U.S. patent application number 12/947784 was filed with the patent office on 2011-03-17 for procedural cannula and support system for surgical procedures.
Invention is credited to William L. Athas, Daniel W. Fifer, Richard A. Glenn, Geoffrey A. Orth, Aurora Pryor, Jeffrey A. Smith, Richard S. Stack, Michael S. Williams.
Application Number | 20110066173 12/947784 |
Document ID | / |
Family ID | 38515465 |
Filed Date | 2011-03-17 |
United States Patent
Application |
20110066173 |
Kind Code |
A1 |
Williams; Michael S. ; et
al. |
March 17, 2011 |
PROCEDURAL CANNULA AND SUPPORT SYSTEM FOR SURGICAL PROCEDURES
Abstract
A system for performing minimally invasive medical procedures
includes an elongate support advanceable into a body cavity. The
elongate support supports a frame that carries a pair of tool
cannulas, each of which has a lumen for receiving a tool useable to
perform a procedure in the body cavity. The frame is expandable to
orient the tool cannulas such that they allow the tools to be used
in concert to carry out a procedure at a common location in the
body cavity.
Inventors: |
Williams; Michael S.; (Santa
Rosa, CA) ; Stack; Richard S.; (Chapel Hill, NC)
; Orth; Geoffrey A.; (Sebastopol, CA) ; Smith;
Jeffrey A.; (Petaluma, CA) ; Glenn; Richard A.;
(Santa Rosa, CA) ; Fifer; Daniel W.; (Windsor,
CA) ; Athas; William L.; (Chapel Hill, NC) ;
Pryor; Aurora; (Durham, NC) |
Family ID: |
38515465 |
Appl. No.: |
12/947784 |
Filed: |
November 16, 2010 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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11789381 |
Apr 24, 2007 |
7833156 |
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12947784 |
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60794563 |
Apr 24, 2006 |
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60801113 |
May 17, 2006 |
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60801034 |
May 17, 2006 |
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60819235 |
Jul 7, 2006 |
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Current U.S.
Class: |
606/167 |
Current CPC
Class: |
A61B 1/00128 20130101;
A61B 2017/2905 20130101; A61B 2017/2906 20130101; A61B 1/00052
20130101; A61B 90/50 20160201; A61B 17/3403 20130101; A61B
2017/3447 20130101; A61B 2017/3445 20130101; A61B 17/3421 20130101;
A61B 1/018 20130101; A61B 2090/372 20160201; A61B 17/0218 20130101;
A61B 1/00135 20130101; A61B 2017/3486 20130101; A61B 2017/003
20130101; A61B 17/29 20130101; A61B 2017/00278 20130101; A61B
2017/3407 20130101 |
Class at
Publication: |
606/167 |
International
Class: |
A61B 17/32 20060101
A61B017/32 |
Claims
1. A natural orifice surgical system comprising: an elongate
support having a flexible position and a rigid position, the
support proportioned for insertion into a body cavity through a
natural orifice; an expandable frame supported by the elongate
support in the rigid system, the frame expandable to an expanded
position; and at least two tool cannulas coupled to the expandable
frame, each tool cannula having a lumen for receiving a tool for
performing a procedure within the body cavity, wherein the frame in
the expanded position positions the lumens to give tools positioned
in the cannulas access to a common operative site.
2. The system of claim 1, wherein the elongate support includes a
segmented spine formed of a plurality of spine elements coupled by
a cable, the support moveable from the flexible to the rigid
position upon application of tension to the cable.
3. The system of claim 1, wherein the elongate support includes a
lumen, and wherein the tool cannula extends through the lumen.
4. The system of claim 1, wherein the tool cannula includes a
plurality of pull wires coupled to a distal portion of the tool
cannula, the distal portion deflectable in response to application
of tension on at least one of the pull wires.
5. The system of claim 4, wherein the pull wires include proximal
ends coupled to a gimbal, the gimbal moveable in multiple
directions to apply tension to the pull wires.
6. The system of claim 5, wherein the gimbal includes a tool port
having an opening, wherein the gimbal is moveable by movement of
the tool port, and wherein the tool port is proported to receive a
distal end of a tool as the distal end of the tool is advanced into
the tool cannula.
7. The system of claim 6, wherein the tool port is moveable through
movement of a handle of a tool positioned within the tool port.
8. The system of claim 1, wherein the frame includes at least two
frame members, each frame member pivotally coupled to a tool
cannula.
9. The system of claim 1, further including an access cannula
insertable into a natural orifice and an anchor coupled to the
access cannula and expandable to retain the access cannula within
an incision formed within a wall of an internal body organ, the
access cannula having a lumen, the elongate support, frame and tool
cannulas insertable through the lumen of the access cannula when
the frame is in a collapsed position.
10. The system of claim 4, wherein the system further includes a
mount, and a pair of actuators on the mount, wherein the pullwires
of each tool cannula are coupled to one of the actuators.
11. The system of claim 10, wherein each actuator includes an
instrument port, such that a tool positioned in one of the tool
cannulas extends through a corresponding one of the instruments
ports, and wherein movement of a handle of a tool within the
instrument port actuates the pullwires.
12. The system of claim 10, wherein the mount is attachable to a
surgical table.
13. A method of performing a minimally invasive medical procedure,
comprising the steps of: advancing an elongate support in a
flexible state through a natural orifice and through an incision in
a body organ into a body cavity; converting the elongate support
from a flexible state to a rigid state; expanding a frame carried
by the elongate support within the body cavity, the frame having a
pair of tool cannulas coupled thereto; positioning medical tools
within the tool cannulas and performing a procedure within the body
cavity using the medical tools.
