JP2000505315A - Tissue separation cannula with incision probe and method - Google Patents

Abstract

SUMMARY A cannula (100) is a tubular body (102) having a proximal end (104) and a blunt distal end (106), at least one lumen extending the length of the body (102). 108), an endoscope (110) having a lit, viewing end (112) located within a lumen (109) near a distal end (106) of the body (102), and a distal end of the body. A tissue separation tip (122) substantially covering the portion. The tissue separation tip (122) is slightly dulled to prevent detachment of tissue and lateral vessels along the incised cavity formed thereby. Endoscopic viewing through the tip is enhanced by tapering its inner wall against the cusp (120) adjacent to the blunt tip to reduce visual distortion. Alternatively, the cannula includes an incision probe (907) and an endoscope (110) to view connective tissue along the incisable cavity and facilitate the incision.

Description

DETAILED DESCRIPTION OF THE INVENTION               Tissue separation cannula with incision probe and method                                 Background of the Invention 1. Related application   This is Albert K. "TISSUE SEPARATION" filed by Chin on July 13, 1995  In a continuation-in-part application of pending application number 08 / 502,494 entitled "CANNULA AND METHOD" Yes, this subject is Albert K. "CANNULA A, filed April 12, 1995 by Chin Application number entitled `` SSEMBLY AND METHOD FOR PROGRESSIVELY DISSECTING TISSUE '' 08 / 421,481, and these earlier applications are assigned to the same assignee as the present application. Assigned. 2. Field of the invention   The present invention generally forms elongated cavities in the tissue plane, especially along the path of small vessels. The tissue separation cannula used for Has a tapered shape and is selectively removed to facilitate incision of tissue adjacent to blood vessels Endoscope for continuous visualization of blunt dissection sites through possible tissue separation members With a cannula. 3. Description of the background art   The current method for the formation of an elongated cavity is through body tissue to achieve a tissue incision Including the use of a dull probe that is pushed down. Actuated by the passage of a mechanical probe Forces may lead to detachment of blood vessels and damage to tissue and internal organs.   The problem is that when cutting and harvesting vessels with small diameters of about 3 to 8 mm, Become big. The technique used for dissection of larger vessels such as the aorta is The aorta is located in the retroperitoneal cavity, separated on one side by the peritoneum and on the other side by the abdomen Not applicable because it is separated by streaks. In the subrenal space located just below the kidney The abduction balloon placed in the inflator accommodates the length of the aorta along the natural cleavage plane when inflated. Will track easily.   The everted type of balloon encounters difficulty when dissecting tissue adjacent to smaller vessels Treat This is because small vessels and small blood vessels, when compared to the aorta and the tissue surrounding the aorta, Due to the presence of less distinct planes between them and the tissue surrounding the vessels. For example, if the abduction balloon is placed adjacent to the saphenous vein in the leg, The incision is oblique during inflation, rather than usually following along the vein. This is a cover Due to the amorphous nature of the fat and connective tissue surrounding the veins.   Abduction balloon catheters are known for use in dilating arteries (eg, See, for example, U.S. Pat. No. 4,479,497 (Fogarty et al., Oct. 30/84) and U.S. Pat. No. 4,863,440. (Chin, 9/5/89)).   Dual lumen abduction balloons such as those disclosed in the Fogarty et al. '497 and Chin' 440 patents The catheter has a through lumen for slidingly receiving an endoscope. While these An endoscope for use with the disclosed catheter is one in which the endoscope is mounted on an abduction balloon. The incision process cannot be monitored because it is in the central lumen close to the part . As the balloon abducts from the catheter, the internal inflation pressure forces the balloon wall Squeeze and close the hyperopic channel. Also, areas requiring monitoring during balloon incision It is located at the forward front of the abducting balloon. This area causes tissue separation Corresponds to the balloon / tissue interface that receives the force. Thus the surviving two The lumen, the endoscope in the central lumen of the abduction balloon catheter, has a double layer of balloon membrane Located between the endoscope and the tissue, blocking the endoscopic line of sight, the area of tissue separation Can not see.   Endoscopes are disclosed in U.S. Pat. No. 5,385,572 (Nobles et al., Jan. 31/95) and EP0642764A1 (S auer et al., published on 3/15/95) for use in optical trocars and US For use in collecting blood vessels, as in No. 5,373,840 (Knighton, 12/20/94) It is disclosed. No. bles et al. '572 patent and Sauer et al.' 764 patent application are trocars Use of a sharp-tipped metal cutting element extending outwardly from an endoscope located within the tool Is disclosed. The incision control is based on the visualization of the tube, the cutting element and the endoscope This is difficult because the collapse of the tissue plane into the area between Further The danger of lateral tube detachment or damage to the tube is greater due to the configuration of the outwardly extending cutting element. Is increased to   The endoscope disclosed in Knighton '840 collects the blood vessels to be collected and the blood to be collected. Lateral dimensions large enough to accommodate at least one tool used to Have. However, the endoscope cannot expand the cavity adjacent to the blood vessel. Obscuring the operation of the incision area and the tube therein. In the tissue incision area Relevant viewing image location obscure side tube identification leading to increased risk of tube separation To Since the tubes are collected through the center of the endoscope, all side tubes are advanced by the endoscope The length of the recovered tube must be substantially the same as the length of the endoscope. Limited by the length of the dee.   Vessel for penetrating body tissue as disclosed in US Pat. No. 5,271,370 (Riek et al.) Is penetrated by the tip using an optical unit located behind the tip tip Equipped with a transparent material tapered tip for viewing the textured tissue. This type of instrument It may include a separate illumination channel ending in the tip to illuminate the tissue to be penetrated.                                 Summary of the Invention   The present invention relates to an elongated cavity within a human or animal body, particularly in tissue along the path of a vessel. Provide a cannula for blunt dissection. Cannula closed end of base And at least one tube having a blunt end and extending the length of the body Includes a tubular body having a cavity. The cannula is also in the lumen near the end of the body Includes an endoscope with a lit, lit viewing end and a transparent, tissue separating section Material, i.e., a blunt tip, which substantially covers the end of the body and is selected therefrom. It can be removed selectively. Tissue separating member or blunt tip placed at end of body Has a sharp tip to reduce visual distortion through an endoscope that is optically aligned with the tip Includes an inclined inner wall.   Method for blunt dissection of an elongated cavity using a cannula, especially along the path of a vessel Are also disclosed. The method involves making a blunt incision in the first cavity; Advance the cannula along the cavity; at least the cavity has a balloon in it Repeat the preceding steps of separating the tissue until it is long enough to advance; The balloon is continuously inflated within the cavity to expand the cavity along the vessel path, Shrinking; Following the incision in the cavity along the vessel, a paired incision At the distal end of the cavity, for example, place a second blunt tip balloon trocar This is done to allow the introduction of tools. Cannula tip body through paired incision The cannula body in the cavity where the tapered tip was opened. And removed. The endoscope resides within the body of the cannula, and the endoscope and crab The body of the ure is in an incised cavity to isolate and facilitate the collection of blood vessels Part is selectively located as a single unit. The method requires an additional cannula Except for the following, a balloon cannula is used to seal the slit in the elongated cavity against gas leakage. Maintaining with insufflated gas passing through, or structural balloon, or incision Including the use of a mechanical structural support within the created cavity.   