum. Moreover, strands of properitoneal fat
interconnecting the peritoneum and the properitoneal fascia make it
difficult to see the site of the hernia.
[0005] The abdominal wall includes various layers of tissue. The
peritoneum (P) is the innermost layer. Overlying the peritoneum are
several layers of tissue, including the properitoneal fat layer
(FL) and the properitoneal fascia (F). The properitoneal fascia is
the layer to which a mesh patch is preferably attached in hernia
repair. The properitoneal fat layer separates the peritoneum from
the properitoneal fascia. The properitoneal fat layer is relatively
weak, which enables the peritoneum to be separated relatively
easily from the fascia.
[0006] When the peritoneum is separated from the fascia, separation
takes place at or in the properitoneal fat layer. The properitoneal
fat layer can remain attached to the properitoneal fascia, or can
come away with the peritoneum. Alternatively, part of the
properitoneal fat layer can remain attached to the peritoneum and
part of the fat layer can come away attached to the peritoneum.
Because of the uncertainty in the point of separation, the layer
which is detached will be called the peritoneum, and the layer from
which the peritoneum is detached will sometimes be denoted as the
overlying layer. Additional layers of tissue lie between the
properitoneal fascia and the skin.
[0007] An inguinal hernia occurs when the contents of the abdominal
cavity break through the abdominal wall. As described above, a
hernia is repaired by attaching a piece of mesh to the abdominal
wall. To prevent the mesh from causing trauma to the bowel, either
through irritation of the bowel by the rough surface of the mesh,
or by adhesion of the bowel to the mesh, it is preferred to attach
the mesh to the properitoneal fascia. With the mesh attached to the
fascia, the peritoneum covers the mesh and isolates the bowel from
the mesh.
[0008] Conventional techniques of attaching the mesh patch to the
properitoneal fascia, both laparoscopic and normal, involve blunt
dissecting the peritoneum away from the properitoneal fascia,
working from inside or outside the belly. The apparatus and methods
according to the invention enable the peritoneum to be separated
from the properitoneal fascia and the mesh patch attached to the
fascia without entering the belly.
[0009] Although the following description will describe apparatus
and methods according to the invention with respect to hernia
repair, the inventive apparatus and methods are not restricted to
hernia repair. The apparatus and methods can also be used in other
procedures in which one layer of tissue is separated from another
to form a working space between the layers. These procedures
include thoracoscopy in patients with pleural adhesions;
pericardioscopy, or the introduction of an endoscope into the
pericardial cavity, in patients with pericardial adhesions;
retroperitoneal lymph node dissection, in which the peritoneum on
the distal aspect of the abdominal cavity is separated from the
underlying tissue which includes lymph nodes; and in separating a
blood vessel from surrounding connective tissue in the course of,
for example, a femoropopliteal arterial bypass graft procedure.
[0010] Laparoscopic techniques to perform hernia repair are being
used increasingly frequently. In the conventional procedure for
carrying out a hernia repair laparoscopically, an endoscope and
instruments are introduced into the belly through one or more
incisions in the abdominal wall, and advanced through the belly to
the site of the hernia. Then, working from inside the belly, a long
incision is made in the peritoneum covering the site of the hernia.
Part of the peritoneum is dissected from the properitoneal fat
layer to provide access to the fat layer. This is conventionally
done by blunt dissection, such as by sweeping a rigid probe under
the peritoneum. In this procedure, it is difficult to dissect the
peritoneum cleanly since patchy layers of properitoneal fat tend to
adhere to the peritoneum.
[0011] In an alternative known laparoscopic hernia repair
procedure, the belly is insufflated. An incision is made in the
abdominal wall close to the site of the hernia. The incision is
made through the abdominal wall as far as the properitoneal fat
layer. The peritoneum is then blunt dissected from the
properitoneal fat layer by passing a finger or a rigid probe
through the incision and sweeping the finger or rigid probe under
the peritoneum. After the peritoneum is dissected from the
properitoneal fat layer, the space between the peritoneum and the
properitoneal fat layer is insufflated to provide a working space
in which to apply the mesh patch to the properitoneal fascia.
[0012] During the blunt dissection process, it is easy to puncture
through the peritoneum, which is quite thin. Additionally, after
initial dissection of the properitoneal space, known surgical
procedures require introduction of various instruments in the space
to conduct the surgery. These instruments can cause inadvertent
puncture of the peritoneum wall after the initial dissection. A
puncture destroys the ability of the space between the peritoneum
and the fascia to hold insufflation gas; pressurized gas can travel
through a puncture in the peritoneum to allow the fluid to migrate
to the abdominal cavity and degrade the pressure differential
maintaining the properitoneal cavity. Also, it is difficult to
dissect the peritoneum cleanly since patchy layers of properitoneal
fat tend to adhere to the peritoneum. Clearing difficult adhesions
can sometimes result in a breach of the peritoneum itself.
[0013] U.S. Pat. No. 5,309,896 (of which this application is a
C.I.P.), discloses a laparoscopic hernia repair technique that
enables a mesh patch to be attached to the properitoneal fascia
without breaching the peritoneum. An incision is made through the
abdominal wall as far as the properitoneal fat layer. A
multi-chambered inflatable retraction device is pushed through the
incision into contact with the peritoneum, and is used to separate
the peritoneum from the overlying tissue layer. The main end
chamber of the inflatable retraction device is then inflated to
elongate the inflatable retraction device towards the site of the
hernia. As it inflates, the inflatable retraction device gently
separates more of the peritoneum from the overlying tissue layer.
Once the main chamber of the inflatable retraction device is fully
inflated, a second inflatable chamber is inflated. The second
inflatable chamber enables the inflatable retraction device to
continue to separate the peritoneum from the other tissue layers
after the main inflatable chamber has been deflated.
[0014] One or more apertures are then cut in the envelope of the
main inflatable chamber to provide access to the site of the hernia
for instruments passed into the main chamber. With such an
arrangement, instruments pass through the main chamber while the
main chamber remains between the peritoneum and the overlying
layers. In this way, a patch can be attached to the properitoneal
fascia without breaching the peritoneum.
[0015] Until the present invention, it had not been known how to
view a space between tissue layers while (or after) dissecting the
layers with a balloon, without removing any portion of the
dissecting apparatus including the balloon, but also without image
degradation resulting from viewing through balloon wall. Nor, until
the present invention, had it been known to design a balloon
(suitable for tissue dissection, tissue retraction, and/or
instrument anchoring) to have any of a wide range of inflated shape
and pressure characteristics. For example, it had not been known to
design a tissue dissection balloon to have inflated shape and
pressure characteristics tailored for producing a working space
(between dissected tissue layers) having a particular size and
shape selected from a broad range of sizes and shapes.
SUMMARY OF THE INVENTION
[0016] In a class of embodiments, the invention is an apparatus for
tissue dissection and instrument anchoring, which includes a
dissection balloon having a viewing window (preferably a rigid,
transparent window) at its distal end. The window can but need not
be a lens (such as a wide angle lens) having a desired focal
length. The window of the dissection balloon is transparent, and
either rigid or non-rigid but sufficiently strong to retain a
desired optical shape while (and after) being pushed against tissue
layers by a rigid obturator (or other rigid instrument) deployed
within the balloon. In preferred embodiments, the window is
cup-shaped, in the sense that it has a recessed base for receiving
and capturing the distal end of a rigid obturator or endoscope.
[0017] In preferred embodiments, the balloon is a long-necked
balloon deployed through a cannula. The balloon has an open distal
end, and a rigid, transparent window (made of polished, clear
polycarbonate or acrylic material or the like) is glued over its
open distal end. When the distal end of the balloon has been
inserted between tissue layers, an endoscope extending through the
cannula within the balloon can view the tissue layers through the
window (whether or not the balloon is inflated).
[0018] In other embodiments, the invention is a dissection balloon
having a viewing window at its distal end, for use in an apparatus
for tissue dissection, tissue retraction, and instrument anchoring.
The window can but need not be a lens (such as a wide angle lens).
In other embodiments, the invention is a dissection balloon
assembly including a long-necked dissection balloon having a
viewing window at its distal end, and a housing to which the
dissection balloon's mouth is attached. The housing is shaped for
removable attachment to a tissue retraction and instrument
anchoring apparatus including a cannula (with the dissection
balloon's neck deployed through the cannula and the window
extending beyond the cannula's distal end).
[0019] In other, simplified, embodiments, the invention is a
dissection balloon, useful for separating tissue layers, attached
to the distal end of a trocar or obturator. A viewing window which
may or may not be a lens (such as a wide angle lens) is provided at
the distal end of the dissection balloon. A longitudinal bore in
the trocar or endoscope allows inflation fluid and instruments to
be introduced into the balloon. The window may be used to view the
tissue layers, via an endoscope inserted through the bore and into
the balloon, regardless of whether the balloon is inflated.
[0020] In another class of embodiments, the invention is an
apparatus for tissue dissection and instrument anchoring, which
includes a dissection balloon having nonuniform elasticity selected
to achieve desired inflated shape and pressure characteristics. In
a preferred embodiment, the dissection balloon comprises a sheet of
relatively inelastic material bonded to another sheet of relatively
elastic material. In another preferred embodiment, the dissection
balloon consists of a first large sheet bonded (such as by
RF-welding) to a second large sheet, and a reinforcing sheet bonded
to the central portion of each large sheet. The two large sheets
are made of material having high elasticity (preferably
polyurethane), and the reinforcing sheet can be made of material
having high or relatively low elasticity.
[0021] In other embodiments, the invention is a balloon (either an
anchoring or dissection balloon) having nonuniform elasticity
selected to achieve desired inflated shape and pressure
characteristics, for use in an apparatus for tissue dissection,
tissue retraction, and instrument anchoring.
[0022] Other embodiments of the invention are methods for using an
apparatus for tissue dissection and instrument anchoring, said
apparatus including a long-necked dissection balloon deployed
through a cannula. The dissection balloon has a window at its
distal end, or nonuniform elasticity selected to achieve desired
inflated shape and pressure characteristics, or both such a window
and such nonuniform elasticity. The distal end of the dissection
balloon is inserted between tissue layers and inflated to dissect
the tissue layers. In some embodiments, after dissection using the
dissection balloon, the dissection balloon is deflated and
withdrawn through the cannula before a medical operation is
performed in a working space between the dissected tissue layers.
In other embodiments, after dissection using the dissection
balloon, the dissection balloon is deflated but retained in the
patient during performance of a medical operation. In other
embodiments, where the dissection balloon has lobes of other
portions shaped so that instruments can be positioned between them,
the dissection balloon remains inflated in the patient after the
tissue layers have been dissected, instruments are then positioned
between the dissected tissue layers without being obstructed by the
inflated dissection balloon (e.g., between lobes or other separated
portions thereof), and the instruments are manipulated to perform a
medical operation.
[0023] Another embodiment of the invention is a technique for
packing a balloon in a manner which provides a tunnel through the
packaged balloon for insertion of a laparoscope or other
instrument, and which eliminates the need for packaging the balloon
with an obturator positioned within it.
BRIEF DESCRIPTION OF THE DRAWINGS
[0024] FIGS. 1A-1C and 2A-2B show a two-component apparatus for
separating tissue layers and insufflating the space between the
separated layers, where:
[0025] FIG. 1A is the separation component of the two-component
apparatus;
[0026] FIG. 1B is part of the distal part of the separation
component of the two-component apparatus with the main envelope in
its everted position;
[0027] FIG. 1C is part of the distal part of the separation
component of the two-component apparatus with the main envelope in
its inverted position;
[0028] FIG. 2A is the insufflation component of the two-component
apparatus with the toroidal inflatable chamber in its collapsed
state; and
[0029] FIG. 2B is the insufflation component of the two-component
apparatus with the toroidal inflatable chamber in its expanded
state.
[0030] FIGS. 3A-3I are longitudinal cross sections of the abdomen
illustrating a method of using a two-component apparatus to
separate the peritoneum from the overlying layer, where:
[0031] FIG. 3A shows an incision made through the abdominal wall,
including the properitoneal fat layer, excluding the
peritoneum;
[0032] FIG. 3B shows the distal part of the separation component of
a two-component apparatus inserted into the incision (the
separation component includes the main envelope in its collapsed
state);
[0033] FIG. 3C shows the main envelope inflated to its expanded
state to separate the peritoneum from the overlying layer;
[0034] FIG. 3D shows the main envelope returned to its collapsed
state;
[0035] FIG. 3E shows the separation component removed from the
incision;
[0036] FIG. 3F shows the distal part of the insufflation component
of the two-component apparatus inserted into the incision;
[0037] FIG. 3G shows the toroidal inflatable chamber of the
insufflation component inflated to its expanded state and the
anchor flange slid into contact with the skin of the abdominal wall
to provide a gas-tight seal;
[0038] FIG. 3H shows the working space between the peritoneum and
the overlying layer insufflated with a gas passed through the bore
of the insufflation component; and
[0039] FIG. 3I shows additional instruments passed through
gas-tight trocar sheaths into the insufflated working space to
repair the hernia by attaching a mesh patch to the properitoneal
fascia.
[0040] FIGS. 4A-4C show an embodiment of a first one-component
apparatus for tissue dissection and instrument anchoring,
where:
[0041] FIG. 4A shows a main embodiment of the one-component
apparatus with the main envelope in its expanded state;
[0042] FIG. 4B shows details of the area marked "A" at the distal
end of the tube assembly in FIG. 4A; and
[0043] FIG. 4C shows the distal part of the tube assembly with the
toroidal inflatable chamber in its expanded state.
[0044] FIGS. 5A-5D show an alternative one-component apparatus for
tissue dissection and instrument anchoring, where:
[0045] FIG. 5A shows the alternative embodiment with the main
envelope in its expanded state;
[0046] FIG. 5B shows the elongated main envelope of the alternative
one-component apparatus;
[0047] FIG. 5C shows the distal part of the tube assembly of the
alternative one-component apparatus with the main envelope in its
everted state; and
[0048] FIG. 5D shows the distal part of the tube assembly of the
alternative one-component apparatus with the main envelope in its
inverted state.
[0049] FIGS. 6A-6H are longitudinal cross sections of the abdomen
illustrating a method of using a one-component apparatus to
separate the peritoneum from the overlying layer, wherein:
[0050] FIG. 6A shows an incision made through the abdominal wall,
including the overlying layer, excluding the peritoneum;
[0051] FIG. 6B shows the distal part of the tube assembly of the
one-component apparatus inserted into the incision. The tube
assembly includes the main envelope in its collapsed state;
[0052] FIG. 6C shows the main envelope inflated to its expanded
state to separate the peritoneum from the overlying layer;
[0053] FIG. 6D shows the main envelope returned to its fully
collapsed state;
[0054] FIG. 6E shows the apparatus advanced into the incision such
that the envelope of the toroidal inflatable chamber clears the
incision;
[0055] FIG. 6F shows the toroidal inflatable chamber inflated to
its expanded state;
[0056] FIG. 6G shows the anchor flange slid into contact with the
skin of the abdominal wall. The anchor flange together with the
expanded toroidal inflatable chamber provides a gas-tight seal;
and
[0057] FIG. 6H shows the space between the peritoneum and the
overlying layer insufflated with a gas passed through the bore of
the apparatus.
[0058] FIGS. 7A and 7B show a second embodiment of a one-component
apparatus, wherein:
[0059] FIG. 7A shows the second one-component apparatus with the
main envelope in its expanded state; and
[0060] FIG. 7B shows the second one-component apparatus with the
main envelope in its collapsed state.
[0061] FIG. 8A shows the second one-component apparatus with the
main envelope in its expanded state and an endoscope passed through
the bore of the outer tube into the main inflatable chamber.
[0062] FIG. 8B shows the second one-component apparatus with the
main inflatable chamber in its partially expanded state and an
endoscope passed through the bore of the inner tube and through the
bore of the main envelope.
[0063] FIGS. 9A-9I show an alternative method of using either a
one-component or two-component apparatus to separate the peritoneum
from the overlying layer near the groin, with the apparatus
inserted through an incision near the umbilicus. FIGS. 9A-9H are
longitudinal cross sections of the abdomen, wherein:
[0064] FIG. 9A shows an incision made through the abdominal wall,
including the overlying layer, excluding the peritoneum;
[0065] FIG. 9B shows the distal part of the apparatus inserted into
the incision. A tube assembly of the apparatus includes a main
envelope in its collapsed state;
[0066] FIG. 9C shows the main envelope inflated to a
partially-expanded state to separate part of the peritoneum from
the overlying layer;
[0067] FIG. 9D shows the main envelope returned to its collapsed
state;
[0068] FIG. 9E shows the apparatus advanced in the direction of the
groin to bring the main envelope to the limit of the separated part
of the peritoneum;
[0069] FIG. 9F shows the main envelope re-inflated to a
partially-expanded state to separate an additional part of the
peritoneum from the overlying layer;
[0070] FIG. 9G shows the main envelope advanced to close to the
site of the hernia and re-inflated to its fully inflated state to
create a working space; and
[0071] FIG. 9H shows a component of the apparatus advanced through
the tunnel into the working space, and the toroidal inflatable
chamber inflated to form a gas-tight seal with the entrance of the
tunnel.