14. The method of claim 13, further including the step of
deflecting the distal portions of a tool cannula to alter the
position of the medical tool extending through the tool cannula
into the body cavity.
15. The method of claim 14, wherein deflecting the tool cannula
includes applying tension to a combination of pull wires coupled to
a distal portion of the tool cannula.
16. The method of claim 15, wherein a proximal portion of the tool
extends through a tool port, wherein the pull wires are coupled to
the tool port, and wherein deflecting the tool cannula includes
manipulating the proximal portion of the tool.
17. The method of claim 16, wherein the method includes adjusting
an amount by which tool cannula deflection is amplified relative to
corresponding movement of the tool.
18. The method of claim 14, further including the step of locking
the tool cannula in a deflected position.
19. The method of claim 18, further including the step of, with the
tool cannula in the deflected position, withdrawing the tool from
the tool cannula and inserting a second tool into the tool
cannula.
20. The method of claim 13, wherein the natural orifice is selected
from the group of natural orifices including the mouth, the vagina
and the rectum.
21. The method of claim 13, wherein in the rigid state the support
member assumes a curvature selected to orient the tool cannulas
towards a target site within the body cavity.
22. The method of claim 21, wherein the incision is in the stomach,
and wherein the curvature causes the support member to extend in
anterior and superior directions from the incision.
23. The method of claim 21, wherein the incision is in the stomach,
and wherein the curvature positions the tools in the tool cannulas
for access to a gall bladder within the body cavity.
24. The method of claim 13, wherein expansion of the frame orients
distal openings in the tool cannulas towards a target site within
the body.
Description
RELATED APPLICATIONS
[0001] This application is a continuation of U.S. application Ser.
No. 11/789,318, filed Apr. 24, 2007, now U.S. Pat. No. 7,883,156,
which claims the benefit of U.S. Provisional Application No.
60/794,563, filed Apr. 24, 2006, U.S. Provisional Application No.
60/801,113, filed May 17, 2006, U.S. Provisional Application No.
60/801,034, May 17, 2006, and U.S. Provisional Application No.
60/819,235, filed Jul. 7, 2006.
FIELD OF THE INVENTION
[0002] The present invention relates to the field of devices and
procedures for use in performing surgery in the peritoneal cavity
using access through a natural orifice.
BACKGROUND OF THE INVENTION
[0003] Surgery in the abdominal cavity is typically performed using
open surgical techniques or laparoscopic procedures. Each of these
procedures requires incisions through the skin and underlying
muscle and peritoneal tissue, and thus results in the potential for
post-surgical scarring and/or hernias.
[0004] Systems and techniques in which access to the abdominal
cavity is gained through a natural orifice are advantageous in that
incisions through the skin and underlying muscle and peritoneal
tissue may be avoided. Use of such systems can provide access to
the peritoneal cavity using an access device inserted into the
esophagus, stomach or intestine (via, for example, the mouth or
rectum). Instruments are then advanced through the access device
into the peritoneal cavity via an incision in the wall of the
esophagus, stomach or intestine. Other forms of natural orifice
access, such as vaginal access, may similarly be used.
BRIEF DESCRIPTION OF THE DRAWINGS
[0005] FIG. 1 is a perspective view of an access cannula anchored
in an incision in a stomach for use in a natural orifice
procedure.
[0006] FIG. 2A is a schematic side view showing the interior of an
abdominal cavity, and further showing use of a first embodiment of
a procedural cannula and support system.
[0007] FIG. 2B is a schematic top view (anterior view) showing the
interior of an abdominal cavity and further illustrating use of the
procedural cannula and support system of FIG. 2A.
[0008] FIG. 3 is a perspective view showing an alternative
procedural cannula and support system.
[0009] FIG. 4 is a perspective view of the spine of the system of
FIG. 3.
[0010] FIG. 5A is a perspective view illustrating two of the spine
elements of the spine of FIG. 4.
[0011] FIG. 5B is a perspective view of an alternative spine
element for use in the system of FIG. 3.
[0012] FIG. 6 is a perspective view showing the distal ends of the
tool cannulas and linkage of the system of FIG. 3.
[0013] FIG. 7 is a cross-section view taken along the plane
designated 7-7 in FIG. 6.
[0014] FIGS. 8A and 8B are a top perspective view and a bottom
perspective view, respectively, of a distal end of the system of
FIG. 3 using an additional tool cannula.
[0015] FIGS. 9 and 10 are perspective views of the system of FIG. 3
extending from an access cannula and including a retractor
extending from a longitudinal tool cannula.
[0016] FIG. 11A is a top perspective view showing an alternative
linkage assembly in combination with a spine, procedural cannulas,
and a central retractor.
[0017] FIGS. 11B and 11C are a top plan view and a side elevation
view of the linkage assembly of FIG. 11A. In FIG. 11C, the center
retractor is shown in a downwardly deflected position, and phantom
lines are shown to illustrate the retractor in an upwardly
deflected position.
[0018] FIG. 11D is a top plan view of the linkage assembly of FIG.
11A in the streamlined position.
[0019] FIG. 11E is a perspective view similar to FIG. 11E
illustrating exemplary movement patterns for the tool cannulas and
associated tools.
[0020] FIG. 12A is a perspective view of one embodiment of a user
interface for the system of FIG. 3.
[0021] FIG. 12B is a perspective view of an alternative user
interface for the system of FIG. 3.