In another embodiment of the invention, the method comprises blunt dissection of the first cavity; sealing the cavity And inflate; and continuous visual observation under inflation until the cavity is fully extended Assisting in separating the tissue along the cavity.   Isolated vessels, such as saphenous veins, are harvested and coronary or peripheral vascular bypass Femoral popliteal artery or femur removed or used in situ for transplantation It may be left in place as an arterial end graft. Lateral branching of the vein is a consequence of both applications. Ligated, clipped, or occluded. Intravenous valve for in situ transplantation Is shut off by means of a valve dissector.                             BRIEF DESCRIPTION OF THE FIGURES   FIG. 1 illustrates the contours of a tissue separation member attached thereto relative to that of the cannula of the present invention. FIG.   FIG. 2 has a straight tapered section suitable for use with the cannula of the present invention. FIG. 9 is an isolated cross-sectional view of another embodiment of a tissue separation member having a blunt spherical tip; is there;   FIG. 3 also shows a bent tapered section suitable for use with the cannula of the present invention. FIG. 6 is an isolated cross-sectional view of another embodiment of a tissue separation member having a blunt tip. The   FIG. 4 shows a tissue having a hemispherical shape suitable for use with the cannula of the present invention. FIG. 4 is a cross-sectional view of another embodiment of the separating member;   FIG. 5 is a flow chart of one embodiment of a tissue separation method using a cannula of the present invention. Is   FIG. 6 is a flowchart of another embodiment of the tissue separation method;   FIG. 7 is a partial side of a patient's leg advancing the flexible cannula of the present invention through a cut; It is a view;   8A and 8B show a removable blunt tip located at the distal end of the cannula. FIG. 4 is a partial cross-sectional side view illustrating an alternative embodiment;   9A and 9B show the assembled and disassembled, respectively, of another alternative embodiment of the present invention. Pictorial side view showing the arranged arrangement;   FIG. 10 is a cross-sectional view of the cannula of FIGS. 9A and 9B;   FIGS. 11A, 11B and 11C are shown with the cannula shown in FIGS. 9A and 9B, respectively. FIG. 7 is a side and cross-sectional view of an alternative incision probe that may be used for;   11D and 11E show an incision in orbital position around the body of the cannula. Figure 5 is an end view of the probe;   12A, 12B and 12C are simplified anatomical side sectional views of the human body, respectively. And an anterior metaphor;   FIGS. 13A and 13B respectively show a retraction of another embodiment of the tissue separation cannula of the present invention. Figure 2 is a side view illustrating a collapsed and extended arrangement;   FIG. 14 shows a viewing, multiplexing for use in the method of the present invention. A pictorial section of a clip applier;   FIG. 15 is a flowchart of the arterial isolation procedure according to the present invention;   FIG. 16 is a flow chart illustrating the procedure in which the cannula of FIGS. 9A and 9B was included. Is a   FIG. 17 is a flow diagram illustrating the procedure in which the cannula of FIGS. 13A and 13B was included. It is a chart.                             Description of the preferred embodiment   According to one embodiment of the invention, the cannula has a closed end at the base and a distal end. Tubular body having a blunt end, at least one lumen extending the length of the body With a brightened, viewing end located within the lumen near the distal end of the body Substantially covers the distal end of the endoscope and body and can be selectively removed from the distal end A functional transparent tissue separating member. The present invention also provides for tissue separation using such a cannula. Form an elongated cavity along the path of a small vessel apart, and then harvest the vessel Or using a blood vessel as an in situ transplant.   FIG. 1 shows one embodiment of a cannula 100 of the present invention. Cannula 100 based A tubular body 102 having a distal end 104 and a distal end 106 is included. At least Another lumen 108 extends the length of body 102. Body inside lumen 108 Endoscope 110 having a viewing end 112 illuminated near the distal end 106 of the scanner Is arranged. The other end of the cannula is a base end cover 114 and an elastic washer 116 to provide a pressurized, sliding fit with the endoscope 110.   The cannula 100 may also include a transparent, tissue component substantially covering the distal end 106 of the body. Includes a release member or blunt tip 118. The tissue separating member 118 has a tapered section 120. Having a blunt, distal end 10 of the tubular body toward the tissue separation tip 122. Bent away from 6. The shape of the tissue separating member 118 may be a traumatic incision in the cavity. Opening, with sufficient control and maneuverability, should prevent tearing or perforation of nearby blood vessels. To do so. Typically, tip 122 is about 0. 30 "to about. 100 ", Preferably about 0. It has an outer radius of curvature of 45 ". The tapered section 120 of the tip The length is about. 500 "long. The tapered shape and dullness of the tissue separation member 118 The tip thus bends the bifurcated vessels to the side of the cannula 100, peeling them off Without the cannula 100 being advanced forward, the cannula can be passed through the incised tissue. Reducing the need for an axial force applied to advance the tip and tip Tolerate.   In a taper of uniform wall thickness with a rounded inner surface near the apex, less distortion A circular spot is centered in the field of view of the endoscope, equal to the diameter of the rounded tapered tip. It was found to be present. This distortion has a sharp point, an internal contour ending at the vertex Forming a transparent taper, while the outer contour is approximately. A rounded tip with a 045 "radius Is substantially removed by holding it as a loop. Undistorted vision through such a tip Visual imaging thus allows the surgeon to follow the blood vessels, identify lateral branches, and To guide the installation past the side branches. About 0. Optimal taper of 5 " The flap facilitates maneuvering of the cannula around the lateral branch and provides a preferred tapered tip arrangement. The arrangement is illustrated in FIGS. 8A and 8B.   An alternative embodiment of the invention provides the necessary control and atraumatic incision Including other shapes for the tissue separating member 118. Figure 2 shows the distal end of the cannula Other than a tissue separating member 218 that substantially covers and provides a transparent covering to the endoscope 110. 1 is illustrated. The tissue separating member 218 is located at the tip of the tissue separating member. , Including a tapered section 220 integrally formed with a duller, spherical section 224.   FIG. 3 substantially covers the distal end 106 of the cannula and is transparent to the endoscope 110. FIG. 19 illustrates another embodiment of a tissue separation member 318 that provides a good shielding. Tissue separation material 318 is a dull section at the tip end 322 to form a very dull-bill shape. Includes a bent tapered portion 320 integrally formed with the minute portion 324. Bent tip Subsection 320 may have a concave or convex shape.   