US20170143338A1 - Apparatus for forming variable height surgical fasteners - Google Patents
Apparatus for forming variable height surgical fasteners Download PDFInfo
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- US20170143338A1 US20170143338A1 US15/426,497 US201715426497A US2017143338A1 US 20170143338 A1 US20170143338 A1 US 20170143338A1 US 201715426497 A US201715426497 A US 201715426497A US 2017143338 A1 US2017143338 A1 US 2017143338A1
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- leg
- staple
- jaw
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- surgical apparatus
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/068—Surgical staplers, e.g. containing multiple staples or clamps
- A61B17/072—Surgical staplers, e.g. containing multiple staples or clamps for applying a row of staples in a single action, e.g. the staples being applied simultaneously
- A61B17/07207—Surgical staplers, e.g. containing multiple staples or clamps for applying a row of staples in a single action, e.g. the staples being applied simultaneously the staples being applied sequentially
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/064—Surgical staples, i.e. penetrating the tissue
- A61B17/0644—Surgical staples, i.e. penetrating the tissue penetrating the tissue, deformable to closed position
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/068—Surgical staplers, e.g. containing multiple staples or clamps
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/068—Surgical staplers, e.g. containing multiple staples or clamps
- A61B17/0682—Surgical staplers, e.g. containing multiple staples or clamps for applying U-shaped staples or clamps, e.g. without a forming anvil
- A61B17/0684—Surgical staplers, e.g. containing multiple staples or clamps for applying U-shaped staples or clamps, e.g. without a forming anvil having a forming anvil staying above the tissue during stapling
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/068—Surgical staplers, e.g. containing multiple staples or clamps
- A61B17/0682—Surgical staplers, e.g. containing multiple staples or clamps for applying U-shaped staples or clamps, e.g. without a forming anvil
- A61B17/0686—Surgical staplers, e.g. containing multiple staples or clamps for applying U-shaped staples or clamps, e.g. without a forming anvil having a forming anvil staying below the tissue during stapling
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/068—Surgical staplers, e.g. containing multiple staples or clamps
- A61B17/072—Surgical staplers, e.g. containing multiple staples or clamps for applying a row of staples in a single action, e.g. the staples being applied simultaneously
- A61B2017/07214—Stapler heads
- A61B2017/07228—Arrangement of the staples
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/068—Surgical staplers, e.g. containing multiple staples or clamps
- A61B17/072—Surgical staplers, e.g. containing multiple staples or clamps for applying a row of staples in a single action, e.g. the staples being applied simultaneously
- A61B2017/07214—Stapler heads
- A61B2017/0725—Stapler heads with settable gap between anvil and cartridge, e.g. for different staple heights at different shots
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/068—Surgical staplers, e.g. containing multiple staples or clamps
- A61B17/072—Surgical staplers, e.g. containing multiple staples or clamps for applying a row of staples in a single action, e.g. the staples being applied simultaneously
- A61B2017/07214—Stapler heads
- A61B2017/07278—Stapler heads characterised by its sled or its staple holder
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/28—Surgical forceps
- A61B17/29—Forceps for use in minimally invasive surgery
- A61B2017/2926—Details of heads or jaws
- A61B2017/2932—Transmission of forces to jaw members
- A61B2017/2944—Translation of jaw members
Definitions
- the present disclosure relates to surgical fastener apparatus. More particularly, the present disclosure relates to apparatus for forming variable height surgical fasteners to body tissue in surgical procedures.
- Surgical devices wherein tissue is first grasped or clamped between opposing jaw structure and then joined by means of surgical fasteners are well known in the art.
- a knife is provided to cut the tissue which has been joined by the fasteners.
- the fasteners are typically in the form of surgical staples.
- Instruments for this purpose may include two elongated members which are respectively used to capture or clamp tissue.
- one of the members carries a cartridge which houses a plurality of staples arranged in at least two lateral rows while the other member includes an anvil which defines a surface for forming the staple legs as the fasteners are driven from the cartridge.
- the stapling operation is effected by a pusher which travels longitudinally through the cartridge carrying member, with the pusher acting upon the staples for sequentially ejecting them from the cartridge.