[0022] FIGS. 13 and 14 are a perspective view and a cross-sectional
side view of a gimbal assembly.
[0023] FIGS. 15A and 15B are perspective views of the gimbal
assembly of FIG. 13 showing two exemplary locking mechanisms.
[0024] FIGS. 16A and 16B are perspective views of an alternative
gimbal system.
[0025] FIG. 17 is a perspective view of a third embodiment of a
procedural cannula and support system.
[0026] FIG. 18 is a detailed perspective view of the proximal end
of the system of FIG. 17.
[0027] FIG. 19 shows the gimbal system of the FIG. 17
embodiment.
[0028] FIG. 20 is an exploded view of the gimbal system of FIG.
19.
[0029] FIG. 21 is a plan view of the distal surface of the ball of
the gimbal system of FIG. 19.
[0030] FIG. 22 is a plan view of the proximal surface of the ball
of FIG. 21, with the cap removed and shown in perspective view.
[0031] FIG. 23 is a top view similar to FIG. 2B showing the system
of FIGS. 9 and 10 in use for surgery on a liver.
[0032] FIG. 24 schematically illustrates an abdominal cavity and
shows an alternative support system mounted to the interior wall of
the abdominal cavity.
DETAILED DESCRIPTION OF THE DRAWINGS
[0033] Applicant's prior Provisional Application No. U.S.
application Ser. No. 11/528,009, TRANSGASTRIC SURGICAL DEVICES AND
PROCEDURES, Filed Sep. 27, 2006 describes various embodiments of
surgical access cannulas for use in gaining access to the
peritoneal cavity of a patient via a natural orifice. When used for
transoral procedures, the distal end of an access cannula 10 (FIG.
1) is advanced orally through the esophagus and into the stomach or
intestine. Instruments are passed through the cannula and are used
to form an incision in the stomach or intestinal wall, giving
access to the peritoneal cavity. The access cannula 10 is anchored
in the incision using expandable anchors 12a, 12b positioned
against the inner and outer surfaces of the stomach wall.
Insufflation gas may be introduced into the peritoneal cavity via
the access cannula to create working space within the cavity. The
access cannula may include valves or seals that allow for sealed
access through the incision, permitting sterile passage of
instruments into the peritoneal cavity without loss of insufflation
pressure. The access cannula 10 may be a flexible tube formed of
polymeric material (e.g. polyurethane) having an embedded braid. In
other embodiments, a more rigid access cannula may be used. The
'009 application, which is incorporated herein by reference,
describes various additional components of access cannula systems,
including anchoring features, elements for forming incisions in an
interior body wall such as the stomach, and closure devices.
[0034] This application describes a procedural cannula and support
system ideally used in combination with an access cannula that has
been used to gain access to the peritoneal cavity. For example,
once access cannula 10 has been passed through the oral cavity and
stomach and secured within a stomach wall incision using anchors
12a, 12b, a procedural cannula and support system of the type
described herein is passed through the access cannula and into the
peritoneal cavity.
[0035] For certain procedures, it would be advantageous to allow
the surgeon to perform a natural orifice surgical procedure in a
manner that allows him/her to approach the surgical target within
the peritoneal cavity from the same direction from which s/he would
typically approach that same structure using a laparoscopic or open
surgical procedure. For example, if a particular procedure utilizes
an anterior approach to the treatment site when carried out using
laparoscopic or surgical techniques, it would also be desirable to
allow the surgeon to approach the treatment site from an anterior
perspective even when using a natural orifice technique. The system
illustrated in the attached drawings allows these same approaches
to be used using natural orifice access, thus allowing a surgeon to
easily and intuitively transition between natural orifice surgical
procedures and open or laparoscopic procedures.
[0036] In general, the disclosed embodiments include at least one
procedural or tool cannula through which instruments are passed to
the operative site. A support system provides rigid support for the
procedural cannula(s) within the body.
[0037] Referring to FIGS. 2A and 2B, one embodiment of a natural
orifice surgical system includes an instrument system 22 and a
support system 24. These figures schematically illustrate the
peritoneal cavity of a patient with the support system and
instrument system extending into the cavity from an incision (not
shown) through the stomach wall. In use, the support system 24
forms a sort of scaffold within the body to support the instrument
system 22 in a location that allows the surgeon to advance the
instruments of the instrument system using a desired approach.
Thus, for example, if performing a procedure that typically uses an
anterior approach when carried out surgically or laparoscopically,
the user might position the support system 24 adjacent the
abdominal wall W as shown in FIG. 2A.
[0038] Support system 24 includes an elongate shaft or spine 26
that extends from an incision in a body organ such as the stomach S
or other hollow organ (e.g. intestine, vagina) from which natural
orifice access has been gained as described above. In a preferred
embodiment, shaft 26 is disposed within an access cannula 10 which
may be of the type shown in FIG. 1. Shaft 26 is preferably one
capable of being sufficiently flexible for passage through the
natural orifice and body organ, and for manipulation within the
peritoneal space, but also capable of being placed in a
self-supporting rigid state once positioned at a desired location.
In one embodiment, shaft 26 is a shaft formed of a plurality of
spine elements 28 having tensioning cables that may be placed under
tension to stiffen the shaft 26. As will be discussed in greater
detail below, the spine elements are shaped such that the shaft 26
will assume a shape predetermined to give the curvature needed to
position the shaft 26 at the desired location. Shaft 26 may include
a lumen (not shown) or other features for supporting an endoscope
(not shown) oriented towards the treatment site.