FIG. 4 shows the distal end 106 of the cannula substantially covered and transparent to the endoscope 110. 15 illustrates another embodiment of a tissue separation member 418 that provides shielding. Tissue separation member 4 18 has a hemispherical shape 424 that covers the distal end 106.   Preferably, the tissue separating members 118, 218 are about 0.5 mm. 5 inches total length and total Around the surface about 0. Have a uniform wall thickness of 06 inches, if wall sections are thickened Endoscope without any image distortion that would otherwise occur if a lens were formed Allows mirror visualization. The wall thickness of the tissue separation member may be enlarged or otherwise A distorted, e.g. asymmetric, fisheye image or the like is transmitted by the endoscope For special applications that require a lens to be contoured to form a lens. Can be A tissue separating member, a suitable material for making a blunt tip, separates the tissue. Polycarbonate strong enough for separation and transparent enough to allow visualization with the endoscope Carbonates and optional materials. 8A, 8B, 9A and 9B. As such, the tissue separating member, i.e., the blunt tip, may be selectively removed during a procedure described herein below. Attached to the cannula with a thread or bayonet-type torsion lock for removal Can be   Referring again to FIG. 1, the cannula 100 is preferably the outer wall 126 of the cannula. It includes a balloon 124 located on the upper distal end 106. Balloon 124 is elastic Or it may be inelastic, but it can achieve a smaller, smoother outer contour Are preferred. Sufficient expansion (as indicated by phantom lines in FIGS. 1, 8A and 8B) When done, the diameter of balloon 124 is about 3 cm. Preferably, balloon 124 Of the balloon is secured to the outer wall 126 of the cannula. 29 and both the base end 130.   Balloon 124 is opposed to a pressurized flow, such as a gas or liquid, through another lumen 132. The body is cannulated from the inflation hole 134 to the proximal and distal ends 129, 130 of the balloon. It is selectively expanded by feeding into holes 136 in the outer wall 126 of the tray. manual A plunger device, such as a syringe, controls inflation of balloon 124 through inflation hole 134. Suitable for connection to control. The lumen 132 has a body as another tubular body 138. And is formed concentrically with the body, forming a space 140 between the two bodies. . Another embodiment suitable for the present invention includes two lumens 108 arranged side by side, 132 may be included. Additional lumens are similarly added to fill and fill in a known manner. Other functions such as inspiration can be provided.   The present invention is illustrated using a sleeve-type balloon for the cannula 100. other Balloon types include, but are not limited to, located in a separate lumen within the cannula. Such as to help separate tissue when inflated using a rollable balloon Are suitable for use in the present invention.   The cannula 100 can be any of a variety of biologically inert, substantially inelastic materials, such as stainless steel. Stainless steel, polyethylene, polyurethane, polyvinyl chloride, polyimide plastic Manufactured from those having a tensile strength of preferably at least 10,000 psi, such as Can be Preferably, each lumen of cannula 100 is about 0.5 mm. 005 inches and 0. 0 It has a wall thickness of between 10 inches.   The endoscope 110 is about 5. 0 mm outer diameter, and one endoscope has a cannula 10 0 or permanently arranged in a conventional manner as shown in FIG. 8A. Advanced through the endoscope lumen 108 through the gas-tight seal 805 It can also be a separate device. The endoscope 110 places the tip in the lumen 108 at the correct position. And the transparent blunting of surrounding tissue and blood vessels outside the cannula 100 Allows unobstructed visualization through hard tips. About 5. Good with 0mm tube diameter A good endoscope 110 is Solos Endoscopy, Inc. of Norcross, Georgia. Commercially available from Possible, but 1. 00 to 1. Other commercially available endoscopes 110 as small as 75 mm Can also be used.   The method of blunt dissection of an elongated cavity using the cannula of the present invention is shown in FIGS. Shown in the flow diagram. A blunt incision in the elongated cavity along the vascular pathway is specifically described However, the present invention is generally suitable for separating any tissue. For example, crab Heure traces along the median nerve from the incision in the patient's arm, It can be used to create a cavity for surgical treatment. The cannula is the median nerve Visualization and tracking, if blind advancement of the balloon cannula was used Prevent and tolerate possible nerve damage. Otherwise, the cannula of the present invention Also cut the cavity adjacent to the mammary artery in the manner described below. Can be used to open.   The method illustrated in the flow diagram of FIG. 5 cuts the skin and selects the selected vessels or vessels. Includes a blunt dissection 501 through the subcutaneous tissue to the level of the nerve. dull An incision is made to separate the vessel from adjacent tissue to a length of about 1-2 cm . The blunt incision is made with a pair of bent Metzenbaum scissors and the tip of the scissors Is used to cut and blunt the tissue in the plane between the blood vessel and adjacent tissue Can be accomplished.   Preferably, a blunt tip balloon cannula is placed between the blood vessel and the overlying tissue. Is introduced into the space. The balloon is then inflated to seal 502 the incision. Form a tight seal. A gas such as carbon dioxide is located far from the balloon It is blown under pressure through another lumen in a cannula having an open external opening. blood The natural perivascular plane around the vessel is expanded by the injected gas and Form a path along. For superficial vessels such as the saphenous vein, the dilated pathway is Be visible. The interior of the extended path is not cleanly open, but rather connected Including Gotsummer-like strands of tissue and fat, preventing unhindered visualization and This makes it difficult for the endoscope to pass along a route adjacent to the blood vessel. If a traditional endoscope If it is pushed in with the intention of forming a cavity adjacent to the blood vessel in the connective tissue For example, the view through a conventional endoscope is due to the tissue in contact with the viewing end of the conventional endoscope. Cloudy. Cloudy view through conventional endoscope is dull perivascular tunnel Increases the possibility for lateral branch dissection during incision.   The cannula 100 is inserted 503 into this incised space. Optical fiber With the endoscope 110 continuously visualizing the blood vessel path, the cannula 100 is moved forward. Vessels in the plane created by blunt dissection, separated by 504 proceeding to (Probe) between and the adjacent perivascular tissue. Transparent tissue separation unit The material 118 allows the endoscope 110 to have a blood vessel section at least comparable to the length of the tapered section 120. Segment is clearly visible.   If a blunt dissection along the vessel path is sufficient to advance balloon 124 therein If not, the method cannulates forward to continue separating tissue along the vascular path. The process returns to step 504 for proceeding with step 505. A sufficiently long cavity cannula 10 0, the balloon 124 is sequentially inflated and deflated 506 and has a diameter of approximately Dilate the cavity to 3 cm.   The method includes the steps of separating the tissue by advancing the cannula 504 as described above. Return to step 506 to selectively inflate and deflate tip and balloon 124 5 07. Subsequent application of these steps creates a cavity along the entire length of the vessel You. Once the elongated cavity is completed, cannula 100 is completely pulled out of the elongated cavity. 508 to be put.   