[0072] FIG. 9I is a plan view of the abdomen showing a component of
the apparatus in position with its distal end in the working space
and its toroidal inflatable chamber forming a gas-tight seal with
the entrance of the tunnel. FIG. 9I shows the lesser extent to
which the peritoneum is detached in the tunnel compared with in the
working space.
[0073] FIG. 10 is a perspective view of a preferred embodiment of
the inventive one-component apparatus for tissue dissection, tissue
retraction, and instrument anchoring.
[0074] FIG. 11 is an exploded view of obturator 515, retaining ring
514, and the dissection balloon subassembly of the FIG. 10
apparatus.
[0075] FIG. 12 is an exploded cross-sectional view of the
dissection balloon subassembly of the FIG. 10 apparatus.
[0076] FIG. 13 is a perspective view of the tissue retraction and
instrument anchoring subassembly of the FIG. 10 apparatus.
[0077] FIG. 14 is a partially side elevational, partially side
cross-sectional view of the FIG. 10 apparatus (with balloon 512
inflated and endoscope 515' substituted for obturator 515).
[0078] FIG. 15 is a perspective view of an alternative instrument
anchoring subassembly, for use in the FIG. 10 apparatus as a
substitute for the FIG. 13 subassembly.
[0079] FIG. 16 is a plan view of a dissection balloon designed in
accordance with the invention.
[0080] FIG. 17 is a cross-sectional view of the balloon of FIG. 16,
taken along line A-A.
[0081] FIG. 18 is a cross-sectional view of the balloon of FIG. 16,
taken along line B-B.
[0082] FIG. 18A is an end view of an alternative implementation of
the dissection balloon of FIG. 16, when inflated, and with a window
attached at its distal end.
[0083] FIG. 18B is a side elevational view of the alternative
implementation of the dissection balloon of FIG. 16, when inflated,
and with a window attached at its distal end.
[0084] FIG. 18C is an end view of a preferred implementation of the
dissection balloon of FIG. 16, when inflated, and with a window
attached at its distal end.
[0085] FIG. 18D is a side elevational view of the preferred
implementation of the dissection balloon of FIG. 16, when inflated,
and with a window attached at its distal end.
[0086] FIG. 19 is a side elevational view of a balloon window for
use as window 508 of the FIG. 10 apparatus.
[0087] FIG. 20 is a side elevational view of another balloon window
for use as window 508 of the FIG. 10 apparatus.
[0088] FIG. 21 is a side elevational view of a third balloon window
for use as window 508 of the FIG. 10 apparatus.
[0089] FIG. 21A is a perspective view of a fourth balloon window
for use as window 508 of the FIG. 10 apparatus.
[0090] FIG. 21B is a side cross-sectional view of the window of
FIG. 21A.
[0091] FIG. 21C is an embodiment of the inventive dissection
balloon whose distal end portion is tapered to receive and capture
an obturator (or endoscope).
[0092] FIG. 22 is a plan view of another dissection balloon
designed in accordance with the invention.
[0093] FIG. 23 is a plan view of another dissection balloon
designed in accordance with the invention.
[0094] FIG. 24 is a plan view of yet another dissection balloon
designed in accordance with the invention.
[0095] FIG. 24A is a plan view of three component sheets of yet
another dissection balloon designed in accordance with the
invention
[0096] FIG. 25 is a partially side elevational, partially side
cross-sectional view of a portion of an alternative embodiment of
the inventive apparatus for tissue dissection and instrument
anchoring.
[0097] FIGS. 26-35 show a method of using the inventive apparatus
(such as that of FIGS. 10-14) to separate the peritoneum from the
overlying layer near the groin, with the apparatus inserted through
an incision near the umbilicus. FIGS. 26-35 are longitudinal cross
sections of the abdomen, wherein:
[0098] FIG. 26 shows an incision made through the abdominal
wall;
[0099] FIG. 27 shows the distal end of the apparatus inserted into
the incision;
[0100] FIG. 28 shows dissection balloon 512 inflated to separate
part of the peritoneum from the overlying layer;
[0101] FIG. 29 shows balloon 512 returned to its collapsed
state;
[0102] FIG. 30 shows the apparatus advanced in the direction of the
groin to bring balloon 512 to the limit of the separated part of
the peritoneum;
[0103] FIG. 31 shows balloon 512 re-inflated to separate an
additional part of the peritoneum from the overlying layer;
[0104] FIG. 32 shows balloon 512 advanced to a position close to
the site of a hernia and re-inflated to create a working space;
[0105] FIG. 33 shows the dissection balloon assembly (512 and 513)
and ring 514 removed from the rest of the apparatus (i.e., the
retraction and anchoring subassembly), and anchor balloon 517
inflated;
[0106] FIG. 34 shows foam collar 504 advanced into contact with the
patient; and
[0107] FIG. 35 shows the working space within the patient being
insufflated (as a final step prior to performing a repair procedure
within the working space).
[0108] FIG. 36 is a perspective view of a balloon assembly for use
in alternative embodiments of the invention.
[0109] FIG. 37 is a plan view of the FIG. 36 assembly.
[0110] FIG. 38 is a plan view of the FIG. 36 assembly with a
portion of the balloon displaced inwardly.
[0111] FIG. 39 shows the FIG. 38 assembly with a rolling device
grasping an end of the first, inwardly-displaced balloon portion
between two rods.
[0112] FIG. 40 is an elevational view of the rolling device of FIG.
39.
[0113] FIG. 41 shows the FIG. 39 assembly during rolling of the
first balloon portion.
[0114] FIG. 42 is a cross-sectional view of the FIG. 36 assembly
with first and second inwardly-displaced portions of the balloon
rolled up into first and second rolls with an obturator positioned
therebetween.
[0115] FIG. 43 shows the FIG. 42 assembly, deployed between tissue
layers and partially inflated.
[0116] FIGS. 44 and 45 are cross-sectional views of the FIG. 36
assembly with the balloon in different stages of packing in
accordance with an alternative method.
[0117] FIGS. 46 and 47 are cross-sectional views of the FIG. 36
assembly with the balloon in different stages of packing in
accordance with another alternative method.
[0118] FIG. 48 is a cross-sectional view of a variation on the FIG.
36 assembly, with a balloon having accordion-folds.
[0119] FIG. 49 is a cross-sectional view of the FIG. 48 assembly
with the balloon having accordion-folds and packed in a compact
state.
[0120] FIG. 50A is an alternative embodiment of a tissue dissection
apparatus in which the dissection balloon is mounted to the distal
end of a trocar. The dissection balloon is shown in an inflated
condition.
[0121] FIG. 50B is an alternative embodiment of a tissue dissection
apparatus in which the dissection balloon is mounted to the distal
end of a semi-rigid obturator. The dissection balloon is shown in
an inflated condition.
[0122] FIG. 50C is an alternative embodiment of a tissue dissection
apparatus in which the dissection balloon is mounted to the distal
end of a rigid obturator. The dissection balloon is shown in an
inflated condition.
[0123] FIG. 51A is a top view of a tissue dissection apparatus
illustrating an alternative embodiment of a technique for packing
the balloon according to the present invention.
[0124] FIG. 51B is a side view of the tissue dissection apparatus
of FIG. 51A further illustrating the inventive packing
technique.
[0125] FIG. 51C is a side view of the tissue dissection apparatus
of FIG. 51B illustrating the use of an obturator to extend the
balloon in the distal direction.
[0126] FIG. 51D is a cross-sectional side view of the proximal
portion of the cannula of the tissue dissection apparatus of FIG.
51A.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
[0127] Throughout the disclosure, including in the claims, the term
"balloon" is used in a broad sense to denote any inflatable
structure, regardless of the elasticity of the material comprising
it. For example, the term balloon is employed to denote both a
thin-walled, inflatable structure consisting of material of low
elasticity (which does not stretch significantly during inflation),
and also a thin-walled, inflatable structure consisting of highly
elastic material such as a sheet of urethane (which does stretch
significantly during inflation). In preferred embodiments to be
described, the invention employs a balloon having nonuniform
elasticity (elasticity which varies from one place to another on
the balloon's surface).
[0128] Throughout the disclosure, the term "one-component"
apparatus denotes, with reference to an apparatus for tissue
dissection and instrument anchoring, an apparatus having a cannula,
wherein after the cannula is inserted into a patient, it remains in
the patient during tissue dissection using the apparatus and during
anchoring of the apparatus in the patient to enable performance of
medical procedures (subsequent to dissection) using the
apparatus.
[0129] Another device for separating tissue layers is disclosed in
U.S. patent application Ser. No. 07/911,714, of which this
application is a C.I.P. The device includes a main envelope that
defines a main inflatable chamber. The apparatus also includes an
introducing device for introducing the main envelope in a collapsed
state between the first layer of tissue and the second layer of
tissue. The introducing device inflates the main envelope into an
expanded state to separate the first layer of tissue from the
second layer of tissue, and to create a working space between the
first layer of tissue and the second layer of tissue. Finally, the
apparatus includes an insufflating device for introducing
insufflation gas into the working space between the first layer of
tissue and the second layer of tissue.
[0130] In a method according to U.S. application Ser. No.
07/911,714, a first layer of tissue is separated from a second
layer of tissue using a main envelope (defining a main inflatable
chamber) and insufflation gas. The main envelope is introduced in a
collapsed state between the first and second layers of tissue, and
the main envelope is then inflated into an expanded state to create
a working space between the first and second layers of tissue.
Finally, insufflation gas is introduced into the working space
between the first and second layers of tissue.
[0131] U.S. Ser. No. 07/911,714 discloses a two-component apparatus
including an inflatable main envelope and a device for introducing
the main envelope (together constituting a first component which
separates a first layer of tissue from a second layer of tissue to
create a working space) and an insufflation device which
insufflates the working space to maintain separation of the first
layer of tissue from the second layer. The insufflation device is
tubular, has an anchor flange slidably mounted on it, and has a
toroidal inflatable chamber at its distal end. The anchor flange
and toroidal inflatable chamber together form a gas-tight seal with
the second layer of tissue.
[0132] In a method disclosed in U.S. Ser. No. 07/911,714 for using
the two-component apparatus, the introducing device pushes the main
envelope in a collapsed state through an incision through the
second layer of tissue to place the main envelope between the first
and second layers of tissue. The main envelope is then inflated to
gently separate the first and second tissue layers. An endoscope
may be passed through the bore of the introducing device into the
main chamber to observe the extent of separation of the layers of
tissue. The main envelope is then returned to a collapsed state,
and the main envelope and introducing device are removed through
the incision. Next, the insufflating device is inserted into the
incision so that its distal end projects into the working space
between the two layers of tissue, and the toroidal inflatable
chamber is inflated. The anchor flange is slid distally along the
insufflating device to compress the second layer of tissue between
it and the expanded toroidal inflatable chamber, and thus to form a
gas-tight seal. Insufflating gas is then passed through the
insufflating device into the working space to maintain the
separation of the first layer of tissue from the second. An
endoscope may be passed through the bore of the insufflating device
into the working space to observe within the working space.
[0133] A two-component apparatus (of the type disclosed in
referenced U.S. Ser. No. 07/911,714) for separating tissue layers
and insufflating the space between the separated layers is shown in
FIGS. 1A-1C and 2A-2B. FIG. 1A shows a partially cut-away view of
separation component 1 of the apparatus. In separation component 1,
introducer tube 3 is a rigid tube having a bore with a circular
cross section that can accommodate an endoscope.
[0134] The proximal end of introducer tube 3 is fitted with a port
5, in the proximal end 7 of which is mounted a flapper valve 2.
Shutter 6 of flapper valve is operated by button 9. Seat 4 of the
flapper valve additionally forms a gas-tight seal with an endoscope
or other instrument inserted though the flapper valve into the bore
of introducer tube 3. Port 5 is also fitted with a valve 11 to
which a supply of a suitable inflation fluid can be connected.
[0135] Main envelope 12 defines a main inflatable chamber 13. Main
envelope 12 is fitted to distal end 15 of introducer tube 3. Main
envelope 12 is shown in a collapsed state in FIGS. 1B and 1C.
Dotted line 12X indicates the extent of main envelope 12 with
chamber 13 in its expanded state. It should be noted that although
the main envelope 12 is illustrated as generally spherical, it can
be formed as oblong, "hockey puck" or disc shaped, kidney bean
shaped or in other shapes as suited for the particular dissection
contemplated.
[0136] Main envelope 12 is preferably formed from an elastomeric
material, such as latex, silicone rubber, or polyurethane. The main
envelope can also be formed from a thin, inelastic material such as
Mylar.RTM., polyethylene, nylon, etc. If an inelastic material is
used, it should be suitably packaged to fit inside the bore of
introducer tube 3 when in its collapsed state.
[0137] The preferred elastomeric main envelope 12 can be simply
attached to the distal end 15 of the introducer tube 3 by
stretching the main envelope over the distal end of the introducer
tube, as shown in FIG. 1B. The main envelope is then kept in place
by friction resulting from the tension caused by stretching. A
suitable adhesive, such as an epoxy or cyanoacrylate adhesive, may
additionally or alternatively be used. Other means of attaching the
main envelope to the inside or the outside of the introducer tube
can be used.
[0138] After attachment, main envelope 12 is inverted into the bore
of the introducer tube, as shown in FIG. 1C. Inverting the main
envelope into the bore of the introducer tube makes it easier to
use the introducer tube to pass the main envelope through an
incision and place it adjacent to the peritoneum, as will be
described.
[0139] The first part of a method (described in U.S. Ser. No.
07/911,714) using separation component 1 of the two-component
apparatus of FIGS. 1A-1C and 2A-2B to separate a first layer of
tissue from a second layer of tissue will next be described with
reference to FIGS. 3A-3E (the entire method, for repairing a
hernia, will be described with reference to FIGS. 3A-3I).
[0140] FIGS. 3A-3I show a longitudinal cross section of the lower
abdomen. As indicated by FIG. 3A, an incision about 12-15 mm long
is made in the abdominal wall (AW), and is carried through the
abdominal wall as far as, and including, the properitoneal fat
layer (FL). Distal end 15 of introducer tube 3 of separation
component 1 is then inserted into the incision to bring the distal
end into contact with the peritoneum (P). Additional gentle
pressure detaches the part of the peritoneum in the immediate
vicinity of the incision from the overlying layer, as shown in FIG.
3B. FIG. 3B shows the peritoneum (P) detached from the
properitoneal fat layer (FL). The deflated main envelope cannot be
seen in FIG. 3B because it is inverted within the bore of
introducer tube 3.
[0141] A source of a suitable inflation fluid (not shown) is
connected to valve 11. A gas, preferably air, is the preferred
inflation fluid, but other gases, such as carbon dioxide, can be
used. A liquid, such as saline solution, can be used, but liquids
are less preferable than gases because liquids change the optical
properties of any endoscope inserted into main inflatable chamber
13. The flow of inflation fluid is turned on, which ejects the main
envelope 12 of main inflatable chamber 13 from the bore of
introducer tube 3.
[0142] The inflation fluid progressively expands the main envelope
12, and hence the main inflatable chamber 13 defined by the main
envelope, into an expanded state (as shown in FIG. 3C). The main
envelope expands between the peritoneum and the properitoneal
fascia, and gently and progressively detaches an increasing area of
the peritoneum from the overlying layer as it expands. When the
main envelope is in its expanded state, the main inflatable chamber
is preferably about 4''-6'' (100-150 mm) in diameter.
[0143] Early in the process of expanding the main envelope 12, an
endoscope E is inserted into flapper valve 2 in port 5, as shown in
FIG. 3C. Endoscope E is passed through the bore of introducer tube
3 into the main inflatable chamber 13. Once partially expanded,
main envelope 12 is sufficiently transparent for the extent of the
detachment of the peritoneum to be observed through the
endoscope.