[0039] Instrument system 22 includes one or more procedural
cannulas 30a, 30b, each having an opening 152 at or near its distal
end. Cannulas 30a, 30b may include a curved distal portion as
shown, and may additionally or alternatively be deflectable in
predetermined directions using pullwires, mandrels, or other
deflection mechanisms, including those known in the art for
deflecting catheters, introducers and guidewires.
[0040] Instruments 32 (e.g. forceps, endoscopes, suture devices,
staplers) are extendable through the procedural cannulas 30a, 30b
and into position at the target site in the peritoneal cavity. As
best shown in FIG. 2B, two procedural cannulas are useful in that
they allow for the simultaneous use of two instruments 32. The
procedural cannulas 30a, 30b may be passed into the peritoneal
cavity via the same access cannula 10 (FIG. 1) through which the
support shaft 26 extends, or they may be passed through one or more
separately placed access cannulas 10, or, as described in detail in
connection with FIG. 3, they may be passed through a lumen in the
shaft 26.
[0041] A coupling 34 couples the instrument system 22 and support
system 24. The coupling 24 may by any type of device that couples
the procedural cannulas 30a, 30b to the shaft 28. In the FIG. 2A-2B
embodiment, the coupling takes the form of a linkage 36 that allows
the cannulas to be suspended from the shaft 26 and also provides
the additional benefit of maintaining the orientation of the
cannulas 30a, 30b relative to one another. The linkage 36, which is
most visible in FIG. 2B, includes a first mount 38 on the shaft 26,
and second mounts 40a, 40b on the procedural cannulas 30a, 30b.
Linkage bars 42a, 42b are pivotally coupled to the mount 38 and the
mounts 40a, 40b. Second linkage bars 44a, 44b are pivotally coupled
to, the mounts 40a, 40b and a pivot point 46. As can be seen in
FIGS. 2A and 2B, the support system 24 positions the procedural
cannulas 30a, 30b so that access to the treatment site can be
gained using an approach that is familiar to the practitioner,
despite the fact that the instruments are inserted into the body
using a drastically different approach. Deflection features of the
cannulas 30a, 30b allow those cannulas to be manipulated so as to
position the instruments 32 where they are needed, without
requiring that the instruments include specialized features for
steering and deflection. The linkage 36 maintains the relative
orientation of the cannulas 30a, 30b towards the treatment
site.
[0042] FIG. 3 shows a second embodiment of a natural orifice
surgical system 100. System 100 includes a locking spine 102 and a
pair of tool cannulas 104. The system 100 is similar to the
embodiment of FIGS. 2A and 2B, but differs in that the tool
cannulas 104 pass through a lumen 105 in the shaft of the locking
spine 102 of the support system, allowing for a more streamlined
system that occupies a reduced amount of space. An endoscope 107
also extends through the spine 102, allowing the user to observe
the procedure being carried out at the distal end of the system.
Instruments 32 extend from the tool cannulas to the operative
sites. Instruments 32 may include forceps, retractors or any other
instruments needed to carry out the desired procedure within the
peritoneum.
[0043] The locking spine 102 is preferably passed into the body
through an access cannula 10 as described in connection with FIG. 1
and as shown in FIGS. 9 and 10.
[0044] Spine 102 is preferably one capable of being sufficiently
flexible for manipulation within the peritoneal space, but also
capable of being placed in a self-supporting rigid state once
positioned at a desired location. In one embodiment, spine 102 is a
shaft formed of a plurality of spine elements having tensioning
cables that may be placed under tension to stiffen the shaft. The
spine elements are shaped such that the spine will assume a shape
predetermined to give the curvature needed to position the distal
end of the spine at the desired location and oriented towards the
treatment site.
[0045] A detailed view of the locking spine 102 is shown in FIG. 4.
Referring to FIG. 4, locking spine 102 is formed of a plurality of
spine segments 106a, 106b threaded over a pair of cables (not shown
in FIG. 4) to form a flexible shaft. Each cable is coupled to a
locking handle 108 that is moveable to the locked position shown in
FIG. 4 to apply tension to the cables and to thereby rigidize the
spine 102. To release the spine to a flexible state, the handles
are moved in the direction of arrows A.
[0046] A plurality of the spine segments 106a are cylindrical
segments having end faces that are perpendicular to the axis of the
cylindrical segments. When a plurality of these cylindrical
segments 106a is strung over the cables, they form a relatively
straight spine section 110 when the handles 108 are locked. Others
of the spine segments 106b have angular end faces and are assembled
such that the chosen combination of angled segments 106b will give
the distal portion 112 of the spine 102 a predetermined bend
configuration when the spine 102 is locked as shown in FIG. 4.
[0047] FIG. 5A is a perspective view showing a pair of angled spine
segments 106b assembled together. Each spine segment includes a
central through hole 114 and a plurality of side through holes 116
surrounding the central through hole 114. Similar hole patterns may
also be included in the cylindrical segments 106a that form the
straight section of the spine. A variety of angled spine segments
with end faces of different angles make up the curved distal
portion of the spine. A group of spine segments with a
predetermined combination of angles are selected to produce an
overall shape for the spine that will support the associated tools
in an optimal position for the procedure to be carried out within
the body. In the FIG. 4 embodiment, spine segments are combined to
create a multi-dimensional bend as shown.