The elongated cavity site is then held 509 in an expanded form by the method of the present invention. . Following the use of a cannula to form an elongated cavity along the path of the blood vessel, The part is to be performed on a vessel, Must be supported to allow such procedures. Dull tip trocar entrance Seals cuts and allows gas injection to keep the cavity in an expanded shape Can be used for One blunt tip balloon toro suitable for use here Carl currently has Mento Park, CA's Origin Medsystems, Inc. It is commercially available from   Another method of holding the cavity in its expanded configuration is to cut the distal extension of the incised cavity. Creating an eye and including inserting the double rod system through the cavity. Double lock The lock is suspended via a laparoscopic mechanical lifting device to hold the cavity. This cis The system allows the instrument to be advanced into the cavity through a simple cut and As is the case, no trocar with gas seal valve is required.   Otherwise, a balloon with an inflatable structure or a cavity in which a mechanical structure is incised Can be used to support For example, the cavity may be mechanically retracted or powered up Mechanical finger-like retractor attached to the arm, plus the side wall of the cavity Can be held by a separate flat balloon retractor used to position . The endoscope 110 is a finger-like retractor leg that couples to a mechanical lifting arm. Can be introduced behind.   Blood vessels are shaped using laparoscopic instruments such as graspers, scissors, hooks and blunt probes. A complete incision is made in the created cavity. The lateral branch to the vessel is tied using sutures. Ligated, clipped using a titanium vascular clip and cauterized using an electric scalpel Or a combination thereof. The dissected blood vessel is removed from the cavity and moved. Used for potential use as a conduit to the pulse bypass process, or the blood vessels It can be left in place to be used as a field bypass graft.   In an alternative embodiment, the method of the present invention provides a small diameter cavity of about 7 mm, with the cavity being Form along the entire length of the vessel before it is dilated. As shown in FIG. Making an incision 501; sealing and inflating the incision 502; To insert 503 the cannula 100 and advance 504 the cannula 100 The step of sequentially separating the tissues is performed as described above. However Alternatively, until the entire length of the elongated cavity is bluntly cut to a small diameter of about 7mm Continue 504 with advancement of the incision cannula.   Only after the entire length of the elongated cavity has been dulled is the alternative method narrowed. The cannula balloon 12 is used to increase the diameter of the distal end of the long cavity to about 3 cm. 4 inflating and deflating 506. The incision cannula 100 is next 508 is retracted partially 508 about the length of the balloon 124. The alternative is balloon Return 510 to step 506 to expand and contract 124. Cannula 100 Again partly retracted 508, the method returns 510 to repeat the above steps. Of an inflated balloon 124 having an overall elongated cavity length of typically about 3 cm. To be expanded to a diameter.   An alternative method involves making a cut in the blood vessel. From tissue adjacent to blood vessels A blunt dissection is performed with a length of 3-4 cm. Dull tip trocar cuts It is placed and gas injection is started.   The cannula 100 is inserted through a blunt tip trocar and the balloon 12 A blunt dissection using 4 is performed in the presence of gas blowing in the cavity. This technology uses gas Since the insufflation is used from the beginning of the blunt dissection, it is useful for visualization during tissue separation. Provides a larger cavity. At the same time, a trocar gas seal with a dull tip is required. Required. If a vascular incision without gas insufflation is performed, then double rod If a system is used to hold the cavity, use a trocar with a blunt tip. Use can be avoided.   Another method of the present invention forms a smaller diameter cavity along the entire length of a blood vessel. You. The cavity was created by the initial inflation at the blunt dissection site. Only expanded. As shown in FIG. 6, a blunt dissection 601 is performed. Sealing and inflating 602, inserting the cannula 100 603, and Steps of serially separating tissue by advancing 604 cannula 100 Is performed as described above. The cannula is incised with the entire length of the elongated cavity dull Forward 60 until inflated only by the inflation gas of preceding step 602 4. The cannula 100 is then fully retracted 605 from the elongated cavity. Incision The light is held 606 in the expanded shape as described above.   The present invention includes a particularly useful method for harvesting veins. In one method, An eye is made near the ankle and the cannula is placed along the saphenous vein to or near the knee Until it passes. Following balloon inflation to expand this segment, A cut is made in the widened cavity near its end point at the knee. Cut at knee The eye is approximately the midpoint of the saphenous vein between the ankle and the groin. The veins are isolated, The lateral branch is extended within the segment between the ankle and the knee and takes this segment. Remove and remove.   The segment from the knee to the groin is sampled next. Is the cannula the lower leg Through the same knee incision used to harvest the veins, or A separate cut into the vein can be made slightly above the knee. The use of separate cuts If the vein is excessively bent or kinked as it passes around the knee Can be useful. The cannula is advanced towards the groin and the balloon Inflated to widen, cuts are made in the widened cavity at its groin, A portion of the saphenous vein present in the thigh is collected.   As an alternative method for saphenous vein harvesting, an initial cut can be made in the knee . From the same cut, the cannula should be moved in both directions, towards the ankle and towards the groin Gradually Next is passed. Next, additional cuts are made at the ankle and at the groin, Allow sampling of the entire length of the vein. Veins can be removed as a single strand Or cut at the knee and removed as two strands.   In some anatomical areas, follow a rigid, straight tissue separator along the vascular path Can be difficult to advance. For example, and referring to FIG. 7, if saphenous vein 7 00 is cut through the cannula 702 from a cut 712 just above the ankle. If taken, the presence of the middle ankle 704 and the foot 706 is otherwise hard Prevents the neura from being bent upwards or into the shunt to follow the vein 700 obtain.   For such impeded situations, cannula 702 may be flexible or similar. Or rigid with a predetermined progressive arc as shown in FIG. It can be formed of a body. Inserted into cannula 702 up to tissue separation member 710 The endoscope 708 is also configured to form a flexible body within the bent cannula. Must be flexible to assist. Such conventional flexible optical fiber endoscope Is commercially available for use in gastrointestinal endoscopes.   In another embodiment of the method and apparatus illustrated in FIGS. 8A and 8B, The tapered and transparent tip 803 of the cannula 800 can be removed from the cannula body. Can be mounted as possible. At the cannulation site, a blunt tip balloon Carl (eg, Origin Medsystems, Inc. Such as those commercially available from Seals the stitch and allows blowing into the space to be incised by cannula 800 The cannula can be used to introduce a blunt tip trocar along the vessel path. Through. The balloon over the cannula is selected to cut through the perivascular space. Is selectively expanded. Following the incision in the cavity along the vessel, the reverse cut is a second blunt chisel. Place a balloon trocar on the distal end of the cavity to allow introduction of the lancing device. Made at the end. Advance the cannula tip out of the body through the reverse cut The tapered tip 803 is removed and the body of the cannula is cut open. Leave in. The endoscope resides inside the cannula body and the endoscope / cannula body Is advanced as a single unit inside the working cavity to isolate and collect blood vessels You.   