- a knife may travel with the pusher between the staple rows to longitudinally cut and/or open the stapled tissue between the rows of staples.
- a later stapler disclosed in U.S. Pat. No. 3,499,591 applies a double row of staples on each side of the incision. This is accomplished by providing a cartridge assembly in which a cam member moves through an elongate guide path between two sets of staggered staple carrying grooves. Staple drive members are located within the grooves and are positioned in such a manner so as to be contacted by the longitudinally moving cam to effect ejection of the staples.
- Other examples of staplers are disclosed in U.S. Pat. Nos. 4,429,695; 5,065,929; and 5,156,614.
- the present disclosure is directed towards a staple fastening assembly for use with a surgical instrument to apply surgical staples.
- the staple fastening assembly includes cooperative first and second jaws, a jaw operating mechanism, and a staple driving assembly.
- One jaw is generally elongate and includes a staple magazine.
- the staple magazine may be fixedly attached or releasably attached to the jaw and includes a plurality of staples arranged in at least one row.
- a first tissue contacting surface is defined on one face of the staple magazine and includes a plurality of retention slots corresponding to the number of staples included in the staple magazine. It is contemplated that multiple rows of staples may be provided and arranged in columns.
- the retention slots may be longitudinally aligned or offset from one another. Each retention slot is configured and adapted for releasably receiving its respective staple.
- Each staple includes first and second substantially parallel legs connected by a backspan forming substantially right angles to each of the legs.
- the second jaw is generally elongate and movable throughout a plurality of positions between an open position and a closed position.
- An anvil member is disposed on the second jaw and includes a second tissue contacting surface.
- the second tissue contacting surface includes a plurality of staple pockets wherein the number and arrangement of staple pockets corresponds to the number and arrangement of retention slots in the staple magazine.
- the second tissue contacting surface is oriented such that it is in juxtaposition with the first tissue contacting surface and defines a tissue gap therebetween.
- Each staple pocket includes a pair of staple forming grooves for capturing the legs of each staple.
- the staple forming grooves are substantially symmetrical about an intermediate point and have opposing inclined surfaces.
- a substantially lemniscate channeling surface is formed about a perimeter of each staple pocket.
- Each staple forming groove urges one leg of each staple towards the other leg while maintaining lateral separation of the legs during and after staple formation.
- the jaw operating mechanism is disposed in a housing that is attached to a proximal portion of the staple fastening assembly.
- the jaw operating mechanism includes a cam rotatably mounted to the housing, a cable, and a spring that are cooperatively coupled to one another.
- An approximating mechanism in the surgical instrument is operatively coupled to the jaw operating mechanism to cause proximal motion of the spring.
- Proximal movement of the spring is coupled to the cam via the cable.
- the cam has an eccentric outer surface for maintaining contact between at least a portion of the outer surface of the cam and an outer surface of the second jaw.
- the cam may include an anti-reverse assembly (i.e. self-locking) to permit counter-clockwise rotation of the cam while inhibiting clockwise rotation of the cam.
- FIG. 1 is a side cross-sectional view of a staple fastening assembly in accordance with an embodiment of the present disclosure in an open position;
- FIG. 2 is a side cross-sectional view of the staple fastening assembly of FIG. 1 in an intermediate position
- FIG. 3 is a side cross-sectional view of the staple fastening assembly of FIG. 1 in a closed position
- FIG. 4 is a top plan view of a staple magazine of the staple fastening assembly of FIG. 1 ;
- FIG. 5 is an exploded perspective view of a staple driving assembly showing the relationship among the several components
- FIG. 6 is a bottom plan view of an anvil member
- FIG. 6A is a top plan view of a staple pocket
- FIG. 7A is a side view of an unformed staple
- FIG. 7B is a side view of the staple of FIG. 7A formed to a first configuration in accordance with the present disclosure
- FIG. 7C is a side view of the staple of FIG. 7A formed to a second configuration in accordance with the present disclosure
- FIG. 7D is a side view of the staple of FIG. 7A formed to a third configuration in accordance with the present disclosure
- FIG. 7E is a side view of the staple of FIG. 7A formed to a fourth configuration in accordance with the present disclosure
- FIG. 7F is a plan view of the staple of FIG. 7B showing an overlap between first and second legs of the staple;
- FIG. 8A is an enlarged side view of a staple pocket, an unformed staple, a staple sled, and a rod sled;
- FIG. 8B is an enlarged side view of the components of FIG. 8A showing the staple formed into a first configuration
- FIG. 8C is an enlarged side view of the components of FIG. 8B showing a backspan of the staple being dimpled by the dimpling rod.