[0048] The spine segments 106a, 106b etc. are "strung" onto cables
118 by passing each of the cables through one of the side through
holes 116 in each of the spine segments. The side hole that is to
receive the cable 118 for a particular spine segment 106b is
selected based on the orientation in which the angled face of that
segment must be placed to give the spine 102 the correct curve at
that particular location on the spine 102. Thus, manufacturing
instructions might list out a sequence of angled segments, giving
for each segment the face angle that is to be used, as well as a
designation of which side holes 116 are to receive each cable for
that particular segment. An exemplary entry on the list might read
"segment #10, angle 15.degree., cable #1 through hole A, cable #2
through hole D".
[0049] The central through holes 114 of the spine segments 106a,
106b align to form the lumen 105 (FIG. 4) of the spine 102.
[0050] FIG. 5B shows an alternative spine segment 106c having a
concave end face 103a and a concave end face 103b, each of which
comes together in a nesting relationship with adjacently placed
spine segments. Slots 113 may be provided the concave face 103a for
receiving corresponding mating ribs (not shown) on the convex face,
allowing the segments to "key" together when assembled to minimize
rotational movement of segments relative to one another.
[0051] In the FIG. 5B embodiment, the central through hole 114c
includes a plurality of lobes 115a, 115b, 115c each sized and
positioned such that one or more instruments passed through the
through hole 114c can seat in a corresponding one of the lobes.
This helps to maintain the instruments in a stable position within
the elongate lumen of the spine formed by the assembly of the
segments 106c. In this embodiment, the holes 116c through which the
cables (not shown) are threaded are positioned in pairs as shown,
although alternate patterns will be equally suitable.
[0052] FIG. 6 is a perspective view of the distal end of the system
100 of FIG. 3, showing the distal ends of the tool cannulas 104. As
with the first embodiment, the system 100 includes features that
work in combination with the spine 102 to support and orient the
tool cannulas 104 as appropriate for a given procedure. A linkage
120 is pivotally connected to the cannulas 104 at pivot points 122
and couples the cannulas 104 to the supporting spine 102. Linkage
120 also provides structural support for the distal portions of the
tool cannulas 104 and maintains the relative orientation of the
cannulas 104. As with the first embodiment and as shown in FIG. 3,
the linkage 120 is attached to a pivot mount 124 on the distal
portion of the locking spine 102. Another of the pivot mounts 125
is coupled to a pull wire 127 that extends proximally through spine
102 to a location outside the body. In an alternative embodiment
shown in FIGS. 8A and 8B, pivot mount 125 may be coupled to the
distal portion of a third longitudinal tool cannula 104a extending
longitudinally from the spine 102, or to a similarly positioned
tool shaft. As another alternative, either or both of the pivot
mounts 124, 125 may extend into free space as shown in FIGS. 9 and
10 instead of being attached to the cannula 104a and/or spine
102.
[0053] The linkage 120 is positionable in a collapsed streamlined
position in which tool cannulas 104 are near the longitudinal axis
of the spine 102 for passage through the access cannula 10. Dashed
lines in FIG. 6 show the arrangement of the linkage 120 and pivot
mounts 122 when in the collapsed position. When in the streamlined
position, the pivot mounts 122 are positioned side by side, thus
orienting the tool cannulas 104 adjacent to one another. When in
the deployed position, the pivot mounts are positioned
approximately 3-7 inches apart, and more preferably approximately
4-6 inches apart.
[0054] Opening the linkage positions the cannulas 104 as shown in
FIGS. 3, 6 and 8A-10 and thus points the instruments 32 positioned
in the cannulas 104 generally towards an operative site. The
linkage 120 of FIG. 6 may be deployed to the open position by
withdrawing pullwire 127, whereas the FIGS. 8A, 8B embodiment can
be deployed by advancing the distal end of the longitudinal tool
cannula 104a in a distal direction to move the linkage 102 out of
the access cannula and/or to deploy the linkage to the expanded
position. In other embodiments, one or more of the pivot points
122, 124, 125 may be spring loaded to facilitate expansion of the
linkage 120. Any combination of these deployment mechanisms, or
others not specifically mentioned, may instead be used to deploy
the linkage 120 in the peritoneal cavity.
[0055] In another alternative shown in FIGS. 11A-11C, linkage 120a
includes a pair of members 130. Each member 130 is attached by a
corresponding one of the tool cannulas 104 by a first hinge 132 and
to a central retractor 104b (or, alternatively, to a longitudinal
tool cannula like cannula 104a of FIG. 8A) by a second hinge 134.
Hinges 132 may be mounted to corresponding collars 136 on the tool
cannulas 104, and hinge 134 may be on a similar collar 138 (FIG.
11B) on retractor 104b. When linkage 120a is in the collapsed
position, members 130 extend in a distal direction as shown in FIG.
11D. To deploy the linkage 120a, central retractor 104b is
withdrawn proximally, causing the members 130 to pivot at hinges
132, 134.
[0056] Referring to FIG. 11C, central retractor 104b includes a
proximal section 140 and a distal section 142. Proximal section 140
is formed of a number of segments 144 strung onto one or more
cables, with shorter segments 146 and an instrument tip 147 on the
distal section 142. Cables within the retractor 104b are arranged
such that the retractor becomes rigid when the cables are
tensioned, and such that distal section 142 will deflect when the
balance of tension within the cables is altered using controls
outside the body. For example, retractor 104b may be deflectable
towards and away from the body tissue as shown in FIG. 11C to allow
tissue to be lifted by the retractor so the tissue may be acted
upon by an instrument carried by one of the tool cannulas 104.
Additional pull cables (not shown) are operable to open and close
the jaws of the retractor tip 147.