Removable tip 803 is located between the tip and the distal end of the cannula body. It can be attached to cannula body 800 using a threaded connection, or Since the yonet-type mating locks the tip onto the cannula, the slot in the tip Can be used in engagement with a pin on the end of the cannula body.   The cannula of this embodiment with a removable tip 803 is shown in FIG. 5 used with a cannula as compared to the cannula embodiment described above. An endoscope with a diameter of mm is often placed along the incised working cavity for unobstructed visualization. Has the advantage of not having sufficient rigidity to allow it to be directed You. For example, the curvature of the calf muscle in the lower leg can be visualized along the surgical cavity The endoscope should bend to allow the muscle tissue to look down into the cavity hole. Must. Endoscope bending about 45cm long and about 5mm diameter is a successful visualization May interfere. The cannula surrounding the endoscope according to the invention has an outer diameter of 8 mm. Having this larger diameter provides stiffness to the endoscope / cannula system . The cannula body may be constructed of stainless steel for additional rigidity.   The ability to remove the tapered tip 803 through a cut at the opposite end of the cavity This results in a reduction in the number of passages that increase or decrease the length of the cavity of the neura and endoscope. this is The number of passes of the full length required through the incised cavity, adding the convenience of the process Reducing the likelihood of vascular injury.   9A and 9B, another embodiment of the cannula 900 of the present invention. Is shown in a retracted and disassembled configuration. In particular, the outer bore of the cannula 900 The dee has a body at its base and distal end as shown in FIGS. 8A and 8B. 10 includes a sleeve-shaped balloon 901 fixed to the As shown, selective inflation via lumen 1010 within the body in communication therewith For.   At the distal end of the body of the cannula 900, remove the clear, blunt tip. 903 is shown retracted over the distal end of the cannula body in FIG. 9A. 9B, mounted on push rod 906 and at the end of cannula body 900. FIG. Endoscope viewing end 905 and crescent shaped incision probe extended beyond end end 907 is shown exposed. Probe 907 is mounted on shaft 909, Inside It facilitates the selective operation of the incision probe 907 within the field of view of the endoscope 905. In FIG. As shown, the push rod 906 is non-circular in the mating non-circular conduit, which Dull to be selectively extended and retracted with respect to the distal end of Rebody-900 The chips 83 are held in alignment in the axial direction. Also, as shown in FIG. The shaft 909 for supporting the valve 907 is circular or cylindrical, and has a cannula body. Dissection probe 9 via a corresponding operation of the shaft on the proximal end of 07 is promoted both in the vertical and rotational directions. Must be For example, shafts 906 and 909 may fit along the outer surface of cannula body 900. A heat-shrinkable PET plastic or other material that exists in a slot having a proper cross-sectional shape With a sheath of bio-inert plastic from the cannula body 900 Hold the shafts 906, 909 in a trapped configuration along.   The incision probe 907 has its anterior and posterior edges and the Facilitates selective dissection of connective tissue strands and lateral branch vessels along veins or other vessels Lengthen. The blunt tip 903 thus selectively exceeds the cannula body 903 Extended (or cannula 900 retracted with respect to tip 903). A selected location along the incised cavity adjacent to the vessel from which lobe 907 is to be harvested Exposure to Selective translation and rotation operations at the base end of shaft 909 Connective tissue and lateral branch vessels along the path of blood vessels harvested via similar operations Make an incision. The incision probe 907 and blunt tip 903 are then retracted from FIG. Pull to align axially with cannula body 900 as shown in the aligned configuration. It can be put. The surgical process involving cannula 900 of FIG. This will be described with reference to the flowchart of FIG.   11A, 11B, and 11C, the incision probe is separate. Spiral segments 1101 and 1103 can be formed. They are spaced axially along the support shaft 909, for example, the arrangement shown in the figure. In the first step, the connective tissue and lateral branch vessels are selectively buffered along the path of the vessel to be harvested. It provides greater convenience for passing or incising. Thus, FIG. As shown in D and 11E, the incision probe 907 (or 1101 and 1103) ) Orbits around the axis of the shaft 909 and the cannula body 90 0 Is rotated on its longitudinal axis to incise the vessel away from the connective tissue and It may facilitate traversal.   12A and 12B, a simplified side and front view of a human anatomy is shown. For example, in preparing an internal mammary artery for coronary artery bypass Another operating environment of the method and method is disclosed. Especially the combined dull chip crab of the present invention The working cavity and the incision probe are formed along the blood vessel, and the blood vessel is cut and divided. Release, or a single cut is made to perform other operations as described later herein. Allow it to go through. This reduces the number of cuts required to collect blood vessels You. The cannula and incision probe of the present invention collects the internal mammary artery in the chest wall and Facilitates its use as a coronary artery bypass graft. Internal mammary artery Is dull incision of the rectus muscle through a single subxiphoid incision The pulse can be exposed to expose the pulse. The cannula tracks along the superior abdominal wall artery, which Directly into the internal mammary artery lying behind the ribs, transverse to the sternum. The internal mammary artery is a chain An incision is made in substantially the manner described previously to its starting point in the subosseous artery. So Side branch is clipped and transected, and at the end it is bypassed Transfected to produce a free end that is anastomosed to the coronary artery to complete It is.   As shown in FIGS. 12A, 12B and 12C, the internal mammary artery (also the internal thoracic artery) (Also known as) runs inward into the costal cartilage, transverse to the ribs and into the sixth and seventh cartilage. Descends to the space between the bones, where it bifurcates into the superior abdominal wall artery and the phrenic vein . The superior abdominal wall artery lies within the rectus sheath. In the upper part, it is the rectus abdominal muscle Lying backwards. The superior abdominal wall artery finally anastomoses to the inferior abdominal wall artery.   Because the superior abdominal wall artery lies within the abdominal wall within the rectus sheath, for example, Doppler hypersound (ultr rectus abdominal muscles, which are easily found using asound) and lie on skin cuts and arteries Separated through a blunt expansion of the Here, the dull chip A dual balloon incision cannula is placed next to the isolated segment of the superior abdominal wall artery, Passed upward, following the path of the superior abdominal wall artery to its junction with the internal mammary artery. Introspection The working cavity of the mirror is formed along the length of the internal mammary artery, in the manner described earlier herein. To allow lateral branch identification and occlusion, and occlude vascular clips or bipolar electric scalpels Followed by scissors traversal. The internal mammary artery is responsible for revascularization of the diseased coronary artery Of the endoscopic working cavity, which is used for Promoted by performance.   The abdominal approach to this internal mammary artery incision is a subclavian or intercostal approach. Is preferable to the above approach. It is the subclavian approach is the subclavian artery and motility Obstructed by the presence of the arch, and the incision risks trauma to these vessels. In contrast, the intercostal approach has limited exposure unless rib spreaders are used. And only a small portion of the internal mammary artery is accessible from the side. Stated here The abdominal approach thus performed ensures that the entire length of the internal mammary artery is exposed. And tolerate. By incising at the level of the superior abdominal wall artery, the vessel or bone Structure does not exist to impede the passage of the incision cannula of the present invention, and This results in a safer approach to the mammary artery.   