- distal refers to that portion of the instrument, or component thereof which is further from the user while the term “proximal” refers to that portion of the instrument or component thereof which is closer to the user.
- a staple fastening assembly shown generally as 100 , includes a fixed first jaw 104 , a moveable second jaw 140 , and a jaw operating mechanism 160 .
- staple fastening assembly 100 is adapted for use in connection with endoscopic or laparoscopic stapling instruments as are known in the art.
- First jaw 104 includes a staple magazine 120 having a first tissue contacting surface 122 .
- a plurality of retention slots 124 is included in staple magazine 120 where they are arranged in rows 126 on first tissue contacting surface 122 (see FIG. 4 ). Each row 126 generally extends along a longitudinal axis of first jaw 104 .
- First tissue contacting surface 122 is generally elongate.
- Each retention slot 124 is configured for receiving a staple 110 and a staple ejector assembly.
- the staple ejector assembly includes a staple ejector 132 , a dimpling rod 138 (see FIG. 5 ), a staple sled 134 , and a rod sled 136 .
- staple magazine 120 may be removably attached to first jaw 104 .
- staple magazine 120 is a removable structure, once its complement of staples 110 have been expended, it may be removed and a new staple magazine 120 is attached to first jaw 104 .
- Each staple magazine 120 includes a full complement of staples 110 and at least one staple driving assembly 130 (shown in FIG. 5 and discussed in detail below).
- Staple magazine 120 includes a plurality of longitudinal channels 128 (see FIGS. 3 and 4 ) that are adapted for slidably receiving staple sled 134 and rod sled 136 .
- the number of channels 128 corresponds to the number of rows 126 of staples 110 included in staple magazine 120 .
- staple magazine 120 include at least two rows 126 of staples 110 , although the procedure being performed, characteristics of the tissue to be fastened, and other considerations are factors in determining the number of rows 126 , as well as the number of staples 110 , included in each staple magazine 120 .
- Each row 126 in the plurality of rows has an identical quantity of staples 110 .
- staple driving assembly 130 includes a staple ejector 132 , staple sled 134 , rod sled 136 , and a dimpling rod 138 .
- Each staple sled 134 is operatively coupled to a drive mechanism (not shown) of the surgical stapling instrument using structures that are known in the art.
- An example of such an instrument that includes a drive mechanism and an actuation mechanism is disclosed in U.S. Pat. No. 6,669,073 to Milliman et al., currently owned by and assigned to United States Surgical, a division of Tyco Healthcare, the contents of which are hereby incorporated by reference in their entirety.
- staple sleds 134 are operatively coupled to the drive mechanism such that their longitudinal travel is synchronized for ejecting a column 127 of staples 110 (see FIG. 4 ) substantially simultaneously during an actuation sequence. Operation of the drive mechanism results in proximal and distal movement of the respective cams in response to actuation of the actuation mechanism.
- Staple sled 134 is a generally elongate structure having a pair of inclined surfaces 135 a , 135 b oriented towards the distal end of staple magazine 120 . Inclined surfaces 135 a , 135 b are laterally spaced apart to define a passage 135 c therebetween. Passage 135 c is substantially flat and dimensioned for slidably receiving rod sled 136 .
- Rod sled 136 is a generally inclined structure having a substantially similar incline to that of staple sled 134 .
- staple ejector 132 includes a pair of legs 132 a, 132 b that are laterally spaced apart and angled at their distal ends for readily engaging inclined surfaces 135 a , 135 b.
- a throughhole 132 c is centrally disposed in body 132 d of staple ejector 132 and is dimensioned for slidably receiving dimpling rod 138 .