[0144] When a sufficient area of the peritoneum has been detached,
the supply of inflation fluid is turned off. The inflation fluid is
then vented from the main inflatable chamber, and main envelope 12
returns to its collapsed state. The peritoneum remains detached
from the properitoneal fascia, however, as shown in FIG. 3D.
Separation component 1, including the collapsed main envelope, is
then withdrawn from the incision 1 (FIG. 3E).
[0145] Insufflation component 21 (shown in FIGS. 2A and 2B) of the
two-component apparatus of FIGS. 1A-1C and 2A-2B will next be
described. Insufflation component 21 comprises inner tube 35 and
outer tube 37 mounted coaxially, with the outer tube covering the
inner tube over most of the length of the inner tube. The inner
tube is similar to the introducer tube 3 (FIG. 1A), and is a rigid
tube having a bore with a circular cross section that can
accommodate a 10 mm endoscope.
[0146] The proximal end of inner tube 35 is fitted with a port 25,
the proximal end 27 of which has a flapper valve 32. Shutter 36 of
the flapper valve is operated by button 29. Seat 34 of the flapper
valve forms a gas-tight seal with an endoscope (not shown) or an
obturator (such as obturator 33) inserted though the flapper valve
into the bore of inner tube 35. Port 25 is also fitted with a first
valve 31 to which a supply of a suitable insufflation fluid can be
connected.
[0147] Distal end 41 of outer tube 37 stops short of distal end 39
of inner tube 35. Insufflation component 21 includes a toroidal
inflatable chamber 43. Envelope 45 of toroidal chamber 43 is a
cylindrical piece of a thin elastomeric material, such as latex,
silicone rubber, or polyurethane. Envelope 45 is placed over the
distal ends of the inner tube and the outer tube. Proximal end 47
of envelope 45 is attached to distal end 41 of the outer tube, and
distal end 49 of envelope 45 is attached to distal end 39 of the
inner tube 35.
[0148] The bore of outer tube 37 is spaced from the outer surface
of inner tube 35. Annular space 51 between the inner tube and the
outer tube interconnects toroidal chamber 43 and a second valve 53.
Second valve 53 is connected to a source of a suitable inflation
fluid (not shown). Thus, toroidal envelope 45 can be inflated using
an inflation fluid passing into toroidal inflatable chamber 43 (the
volume enclosed by envelope 45) via the second valve 53 and the
annular space 51. Toroidal inflatable envelope 45 is shown in its
collapsed state in FIG. 2A, and in its expanded state in FIG.
2B.
[0149] Anchor flange 55 is slidably mounted on the outer tube 37,
and can be locked in a desired position along the length of the
outer tube with a simple over-center action locking lever (not
shown). As will be described in detail below, the anchor flange and
the toroidal inflatable chamber, in its expanded condition, enable
the insufflator component 21 to form a gas-tight seal to prevent
insufflation gas passed through the insufflator component from
escaping.
[0150] The use of insufflation component 21 in the second part of
the method of FIGS. 3A-3I using the two-component apparatus of
FIGS. 1A-1C and 2A-2B will next be described. It is preferred to
use separation component 1 in conjunction with the first part of
the method (described with referenced to FIGS. 3A-3E) and for
dissecting the first and second tissue layers, but the second part
of the method (using insufflation component 21) may be used in
following any other dissection operation including manual
dissection with an endoscope, graspers, operating scope or any
blunt instrument which may be used to dissect the tissue layers by
sweeping the area between the layers.
[0151] With reference to FIG. 3F, obturator 33 of component 21,
having blunt tip 57, is inserted past flapper valve 32 (shown in
FIG. 2B) into the bore of inner tube 35. Tip 57 of obturator 33
projects beyond the distal end of the inner tube to provide
insufflation component 21 with a blunt nose. The blunt nose enables
the distal end of insufflation component 21 to be atraumatically
inserted into the properitoneal space through incision I. The
insufflation component is advanced through the incision until the
proximal end of the cylindrical envelope 45 is in the properitoneal
space, clear of the incision, as shown in FIG. 3F.
[0152] A suitable source (not shown) of an inflation fluid is
attached to second valve 53. A gas, such as air or carbon dioxide,
can be used for the inflation fluid; alternatively, a liquid, such
as saline can be used. Since the volume of inflation fluid required
to inflate the toroidal inflatable chamber is small, about 15 ml in
the preferred embodiment, the inflation fluid can be forced into
the toroidal inflatable chamber from a large syringe. Inflation
fluid is fed into toroidal inflatable chamber 43 to expand the
toroidal inflatable chamber to its expanded condition, as shown in
FIG. 3G.
[0153] Anchor flange 55 is then advanced in the direction of arrow
59 along outer tube 37 to bring anchor flange 55 into contact with
the skin of the abdominal wall (as shown in FIGS. 3G and 3H).
Insufflation component 21 is then gripped, and the anchor flange is
further advanced slightly. This forces the expanded toroidal
inflatable chamber 43 into contact with the overlying layer, and
slightly compresses the abdominal wall (including the overlying
layer but excluding the peritoneum) between the toroidal inflatable
chamber and the anchor flange. Once adjusted, the anchor flange is
locked in position on the outer tube. The expanded toroidal
inflatable chamber is held against the overlying layer, and forms a
gas-tight seal between the insufflation component and the abdominal
wall (including the overlying layer but excluding the peritoneum).
A suitable source (not shown) of an insufflation gas is attached to
first valve 31, and insufflation gas is passed through the bore of
inner tube 35 into the working space between the peritoneum and the
overlying layer created by separating by the peritoneum from the
overlying layer using the separation component of the apparatus in
the first part of the method described above. The pressure of the
insufflation gas re-separates the peritoneum from the overlying
layer, as shown in FIG. 3H, and provides a working space in which
repair of the hernia can be carried out. The obturator is removed
from the bore of inner tube 35. The bore of inner tube 35 can then
be used to pass instruments, such as the endoscope, into the
working space to perform the repair procedure. Insufflation
pressure is maintained by flapper valve 32.
[0154] As part of the hernia repair procedure, additional gas-tight
trocar sheaths are inserted through the abdominal wall into the
working space, as shown in FIG. 3I. An endoscope (not shown) can be
passed into the working space through the bore of inner tube 35, or
through one of the additional trocar sleeves for observation. If
the properitoneal fat layer remains attached to the properitoneal
fascia, it is scraped off the fascia around the site of the hernia
so that the patch can be attached directly to the fascia.
[0155] A patch, preferably a Dacron.RTM. or Teflon.RTM. mesh, shown
gripped by grippers, is passed through the sleeve of one trocar
into the working space. Using the grippers, the patch is
manipulated to place it in contact with the properitoneal fascia
over the site of the hernia. The patch is attached to the
properitoneal fascia by staples inserted using a stapler passed
through the trocar sleeve into the working space. Sutures can
alternatively be used to attach the patch to the properitoneal
fascia.
[0156] After the treatment procedure is completed, first valve 31
is operated to release the insufflation gas from the working space.
Second valve 53 is operated to release the inflation fluid from
toroidal inflatable chamber 43. Envelope 45 of the toroidal
inflatable chamber returns to its collapsed state, flush with the
outer surfaces of the inner tube and outer tube 37. Insufflating
component 21 is then withdrawn from the incision, and the incision
is closed using sutures or clips. The pressure of the viscera
against the peritoneum returns the peritoneum into contact with the
overlying layer. Over time, the peritoneum reattaches to the
overlying layer.
[0157] Several embodiments of a one-component apparatus are
disclosed in U.S. Ser. No. 07/911,714. Each such one-component
apparatus includes assemblies for performing multiple functions,
including: introducing and inflating a main envelope to dissect
tissue layers within a patient; anchoring the apparatus to the
patient and insufflating the working space; and returning the
inflated main envelope to a collapsed state. In some of these
embodiments, the main envelope is deployed through an elongated
tube, and the anchoring means includes an anchor flange slidably
mounted on the elongated tube and a toroidal inflatable chamber at
the distal end of the elongated tube. The anchor flange and
toroidal inflatable chamber can be controlled to form, together, a
gas-tight seal with the second layer of tissue.
[0158] One-component apparatus 121 (one of the one-component
apparatus embodiments disclosed in U.S. Ser. No. 07/911,714) is
shown in FIG. 4A. Apparatus 121 is similar to insufflation device
21 of FIGS. 2A-2B, and components of apparatus 121 corresponding to
those of device 21 are identified by the same reference numbers as
in FIGS. 2A-2B with "100" added thereto. Apparatus 121 comprises
tube assembly 160, including an inner tube 135 coaxially mounted
inside an outer tube 137. Outer tube 137 covers inner tube 135 over
most of the length of the inner tube. The inner tube is a rigid
tube having a bore with a circular cross section that can
accommodate an endoscope (not shown).
[0159] The proximal end of the inner tube 135 is fitted with a port
125, the proximal end 127 of which includes a flapper valve 132.
The shutter 136 of the flapper valve is operated by the button 129.
Additionally, the seat 134 of the flapper valve forms a gas-tight
seal with an endoscope (not shown), or other instrument, inserted
though the flapper valve into the bore of the inner tube 135. The
port 125 is also fitted with a first valve 131 to which a supply of
a suitable insufflation fluid can be connected.
[0160] Unlike insufflator device 21 of FIGS. 2A and 2B, the distal
end of outer tube 137 extends as far as the distal end of inner
tube 135. Tubes 135 and 137 are connected together over a distal
portion 167 of their lengths (see detail in FIG. 4B).
Circumferential groove 169 is formed in the inner wall of distal
portion 167. Groove 169 is shown with a wedge-shaped cross section,
but can have other cross sections, such as square, or
semi-circular. Circumferential groove 169 retains main envelope
112, which defines main inflatable chamber 113, in the bore of
inner tube 135.
[0161] Envelope 145 of toroidal inflatable chamber 143 covers the
distal part of tube assembly 160. Envelope 145 is a cylindrical
piece of thin elastomeric material, such a latex, silicone rubber,
or polyurethane. The proximal end 147 and the distal end 149 of the
envelope are attached to the outer surface 163 of the tube assembly
using a circumferential line of adhesive applied at each end of the
envelope. An epoxy or cyanoacrylate adhesive is preferably used.
When chamber 143 is in its collapsed state, envelope 145 lies
almost flush with the outer surface of tube assembly 160.
[0162] Outer tube 137 is spaced from inner tube 135 over at least
part of its circumference. Space 151 between the inner tube and the
outer tube, and radial passage 161 through the wall of the outer
tube interconnect chamber 143 and second valve 153. Second valve
153 is connected to a source of suitable inflation fluid (not
shown). Chamber 143 is shown in its collapsed state in FIGS. 4A and
4B, and in its expanded state in FIG. 4C.
[0163] Anchor flange 155 is slidably mounted on tube assembly 160,
and can be locked in a desired position along the length of the
tube assembly with a simple over-center action locking lever (not
shown). As will be described below, anchor flange 155 and toroidal
inflatable chamber 143 in its expanded condition form a gas-tight
seal to prevent insufflation gas from escaping.
[0164] The apparatus of FIGS. 4A-4C also includes main envelope 112
detachably attached to the bore of inner tube 135. The main
envelope defines main inflatable chamber 113. Main envelope 112 is
preferably formed of an elastomeric material such as latex,
silicone rubber, or polyurethane (but can also be formed from a
thin, inelastic material such as Mylar.RTM., polyethylene, nylon,
etc.). If an inelastic material is used for envelope 112, it should
be suitably packaged to fit inside the bore of the inner tube when
in its collapsed state.
[0165] Main envelope 112 is formed such that it has a substantially
spherical shape when in its expanded state, and is also formed with
a neck 165. Neck 165 has an outside diameter substantially equal to
the diameter of the bore of inner tube 135. Neck 165 can be rolled
outward a number of times, as in the neck of a common toy balloon,
or the neck can be attached to a suitable O-ring 171 as shown in
FIG. 4B. The rolled neck, or the O-ring attached to the neck,
engages with the circumferential groove 169 in the inner wall in
the inner tube to attach main envelope 112 to the inner tube. Main
envelope 112 is housed in the bore of the inner tube when the main
inflatable chamber is in its collapsed state.
[0166] Rip cord 173, attached to neck 165 of main envelope 112,
runs proximally up the bore of inner tube 135 and emerges from port
125 through flapper valve 132. The part of the rip cord 173
emerging from the flapper valve can be gripped and pulled in a
proximal direction to release the rolled neck 165 or the O-ring 171
from the circumferential groove 169. By pulling further on the rip
cord, the entire main envelope can be pulled proximally through the
bore of the inner tube.
[0167] FIG. 5A shows a one-component apparatus (which is a
variation on the apparatus of FIGS. 4A-4C) having an elongated main
envelope 112A. As shown in FIG. 5A (and described in referenced
U.S. application Ser. No. 07/911,714), tube assembly 160A includes
inner tube 135A mounted coaxially inside outer tube 137A, with the
proximal and distal ends of the tubes interconnected. Space 151A
between the inner tube and the outer tube communicates with the
toroidal inflatable chamber through a radial passage in the wall of
the outer tube. The space between the inner tube and the outer tube
also communicates with the toroidal chamber inflation valve 153A.
The bore of the inner tube 135A communicates with the port 125A,
fitted with the insufflation valve 185. The port 125A is also
fitted with a flapper valve 132A, including the flapper valve seat
134A, which maintains gas pressure when the apparatus is used for
insufflation. Flapper valve seat 134A also provides a gas-tight
seal around any instrument, such as endoscope E, passed through the
flapper valve.
[0168] Elongated main envelope 112A is shown in FIG. 5B. The main
envelope is an elongated cylinder with a closed distal end 177. The
main envelope is preferably formed from an elastomeric material,
such as latex, silicon rubber, or polyurethane. Attached to the
proximal end of the main envelope is a manifold 175 which mates
with the proximal face 127A of the port 125A. The manifold 175 is
fitted with an O-ring seal 187, which forms a gas-tight seal with
any instrument passed through it. The manifold 175 is also fitted
with the main chamber inflation valve 131A to which a supply (not
shown) of a suitable inflation fluid can be attached to inflate the
main inflatable chamber 112A.
[0169] Elongated main envelope 112A is passed through flapper valve
132A into the bore of inner tube 135A. The manifold 175 is engaged
with the proximal face 127A of the port 125A. When the manifold is
engaged, the distal end 177 of the main envelope projects beyond
the distal end of the tube assembly 160A, as shown in FIG. 5C. The
distal end of the main envelope is then inverted into the bore of
the inner tube 135A, as shown in FIG. 5D.
[0170] An endoscope, or other suitable instrument, is inserted
through O-ring seal 187 to seal the manifold before inflation fluid
is passed through main chamber inflation valve 131A to inflate main
inflatable chamber 113A.
[0171] Alternatively, seal 187 can be replaced by an additional
flapper valve (not shown) so that the main inflatable chamber can
be inflated without the need to use an instrument to seal the
manifold.
[0172] When inflation fluid is passed into main inflatable chamber
113A through valve 131A, distal end 177 of main envelope 112A is
ejected from inner tube 135A. The inflation fluid then
progressively expands the main envelope 112A, and hence main
inflatable chamber 113A defined by the main envelope, into an
expanded state as shown in FIG. 5A. The part of the main envelope
inside the inner tube is subject to the same inflation pressure as
the distal end 177 of the main envelope, but is constrained by the
inner tube and so does not inflate.
[0173] After using main envelope 112A to separate (dissect) the
peritoneum from an adjacent tissue layer, as will be described
below, the inflation pressure fluid is vented from main inflatable
chamber 113A, and main envelope 112A returns to its collapsed
state. When the main envelope is in its collapsed state, it can
move freely in the bore of inner tube 135. The main envelope is
removed from the inner tube by disengaging manifold 175 from the
proximal face 127A of port 125A, and using manifold 175 to pull the
main envelope proximally through the bore of the inner tube.
[0174] Inflation fluid for the toroidal inflatable chamber
(envelope 145A of which is shown in FIG. 5A), is passed through
toroidal chamber inflation valve 153A. Insufflation gas is passed
through insufflation valve 185.
[0175] The toroidal inflatable chamber and anchor flange 155A of
the embodiment of FIGS. 5A-5D are the same as in the embodiment of
FIGS. 4A-4C, and will not be described again.