In particular, with reference to the flowchart of FIG. The method of creating a working space is to cut skin 1501 and dull incision (blunt dissection). C.) Forming 1503 and extension of the rectus abdominal muscles lying on the artery. FIG. Or a balloon cannula illustrated in 8A, 8B or 9A, 9B, 13A, 13B. The insert is inserted into the blunt dissected cavity next to the isolated section of the superior abdominal wall artery. The cannula is advanced along the path of the superior abdominal wall and internal mammary artery. Due to the iterative process of visualizing the incision of the tissue through the transparent tip, 1505 is advanced until resistance to tissue penetration is felt. Balloon adjacent to artery Inflated to expand the cavity around the cannula, then deflated, and then The cannula is advanced again and the vascular path is reached substantially to its junction with the subclavian artery. Retracted, redirected, and forwarded as required to properly track Can be The tunnel, or cavity, thus formed along the artery is In one embodiment of the invention, the method includes the step of: The balloon is continuously inflated and deflated from the working cavity thus formed. This establishes a suitable working cavity as the cannula is fully withdrawn 1507 can be completely removed to   Next, the artery is inserted into the working cavity at the abdominal incision with a blunt tip trocar. Mosquito Can be incised from the cavity wall by placing Inflated next. An incision probe (dissection p) located within the lumen of the cannula robe) and the endoscope 1511 include a gas tight hole in the trocar. And the incision probe is positioned near the artery. Incision pro The probe is then translated and rotated 1513, FIGS. The artery is released from the connective tissue as shown in 1E. Axis in perimeter of incision probe Directional opening 908 passes over lateral branch vessels encountered along the path of the artery to be isolated Help to do. Endoscopy when arteries and lateral branches are completely free of connective tissue The cannula with the mirror and dissection probe is removed 1515 from the working cavity.   Thereafter, as shown in FIG. 14, a clip applier 1401 and the Viewing, multiple click, including endoscope 1403 and having a circular cross section An applicator is inserted 1517 through the trocar aperture and each side of the isolated artery is Two surgical clips on the branch with sufficient spacing between them to divide the branch vessel 1519. After all the side branch vessels have been clipped in this way, The viewing multiple clip applier is completely removed 1521. otherwise A two-hole trocar gas seal is attached to the blunt tip trocar, and An endoscope is inserted through one hole and a clip applier or electric scalpel is inserted through the other hole. And inserted to clip or otherwise occlude the side branch vessels. Dull chi Double-hole seal for the trocar on the clip Facilitated its replacement by, which can be operated at the base and previously placed Operated 1523 to cut and split each of the side branch vessels between the clips Or the electroablated segment prepared 1403 while looking through an endoscope It is done through. Then the blades of the scissors are removed and the internal milk thus separated The artery is then 1525 to revascularize the diseased coronary artery, eg, isolated internal Transsect free end of the mammary artery under marked stenotic obstruction It can be used by implanting into the left anterior descending coronary artery of the stream.   13A and 13B, another example of an incision cannula according to the present invention is provided. FIG. 4 shows a side view of the retracted and extended configuration of the embodiment. This implementation The embodiment includes a blunt, tapered tip 1301 that bends to one side of the endoscope 1303 And allow visualization outside the cannula 1300 during vascular dissection and dissection. Incision Probe 1305 is the base of tapered tip 1301 and cannula body 1300 To make an incision around the blood vessel to be harvested and its side branches To extend forward. The incision probe shaft 1307 is the cannula body 1 It may run through separate lumens within 300. The cannula body 1300 is inside Endoscope on the side of the cannula body, which can include curvature and near the tip A hole 1309 for the outlet of 1303 may be included. A mosquito with a normally bent form The new body becomes straight when the rigid, straight endoscope 1303 is introduced. Introspection The partial retraction of the mirror 1303 allows the cannula to flex, and the endoscope flexes. To see the outside of the cannula tip 1301, the cannula body 1300 It is advanced through the inner side hole 1309.   The surgical procedure involving the cannula 1300 shown in FIG. Illustrated in the chart. In particular, the initial cut and the dull incision should be 1701 performed to prepare The cavity is then sealed in the usual way, The cannula 1300 inserted 1707 into the cavity through a normal gas tight seal Inflated 1705 to facilitate insertion. The cannula is advanced 1709, The perimeter balloon 128 on the cannula was inflated 1711 and incised. To expand the cavity, which in turn promotes further advancement of the cannula and reinflation of the balloon. Contracted. If the procedure is of sufficient size or length to create an incised cavity, Repeated 1712, 1713 until formed along the tube. The incised cavity is already 1715 held by insufflation or mechanical traction or otherwise as described, The tube is retracted 1717 to a selected location within the cavity, where the endoscope 130 is moved. 3 is the bending of the blunt tip 1301 away from the tip of the endoscope as shown in FIG. 13B. 1719 can be retracted against the body of the cannula to allow the song. Then introspection Mirror 1303 is extended for viewing through blunt tip 1301 and dissected The tube 1305 is also stretched 1723 to cut the vessel of interest from the remaining connective tissue. It can be manipulated within the incised cavity to open.   Next, referring to the flowchart of FIG. 16, the cannula 90 shown in FIG. Surgical procedures, including zero, make initial cuts to form the original incised cavity. And blunt dissection (blunt incision). The cavity is the next spear Insertion of cannula 900 into cavity through normal gas tight seal Inflated 1605 to facilitate 1607. Cannula 900 is advanced 1609, and a perimeter balloon 901 on the cannula expands the incised cavity. Inflated 1611 for tensioning and further advancement of the cannula and re-ballooning. It is contracted to encourage expansion. This procedure should be performed on incisions of sufficient size or length. The steps are repeated 1612, 1613 until the cavity is formed along the vessel of interest. The incised cavity is retained 1615 as described above, and cannula 900 is Removing the blunt tip 903, 1617, fully retracted into the incised cavity And / or facilitating stretching 1619 and also extending 162 of incision probe 907 Promote one. One or more of steps 1617, 1619 and 1621 The procedure can be repeated for 1623 in which the connective tissue is dissected to harvest the vessel of interest.   Therefore, the surgical procedure of the cannula and dissection probe and combination may be Remove the blunt dissection (dull incision) in the working cavity along the vessel Blunt tip of clear material and located on the forward end of the cannula Facilitates visualization through the selected optical arrangement. Accomplished on the cannula Selective remote placement and remote operation of dissected (dissection) probes is of interest Facilitates incision around the vessel and around the side branch vessels along the vessel of interest , Which facilitates removal of the dissected tissue from within and along the working cavity.