[0057] In the disclosed embodiments, each tool cannula 104
preferably has a pre-shaped curve in its distal region. The curve
orients the cannula 104 such that when the linkage is opened,
instruments 32 (FIGS. 10A, 10B) passed through the central lumens
126 of the cannulas 104 can access a common treatment site. The
preformed shape may be set using any of a number of methods. For
example, the shaped region may have a segmented construction
similar to the segmented spine 102, with the individual segments
shaped to give the tool cannulas a shape that will orient the
cannulas as shown in FIGS. 3, 9 and 10 when the cables running
through the segments are tensioned. With this design, the entire
length of the cannula may be segmented, or the distal portion may
be formed of polymer tubing to allow flexibility. Alternatively,
cannulas 104 can be made of pre-curved tubing having rigidity
sufficient to prevent buckling during use. Reinforcing braid made
of stainless steel or other materials may be formed into the walls
of the tubing in the rigid section of the cannulas 104.
[0058] As with the FIG. 2A-2B embodiment, the distal end of each
tool cannula 104 further includes a region that is deflectable in
multiple directions to allow positioning and manipulation of the
operative ends of the instruments. This avoids the need for
sophisticated steerable surgical instruments. Instead, instruments
32 (FIG. 10) having flexible shafts are positioned in the tool
cannulas 104, and steering of the instruments is achieved by
deflecting the tool cannulas 104. Because the tools 32 are
flexible, it may be necessary to "stiffen" the shaft of the tool 32
to allow the tool to be successfully used. A slideable stiffening
cannula 33 (FIG. 10) may be advanced from within the tool cannula
104 over a portion of the shaft of the tool 32 to effectively
stiffen the tool's shaft during the procedure, thus allowing the
tool to be pressed into contact with body tissue without buckling.
Other internal structures such as stiffening mandrels, reinforcing
collars or braids, may instead be used for this purpose.
[0059] In a preferred embodiment, deflection of the tool cannulas
104 is performed using a pullwire system. Referring to FIG. 7,
pullwires 128 extend through corresponding pullwire lumens 130,
preferably spaced at intervals of 90.degree.. The distal ends of
the pullwires are anchored in the distal sections of the cannula
104 such that the distal section of the cannula can be made to
deflect in a desired direction by pulling on the desired
combination of pullwires. FIG. 11E illustrates in dashed lines V1 a
conical volumes defined by an exemplary movement pattern for the
tool cannula 104, and the corresponding volume V2 defined by the
tool 32 within the cannula 104.
[0060] Actuation of the pullwires is achieved using features that
during use are positioned outside the body. A deflection system is
provided that allows the user to intuitively actuate the pullwires
for a particular one of the tool cannulas 104 by manipulating the
handle 152 of the instrument 32 that resides within that tool
cannula. For example, if the user wishes to have the distal end of
a tool move in a downward direction, s/he will intuitively raise
the handle 152 of that tool to cause the corresponding tool cannula
to deflect downwardly, thus moving the tool to the desired
position.
[0061] Referring to FIG. 3, the proximal ends of the pullwires 128
extend from the proximal ends of the cannulas 104 and feed into a
corresponding deflection system, which in the illustrated
embodiments is a control gimbal 148.
[0062] The gimbal 148 may be mounted to a work stand 150 as shown
in FIG. 12A. In use the work stand 150 may be set on top of the
patient's torso or mounted to supports coupled to one or both
side-rails of the surgical table, or carried on a cart. In either
case, the work stand 150 is positioned to give the surgeon
convenient and intuitive access to the handles 152 while s/he
observes the procedure on an endoscopic display (not shown). As
shown in FIG. 12B, use of the system may be facilitated by
providing a "cockpit" for the user, coupling an endoscopic display
154 to the work stand 150 that supports the control gimbals 148, as
well as the proximal controls for the endoscope 107, and other
ports 111 for passing instruments through the access cannula to the
peritoneal space.
[0063] The work stand 150 is proportioned to allow the surgeon to
position his or herself in a comfortable position with his/her
hands on the handles 153 of the tools 32. The work stand 150
preferably positions the tool handles 153 approximately 10-15
inches apart.
[0064] A preferred control gimbal 148 is shown in FIG. 13. It
includes a base 168 mounted to the work stand (not shown in FIG. 7)
and having a tubular channel 170. A c-shaped mount 172 is connected
to the base 168 and includes a through hole 174 continuous with the
lumen of the tubular end piece 170. In a slight modification, the
hole 174 might be accompanied by four separate through holes 174a-d
might be used for receiving pull wires as in the FIG. 19
embodiment. A ring 176 is pivotally mounted to the mount 172 at
pivot bearings 178. A semi-spherical ball 180 is pivotally mounted
within the ring at pivots 182. Four pull-wire ports 184 extend from
the interior of the ball 180 to its outer surface.
[0065] Instrument port 186 includes side channels 190 having distal
openings 192 and proximal openings 194. The four pullwires 128 from
the tool cannulas 104 extend through the tubular end piece 170 and
each passes through hole 174, through the hollow interior of the
ball 180, and out corresponding ones of the pull-wire ports 184 in
the ball. The pullwires further extend into the instrument port
side channels 190 and are secured there by anchors 196.
[0066] Instrument port 186 has a lumen 188 extending proximally
from the spherical ball 180. The shaft 152 of an instrument 32 (see
FIG. 12A, not shown in FIGS. 13-14) extends through the lumen 188
and the ball 180, through hole 174 in the c-shaped mount 172, and
via tube 170 and the work stand 150 (FIG. 12A), into the
corresponding tool cannula 104. The operative end of the instrument
32 extends from the distal end of the tool cannula 104.