[0176] In a method according to U.S. Ser. No. 07/911,714 of using a
one-component apparatus to separate a first layer of tissue from a
second layer of tissue, the elongated tube pushes the main envelope
in a collapsed state through an incision through the second layer
of tissue to place the main envelope between the first layer of
tissue and the second layer of tissue. The main envelope is then
inflated to gently separate the first layer of tissue from the
second layer of tissue, thereby creating a working space between
the two layers of tissue. An endoscope may be passed through the
bore of the single elongated tube into the main chamber to observe
the extent of separation of the layers of tissue. The main envelope
is then returned to a collapsed state, detached from the elongated
tube, and removed from the working space between the layers of
tissue through the bore of the elongated tube. The toroidal
inflatable chamber at the distal end of the elongated tube is then
inflated into an expanded state. The anchor flange is slid distally
along the elongated tube to compress the second layer of tissue
between it and the expanded toroidal inflatable chamber to form a
gas-tight seal. Insufflating gas is passed through the elongated
tube into the working space to maintain the separation of the first
and second tissue layers. An endoscope may be passed through the
bore of the single elongated tube into the working space to observe
within the working space.
[0177] Such a method (described in U.S. Ser. No. 07/911,714) of
using either the apparatus of FIGS. 4A-4C or that of FIGS. 5A-5D to
separate a first layer of tissue from a second layer of tissue will
next be described with reference to FIGS. 6A-6H. For specificity,
FIGS. 6A-6H will be described with reference to separation of the
peritoneum from the properitoneal fascia in the course of repairing
a hernia using the apparatus of FIGS. 4A-4C.
[0178] FIGS. 6A-6H show a longitudinal cross section of the lower
abdomen. Incision 1 about 12-15 mm long is made in the abdominal
wall, and carried through the abdominal wall as far as, and
including the properitoneal fat layer as shown in FIG. 6A. Distal
end 115 of tube assembly 160 of apparatus 121 is then inserted into
the incision to bring the distal end into contact with the
peritoneum. Additional gentle pressure detaches the part of the
peritoneum in the immediate vicinity of the incision from the
overlying layer, as shown in FIG. 6B. FIG. 6B shows the peritoneum
detached from the properitoneal fat layer. The main envelope cannot
be seen in FIGS. 6A and 6B because it is inverted within the bore
of the tube assembly.
[0179] A source of inflation fluid (not shown) is connected to
valve 131. A gas, preferably air, is the preferred inflation fluid,
but other gases, such a carbon dioxide can be used. A liquid, such
as saline solution can be used, but liquids are less preferable
because they change the optical properties of any endoscope
inserted into main inflatable chamber 113. The flow of inflation
fluid is turned on, which ejects main envelope 112 from the bore of
tube assembly 160.
[0180] The inflation fluid progressively expands main envelope 112,
and hence main inflatable chamber 113 defined by the main envelope,
into an expanded state as shown in FIG. 6C. The main envelope
expands between the peritoneum and the properitoneal fat layer, and
gently and progressively detaches an increasing area of the
peritoneum from the overlying layer as it expands. When the main
envelope is in its expanded state, the main inflatable chamber is
preferably about 4''-6'' (100-150 mm) in diameter.
[0181] Early in the process of expanding main envelope 112, an
endoscope E is inserted into flapper valve 132 in port 125 as shown
in FIG. 6C. Endoscope E is passed through the bore of tube assembly
160 into main inflatable chamber 113. Once the main envelope is
partially expanded, the main envelope is sufficiently transparent
for the extent of the detachment of the peritoneum to be observed
using the endoscope.
[0182] When a sufficient area of the peritoneum is detached, the
supply of inflation fluid is turned off. The inflation fluid is
then vented from main inflatable chamber 113, and the main envelope
progressively returns to its collapsed state. The peritoneum
remains detached from the overlying layer, however, as shown in
FIG. 6D. The main envelope is then removed from the bore of tube
assembly 160. The different methods of removing the main envelope
from the bore of the tube assembly for the different forms of the
one-component apparatus (that of FIGS. 4A-4C and that of FIGS.
5A-5D) are described above.
[0183] After main envelope 112 has been removed from the bore of
the tube assembly, the tube assembly is advanced into the incision
in the direction of arrow 162 until the proximal end of envelope
145 of the toroidal inflatable chamber is in the properitoneal
space, clear of the incision, as shown in FIG. 6E.
[0184] A suitable source (not shown) of an inflation fluid is
attached to valve 153. A gas, such as air or carbon dioxide, can be
used for the inflation fluid; alternatively, a liquid, such as
saline can be used. Since the volume of inflation fluid required to
inflate the toroidal inflatable chamber is small, about 15 ml in
the preferred embodiment, the inflation fluid can be contained in a
large syringe. Inflation fluid is fed into toroidal inflatable
chamber 43 to expand the toroidal inflatable chamber to its
expanded condition, as shown in FIG. 6F.
[0185] Anchor flange 155 is then advanced in the direction of arrow
159 along tube assembly 160 to bring the anchor flange into contact
with the skin S of abdominal wall AW. Tube assembly 160 is then
gripped, and the anchor flange is further advanced slightly. This
forces the expanded toroidal inflatable chamber 143 into contact
with the overlying layer, and slightly compresses abdominal wall
AW, including the overlying layer but excluding the peritoneum P,
between the expanded toroidal inflatable chamber and the anchor
flange, as shown in FIG. 6G. Once adjusted, the anchor flange is
locked in position on the tube assembly. The expanded toroidal
inflatable chamber is held against the overlying layer and forms a
gas-tight seal with the abdominal wall, excluding the
peritoneum.
[0186] A suitable source (not shown) of insufflation gas is
attached to first valve 131, and insufflation gas is passed through
the bore of inner tube 135 into working space WS between the
peritoneum P and the overlying layer created by separating the
peritoneum from the overlying layer. The pressure of the
insufflation gas re-separates the peritoneum from the overlying
layer, as shown in FIG. 6H, and provides a working space in which
repair of the hernia can be carried out. The bore of tube assembly
160 can be used to pass instruments, such as endoscope E, into the
working space to perform the repair procedure. When no instrument
is inserted into the bore of the tube assembly, insufflation
pressure is maintained by the flapper valve.
[0187] As part of a hernia repair procedure, additional gas-tight
trocar sleeves (not shown) are inserted through the abdominal wall
into the working space. The same procedure described above in
connection with FIG. 31 is used to attach a mesh patch to the
properitoneal fascia over the site of the hernia. The process can
be observed using an endoscope passed through the bore of tube
assembly 160, or through one of the additional trocar sleeves.
[0188] After the treatment procedure is completed, valve 131 is
operated to release the insufflation gas from the working space WS.
Valve 153 is operated to release the inflation fluid from toroidal
inflatable chamber 143, which releases compression of the abdominal
wall AW, excluding the peritoneum. Toroidal inflatable chamber 143
returns to its collapsed state, with its envelope 145 flush with
the outer surface tube assembly 160. The tube assembly is then
withdrawn from the incision, and the incision is closed using
sutures or clips. The pressure of the viscera against the
peritoneum returns the peritoneum into contact with the overlying
layer. Over time, the peritoneum reattaches to the overlying
layer.
[0189] In a second embodiment of a one-component apparatus
according to U.S. Ser. No. 07/911,714, the introducing device is an
outer elongated tube, and the insufflating device comprises an
inner elongated tube mounted in the bore of the outer tube. The
proximal ends of the tubes are flexibly coupled together. One end
of the main envelope is everted with respect to the other, and is
attached to the distal end of the outer elongated tube. The other
end of the main envelope is attached to the distal end of the inner
elongated tube. The main inflatable chamber defined by the main
envelope is thus substantially toroidal. The outer elongated tube
has an anchor flange slidably mounted on it. The anchor flange and
the main inflatable chamber together form a gas-tight seal with the
second layer of tissue.
[0190] Such second embodiment of a one-component apparatus is shown
in FIGS. 7A-7B and 8A-8B. In this embodiment, a substantially
toroidal shape of the main chamber avoids the need to detach and
remove the main envelope at the end of the separation process, and
the toroidal main chamber provides both the separating function of
the main chamber and the sealing function of the toroidal chamber
of the embodiment of FIGS. 4A-4C.
[0191] The apparatus of FIGS. 7A and 7B comprises tube assembly
260, including outer tube 237 to which is attached a twin port
assembly 225 comprising first port 226 and second port 228. The
first port is provided with a first flapper valve 202, including
flapper valve seat 204. The second port is provided with a second
flapper valve 206, including flapper valve seat 208. Each flapper
valve seat forms a gas-tight seal with an instrument passed through
it.
[0192] Tube assembly 260 also includes inner tube 235. Inner tube
235 is shorter than outer tube 237. The proximal end 210 of the
inner tube is flexibly attached to the proximal end 222 of outer
tube 237 and to first port 226. The flexible attachment enables the
distal end 214 of the inner tube to move in the direction shown by
the arrow 216. The first port communicates with the bore of inner
tube 235, and the second port communicates with the bore of outer
tube 237.
[0193] Insufflation valve 285 communicates with first port 226, and
the bore of inner tube 235. Main chamber inflation valve 231
communicates with second port 228, and the bore of outer tube
237.
[0194] Main envelope 212 defines the main inflatable chamber 213
and comprises a cylindrical piece of an elastomeric material such a
latex, silicone rubber, or polyurethane. The apparatus is shown
with its main envelope in its collapsed state in FIG. 7B, in which
the structure of the main envelope can also be seen. The main
envelope preferably has a diameter smaller than the outside
diameter of the inner tube. One end 230 of the main envelope is
attached to distal end 214 of inner tube 235 by means of a suitable
adhesive, such as an epoxy or cyanoacrylate adhesive. The other end
232 of the main envelope is everted (i.e., turned back on itself to
bring the inside surface 234 of the main envelope to the outside)
and attached to the distal end 236 of the outer tube using the same
type of adhesive. The main envelope is preferably attached to the
outer surfaces of the inner tube and the outer tube.
[0195] FIG. 7A shows main envelope 212 in its expanded state. To
reach this state, a source of inflation gas is connected to valve
231 and the gas flows into the main inflatable chamber through the
bore of outer tube 237. The pressure acting on surface 238 of the
main envelope 212 causes the main envelope to assume the toroidal
shape shown in FIG. 7A to define toroidal main chamber 213, with
surface 234 defining the "hole" or "bore" through the toroidal main
envelope. FIGS. 7A and 7B show the correspondence between the
surfaces 234 and 238 of the main envelope when the main envelope is
in a collapsed state (FIG. 7B) and in an expanded state (FIG.
7A).
[0196] Anchor flange 255 is slidably mounted on tube assembly 260,
and can be locked in a desired position along the length of the
tube assembly. Anchor flange 255 is identical or similar to anchor
flange 55 (of FIG. 2A) and thus will not be described further.
[0197] FIG. 8A shows an endoscope E passed through second flapper
valve 206, second port 228, and the bore of outer tube 237 into
main inflatable chamber 213. The flexible mounting of inner tube
235 in the outer tube enables the endoscope to displace inner tube
235 in direction of the arrow 216 to gain access to the main
inflatable chamber. The endoscope is inserted through the second
port into the main inflatable chamber during tissue separation
using the apparatus to observe the extent of the separation.
[0198] FIG. 8B shows an endoscope E passed through first flapper
valve 202, first port 226, the bore of inner tube 235, and bore 234
of main envelope 212. The distal part of the endoscope emerges from
the bore of the main envelope 212, and can be advanced beyond the
main inflatable chamber 213 to observe tissue such as the site of
the hernia more closely. The endoscope is inserted through the
first port, the inner tube, and the bore of the main envelope
during insufflation using the apparatus. Instruments other than
endoscopes can also be passed to the site of the hernia through the
first flapper valve, the first port, the inner tube, and the bore
of the main envelope if desired.
[0199] As shown in FIG. 8B, main envelope 212 is in a partially
collapsed state that it preferably assumes during the insufflation
phase of the procedure. During this part of the procedure, the
partially collapsed main inflatable chamber and anchor flange 255
together provide a gas-tight seal to prevent the leakage of
insufflation gas. Alternatively, insufflation can be carried out
with the main inflatable chamber in a fully expanded state.
[0200] In a method described in U.S. Ser. No. 07/911,714 of using
the embodiment of FIGS. 7A, 7B, 8A, and 8B to separate a first
layer of tissue from a second layer of tissue, the outer elongated
tube pushes the main envelope in a collapsed state through an
incision through the second layer of tissue to place the main
envelope between the first layer of tissue and the second layer of
tissue. The main envelope is then inflated to gently separate the
first layer of tissue from the second layer of tissue, and to
create a working space between the layers of tissue. An endoscope
may be passed through the outer elongated tube into the main
chamber to observe the extent of separation of the layers of
tissue. The anchor flange is slid distally along the introducing
device tube to compress the second layer of tissue between it and
the main inflatable chamber, to form a gas-tight seal. Insufflating
gas is then passed through the bore of the inner elongated tube and
the bore of the main envelope into the working space to maintain
the separation of the first layer of tissue from the second. An
endoscope may be passed through the bore of the inner elongated
tube and the bore of the main envelope into the working space to
observe within the working space.
[0201] More specifically, in performing this method, an incision
about 12-15 mm long is made in the abdominal wall, and carried
through the abdominal wall as far as, and including, the
properitoneal fat layer. The distal end of tube assembly 260 is
then inserted into the incision into contact with the peritoneum.
Additional gentle pressure detaches the part of the peritoneum in
the immediate vicinity of the incision from the overlying layer (at
this time, main envelope 212 is inverted within the bore of the
tube assembly). A source of inflation fluid is then connected to
valve 231. A gas, preferably air, is the preferred inflation fluid,
but other gases, such a carbon dioxide can be used. A liquid such
as saline solution can be used, but a gas is preferred to a liquid
because liquids change the optical properties of any endoscope
inserted into the inflatable chamber. The flow of inflation fluid
is turned on, which ejects the main envelope 212 from the bore of
tube assembly 260.
[0202] The inflation fluid progressively expands main envelope 212,
and hence main inflatable chamber 213 defined by the main envelope,
into an expanded state. The main envelope expands between the
peritoneum and the properitoneal fat layer, and gently and
progressively separates an increasing area of the peritoneum from
the overlying layer as it expands. When the main envelope is in its
expanded state, the main inflatable chamber is preferably about
4''-6'' (100-150 mm) in diameter.
[0203] Early in the process of expanding main envelope 212, an
endoscope is inserted into first flapper valve 202. The endoscope
is passed through the bore of outer tube 237 into main inflatable
chamber 213. Once partially expanded, main envelope 212 is
sufficiently transparent for the extent of the separation of the
peritoneum to be observed using the endoscope.
[0204] When a sufficient area of the peritoneum is separated, the
supply of inflation fluid is turned off and the endoscope is
removed from main inflatable chamber 213. Valve 231 is then opened
to allow inflation fluid to vent partially from main inflatable
chamber 213 (allowing main envelope 212 to return at least
partially to its collapsed state). Alternatively, main envelope 212
may be kept fully expanded.
[0205] Anchor flange 255 is then advanced along tube assembly 260
to bring the anchor flange into contact with the skin of the
abdominal wall. Tube assembly 260 is then gripped, and the anchor
flange is further advanced slightly. This forces the main envelope
212 into contact with the overlying layer, and slightly compresses
the abdominal wall, including the overlying layer but excluding the
peritoneum, between the main envelope and the anchor flange. Once
adjusted, anchor flange 255 is locked in position on the tube
assembly, and main envelope 212 forms a gas-tight seal with the
abdominal wall and the peritoneum.
[0206] A suitable source of insufflation gas is attached to second
valve 285, and insufflation gas is passed through the bore of inner
tube 235, and bore 234 of main envelope 212, into the working space
between the peritoneum and the overlying layer. The pressure of the
insufflation gas re-separates the peritoneum from the overlying
layer, and provides a larger working space in which repair of the
hernia can be carried out.
[0207] An instrument such as an endoscope can be passed through
second flapper valve 206, the bore of inner tube 235, and bore 234
of main envelope 212, into the working space to perform a repair
procedure. When no instrument is so inserted, insufflation pressure
is maintained by second flapper valve 206.
[0208] After the treatment procedure is completed, valve 285 is
operated to release the insufflation gas from the working space.
Valve 231 is operated to release the inflation fluid from main
inflatable chamber 213, which releases compression from the
abdominal wall, excluding the peritoneum. Main envelope 212 returns
to its collapsed state inside the bore of outer tube 237.
[0209] The tube assembly is then withdrawn from the incision, and
the incision is closed using sutures or clips. The pressure of the
viscera against the peritoneum returns the peritoneum into contact
with the overlying layer. Over time, the peritoneum reattaches to
the overlying layer.