[Procedure for amendment] [Date of submission] June 16, 1999 (June 16, 1999) [Details of amendment] Claims 1. A cannula for dissecting an elongated cavity in tissue, particularly along a vessel path, comprising: a tubular body having a proximal end and a distal end; and at least one lumen extending within the length of the body. An endoscope having a lit, viewing end disposed within a lumen proximate the distal end of the body; and an end of the body for substantially covering the distal end of the body and for direct contact with tissue. and a transparent tissue separating member having an external surface surface which is tapered conically converging towards the blunt tip disposed in front of the end, the members and non-disintegration of the wall substantially rigid Having an inner surface for converging on the cusp in a location substantially aligned with the viewing end of the endoscope, and thereby providing visualization with reduced distortion through the wall of the member . Against the outer wall of the tubular body of the cannula A balloon mounted Te at the outer surface in a location that is far away near the member to the distal end of the Jo body, selective balloon in response to a pressurized fluid leading a lumen extending within the tubular body Rise performs Zhang and contraction, the cannula comprising a balloon, does not interfere with visualization through the member passing through the endoscope by the expansion or contraction balloon. 2. The outer surface of the tissue separation member is substantially about. 030 inches (0.076 cm) to approx. The cannula according to claim 1, wherein the cannula forms a tapered outer surface that converges toward a blunt tip having a radius of curvature in the range of up to 100 inches (0.254 cm) . 3. The outer surface of the tissue separation member is approximately. 3. A cannula according to claim 2 forming a blunt tip having a radius of curvature of 045 inches (0.114 cm) . 4. In particular, a cannula for dissecting an elongated cavity in tissue along a path of a blood vessel, the cannula comprising: a tubular body having a proximal end and a distal end; at least a length extending into the length of the body. and one lumen; located near the lumen to the distal end of the body, is bright, the endoscope and to have a end view; covering substantially the distal end portion of the body, and tissue directly and a transparent tissue separating member having an end edge has an outer surface tapering conically converging towards the blunt tip that is disposed in front of the end of the body for contacting, the member is substantially rigid And has a non-collapsible wall and converges toward the cusp where it is substantially aligned with the viewing end of the endoscope, thereby providing a visualization with reduced distortion through the wall of the member. It has an inner surface of the Me row of song, and its members Bo It is selectively movable from the distal end of the I over the cannula. 5. 5. The cannula according to claim 4, wherein the tissue separating member is rotatably attached to the distal end of the body for selective rotational removal of the member from the body. 6. 5. The cannula according to claim 4, wherein the member is supported on a shaft mounted within the body for selective movement relative to the body to selectively position the member away from the distal end of the body. 7. 7. The cannula according to claim 6, wherein the member is supported on the shaft for its lateral movement relative to the distal end of the body in response to operation of the shaft near the proximal end of the body. 8. The body is bendable laterally and includes a hole near the distal end of the body, and the endoscope is slidable into a lumen within the body and selectively emerges from the hole in response to the lateral bending on the body. A cannula according to claim 4, wherein 9. 9. The cannula according to claim 8, including an incision probe mounted for movement relative to the body and positioned therein to emerge from a distal hole in the endoscope in response to lateral bending of the body. 10. 7. The cannula according to claim 6, including an incision probe mounted within the body for selective movement therewith and exposed in movement of the member relative to the distal end of the body. 11. Including a dissection probe and a member mounted on a shaft positioned along the length of the body relative to its proximal end, for selectively moving the probe and member relative to the distal end of the body 11. The cannula according to claim 10, wherein said cannula facilitates manual operation. 12. The incision probe mounted on a shaft disposed within the body, the incision probe moving a probe near its distal end in response to manual operation of the shaft near the proximal end of the body. By cannula. 13. The incision probe includes a crescent shaped member disposed on the shaft in a substantially concentric configuration with the body to effect selective movement relative to a distal end of the body for cutting tissue therearound. 12 cannula. 14． The dissection probe includes at least one partially circular element disposed on the shaft in a substantially concentric configuration with the body, and selective movement relative to the distal end of the body for cutting tissue therearound. 13. The cannula according to claim 12, wherein: 15. A balloon mounted At a location in the far from the outer surface of the near said member relative to the outer wall of the tubular body of the cannula distal end of the tubular body, pressurized fluid leading a lumen extending tubular ball in Dee 5. The cannula according to claim 4, including a balloon that selectively inflates and deflates the balloon in response to pressure, such that the inflating or deflating balloon does not interfere with visualization through the member through the endoscope. 16. A cannula for dissecting an elongated cavity in tissue, particularly along the path of a blood vessel, the cannula having: a proximal end and a distal end, a laterally deflectable portion, and a distal end of the body. A tubular body including a hole near the end end; at least one lumen extending within the length of the body; a lit, viewing end disposed within the lumen near the distal end of the body. the endoscope to have a part, an endoscope and which is slidably disposed within the lumen of the body selectably emerge from the hole in accordance with the distortion of the transverse direction of the body; distal end portion of the body A transparent tissue member having a conically tapered outer surface substantially covering the distal end of the body and converging toward a blunt tip disposed in front of the distal end of the body , the member being substantially rigid. in a and non-disintegrating, and the end view of the endoscope Cannulation Moltrasio having an inner surface converging towards the cusp at the location to align the quality. 17． A cannula for dissecting an elongated cavity in tissue, particularly along the path of a blood vessel, the cannula having: a tubular end having a proximal end and a distal end and including a hole near a distal end of a body. and Bo Dee; and at least one lumen extending within the length of the body; located within the lumen near the distal end of the body, are bright, have a end view, transversely of the body an endoscope selectively emerge from the hole in accordance with the distortion; substantially covers the distal end of the body, and towards the blunt tip that is disposed in front of the end edge end of the body for direct contact with tissue and a transparent tissue separating member which have a tapered has an outer surface converging Te, where the members are and non-disintegrating in substantially rigid, that substantially aligned with the end look of the endoscope and converge towards the peak in, it is reduced through the member Possess an internal surface for performing the visualization that in distortion, and the member is movable in response to the distortion from the end view of the endoscope close to the distal end of the body in the lateral direction of the body, Cannula. 18. The cannula according to claim 1 , wherein the conically tapered outer surface to the blunt tip is about 0.5 inches ( 1.27 cm) in length . 19. Cannula by claim 1 dimensions in member is about 8mm in the distal end of the tubular body.