- staple sled 134 Upon actuation of the actuation mechanism, staple sled 134 is driven through staple magazine 120 in a generally distal direction by the drive mechanism. As it translates through staple magazine 120 , staple sled 134 sequentially engages each staple ejector 132 . Staple sled 134 and staple ejector 132 have engaging surfaces with complementary angles such that distal horizontal motion of staple sled 134 results in vertical motion of staple ejector 132 which, in turn, drives staple 110 in a generally vertical direction towards anvil member 142 . During distal movement of staple sled 134 , rod sled 136 remains stationary in a proximal region of the magazine. In instances where a staple height of less than about 2.5 mm is desirable, as determined by tissue gap 102 , the actuation mechanism actuates the drive mechanism and drives rod sled 136 distally as will be discussed in detail hereinafter.
- a gap sensor 106 is disposed in a proximal portion of staple fastening assembly 100 .
- Gap sensor 106 is a generally elongate structure having a throughhole 109 disposed near one end. Further still, gap sensor 106 is fixedly attached to second jaw 140 and slidably received in an opening 105 .
- a dimple window 103 is disposed near a proximal portion of first jaw 104 and is configured for slidably receiving a dimpling rod driver 107 .
- Dimpling rod driver 107 is operatively coupled to the actuation mechanism and engages staple dimpling cam 136 when dimple window 103 is aligned with dimpling rod driver 107 .
- Gap sensor 106 is configured and dimensioned such that dimpling window 103 is aligned with dimpling rod driver 107 only when tissue gap 102 indicates that a staple height of less than about 2.5 mm is desired.
- staple sled 134 leads rod sled 136 ( FIG. 5 ) during their travel through staple magazine 120 .
- rod sled 136 follows it after a predetermined time delay.
- Rod sled 136 is guided along its path by passage 135 c of staple sled 134 . Therefore, staple sled 134 ejects staple 110 and drives it against anvil member 142 to form a staple having a height of about 2.5 mm as discussed above.
- sled 136 engages dimpling rod 138 .
- rod sled 136 translates distally with staple sled 134 , it contacts dimpling rod 138 causing vertical motion thereof to engage backspan 116 .
- Rod sled 136 drives dimpling rod 138 such that it forms a depression in the center of backspan 116 and further increasing the holding strength of the formed staple 110 .
- staple magazine 120 may have a plurality of rows 126 where retention slots 124 in each row 126 may be longitudinally offset from retention slots 124 in an adjacent row 126 . Since retention slots 124 are longitudinally offset, staple crimping cams 134 are operatively arranged and synchronized to eject the first staple 110 from each row 126 and advancing sequentially towards a distal end of staple magazine 120 and sequentially ejecting staples 110 from each row 126 .
- second jaw 140 is spaced apart from first jaw 104 defining a tissue gap 102 therebetween.
- Second jaw 140 is moveable through a plurality of positions between an open position and a closed position.
- first jaw 104 and second jaw 140 are substantially parallel to one another throughout the plurality of positions.
- second jaw 140 is moved towards first jaw 104 by jaw operating mechanism 160 that maintains a substantially parallel relationship between jaws 104 and 140 .
- jaw operating mechanism 160 is disposed in a housing 170 and includes a cam 162 , a cable 164 , and a spring 166 .
- Cam 162 , cable 164 , and spring 166 are operatively connected to one another.
- a proximal portion of second jaw 140 is disposed within housing 170 and secured thereto.
- spring 166 is operatively coupled to an approximating mechanism (not shown) of the stapling instrument by structures as are known in the art.
- the approximating mechanism causes spring 166 to move proximally. Since cable 164 is operatively connected to spring 166 , this proximal movement of spring 166 results in proximal movement of cable 164 and counter-clockwise rotation of cam 162 .
- cam 162 contacts an outer surface 146 of second jaw 140 and it is self-locking in the counter-clockwise direction of rotation.
- Cam 162 has a centrally disposed orifice 163 for rotatably attaching it to housing 170 .
- orifice 163 is substantially circular, cam 162 has a generally eccentric shape, particularly along an outside surface, such that counter-clockwise rotation of cam 162 causes at least a portion of cam 162 to maintain contact with outer surface 146 thereby urging second jaw 140 towards first jaw 104 during counter-clockwise rotation.