[0210] In another method described in U.S. Ser. No. 07/911,714,
access is provided through the abdominal wall from near the
umbilicus to repair a hernia. This method will be described with
reference to FIGS. 9A-9I. This method is often preferable to the
hernia repair methods described above in which the incision is
placed close to the site of the hernia, since in practice, it is
preferred to make the incision at or near the umbilicus because the
boundary between the peritoneum and the properitoneal fat layer can
be more directly accessed near the umbilicus. The midline location
of the umbilicus is devoid of muscle layers that would otherwise
need to be traversed to reach the properitoneal fat layer.
[0211] In the method of FIGS. 9A-9I, the main envelope is partially
expanded, collapsed, and advanced toward the site of the hernia.
This sequence is repeated to progressively separate the peritoneum
from the overlying layer and form the tunnel from the umbilicus to
the site of the hernia. Then, at or near the site of the hernia,
the main envelope is fully expanded to provide the working space at
the site of the hernia. The working space is then insufflated to
maintain the separation of the peritoneum from the overlying layer.
The method of FIGS. 9A-9I can be practiced using any of the
two-component or one-component apparatuses described above. For
specificity, the method will be described with reference to a
two-component apparatus.
[0212] An incision about 12-15 mm long is made in the abdominal
wall AW, and is carried through the abdominal wall as far as, and
including, the properitoneal fat layer FL. The incision is made at
the umbilicus U, as shown in FIG. 9A.
[0213] Distal end 15 of introducer tube 3 of separation component 1
is then inserted into the incision to bring the distal end into
contact with the peritoneum P. Additional gentle pressure detaches
the part of the peritoneum in the immediate vicinity of the
incision from the overlying layer, as shown in FIG. 9B. In FIG. 9B,
the peritoneum is shown detached from the properitoneal fat layer
FL. Main envelope 12 cannot be seen in FIGS. 9A and 9B because it
is inverted within the bore of introducer tube 3.
[0214] A source of a suitable inflation fluid (not shown), as
previously described, is connected to valve 11. The flow of
inflation fluid is turned on, which ejects main envelope 12 of main
inflatable chamber 13 from the bore of introducer tube 3. The
inflation fluid progressively expands main envelope 12, and hence
main inflatable chamber 13 defined by the main envelope, into a
partially-expanded state, as shown in FIG. 9C. The main envelope
expands between the peritoneum and the properitoneal fat layer FL,
and gently and progressively detaches an increasing area of the
peritoneum P from the overlying layer near the umbilicus as it
expands.
[0215] An endoscope (not shown) can be inserted into main
inflatable chamber 13 through flapper valve 2 and the bore of
introducer tube 3. The endoscope can be used to observe the extent
of the separation of the peritoneum, as described above.
[0216] When main envelope 12 expanded such that the main inflatable
chamber 13 is about one-fourth of its fully-expanded diameter,
i.e., about 1.0''-1.5'' (25-37 mm) in diameter, the supply of
inflation fluid is turned off. Valve 11 is then operated to vent
inflation fluid from the main inflatable chamber 13. The main
envelope progressively returns to its collapsed state, as shown in
FIG. 9D. The peritoneum portion DP that was separated by the main
inflatable chamber remains detached from the overlying layer, as
shown. Alternatively, the main envelope can be inflated to a
fully-expanded state.
[0217] Separation component 1, including the collapsed main
envelope 12, is then manipulated in the direction indicated by
arrow 14, and then in the direction indicated by arrow 16, to
advance distal part 15 of introducer tube 3 to the limit of the
detached part DP of the peritoneum in the direction of the groin,
as shown in FIG. 9E. An endoscope E inserted through flapper valve
2 into the bore of introducer tube 3 enables the position of the
distal part 15 relative to the detached part DP of the peritoneum
to be observed.
[0218] Once distal part 15 of the introducer tube has been
positioned, the separation component 1 is clamped in position, or
is gripped, and inflation fluid is once more passed through the
valve 11 and the bore of introducer tube 3 into main inflatable
chamber 13. The main envelope 12 expands once more, increasing the
extent of the detached part of the peritoneum towards the groin, as
shown in FIG. 9F. The increased extent of the detached part of the
peritoneum is indicated by line DP' in FIG. 9F. The extent of the
detached part of the peritoneum is increased in the direction from
the umbilicus to the groin, but not in the direction transverse to
this direction. Endoscope E is used to observe the extent of the
separation.
[0219] The process of collapsing the main envelope 12, advancing
the distal part 15 of the introducer tube to the limit of the
detached part DP' of the peritoneum in the direction of the groin,
holding the introducer tube in position, and partially re-inflating
main envelope 12, is repeated until the detached part of the
peritoneum includes the peritoneum over the site of the hernia.
This process provides a tunnel T between the incision at the
umbilicus and the site of the hernia (as shown in FIGS. 9G, 9H, and
9I).
[0220] When the main envelope is in the vicinity of the site of the
hernia H, main envelope 12 is fully inflated to form a working
space WS including the site of the hernia. This is shown in FIG.
9G.
[0221] The working space at the site of the hernia is then
insufflated. With the two-component apparatus, inflation fluid is
vented from the main inflatable chamber 13 to collapse main
envelope 12, and the separation component 1 is withdrawn from
tunnel T through incision I. Insufflation component 21 is
introduced into the incision, and advanced through the tunnel until
envelope 45 of toroidal inflatable chamber 43 lies within the
working space WS, clear of the tunnel. Toroidal inflatable chamber
43 is inflated, the anchor flange is clamped in position, and
insufflation gas is passed into the working space, as shown in FIG.
9H. Toroidal inflatable chamber 43 provides a gas-tight seal with
the entrance of the tunnel.
[0222] FIG. 9I is a plan view of the abdomen with insufflation
component 21 in place. The anchor flange has been omitted for
clarity. Toroidal inflatable chamber 43 provides a gas-tight seal
with the entrance of tunnel T. The extent of the separated
peritoneum is indicated by dotted line DP. It can be seen that the
lateral extent of the separated peritoneum is considerably greater
in working space WS than in tunnel T.
[0223] At this stage, if a one-component apparatus had been used
(with the main inflatable chamber remaining in the working space),
inflation fluid would be vented from the main inflatable chamber to
collapse the main envelope, and the main envelope would be
withdrawn from the working space through the bore of the tube
assembly. The tube assembly would be partially withdrawn until the
envelope of a toroidal inflatable chamber 43 lies within the
working space, clear of the entrance to the tunnel. The toroidal
inflatable chamber 43 would then be inflated, the anchor flange
clamped in position, and insufflation gas passed into the working
space, as already described. The toroidal inflatable chamber 43
would seal against the entrance from the tunnel into the working
space.
[0224] Alternatively, if another type of one-component apparatus
had been used (with the main inflatable chamber remaining in the
working space), the main envelope would preferably be returned to a
partially collapsed state, and the tube assembly partially
withdrawn until the main inflatable chamber lies within the working
space, adjacent to the entrance of the tunnel. The anchor flange
would be clamped in position, and insufflation gas is passed into
the working space as already described. The partially-collapsed
main chamber would seal against the entrance from the tunnel into
the working space.
[0225] Regardless of the embodiment of the apparatus used to create
the insufflated working space WS shown in FIG. 9I, the hernia is
then repaired using a procedure such as that described in
connection with FIG. 31.
[0226] Before either component 1 or component 21 (or a
one-component apparatus that performs the functions of both
components 1 and 21) is inserted into the patient, its inflatable
envelopes and chambers are deflated and packed into a sheath. One
method of packing an inflatable chamber in its deflated, compact
state is to roll the chamber inwardly from opposing lateral
sides.
[0227] Above-referenced U.S. Ser. No. 08/405,284 discloses a device
which performs both dissection and retraction of tissue layers
while at least a part of the device remains in the patient
throughout the dissection and retraction procedure, so that the
user need not remove one assembly from the patient and then insert
a second assembly into the patient (searching for the dissected
spatial plane in order to deploy the second assembly in the proper
position) between the dissection and retraction steps. In a
preferred implementation, the distal end of the device is moved to
a position between tissue layers in the patient. A first balloon is
then inflated between the tissue layers to dissect the tissue
layers. A second balloon, which is used to retract the tissue
layers, is then inflated between the tissue layers. The distal end
of the device for introducing and inflating first balloon remains
in the patient until the second balloon has been inflated, so that
the tissue layers remain at least partially separated at all times
after initial introduction of the device between such layers. After
retracting the tissue layers with the second balloon, the first
balloon is deflated, e.g., by a puncturing step which creates an
opening in the first balloon. Instruments are then introduced into
a working space through the opening in the first balloon. The
second balloon, which can be positioned in the interior of the
first balloon, is inflated to seal the working space so that
insufflating fluid is impeded from escaping.
[0228] A preferred embodiment of the inventive one-component
apparatus (identified by reference numeral 600) for tissue
dissection and instrument anchoring, and also tissue retraction,
will be described with reference to FIGS. 10, 11, 12, 13, and
14.
[0229] FIG. 10 is a perspective view of apparatus 600. FIG. 14 is a
partially side elevational, partially side cross-sectional view of
apparatus 600. FIGS. 11, 12, 13, 16, 17, 18, 19, 20, and 21 are
views of portions (or substitutes for portions) of apparatus 600.
FIG. 11 is an exploded view of obturator 515, retaining ring 514,
and the dissection balloon subassembly of apparatus 600. FIG. 12 is
an exploded cross-sectional view of the dissection balloon
subassembly of apparatus 600. Each of FIGS. 19, 20, and 21 is a
side elevational view of a balloon window for use as window 508 of
apparatus 600. FIG. 13 is a perspective view of the tissue
retraction and instrument anchoring subassembly of apparatus
600.
[0230] The assembly of FIG. 15 is an alternative anchor balloon
assembly which can be substituted for that of FIG. 13 in apparatus
600 of FIGS. 10, 11, 12, and 14.
[0231] With reference to FIG. 10, apparatus 600 includes housing
509, cannula 505 (connected to housing 509 and extending out from
distal face 509A of housing 509), retaining ring 514 (around
housing 509), clamp 503 (around cannula 505), foam collar 504
(around cannula 505, and attached to clamp 503 so that clamp 503
and collar 504 can slide together as a unit along cannula 505 until
clamp 503 locked in a fixed position along cannula 505), housing
513, dissection balloon 512 having a long neck 512A (shown in FIG.
11) whose free end is attached to housing 513 and which extends
through cannula 505, anchor balloon 517 attached to cannula 505
(near distal end 505A of cannula 505 as shown in FIG. 14), sheath
506 which encloses balloons 517 and 512, and obturator 515
(extending through housing 513, housing 509, and cannula 505 into
the interior of balloon 512).
[0232] Flapper valve 521 is mounted within housing 509, and a
biasing spring (not shown) biases valve 521 in a closed position
(not shown in FIG. 14) in which valve 521 rests against an
elastomeric seal around an end port in the proximal face of housing
509 (the face at the right end of housing 509 in FIG. 14) thus
sealing the port. When button 520 is depressed (such as by ring 514
fitted around housing 509), mechanical linkage 522 (connected
between button 520 and valve 521) holds valve 521 in the open
position shown in FIG. 14, in which obturator 515 (or a similarly
shaped endoscope or other instrument) is free to pass into the port
through the proximal face of housing 509, and through the central
channel extending through housing 509. When button 520 is released
(such as when ring 514 is removed), linkage 522 allows
spring-biased valve 521 to return to its normally closed position
sealing the port in the proximal face of housing 509. The seat of
flapper valve 521 (around the end port in the proximal face of
housing 509) preferably forms a gas-tight seal with obturator 515
(or an endoscope or other instrument) inserted though the end port
and into cannula 505.
[0233] During use of the apparatus, after balloon 512 has been
inflated (with obturator 515 or another instrument inserted through
the end port in the proximal face of housing 509 and into cannula
505), balloon 512 can be deflated as follows. The obturator (or
other instrument) is withdrawn through the end port in the proximal
face of housing 509 while button 520 remains depressed (e.g., while
ring 514 remains in place over button 520), thus allowing the
inflating fluid to escape past the open flapper valve 521 out the
end port in the proximal face of housing 509. Any remaining
inflating fluid within balloon 512 can be pumped out using a
deflation bulb (or other pump) positioned against port 531 (port
531 can include a valve, or it can simply be an open port which
accepts a hand bulb or syringe), or any such remaining inflating
fluid can be forced out by compressing balloon 512.
[0234] With housing 513 detached from the proximal face of housing
509, it is sometimes useful to mount a converter in the end port in
the proximal face of housing 509, to maintain a fluid seal when an
instrument is inserted through the converter (and through the end
port) into cannula 505. By using differently sized and shaped
converters, instruments of different sizes and shapes can be
introduced into cannula 505. When performing a procedure in an
insufflated working space in the patient using such an instrument,
use of a converter of an appropriate size and shape may be needed
to prevent undesired deflation of the working space due to
undesired leakage of insufflation gas through the end port in the
proximal face of housing 509 around the instrument (if the outer
diameter of the instrument is less than the diameter of the end
port).
[0235] Mouth 512B of dissection balloon 512 is attached (preferably
by glue) to tube portion 564 of housing 513, as shown in FIGS. 14
and 12. With reference to FIG. 14, the apparatus is preferably
assembled by removably attaching the distal face of housing 513
(the left face in FIG. 14) to the proximal face of housing 509
(such as by snap fitting or bayonet fitting means). Elongated neck
512A of balloon 512 is extended through tube portion 564 of housing
513, through the central channel of housing 509, and through
cannula 505. Endoscope 515' is inserted through seal 560 of housing
513, and (within balloon 512) through tube portion 564 of housing
513, the central channel of housing 509, and cannula 505 until the
distal end 515A of endoscope 515' abuts window member 508 at the
distal end of balloon 512 (as shown in FIG. 14).
[0236] In a class of preferred embodiments (to be discussed below),
balloon 512 comprises a first sheet of thin elastomeric material
(such as polyurethane, latex, or silicone rubber) bonded (e.g.,
RF-welded) to a second sheet of thin, inelastic (or having
relatively low elasticity) material such as polyester,
polyethylene, or nylon film. Balloon 512 is preferably formed to
have a wide profile when expanded, in the sense that its width
(dimension W shown in FIG. 11) when expanded is much greater than
its expanded height (dimension H shown in FIG. 14). Another
dissection balloon having a different expanded shape can be
substituted for balloon 512 in alternative embodiments.
[0237] Before the apparatus is first used, balloon 512 is packed
against obturator 515 so as to occupy a small volume (as shown in
FIG. 10), so that the packed balloon 512 does not significantly
impede insertion of obturator 515 into the patient. At an
appropriate time during use of the apparatus (e.g., before or
during inflation of balloon 512), balloon 512 is expanded (inflated
as shown in FIG. 14) to occupy a larger volume. Obturator 515 is
withdrawn and replaced by an endoscope (e.g., endoscope 515' of
FIG. 14) for viewing the patient through window 508 of balloon 512.
Alternatively, before the apparatus is first used, balloon 512 is
packed against an endoscope (e.g., endoscope 515') so as to occupy
a small volume, so that the packed balloon 512 does not
significantly impede insertion of the endoscope into the patient,
and allows visualization of anatomy during insertion of the
device.
[0238] Anchor balloon 517 is attached to cannula 505, near distal
end 505A of cannula 505 as shown in FIG. 14. Before the apparatus
is first used, balloon 512 is packed against cannula 505 (as shown
in FIG. 14) so as to occupy a small volume, so that the packed
balloon 517 does not significantly impede insertion of cannula 505
into the patient. Before the apparatus is first inserted into a
patient, both packed balloons 512 and 517 are preferably packed
into sheath 506 (sheath 506 is shown in FIG. 10, but not in FIG.
14). At an appropriate time during use of the apparatus, balloon
517 is expanded (inflated) to occupy a larger volume (as shown in
FIG. 13). Preferably, balloon 517 has a rounded triangular shape
when expanded as shown in FIG. 13. In alternative embodiments,
another anchor balloon having a different expanded shape (such as
toroidal balloon 519 of FIG. 15) can be substituted for balloon
517. As will be described below, balloon 517 is used for retracting
tissue layers and for maintaining insufflation fluid in a working
space.
[0239] When clamp 503 is locked in a position along cannula 505
pressing foam collar 504 against the patient, foam collar 504 helps
to immobilize the entire apparatus (including housing 509 and
cannula 505) and collar 504 applies a modest compressive force to
the tissue between clamp 503 and inflated balloon 517, thereby
helping balloon 517 form a seal to limit the escape of insufflation
gas during laparoscopic procedures.