Claims (1)

[Claims] 1. Especially with a cannula to cut an elongated cavity in tissue along the path of a blood vessel A tubular body having a base end and a distal end; At least one lumen extending and disposed within the lumen near the distal end of the body An endoscope having a brightened, viewing end, and substantially covering the distal end of the body. Transparent tissue portion having a blunt tip disposed in front of the distal end of the body An endoscope to reduce distortion of visualization through the member. Has an inner surface that converges substantially pointed at a position substantially aligned with the viewing end of the A cannula consisting of things. 2. The outer surface of the tissue separation member is substantially about. From 030 inches. Up to 100 inches 2. A cannula according to claim 1 which forms a blunt tip having a radius of curvature in the range of . 3. The outer surface of the tissue separation member is approximately. Dull tip with 045 inch radius of curvature 3. A cannula according to claim 2 forming: 4. The method of claim 1, wherein the tissue separating member is selectively displaceable from a distal end of the body. According cannula. 5. Tissue separation member is rotatable for selective rotational removal of the member from the body 5. The cannula according to claim 4, which attaches to the distal end of the body. 6. The member is positioned to selectively position the member away from the distal end of the body. Supporting on a shaft mounted in the body for selective movement with respect to the body A cannula according to claim 4 carried. 7. The end of the body responds to manipulation of the shaft when the member is near the base end of the body. 7. According to claim 6, supported on a shaft for its lateral movement with respect to the end. Cannula. 8. The body is bendable sideways and includes a hole near the end of the body, allowing the endoscope to Slidable into lumen in body and selective from hole in response to lateral bending on body 5. The cannula according to claim 4, wherein the cannula appears in the cannula. 9. Installed for exercise on the body and in which the body bends laterally Including an incision probe positioned to emerge from the distal hole of the endoscope in response to The cannula according to claim 8. 10. In the body, for selective exercise against it and at the end of the body A contractor including an incision probe mounted for exposure in movement of the member relative to the end The cannula according to claim 6. 11. The length of the body relative to the dissection probe and its proximal end Including a member mounted on a shaft disposed along the distal end of the body. To facilitate manual operation of the probe and member to selectively move the part relative to the part A cannula according to claim 10, wherein 12. An incision probe mounted on a shaft disposed in the body, Close to its distal end in response to manual operation of the shaft near the proximal end of the body The cannula according to claim 1, including an incision probe for moving the probe. 13. An incision probe is positioned on the shaft in a substantially concentric configuration with the body. End of the body, including a crescent shaped member, for cutting tissue around it 13. The cannula according to claim 12, wherein the cannula performs a selective movement on the part. 14． An incision probe is positioned on the shaft in a substantially concentric configuration with the body. Including at least one partially circular element and cutting tissue around it Performing a selective movement with respect to the distal end of the body for performing Cannula. 15. A cannula with a clear tissue dissection tip that faces the outer wall of the cannula With a balloon mounted near its distal end, and with a tip inside the body. In a patient's body using a cannula containing an endoscope positioned for visualization through A method of incising an elongated cavity in tissue along a selected path, comprising the steps of: Making a first cut at some location in the stomach and dull incision in the first cavity; endoscope And a cannula to visualize through the tip and separate tissue around the tip Insert and advance; selectively inflate balloon to create cavity in isolated tissue Dilate the tissue; selectively deflate the balloon and advance the cannula to separate the tissue Release and extend the cavity; and displace the tip relative to the body of the cannula Exposing the endoscope therein; 16. Forming a counterincision at selected locations along the cavity; Position selected portions of the tip and cannula through the reverse cut; and R Remove the exposed tip from the body of the cannula through the eye; 16. The method according to claim 15, wherein 17． Make sure that the body of the cannula is elastic at least near its distal end. And including therein a hole for a passage passing beside the endoscope, and The method is to selectively displace the distal end of the body laterally to the length of the body. 16. The method according to claim 15, including the additional step of displacing the endoscope through the hole. Law. 18. A cannula is mounted on the shaft carried by the body and the cannula Includes an incision probe located near the distal end of the uree, near its proximal end A method of performing a selective motion relative to a shaft operation in response to the operation of the shaft, the method comprising: Displace the tip with respect to the body of the Selectively incising tissue in response to movement and visualized via an endoscope; 16. The method according to claim 15, comprising the additional step of: 19. A cannula with a clear tissue dissection tip that faces the outer wall of the cannula With a balloon mounted near its distal end, and with a tip inside the body. Including an endoscope positioned for visualization through and supported by a cannula Incision probe for manual operation of the proximal end of the support relative to the probe In response, a crab containing an incision probe that is selectively movable with respect to the distal end of the body. Incision of an elongated cavity in tissue along a selected path within the patient using a ure Make an initial cut at some location near the blood vessels in the patient's body. And dull incision of the first cavity; visualized through the endoscope and tip Insert and advance cannula to separate tissue around tip along path Allowing the balloon to be selectively inflated to separate lumens in tissue along the path of the blood vessel Dilate the tissue; selectively deflate the balloon and advance the cannula to separate the tissue Release and extend the cavity; and select an incision probe against the body of the cannula. Optionally manipulate to dissect connective tissue along blood vessels as visualized through an endoscope A method comprising the steps of: 20. An incision probe supported by the body and rotatable relative to the body; A method that is mounted on a movable shaft, where the tip is cannulated. Selectively displacing the probe with respect to the distal end of the body to expose the incision probe; The shaft to rotate and move the incision probe relative to the distal end of the body. Making; a method according to claim 19, comprising an additional step. 21. An incision probe is placed in a substantially concentric configuration with respect to the body of the cannula. Including a portion of a substantially cylindrical element mounted on a shaft, and In addition, the incision probe may be inserted into the elongated cavity along the blood vessel and laterally therefrom. Manipulate around the blood vessel to dissect connective tissue and isolate the blood vessel in the elongated cavity 20. A method according to claim 19 comprising steps. 22. Partially cylindrical element having an incision cannula and an open portion around it For isolating blood vessels in a patient's body using an incision probe substantially formed as Forming a cut and incising down into the blood vessel; tissue along the path of the blood vessel Bluntly dissecting to form an elongated working cavity; Dissect connective tissue along the working cavity and adjacent to the vessel Passing the incision probe around a vessel that branches laterally along the length of the vessel; Place along the vessels that branch laterally, spaced from their junction with the vessels Occlusion at the site; and cutting laterally branched vessels to the location of the occlusion along them A method comprising the steps of: 23. Partially cylindrical element having an incision cannula and an open portion around it Separation of arterial segments within a patient using an incision probe formed substantially as A method for   Make an abdominal cut lying over the superior abdominal wall artery and cut down to the artery; Cut the tissue bluntly along the path of the abdominal wall artery and continue along the path of the internal mammary artery Forming an elongated working cavity; placing the incision probe around the working cavity and the superior abdominal wall artery And incision of connective tissue along and adjacent to the internal mammary artery; Along the length of the superior abdominal wall artery and internal mammary artery around the artery Qualitatively pass to its junction with the subclavian artery; Two spaces apart from their junction with the superior abdominal wall artery and the internal mammary artery. Occlude where they have; and reduce the distance between the occlusions along them Cut between the locations to separate the superior abdominal wall artery and internal mammary artery within the elongated cavity A method comprising the steps of: 24. The step of occluding is on each laterally branching artery and along the superior abdominal wall artery Surgical clips placed two spaced apart from the internal mammary artery Revascularization via the internal mammary artery or superior abdominal wall artery from which the patient's coronary artery has been isolated 24. The method according to claim 23, comprising: 25. The step of occluding branches off each side laterally from the superior abdominal wall artery and internal mammary artery Apply an electrocautery current over the artery; transverse at the center of the cauterized occluded section Cut off the arteries branching into the vein; and via the isolated internal mammary artery or the superior abdominal wall artery Performing a revascularization of the patient's coronary arteries. 26. A method for dissecting tissue from one segment of an artery in a patient's body Cut through the cavity along the path of the artery and adjacent to one segment of the artery Visualize and dissect tissue dissection from the artery from within the cavity Releasing a segment of the artery from the tissue; 27. An endoscope is positioned to visualize the tissue to be dissected and within the visualization of the endoscope Includes a steerable incision probe and the visualization step moves the incision probe beyond the endoscope From within the cavity along the path of the arterial segment To the artery and its side branches, visualized from within and along the cavity adjacent to the tract 27. The method according to claim 26, comprising incising the connective tissue along.