[0067] When it becomes necessary for the surgeon to change the
orientation of the distal end of an instrument 32, s/he need only
intuitively move the handle 152 of that instrument and the distal
portion of the instrument will deflect accordingly as a result of
the action of the gimbal on the pullwires of the tool cannula.
Vertical movement of the handle 152 will cause the ball 180 to
rotate relative to pivots 182, thus applying tension to the upper
or lower pullwire 128 to cause upward or downward deflection of the
tool cannula 104 (and thus the distal end of the instrument 32).
Lateral movement of the handle 152 will cause the ball 180 and ring
176 to rotate about pivots 178 and to therefore tension one of the
side pullwires to change the lateral bend of the tool cannula 104.
The control gimbal allows combinations of vertical and lateral
deflection, giving 360.degree. deflection as shown in FIG. 11E.
Thus user may additionally advance/retract the tool 32
longitudinally within the tool cannula 104, and/or axially rotate
the tool 32 relative to the tool cannula when required.
[0068] The control gimbal 148 includes a locking mechanism that
allows an instrument orientation to be temporarily fixed until
further deflection is needed. This feature allows a user to fix a
trajectory for multiple instruments that are to be sequentially
used at a particular location. For example, once the orientation of
a tool cannula 104 is set, a certain step in the procedure may be
performed using a first instrument passed through that cannula.
When a subsequent step requiring a different instrument is to be
performed, the instruments are exchanged without moving the tool
cannula 104. This allows the second instrument to be advanced to
the exact location at which it is needed without additional
steering.
[0069] One exemplary locking mechanism includes a pair of locking
screws 198 that are tightened as shown by arrows in FIG. 15A to
lock the C-mount 172 to the ring 176 and to lock the ring 176 and
the ball 180. Alternatively, as shown in FIG. 15B, a simple
pneumatic shaft lock 200 could be employed on each of the gimbal's
pivot axes. A solenoid or similar device might be used in place of
the pneumatic lock 200.
[0070] An alternate gimbal arrangement is shown in FIGS. 16A and
16B. As shown, a cone shaped instrument port 202 is mounted to the
proximal end of each cannula, and includes a diaphragm seal 204
having a slit 206 sealable around an instrument shaft 208 passed
into the instrument port 202. In FIGS. 16A and 16B only the handle
of instrument shall 208 is shown to permit easier viewing of the
surrounding features.
[0071] A gimbal 210 includes a collar 212 mounted on the instrument
port 202 and four wings 214 radiating from the collar 212. Each
pullwire 128 is coupled to one of the wings 214. Struts 216 extend
proximally from the wings 214 and are joined to a sleeve 218
through which a portion of the instrument shaft 208 extends. Collar
212 is moveable relative to the instrument port 202, and in
particular collar 212 is rotatable about its central axis, and
pivotable in multiple directions. Movement of the collar 212 places
one or more of the pullwires 128 under tension and results in
deflection of the cannula 104. Since the instrument shaft 208 is
coupled to the collar 212 by struts 216, a user can manipulate the
instrument shall 208 handle in an intuitive manner similar to a
joystick to allow the user to steer the distal end of the cannula
104 in the desired direction.
[0072] FIG. 17 illustrates an alternative natural orifice surgical
system 300. System 300 includes features that are largely similar
to those described elsewhere. For example, the system 300 uses the
linkage 120a of FIG. 11A, and a gimbal system similar to that
described in connection with FIG. 13. The system 300 differs from
the earlier embodiments in that it allows a user to adjust the
sensitivity of the gimbals. In other words, the gimbal can be fine
tuned such that the amount of deflection of the tool cannulas
corresponds directly to the amount by which the user moves the tool
handles 152 within the gimbal system, or the amount of deflection
can be greater than or less than the corresponding movement of the
tool handles.
[0073] Referring to FIG. 19, many of the features of the gimbal 302
are similar to those of gimbal 148 of FIGS. 12 and 13. These
similar features include base 168, which is coupled to frame 304.
Four through-holes 174a-d (three of which are visible in FIG. 19),
one for each pull wire, extend from c-shaped mount 172 through base
168. The pullwires feed into the through-holes 174a-d from cable
housings 175 that pass through the frame 304. The more distal
segments of the pullwires extend from the from the frame 304 into
the tool cannulas 104 extending distally from the frame 304.
[0074] A ring 176 is pivotally mounted to mount 172 at pivots 178,
and semi-spherical ball 180 is pivotally mounted within the ring
176 at pivots 182.
[0075] The gimbal 302 of FIG. 19 differs from the gimbal 148 of
FIGS. 12-13 in its inclusion of a microadjustment assembly 306. As
with the prior gimbal arrangements, the four pullwires of one of
the tool cannulas terminate in the gimbal at 90 degree quadrants.
Motion of the instrument shaft 152 (FIG. 17) alters the tension on
the various pullwires, which causes deflection of the tool cannula
tip and corresponding movement of the tool within the tool cannula.
The effect lever arm of each pull wire is altered in the FIG. 19
embodiment by moving the point of termination of each pull wire
towards or away from the gimbal's center of rotation. Moving the
pullwire terminations away from the center of rotation causes
movement of the tool cannula 104 to be amplified relative to the
movement of the tool handle 152, whereas moving the pullwire
terminations towards the center of rotation decreases the
amplification.
[0076] Ball 180 includes a distal surface 314 as shown in FIG. 21A,
and a planar proximal surface 316 as shown in FIG. 20. Four radial
slots 318a-d extend through between the surfaces 314, 316.