[0240] Sheath 506 (shown in FIG. 10) is preferably perforated but
may be formed in any other manner permitting easy opening.
Inflation of balloon 512 tears a perforated sheath 506 along the
perforation and releases both balloon 512 and balloon 517.
Alternatively, sheath 506 may include an independent opening
mechanism, such as a removable thread which binds the sheath
together, and which can be opened by the operator at a desired
time.
[0241] Inflation port 531 of housing 513 is used for inflating and
deflating balloon 512. Port 531 is opened by inserting an inflation
device, such as bulb 500 of FIG. 10, into it. When opened, port 531
provides a path for inflating balloon 512 by pumping gas (or other
fluid) through mouth 512B of balloon 512 into the interior of
balloon 512, and for deflating balloon 512 by allowing inflation
fluid to escape from balloon 512 out through port 531. A
conventional hand bulb 500 or a syringe can be used to inject the
fluid through port 531 (or through valves 510 and 511 to be
discussed below). Alternatively, port 531 can be a continually open
port that accepts a hand bulb or syringe.
[0242] Inflation valve 510 of housing 513 is used for inflating and
deflating anchor balloon 517. Valve 510 is opened by inserting an
inflation device, such as bulb 500 of FIG. 10, into it. When
opened, valve 510 provides a path for inflating balloon 517 by
pumping gas (or other fluid) through cannula 505 through mouth 517M
of balloon 517 into the interior of balloon 517, and for deflating
balloon 517 by allowing inflation fluid to escape out from mouth
517M of balloon 517 and then out through valve 510.
[0243] Insufflation valve 511 is used to supply insufflation gas or
liquid into a working space within the patient. Valve 511 is
typically used when obturator 515 (or endoscope 515'), the
dissection balloon assembly comprising balloon 512 and housing 513,
and ring 514 have been removed from the remaining portion (the
tissue retraction and instrument anchoring subassembly) of the FIG.
10 apparatus (and valve 521 has been closed, and the anchoring
assembly comprising collar 504 and clamp 503 has been locked to
anchor the remaining portion of the apparatus to the patient).
Valve 511 is opened by inserting an inflation device into it. When
opened, valve 511 provides a path for insufflation fluid to flow
through the channel surrounded by cannula 505 into the working
space (sealed by expanded balloon 517 and the clamp assembly 503,
504) and provides a path for allowing insufflation fluid to escape
out from the working space through valve 511.
[0244] We next describe a preferred structure of the dissection
balloon assembly in more detail with reference to FIG. 12. To
assemble this assembly, mouth 512B of balloon 512 is glued to a
cylindrical rim on the left face of base 562 (as shown in FIG. 12)
of housing 513. Tube 564 is glued to a cylindrical rim on the
opposite face of base 562, and the neck 512A of balloon 512 is
pulled to the right through base 562 and tube 564 into the
configuration shown in FIG. 12. Then, cover 566 is glued to base
562 to form housing 513. Thus, when inflation port 531 of cover 566
is opened, inflation fluid can be pumped through port 531 and the
volume enclosed by housing 513 into mouth 512B of balloon 512. Main
seal 560 is glued around the central orifice through cover 566, to
provide a fluid seal preventing fluid from escaping out through
this orifice when an obturator or other rod-shaped instrument is
inserted through the orifice into the interior of balloon 512.
Typically, the assembled FIG. 10 apparatus is packaged with an
obturator such as obturator 515 extending through seal 560 into the
interior of balloon 512. At various times during use of the
apparatus, the obturator is removed and replaced by an endoscope
(e.g., endoscope 515' of FIG. 14) having the same or similar outer
dimensions. Seal 560 is preferably made of rubber or another
elastomer.
[0245] Next, with reference to FIGS. 13 and 14, we describe a
preferred structure of the anchoring and tissue retraction assembly
including housing 509 and balloon 517. In some implementations, a
converter door 516 (made of rigid plastic) is slidably mounted to
the outside of housing 509. In the position shown in FIG. 13, door
516 covers a port (not shown) through the side wall of housing 509.
Door 516 can be slid proximally (away from balloon 517) to uncover
this port. The port is normally sealed by a closed second flapper
valve (similar to valve 521 of FIG. 14) within housing 509. In
response to depression of button 520, a second mechanical linkage
(similar to linkage 522 of FIG. 14) moves the second flapper valve
to open the port, so that (when door 516 is open) an instrument can
be inserted through the opened port into housing 509 and then
through cannula 505 into the working space within the patient. In
some implementations, door 516, the port (through the side wall of
housing 509) which can be covered by door 516, and the associated
valve means for opening and closing the port, are omitted.
[0246] In a preferred implementation of the FIG. 10 apparatus, port
531, housing 513 (including cover 566 and base 562), and housing
509 are made of hard plastic (such as that known as ABS plastic),
obturator 515 and ring 514 are made of hard plastic (such as
polypropylene or ABS plastic), clamp 503, cannula 505, and
dissection balloon window 508 (which can be shaped as a lens) are
made of polycarbonate, foam collar 504 is made of polyurethane
foam, sheath 506 is made of polyurethane, valves 510 and 511 are
made of stainless steel and plastic, the flapper valve assembly
comprising button 520, link 522, valve 521, and the seat against
which valve 521 rests when closed is made of stainless steel, ABS
plastic, and silicone rubber, and the converter door assembly
comprising door 516 is mode of silicone rubber and
polyetherimide.
[0247] Any of the balloon cannula systems of referenced U.S. Ser.
No. 08/365,096 can be employed in alternative implementation of the
present invention, e.g., to provide a supporting portion which
extends into the interior of the dissection balloon to provide
support for the dissection balloon during inflation.
[0248] With reference again to FIG. 13, anchor balloon 517 is
substantially bell-shaped, and composed of two sheets (517A and
517B) bonded together (e.g., by RF-welding) at seams 518A, 518B,
and 518C. Outer seam 518A defines the outline of a bell-shape,
semi-circular seam 518B reduces pressure induced stresses at the
periphery of balloon 517 (and eliminates the need to provide
baffles), and seam 518C defines a circular throughhole (through
which the longitudinal axis of cannula 505 extends, and through
which an instrument such as an endoscope can be extended). Outer
seam 518A has a semi-circular upper portion which is substantially
concentric with a throughhole defined by seam 518C. Sheet 517A has
a mouth portion 517M (shown in FIG. 14), and balloon 517 is
attached at mouth portion 517M to cannula 505, so that balloon 517
can be inflated and deflated using valve 510. The shape of balloon
517 and the strength and elasticity of its component sheets (and
thus the inflating fluid pressure within it during use) are chosen
so that inflated balloon 517 (positioned between two dissected
tissue layers) not only anchors cannula 505 to the patient but also
retracts the dissected tissue layers by a desired amount and
alternatively-shaped and structured anchor balloons will be used
for alternative uses. Preferably, sheet 517A is an inelastic
plastic sheet (e.g., made of polyester) which does not stretch
significantly during inflation of balloon 517 (to define the
desired inflated structure of the balloon even with inflating fluid
pressure within the balloon that is adequate for retracting the
tissue layers by the desired amount). Also preferably, sheet 517B
is a highly elastic sheet (e.g., made of polyurethane) which does
stretch significantly during inflation. In alternative embodiments
(to be described), anchor balloon 517 is replaced by another
balloon having nonuniform elasticity tailored for the particular
intended use in any of the ways discussed below (e.g., the anchor
balloon of the invention can comprise two large sheets of
relatively low elasticity as does the balloon of FIG. 23, with
relatively elastic insert sheets bonded to the large sheets as in
FIG. 23).
[0249] FIG. 15 is a perspective view of an alternative anchoring
subassembly for use in the FIG. 10 apparatus as a substitute for
the FIG. 13 subassembly. The FIG. 15 subassembly differs from that
of FIG. 13 only in that the former includes toroidal anchor balloon
519 mounted around cannula 505 while the latter includes
above-described anchor balloon 517 mounted around cannula 505.
Preferably, anchor balloon 519 of FIG. 15 is made of a thin, highly
elastic material such as polyurethane or silicon coated latex, and
has a mouth portion at which balloon 519 is mounted to cannula 505
(so that balloon 519 can be inflated or deflated using valve 510).
When inflated, balloon 519 functions to anchor cannula 505 to the
patient, but typically does not retract dissected tissue layers to
the degree that inflated balloon 517 would retract the same
layers.
[0250] We next describe preferred implementations of dissection
balloon 512 (and variations thereon) in more detail. FIGS. 16-18
show a first preferred embodiment of balloon 512.
[0251] In the embodiment of FIGS. 16-18, balloon 512 includes:
first and second sheets 513A and 513B attached together at seam
512C such as by RF (radio frequency) welding; and neck reinforcing
sheet 513C attached to sheet 513A (such as by RF welding) at neck
512A of balloon 512. Preferably, sheets 513A and 513B are
polyurethane sheets of 0.002 inch thickness (each having high
elasticity so that it stretches substantially during inflation) and
sheet 513C is made of material having low elasticity (e.g.,
polyester film, or a multilayer film commercially available from
Rexham comprising polyurethane and polyester layers) so that it
does not stretch significantly during inflation. This preferred
embodiment (with window 508 attached to its distal end), when
inflated, has the appearance shown in FIGS. 18C and 18D, where FIG.
18C is an elevational view of the distal end of the inflated
balloon and FIG. 18D is a side elevational view of the distal end
of the inflated balloon.
[0252] In an alternative embodiment, reinforcing sheet 513C is
omitted, sheet 513A is made of thin, highly elastic material such
as polyurethane or silicon coated latex (having high elasticity so
that it stretches substantially during inflation) and sheet 513B is
made of material (e.g., a multilayer film commercially available
from Rexham comprising polyurethane and polyester layers) having
low elasticity so that it does not stretch significantly during
inflation. This alternative embodiment (with window 508 attached to
its distal end), when inflated, has the appearance shown in FIGS.
18A and 18B, where FIG. 18A is an elevational view of the distal
end of the inflated balloon and FIG. 18B is a side elevational view
of the distal end of the inflated balloon. If both sheets 513A and
513B were inelastic, there would be relatively high localized
stress (and wrinkles) at seam 512C when balloon 512 were inflated.
By constructing balloon 512 from two sheets 513A and 513B having
substantially different elasticities in accordance with the
invention, puckering and wrinkling at seam 512C is reduced when
balloon 512 is inflated, and the balloon's inflation
characteristics can be tuned for desired results, including but not
limited to increased lateral dissection, reduced incidence of
epigastric (vein) stripping, and preferential, controlled
dissection.
[0253] With reference to FIG. 16, distal end portion 512E of
balloon 512 (opposite the neck 512A) is shaped to accept the end of
an obturator or endoscope for control and manipulation of the
balloon, and to receive a window 508 having a groove around a
generally cylindrical side wall (best shown in FIGS. 10, 11, and
14).
[0254] A preferred technique for manufacturing balloon 512 of FIG.
16 is to bond together sheets 513A and 513B with a weld (indicated
by the dashed line around the periphery of FIG. 16) of width X
around the sheets' peripheries, and then to bond sheets 513A and
513C together with a weld of width X around their peripheries.
Then, the weld is trimmed to a width Y (in FIG. 16), the trimmed
weld's outer periphery is the solid line around the periphery of
seam 512C. Then, end portion 512E is formed by cutting bonded
sheets 513A and 513B along line 512F (shown in FIG. 16). The latter
cut gives end portion 512E a cylindrical shape to which a suitable
window 508 (made of rigid material) can be glued.
[0255] The width W of balloon 512 of FIG. 16 is longer than the
length (the distance from line B-B to line 512F) of balloon 512, in
order to increase the lateral extent of the tissue layers dissected
by this balloon when it is inflated. In a typical implementation of
balloon 512 of FIG. 16, width W is 6.8 inches, length L of sheet
513C is 5.875 inches, width Z of reinforcing sheet 513C is 0.82
inch, width X of the original (untrimmed) weld around the periphery
of balloon 512 is 0.125 inch, and width Y of the trimmed weld
around the periphery of balloon 512 is 0.06 inch.
[0256] Each of FIGS. 19, 20, and 21 is a side elevational view of a
balloon window for attachment to the distal end of the inventive
dissection balloon, as window 508 is attached to the distal end of
balloon 512 of apparatus 600 of the embodiment of FIGS. 10-14. The
window shown in each of FIGS. 19-21 is preferably composed of
transparent, rigid material such as polished, clear polycarbonate
or acrylic material. The window of each of FIGS. 19-21 (and window
508 of FIGS. 10 and 14) functions mechanically to separate tissue
layers when pushed against the tissue layers by a rigid obturator
(or a rigid endoscope such as endoscope 515' of FIG. 14 whose
distal end 515A is pushed against window 508 as shown in FIG. 14).
In alternative embodiments, the window of the inventive balloon is
transparent and either rigid or non-rigid, but sufficiently strong
to retain a desired optical shape while (and after) being pushed
against tissue layers by a rigid obturator (or other rigid
instrument) deployed within the dissection balloon.
[0257] The window of each of FIGS. 19-21 has a circular groove 508A
around its generally cylindrical side wall, so that end portion
512E of dissection balloon 512 shown in FIG. 16 (or a corresponding
end portion of alternative embodiment of the inventive dissection
balloon) can be conveniently glued to groove 508A. Alternatively,
it can be stepped or formed in another fashion with a surface
conducive to gluing or mechanical fastening, and can have a hollow
base for accepting the distal end of an endoscope or obturator (as
does the window of FIGS. 21A and 21B to be discussed below).
[0258] The window of FIG. 19 is a wide angle lens, and each of its
front surface 508B and its rear surface 508C (shown in phantom view
in FIG. 19) has a curvature chosen to achieve desired wide angle
lens optical properties.
[0259] The window of FIG. 20 is a lens (but not a magnifying lens),
and each of its front surface 508D (having greater curvature than
surface 508B of FIG. 19) and its rear surface 508C (shown in
phantom view in FIG. 20) has a curvature chosen to achieve the
desired lens optical properties.
[0260] The window of FIG. 21 is a magnifying lens, having a flat
rear surface 508E (not a curved rear surface such as curved surface
508C of FIG. 20). Its front surface 508D has a curvature chosen to
achieve the desired lens optical properties.
[0261] The window of FIGS. 21A and 21B is a lens, which has a flat
rear optical surface 508F and a curved front optical surface 508G.
Surface 508G has a curvature chosen to achieve the desired lens
optical properties. The window of FIGS. 21A and 21B has a
cylindrical skirt 508H which extends in the proximal direction
(away from front surface 508G) from the periphery of surface 508F.
Skirt 508H has multiple functions: to provide a surface conducive
to gluing or mechanical fastening of a dissection balloon to the
window; and (after the balloon has been attached to the window) to
guide the distal end of an endoscope or obturator within the
balloon into engagement with surface 508F and allow for positive
control and manipulation of the balloon in response to movement of
the endoscope or obturator (without tearing the balloon).
[0262] As an alternative (or in addition) to employing a cup-shaped
window (such as the skirted window of FIGS. 21A and 21B), the
balloon itself is shaped so that when the window is attached to the
balloon's distal end, the balloon defines a channel that guides the
distal end of an endoscope or obturator within the balloon into
engagement with the window. Such a channel also allows for positive
control and manipulation of the balloon in response to movement of
the endoscope or obturator (without tearing the balloon). An
example of a dissection balloon having such a shape is dissection
balloon 912 of FIG. 21C, whose distal end portion 912A is tapered
to define a channel for receiving and capturing an obturator (or
endoscope) 515. When obturator (or endoscope) 515 is moved, the
force (e.g., frictional force) it exerts on distal end portion 912A
allows for positive control and manipulation of balloon 912 in
response to such movement.
[0263] The dissection balloon of the invention can have the
alternative shape shown in FIG. 22. Dissection balloon 512' of FIG.
22 is identical to dissection balloon 512 of FIG. 16 except in that
it has a circular cross-section (having radius R in the plane of
FIG. 22 as shown) rather than an oblong cross-section (as does
balloon 512 in the plane of FIG. 16). As shown in FIG. 22, balloon
512' includes rectangular neck reinforcing sheet 513C', but some
alternative versions of balloon 512' do not include such a neck
reinforcing sheet. The same materials can be used to manufacture
balloon 512' (and each variation on balloon 512') as are used to
manufacture each corresponding version of balloon 512. In a typical
implementation of balloon 512' including neck reinforcing sheet
513C' as shown in FIG. 22, radius R is 2.125 inches, width Z of the
neck reinforcing sheet is 0.82 inch, and length L of the neck
reinforcing sheet is 5.875 inches.
[0264] It is within the scope of the invention to employ a
dissection balloon (and/or an anchoring balloon) having nonuniform
elasticity selected to achieve desired inflated shape and pressure
characteristics. For example, dissection balloon 512 of FIG. 16 has
been described in an embodiment comprising one sheet of relatively
inelastic material bonded to another sheet of relatively elastic
material (with or without a third sheet of material for reinforcing
the balloon neck).
[0265] Numerous other implementations of dissection balloons
(and/or anchoring balloons) having nonuniform elasticity are
contemplated. For example, dissection balloon 712 of FIG. 23 has
nonuniform elasticity selected to achieve desired inflated shape
and pressure. Dissection balloon 712 includes a first large sheet
700 bonded (such as by RF-welding around the periphery of FIG. 23)
to a second large sheet (identical to sheet 700 but not visible in
FIG. 23). The two large sheets are made of material having low
elasticity (preferably a multilayer film-commercially available
from Rexham comprising polyurethane and polyester layers, but
alternatively a film of other material such as polyester). Two
disk-shaped sheets 704 of material having high elasticity
(preferably, polyurethane) are bonded to each large sheet. For
example, two disk-shaped sheets 704 are bonded (such as by
RF-welding) to sheet 700, each at annular weld region 702 as shown
in FIG. 23. Each disk-shaped sheet 704 bonded to large sheet 700 is
RF-welded to the corresponding disk-shaped sheet (the disk-shaped
sheet below it, and thus not visible in FIG. 23) at annular weld
region 708 shown in FIG. 23. Thus, when balloon 712 is inflated,
its inelastic large sheets do not stretch significantly, but the
elastic annular regions surrounding welds 708 do stretch
significantly (and thus function as elastic baffles). As a result,
balloon 712 has a very flat profile (in the sense that its inflated
height in a direction perpendicular to the plane of FIG. 23 is very
small relative to its maximum dimension in the plane of FIG. 23),
it can be inflated to a greater pressure (when compared to a
balloon made entirely of the inelastic material), and the stresses
at its welds are more evenly distributed (when compared to a
balloon made of two inelastic sheets bonded together at a single
long weld).
[0266] As another example, dissection balloon 812 of FIG. 24 has
nonuniform elasticity selected to achieve desired inflated shape
and pressure. Dissection balloon 812 consists of a first large
sheet 722 bonded (such as by RF-welding around the periphery of
FIG. 24) to a second large sheet (identical to sheet 722 but not
visible in FIG. 24), and a reinforcing sheet bonded to the central
portion of each large sheet. The two large sheets are made of
material having high elasticity (preferably, polyurethane) having a
first thickness. A reinforcing sheet 720 (which can be of the same
material and can have the same thickness as sheet 722) is bonded to
the central region of each large sheet (one such reinforcing sheet
720 is shown in FIG. 24 RF-welded to sheet 722 at weld regions
721). Unreinforced portions of sheet 722 are visible in FIG. 24 at
neck portion 812A of balloon 812 and at the lateral end regions of
balloon 812. Thus, in the FIG. 24 embodiment, at least part of neck
portion 812A and the lateral end regions of balloon 812 have
greater elasticity than the central portion to which sheet 720 is
bonded. So, when balloon 812 is inflated, it has an hourglass
profile (in the sense that its inflated lateral end portions
stretch substantially more than its reinforced center portion).
This structure is useful for certain tissue dissection applications
where it is desired to increase the lateral extent of the tissue
layers dissected.
[0267] In a variation on the FIG. 24 embodiment to be described
with reference to FIG. 24A, the dissection balloon also has
nonuniform elasticity selected to achieve desired inflated shape
and pressure. This dissection balloon consists of a six sheets
(three of which are shown in FIG. 24A, and the other three of which
are identical to those shown in FIG. 24A). The six sheets are
bonded together (such as by RF-welding). Four of the sheets are
lateral end sheets 722' made of material having high elasticity
(preferably, polyurethane). The two other sheets 720' are central
sheets made of material having lower elasticity (or lower heat
deflection temperature sensitivity) than sheets 722'. To construct
the balloon, two end sheets 722' are bonded to the lateral edges of
each central sheet 720' to make a composite sheet, one composite
sheet is placed on the other (with the peripheries of the two
composite sheets matched), and the two composite sheets are then
bonded together around their matched peripheries.
[0268] In another variation on the FIG. 24 embodiment, a dissection
balloon consists of two large sheets (having identical shape)
bonded together at their peripheries, but at least one of the
sheets (and preferably each of the sheets) has greater thickness
(and hence lower elasticity) at its central portion and lesser
thickness (and hence greater elasticity) at its lateral end
portions. For example, each large sheet is made of polyurethane,
its central portion has the same size and shape as does sheet 720
of FIG. 24 with 0.004 inch thickness, and its lateral end portions
have 0.002 inch thickness.
[0269] In other embodiments, the desired nonuniform elasticity of
the inventive balloon (either an anchoring balloon or a dissection
balloon) is achieved by any one (or combinations of two or more) of
the following:
[0270] 1. at least one portion of the balloon is a sheet having a
first thickness and at least one other portion is a sheet having a
second thickness different than the first thickness;
[0271] 2. at least one portion of the balloon is made of multilayer
material comprising a first number of layers and at least one other
portion is made of multilayer material comprising a second number
of layers, where the second number is different than the first
number (in such embodiments, all the layers typically have the same
thickness, but alternatively some of the layers are thicker than
others); and
[0272] 3. the balloon is made of materials whose elasticity varies
with temperature, and at least two different portions of the
balloon are made of different materials with different heat
deflection temperatures so that these portions have different
elasticities (e.g., because the elasticity of each material depends
on exposure to heat, and one portion of the balloon stretches more
than another portion when both portions are subjected to the same
temperature and pressure).
[0273] With reference again to FIGS. 10-14, the apparatus of FIGS.
10 and 14 is designed so that insufflation can be performed after
obturator 515 (or endoscope 515'), the dissection balloon assembly
(comprising balloon 512 and housing 513), and ring 514 have been
removed from the anchoring and tissue retraction assembly
(comprising elements 509, 503, 504, 505, and 517), and after valve
521 has been closed, balloon 517 has been inflated, and collar 504
and clamp 503 have been locked to anchor the tissue retraction
assembly to the patient. After removal of obturator 515, ring 514,
and the dissection balloon assembly, an endoscope (or other
instrument) can be inserted through the end port of housing 509
(thereby displacing flapper valve 521), and through cannula 505
into the working space within the patient (in order to view the
working space or perform some medical procedure therein). However,
alternative embodiments of the invention enable such a viewing
operation (or medical procedure) to be performed (unimpeded by the
dissection balloon) in other ways.
[0274] For example, the FIG. 25 embodiment enables such a viewing
operation (or medical procedure) to be performed in the following
manner. The FIG. 25 embodiment is intended to replace the
dissection balloon assembly of FIG. 11 (which comprises housing 513
and balloon 512). The FIG. 25 apparatus includes control lever 670
having two ports therethrough: cannula access port 672; and
dissection balloon access port 674. Control lever 670 is slidably
mounted between housing members 666 and 664. Mouth 512B of
dissection balloon 512 is attached around the circular rim of port
674, and balloon 512 is pulled through central channel 664A through
member 664 so that elongated neck 512A of balloon 512 extends
through channel 664A as shown in FIG. 25. Thus, when lever 670 is
moved to its upper position (shown in FIG. 25), with port 674
aligned with channel 664, an endoscope (or obturator) can be
inserted through central channel 666A of member 666, through port
674, into the interior of balloon 512 (such as during a tissue
dissection and tunneling operation).
[0275] To inflate the dissection balloon with the endoscope or
obturator in place as described, inflation gas is pumped through
port 631 (i.e., through an opened valve, not shown, in port 631)
into mouth 512B of the balloon. O-ring seal 675 between lever 670
and member 666, and O-ring seal 676 between lever 670 and member
664, prevent the inflation gas from escaping out from between
members 664 and 666. O-ring seal 678 mounted to lever 670 around
port 674 is compressed against the endoscope, thus preventing the
inflation gas from escaping out through channel 666A around the
endoscope. Thus, a tunneling operation can be viewed using the
endoscope (with imaging light entering the endoscope through a
window such as window 508 mounted at the distal end of balloon
512).
[0276] To implement a viewing operation or medical procedure (in a
manner unimpeded by dissection balloon 512, such as where it is not
desired to view through a window mounted at the balloon's distal
end), balloon 512 is deflated (the inflation gas escapes out
through the opened valve in port 631), the endoscope or obturator
is removed from within balloon 512 and port 674, and lever 670 is
then pushed down to align port 672 with aligned channels 664A and
666A. This translation of lever 670 causes lever 670 to move mouth
512B of the balloon downward, so that the portion of balloon neck
512A adjacent to mouth 512B moves against tapered section 665 of
member 664, away from the aligned longitudinal axes of channels
664A and 666A. In this configuration, an endoscope (or other
instrument) can be inserted though central channel 666A of member
666, through port 672, and through channel 664 (but not into the
interior of balloon 512) into the working space within the patient
(to enable viewing of the working space, or performance of a
medical procedure therein, in a manner unobstructed by the
dissection balloon).
[0277] As an alternative to implementing the FIG. 25 embodiment
(but with use of a long-necked dissection balloon deployed through
a cannula such as cannula 505 of FIG. 10, with a rigid window such
as window 508 of FIG. 10 attached to the balloon's distal end), it
may be desirable to attach the window to the distal end of the
dissection balloon non-permanently, such as by a tether or hinge
(e.g., a living hinge), rather than permanently (e.g., by glue).
Then, at the end of tunneling using the inflated balloon, the
balloon is deflated, the obturator or endoscope employed for
tunneling is removed from within the balloon, the non-permanently
attached window is moved away (e.g., rotated on its hinge, or
pushed away but retained on a tether) from the longitudinal axis of
the cannula. Then, a surgical instrument or endoscope can be
inserted through the cannula into the working space within the
patient in a manner unimpeded by the window but without removing
the balloon from the cannula. Where the window is tethered, it can
be pushed out the distal end of the cannula after tunneling (so as
to dangle on the tether in the balloon or between the dissected
tissue layers), or the tether can be pulled out through the
proximal end of the cannula (to remove the tethered window from the
working space within the patient).
[0278] Alternative embodiments of the invention employ an
alternative means (other than that embodied in the dissection
balloon assembly of FIG. 25 or that of FIG. 10) for mounting a
long-necked dissection balloon so that the balloon can be deployed
through a cannula during dissection, and then positioned (after
dissection) so as not to impede or obstruct viewing of a working
space or performance of a surgical procedure. For example, some
embodiments employ a mechanism to disconnect the mouth of the
deflated dissection balloon (after dissection) from a housing to
which the balloon mouth is attached during dissection. With the
balloon mouth so disconnected from the housing (but with the
deflated balloon remaining in the working space), an endoscope or
other instrument is inserted through the housing (without entering
the mouth or interior of the balloon) and into a working space
between the dissected tissue layers.
[0279] In other embodiments, the deflated dissection balloon is
pulled out of the cannula (through the cannula's proximal end)
after dissection. In one of these embodiments, the mouth of the
dissection balloon is attached to a sliding element in a housing
and the body of the balloon extends through a cannula attached to
the housing. The balloon is introduced into a patient and inflated
to perform tissue dissection. After dissection, the balloon is
deflated, inverted, and pulled back through the cannula. The
sliding element is then slid out of the way (e.g., away from the
cannula's central longitudinal axis) and an endoscope or other
instrument is inserted through the housing and the cannula (without
entering the mouth or interior of the balloon) into a working space
between the dissected tissue layers.
[0280] With reference to FIGS. 26-35, we next describe an
embodiment of the inventive method for using an apparatus (such as
that of FIGS. 10-14) having a long-necked dissection balloon
deployed through a cannula and having a window at its distal end.
For specificity, FIGS. 26-35 are described with reference to the
embodiment of FIGS. 10-14 which includes dissection balloon 512,
deployed through cannula 505, which has a rigid window 508 (which
can be a lens) mounted at its distal end, and which also has an
endoscope 515' deployed through cannula 505 and balloon 512 (with
the distal end of the endoscope abutting window 508). For the
purpose of illustration only, the method is described in the
context of separating the peritoneum from the properitoneal fascia
in the course of repairing a hernia. Variations on the described
embodiment (and in the apparatus employed to perform it) are useful
for performing other medical procedures throughout the body.
[0281] As shown in FIG. 26, an incision about 12-15 mm long is made
in the abdominal wall AW, and is carried through the abdominal wall
as far as, and including, the properitoneal fat layer FL. The
incision is made at the umbilicus U. The distal end of the
apparatus (i.e., window 508 and the distal portion of balloon 512
to which window 508 is attached) is lubricated and then inserted
into the incision to bring the distal end into contact with the
peritoneum. Additional gentle pressure is exerted on the proximal
end of endoscope 515', which presses window 508 against the
peritoneum, thereby detaching the part of the peritoneum in the
immediate vicinity of the incision from the overlying layer (as
shown in FIG. 27). In subsequent steps, the apparatus is advanced
along the posterior surface of the peritoneum (toward the right in
FIG. 26) until the distal end of the device is located at or near
the groin.
[0282] Alternatively, in any of the dissection steps of the method,
an obturator or other instrument (having substantially the same
shape as endoscope 515') can be substituted for endoscope 515'.
Such other instrument can be removed and replaced by an endoscope
at any time to enable viewing of the space within the dissected
tissue using the endoscope.
[0283] At any time, including during inflation of dissection
balloon 512 and during advancement of window 508 between layers of
tissue in the patient, the patient can be viewed by light that has
propagated through window 508 into endoscope 515'. To inflate
balloon 512, a source of a suitable inflation fluid (not shown, but
as previously described), is connected to port 531 which protrudes
from dissection balloon housing 513, and the flow of inflation
fluid is turned to inflate dissection balloon 512 at least
partially (as shown in FIG. 28). Balloon 512 expands between the
peritoneum P and the properitoneal fat layer FL and progressively
detaches an increasing area of the peritoneum from the overlying
tissue over the entire dissection area. When using the preferred
embodiment of the apparatus in which balloon 512 has an oval
profile when expanded (in the sense that its expanded width is much
greater than its expanded height), balloon 512 should be packed and
the apparatus deployed so that expanded balloon 512's largest
cross-sectional area is parallel to the tissue layers being
dissected (the largest cross-sectional area should be oriented in a
plane perpendicular to the plane of FIG. 28 to maximize the area of
the tissue dissection while minimizing trauma to the patient).
[0284] With reference to FIGS. 29-32, balloon 512 may be inflated
and deflated a number of times, rather than just once, to dissect
progressively the tissue layers. After inflating balloon 512 the
first time (thereby partially dissecting the tissue layers), the
inflation fluid in balloon 512 is vented and balloon 512 returns to
its collapsed state, as shown in FIG. 29. The peritoneum DP that
was separated by balloon 512 remains detached from the overlying
layer. The apparatus, including collapsed dissection balloon 512,
is then manipulated to advance the distal end (window 508) to the
limit of detached peritoneum DP in the direction of the groin, as
shown in FIG. 30. Endoscope 515' enables the position of the distal
end relative to the detached part of the peritoneum to be
observed.
[0285] Balloon 512 is then inflated again thereby increasing the
extent of the detached part of the peritoneum towards the groin, as
shown in FIG. 31. The extent of the detached part of the peritoneum
is increased in the direction from the umbilicus to the groin, but
is not significantly increased in the direction transverse to this
direction. Endoscope 515' is again used to observe the extent of
the separation (in the manner described above).
[0286] The "tunneling" process of collapsing dissection balloon
512, advancing the distal end of the apparatus to the limit of the
detached part of the peritoneum in the direction of the groin,
holding the distal end in position, and re-inflating the dissection
balloon, is repeated until the detached part of the peritoneum
includes the site of the hernia. Care should be exercised to avoid
dissecting tissue below the pubic bone, and to avoid forcing the
dissection balloon downward into the deep pelvis in a manner that
would cause trauma to the bladder.
[0287] Then, dissection balloon 512 is deflated (by removing
endoscope 515' from the proximal end of the apparatus while ring
514 remains in place to hold the flapper valve within housing 509
open). Then, the dissection balloon assembly (comprising housing
513 and deflated balloon 512) and ring 514 are removed from the
retraction and anchoring assembly of the apparatus, leaving the
retraction and anchoring assembly shown in FIG. 33 (with the
flapper valve within housing 509 closed as a result of removal of
ring 514). Then, a suitable source of inflation fluid is attached
to anchor balloon inflation valve 510, and anchor balloon 517 is
inflated, leaving the retraction and anchoring assembly in the
configuration shown in FIG. 33. When fully inflated, anchor balloon
517 should not be in direct contact with the bladder's surface.