Referring to FIG. 20, four sliding terminal plates 308a-d, each
including a pullwire terminal 310a-d and a proximally-extending
follower pin 312a-d, are positioned in contact with the planar
proximal surface 316. A peg 317 on the distal side of each terminal
plate is received in the corresponding one of the slots 318a-d.
[0077] Each pullwire used to deflect the tool cannula extends
through one of the slots 318a-d and is anchored within a terminal
310a-d of one of the four sliding terminals 308a-d. FIG. 21A shows
the distal facing side 314 of the ball 180, with the terminals
310a-d positioned over the slots 318a-d. The pull wires themselves
are not shown.
[0078] A tubular instrument port 320 is centrally positioned on the
proximal surface 316 of the ball 180. A retainer cap 322 covers the
surface 316, such that the instrument port 320 extends through a
central opening 324 in the retainer cap. The sliding terminal
plates 308a-d are sandwiched between the surface 316 and the
retainer cap 322. FIG. 22 shows the cap 322 removed from the ball
180. The inner, distal facing, surface of the cap 322 includes a
spiral rib 326 defining a spiral shaped slot 328. Each of the
follower pins 312a-d of the terminal plates 308a-d are disposed
within the spiral slot 328.
[0079] A retaining ring 330 is engaged with the instrument port 320
and functions to hold the cap 322, terminal plates 308a-d, and ball
180 together such that the follower pins 312a-d remain within the
spiral slot 328. Cap is rotatable in clockwise and counterclockwise
directions relative to the instrument port 320. Rotation of the cap
will increase or decrease the sensitivity of the gimbal system.
More specifically, if the cap is rotated in a first direction, the
spiral rib 326 will cause the pins 312a-d to advance through the
spiral slot towards the outer circumference of the cap, causing the
terminal plates to slide radially outwardly within slots, thereby
increasing the sensitivity of the gimbal system. If the cap is
rotated in a second direction, the pins will advance through the
spiral slot toward the center of the cap, causing the terminal
plates to slide radially inwardly within the slots so as to loosen
the tension on the pullwires and to decrease the sensitivity of the
gimbal, system. Markings 328 on the cap 322 and a corresponding
pointer 330 instruct the user as to the level of sensitivity
achieved when the cap is in one of the designated rotational
positions relative to the pointer 330.
[0080] In alternative configurations for adjusting gimbal
sensitivity, the user may have the option to set different
sensitivity levels for different ones of the pull wires.
[0081] The system is preferably packed in a kit containing
instructions for use instructing the user to use the system in the
manner disclosed herein.
[0082] FIG. 23 schematically illustrates use of the system of FIGS.
9 and 10 as used such as for a cholecystectomy procedure. According
to such a procedure, the access cannula 10 is placed transorally
and moved into the peritoneal cavity via a left anterior stomach
wall puncture. The access cannula 10 is anchored in a stomach
incision as described above. The locking spine 102 is introduced
into the peritoneal space and made rigid (via application of
tension on the cables as described above) such that it is oriented
towards the procedural site as shown. The liver retractor 35a is
used to lift and retract the liver superiorly away from the
gallbladder and the operational area of the instruments 32.
Instruments 32 are advanced through the tool cannulas and used to
perform the procedure. Tool cannulas 104 are deflected as needed to
manipulate the instruments. Whereas prior art laparoscopic
procedures involve formation of three surgical ports or incision X
(tool port), Y (endoscope port), Z (tool port) to perform the
cholecystectomy procedure, use of the disclosed system allows the
procedure to be performed less invasively while allowing the
surgeon to carry out the procedure from the same familiar
perspective from which s/he would have performed the laparoscopic
procedure.
[0083] The embodiments disclosed above utilize locking spine
devices in natural orifice procedures to locate tools at or near
the abdominal walls such that the tools may be manipulated in a way
that is intuitive to the surgeon given his/her experience with
laparoscopic and/or open surgical techniques. Other systems that
achieve this objective without the use of a locking spine are also
useable and fall within the scope of this disclosure. One example
is shown in FIG. 24 in which a system 400 may be attached to the
interior of the abdominal wall using a screw 402, t-bar 404,
inflatable balloon anchor, expandable braid, or similar device
embedded in the facial layer of the stomach wall W. According to
this embodiment, the system 400 includes features that support a
procedural cannula 406 introduced into the peritoneal space via a
natural orifice as described above. In the example shown, the
procedural cannula 406 is passed through or engaged with a guide
ring 408 that helps to orient the distal end 410 of the procedural
cannula 406, and thus tools 412 passed through the procedural
cannula 406, towards the treatment site. As another alternative
embodiment, the system may use magnetism to support, retain and/or
locate tools at the desired vantage point, such as near the inside
of the abdominal wall. This embodiment might use cannulas having
magnetic features within the body, and an external electromagnetic
outside the body. Alternatively, the embodiment might employ a
steel/iron plate outside the body and magnetic cannulas that are
attracted to the steel/iron plate.
[0084] While certain embodiments have been described above, it
should be understood that these embodiments are presented by way of
example, and not limitation. While these systems provide convenient
embodiments for carrying out this function, there are many other
instruments or systems varying in form or detail that may
alternatively be used within the scope of the present invention.
This is especially true in light of technology and terms within the
relevant art(s) that may be later developed. Moreover, the
disclosed embodiments may be combined with one another in varying
ways to produce additional embodiments.
[0085] Any and all patents, patent applications and printed
publications referred to above are incorporated by reference,
including those relied upon for purposes of priority.
* * * * *