[0288] Then clamp 503 is advanced along cannula 505 toward the
incision in the patient (preferably also, housing 509 is pulled
back away from the incision in the patient), and clamp 503 is
locked in a position along cannula 505 in which clamp 503
compresses foam collar 504 against the patient (as shown in FIG.
34). In this configuration, collar 504 helps to immobilize the
anchoring and retraction assembly (including housing 509 and
cannula 505) to the patient, and collar 504 applies a modest
compressive force to the tissue between clamp 503 and inflated
anchoring balloon 517, thereby helping balloon 517 form a seal to
limit the escape of insufflation gas from working space WS within
the patient out through tunnel T (between collar 504 and balloon
517 in the patient) during subsequent medical procedures. Inflated
anchor balloon 517 itself preferably provides a substantially
gas-tight seal with the entrance of the tunnel T. Of course, in
alternative embodiments, anchor balloon 519 (described with
reference to FIG. 15) is employed rather than anchor balloon 517
shown in various ones of FIGS. 26-35.
[0289] With reference to FIG. 35, the working space WS at the site
of the hernia is then insufflated if necessary, by providing
insufflation fluid (indicated by arrow F in FIG. 35) through valve
511 and cannula 505 into the working space WS. The hernia is then
repaired using a known procedure. During such procedure,
instruments can be removed from or inserted through the end port in
housing 509 and cannula 505 (and/or instruments can be introduced
into the working space through other incisions in the abdominal
wall of the patient). At the end of the procedure, the
extraperitoneal cavity can be quickly deflated by pressing button
511 to open the flapper valve within housing 509.
[0290] In other embodiments of the inventive method (also employing
a long-necked dissection balloon deployed through a cannula), after
dissection using the balloon, the balloon is deflated and retracted
before a repair operation is performed in a working space between
the dissected tissue layers. In alternative embodiments (also
employing a long-necked dissection balloon deployed through a
cannula), after dissection using the balloon, the balloon is
deflated but retained in the patient during performance of a repair
operation. In other embodiments employing a long-necked dissection
balloon deployed through a cannula, where the balloon has lobes or
other portions shaped so that instruments can be positioned between
them, the balloon remains inflated in the patient after tissue is
dissected using the balloon, instruments are then positioned
between the dissected tissue layers without being obstructed by the
inflated balloon (e.g., between lobes or other separated portions
of the inflated balloon), and the instruments are manipulated to
perform a repair operation.
[0291] FIGS. 36 and 37 show a preferred dissection balloon 901 for
use in the FIG. 10 apparatus (for dissecting the preperitoneal
space) as a substitute for balloon 512 of FIG. 10. When inflated,
balloon 901 has an oval profile, with an oblong cross-section (as
shown in FIG. 37) in the plane containing its longest dimension. It
is understood that the present invention may be practiced using a
dissection balloon of any of a wide variety of shapes (suitable for
deploying the balloon through a cannula) and that the shape of
balloon 901 in FIG. 37 is merely an example. For example, balloon
901 may be spherical, flat, kidney-shaped, cylindrical, or may have
any other shape suited for the particular dissection and/or
retraction contemplated.
[0292] Balloon 901 is preferably mounted to housing 513 (of the
type described with reference to FIGS. 11 and 12) as shown in FIGS.
36 and 37 but may alternatively be attached to any other housing.
Elongated neck 901A of balloon 901 has a circular cross-section
that can accommodate an endoscope.
[0293] As shown in FIG. 36, balloon 901 is formed from first sheet
913 and second sheet 915 (connected at seam 943) in a manner
described above with reference to FIGS. 16-18. Balloon 901 is
preferably made of the materials and fabricated in the manner
described above in connection with FIGS. 16-24, and can be elastic,
inelastic, or partially elastic and partially inelastic.
[0294] A preferred method of packing balloon 901 will be described
with reference to FIGS. 38-42. As shown in FIG. 38, first lateral
portion 917 of balloon 901 is initially displaced inwardly (i.e.,
pushed "inside-out" into the interior of the balloon). Although it
is preferred to displace first portion 917 in a direction
perpendicular to the longitudinal axis of the balloon's neck 901A,
first portion 917 can alternatively be displaced inwardly in any
other direction.
[0295] Inwardly-displaced portion 917 is then rolled up using a
rolling device 921 inserted through neck 901A. Referring to FIGS.
39 and 40, rolling device 921 includes two rolling rods 923 for
grasping first inwardly-displaced portion 917, when rods 923 are
disposed in the interior of the balloon. Each rod 923 has a
diameter of about 1/8 inch and rods 923 are separated by a gap of
preferably less than 1/16 inch. The gap size and diameter of the
rods 923 may vary, depending on the thickness of the balloon
material. Furthermore, the rolling device 921 may include any other
feature for grasping the inwardly displaced portion, such as a pair
of jaws, a clamp or a pair of elastically deformable arms. The
rolling device has a knurled handle 925 which is gripped to
manipulate it.
[0296] Rolling device 921 is rotated to roll the portion 917 as
shown in FIG. 41 into a roll 931 (shown in FIG. 42). After portion
917 has been rolled into a sufficiently compact roll 931, second
lateral portion 927 of balloon 901 (opposite first portion 917) is
displaced inwardly and rolled in the same manner as portion 917 to
form a roll 929 (shown in FIG. 42). An obturator (or endoscope) 935
is positioned through neck 901A of balloon 901 between rolls 929
and 931 to provide structural support for balloon 901 during
insertion into the patient. Rolls 929, 931 are positioned on
opposite sides of obturator (or endoscope) 935 with obturator (or
endoscope) 935 preferably including concave portions 938 for
receiving the rolls 929, 931. The two rolls 929, 931 (and the
portion of element 935 between them) are then encased within sheath
933, which is similar or identical to sheath 506 described above in
conjunction with the apparatus of FIGS. 10-14.
[0297] The compact, deflated, sheathed balloon 901 is introduced
into the patient between two tissue layers to be separated and is
then inflated. Balloon 901 may be used for dissecting and/or
retracting tissue planes throughout the body. Referring to FIG. 43
which shows balloon 901 during inflation in the peritoneum, the
inwardly-displaced portions evert during inflation so that
differential motion between balloon 901 and adjacent tissue layers
937 is minimized thereby reducing trauma to the tissue layers.
[0298] Although it is preferred to roll the first and second
inwardly-displaced portions into first and second rolls 929, 931
within the interior of balloon 901 (after pushing these portions
inside-out into the balloon's interior), balloon 901 may be packed
in any other manner so long as an inwardly-displaced portion is
provided which everts during inflation. For example, with reference
to FIGS. 44 and 45, inwardly-displaced portions 917, 927 can be
displaced to a side opposite the initial displacement and then
rolled into rolls 929, 931 as previously described.
[0299] First and second inwardly-displaced portions 917, 927 can
alternatively be rolled in a conventional manner from opposing
lateral sides after portion 917, 927 have been displaced inward as
shown in FIGS. 46 and 47. In this case, displaced first and second
portions 917, 927 divide balloon 901 into an upper part 939 and a
lower part 941. The upper part 939, first portion 917, and lower
part 941 are then rolled up in a conventional manner as shown in
FIG. 47. When balloon 901 is rolled in the manner shown in FIGS.
46-47, the balloon 901 will suffer the problem of relatively high
differential motion between balloon 901 and the adjacent tissue
layers during initial inflation and deployment, however, during the
end of the inflation, the balloon will have relatively low
differential motion relative to the tissue layers. This method of
packing a balloon is useful when problematic internal structures
are positioned laterally outward from the obturator. When the
balloon is formed from first and second sheets 913, 915, the upper
and lower parts 939, 941 are preferably formed by the first and
second sheets, respectively. By configuring balloon 901 in this
manner, the first and second portions include a part of seam 943
between the first and second sheets 913, 915. When coupling the
first and second sheets 913, 915 together with an RF weld, seam 943
forms a relatively thin, rigid periphery which can cut or otherwise
traumatize the tissue layers. Referring to FIG. 43, seam 943 everts
into a space 945 between the tissue layers along the lateral edges
of balloon 901 thereby minimizing contact between seam 943 and the
tissue layers.
[0300] A balloon 901' having a number of inwardly-displaced
portions in the form of accordion-folds 947 (when inflated) as
shown in FIG. 48 can be employed in place of balloon 901 of FIGS.
36-37. FIG. 48 also shows obturator (or endoscope) 935 within
balloon 901' (having been inserted through neck 902' of balloon
901'). FIG. 49 shows balloon 901' of FIG. 48 in a compact, deflated
state.
[0301] Although preferred balloon packing techniques have been
described, the invention can be practiced using other packing
techniques or combinations of features of the described techniques.
For example, a small roll may be formed in the manner shown in the
FIGS. 39 and 41 followed by the procedure described with reference
to FIG. 47.
[0302] FIG. 50A shows a simplified version of an apparatus 1000
according to the present invention. This apparatus 1000 comprises
an introducer tube or trocar 1 which may be similar to the
introducer tube 1 described in referenced application Ser. No.
07/911,714 and described herein with respect to FIGS. 1A-1B and
2A-2C. Trocar 1 includes a cannula 3 which has a rigid tube having
a bore with a circular cross section that can accommodate an
endoscope.
[0303] The proximal end of trocar 1 is preferably fitted with a
port 5, in the proximal end 7 of which is mounted a flapper valve
2. Shutter 6 of flapper valve is operated by button 9. Seat 4 of
the flapper valve additionally forms a gas-tight seal with an
endoscope or other instrument inserted though the flapper valve
into the bore of trocar 1. Port 5 is also fitted with a valve 11 to
which a supply of a suitable inflation fluid can be connected.
Naturally, trocar 1 may be provided with various other types of
seals and ports without diverging from the scope of the present
invention.
[0304] Attached to distal end 15 of the cannula 3 is a dissection
balloon 1512 preferably having the materials, features, and
construction of dissection balloon 512 of FIG. 10 (including any of
the implementations of balloon 512 discussed above, such as those
in which balloon 512 has nonuniform elasticity) but preferably
having a shorter neck 1512A than balloon 512 (see elongate neck
512A of FIG. 11). Balloon 1512 can be attached to the distal end 15
of cannula 3 by stretching neck 1512A over the distal end of the
trocar and held in place by friction resulting from the tension
caused by stretching. A suitable adhesive, such as an epoxy or
cyanoacrylate adhesive, may additionally or alternatively be used.
Other means of attaching the balloon to the inside or the outside
of the cannula can be used.
[0305] The balloon 1512 is preferably packed inside or around the
distal end of an obturator and covered with a sheath prior to
insertion of the balloon 1512 into the patient in a manner similar
to that described with respect to the embodiment of FIG. 10 (see
obturator 515 and sheath 506 described with respect to the
embodiment of FIG. 10; an obturator may be inserted through cannula
3 in a similar manner). Once the trocar is positioned within the
patient, an inflation medium is supplied to the balloon via the
valve 11 in the trocar 1. An endoscope may be inserted into the
balloon before inflation for observation through the lens, or
during and/or after inflation for viewing through the balloon wall,
to permit observation of balloon position and surrounding
tissue.
[0306] The apparatus 1000 is simpler than the previously described
embodiments in that it may be provided without a subassembly and
anchor balloon 517 such as those shown in FIG. 13. Moreover,
because the balloon 1512A is itself mounted on the trocar 1, rather
than on a narrower tube such as the cannula 505 which during use is
normally inserted into and withdrawn from the body through a
trocar, balloon 1512 can be a larger and bulkier balloon than
balloon 512 of FIGS. 10-12 will typically be.
[0307] From this example it should be apparent that the balloons
described herein may be delivered to an anatomical site within a
patient by a variety of cannulas or other means in addition to
those described with respect to the assembly of FIG. 10 and the
trocar 1 of FIG. 50A. For example, a balloon of the type described
herein may be attached to the distal end of a semi-rigid obturator
(designated 3A in FIG. 50B) for insertion into a patient's body, or
it may be attached to a flexible obturator (designated 3B in FIG.
50C) and contained within a rigid sheath 3C telescopically received
over the flexible obturator 3B and slidably withdrawn from the
balloon prior to inflation (FIG. 50C). As with the previously
described embodiments, an obturator having a cannula to which the
balloon 1512 is attached would preferably include a sealed port at
its proximal end through which instruments and inflation fluid may
be introduced for passage into the balloon. Moreover, although the
balloon 1512 shown in FIGS. 50A-50C is of the type having a lens
1508 (which can be identical to above-described lens 508, or any of
the above-described variations on lens 508), it should be
appreciated that the configuration of FIG. 50A, 50B, or 50C can be
used with any type of balloon, including those of various shapes
and sizes, those formed of various materials, and those provided
without viewing windows.
[0308] An alternative balloon packing technique is illustrated in
FIGS. 51A-51D. This technique is one which allows the balloon to be
packaged in a manner in which the overall length of the package is
decreased. Such a technique may be desirable for a number of
reasons.
[0309] For example, if a procedure is being carried out on a
smaller patient using a dissecting balloon which is packaged in a
manner which gives the packaged balloon substantial length, the
distal end of the balloon may reach its destination within the body
before essential features of the device (e.g., the anchor balloon
517 of FIG. 10) have passed into the fascia. Utilizing shorter
balloons in such instances is not necessarily desirable because
smaller balloons have less dissecting capacity than do larger
balloons and thus may not provide effective dissection.
[0310] Packing the balloon to have a shortened packaged length is
also advantageous in that it decreases the amount of packaging
materials needed for the device and it thereby reduces packaging
costs.
[0311] A new packing method according to the invention is one in
which the overall packaged length of the device is shortened by
packaging the device without including an obturator within the
packaged device. Referring to FIG. 51A, as with several of the
embodiments described above, dissection balloon 512 is provided
attached to a distal portion of a flexible or rigid tube such as
the cannula designated 3D (see, for example, trocar 1 of FIG. 50A,
or obturators 3A and 3B of FIGS. 50B and 50C, respectively). The
cannula 3D may be formed of a single piece of molded flexible
polymer having a port 11A for delivering inflation fluid to the
balloon and further having an integral self-sealing seal 2A. The
seal 2A permits passage of instruments (such as obturator 515B
shown in FIG. 51C) into the cannula and seals itself around such
instruments to prevent loss of inflation pressure.
[0312] Although the balloon 512 shown in the drawings is of the
type having a lens 508 as described above, it should be appreciated
that this packing technique may be used for any type of balloon,
including those of various shapes and sizes, those formed of
various materials, and those provided without viewing windows.
[0313] To pack the balloon 512 according to the present embodiment,
the balloon is flattened and then folded proximally against the
cannula 3D to the orientation shown in FIG. 51A (top view) and 51B
(side view), in a manner similar to that in which an umbrella
closes around its shaft. Next, the balloon 512 is folded into a
sheath such as sheath 506 described above with respect to the
embodiment of FIG. 10.
[0314] This packing technique differs from the techniques
previously described herein in that with those techniques the
balloon is folded tightly against an obturator (such as obturator
515 of FIG. 11) inserted through the balloon. In such embodiments,
if the obturator is removed prior to deployment of the balloon, a
"tunnel" remains within the packaged balloon and a laparoscope may
subsequently be inserted into the "tunnel" if desired. However, if
the apparatus is packaged and shipped without the obturator in
place, portions of the balloon will migrate into the tunnel during
shipping and will therefore impede insertion of a laparoscope
through the balloon prior to inflation.
[0315] When the balloon is folded over the flexible or rigid neck
or cannula as described above, the neck maintains a tunnel through
the folded and compressed balloon. This facilitates insertion of a
laparoscope or other instrument (such as an obturator) through the
tunnel and into the balloon to provide visualization and/or to
provide stiffness which facilitates insertion of the balloon into
the body cavity.
[0316] In the present embodiment, an obturator 515B may, but need
not, be positioned within the cannula 3D during packing. Referring
to FIG. 51C, when the apparatus is to be used for large patients an
obturator 515B may be advanced through the cannula 3D to push the
balloon 512 distally so as to increase the overall length of the
apparatus. Doing so helps the balloon 512 to reach the desired
depth within the patient for dissection.
[0317] It is contemplated that numerous modifications of and
variations on the disclosed embodiments can be made without
departing from the scope of the invention as defined by the
following claims.
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