- cam 162 After cam 162 has rotated a desired amount, it locks in position such that no clockwise rotation is possible (i.e. self-locking), but additional counter-clockwise rotation is possible.
- a release mechanism operatively couples jaw operating mechanism 160 to the surgical stapling instrument. After a complete actuation sequence, the release mechanism is actuated to unlock cam 162 and permit clockwise rotation of cam 162 . Thusly, second jaw 140 is urged away from first jaw 104 by a biasing mechanism as is known in the art to separate the jaws and allow removal of the surgical stapling instrument.
- cam 162 , cable 164 , and spring 166 are selected such that tissue T is captured and maintained between jaws 104 , 140 using a minimum amount of applied pressure.
- the advantageous combination of cam 162 , cable 164 , and spring 166 captures different thicknesses of tissue T (i.e. each tissue thickness corresponds to a particular tissue gap 102 ) while minimizing trauma to tissue T as jaws 104 , 140 capture tissue T therebetween.
- Anvil member 142 is generally elongate and includes a plurality of staple pockets 150 (see FIG. 6A ) disposed on an second tissue contacting surface 144 where the number and arrangement of staple pockets 150 correspond to the number and arrangement of retention slots 124 in first tissue contacting surface 122 .
- An example of a staple pocket is disclosed in U.S. Pat. No. 5,480,089 to Blewett.
- each staple pocket 150 has a first staple leg forming groove 152 and a second staple leg forming groove 154 for forming respective legs 112 , 114 of staple 110 (see FIG. 7A ).
- Each staple forming groove 152 , 154 is dimensioned to accommodate legs 112 , 114 respectively.
- Staple leg forming grooves 152 and 154 are symmetrical about an intermediate point 156 .
- a substantially lemniscate (figure-eight shaped curve) channeling surface 158 is also formed in second tissue contacting surface 144 around a perimeter of staple pocket 150 .
- Each channeling surface 158 forms an angle ⁇ , with respect to a plane defined by second tissue contacting surface 144 , wherein 0° ⁇ 90°.
- Each staple forming groove 152 , 154 has a different slope than that of adjacent channeling surface 158 . More particularly, each staple forming groove 152 , 154 has a sloped end 152 a, 154 a to direct a corresponding staple leg 112 , 114 towards a backspan 116 of staple 110 . Sloped ends 152 a, 154 a are longitudinally opposed to one another.
- staple 110 is ejected from retention slot 124 and directed towards anvil member 142 thereby driving legs 112 and 114 through tissue T to enter staple forming grooves 152 , 154 respectively.
- staple forming grooves 152 , 154 direct legs 112 , 114 towards each other while maintaining lateral separation of legs 112 , 114 so that they overlap one another as shown in FIG. 7F .
- staple forming groove 152 in cooperation with channeling surface 158 , directs leg 112 towards backspan 116 alongside and substantially parallel to an unformed portion of leg 114 .
- staple forming groove 154 in cooperation with channeling surface 158 , directs leg 114 towards backspan 116 alongside and substantially parallel to an unformed portion of leg 112 .
- the amount of parallel overlap between leg 112 and the unformed portion of leg 114 is a function of tissue gap 102 .
- the amount of parallel overlap between leg 114 and the unformed portion of leg 112 is also a function of tissue gap 102 that is controlled by the thickness of tissue T and operation of jaw operating mechanism 160 .
- a larger tissue gap 102 results in a larger staple 110 height (e.g. about 4.8 mm as shown in FIG. 7B ) while a smaller tissue gap 102 yields a smaller staple 110 height (e.g. about 2.5 mm as shown in FIG. 7D ).
- the actuation mechanism in cooperation with staple magazine 120 and anvil member 142 , forms staples 110 having a height of between about 4.8 mm (i.e. the open position of second jaw 140 ) and about 2.5 mm (i.e. the closed position of second jaw 140 ) as determined by the thickness of tissue T and tissue gap 102 .
- staples 110 may be formed having any height that is in the range of about 4.8 mm and about 2.5 mm as determined by the thickness of tissue T (an example is illustrated in FIG. 7C ).
- tissue T thickness indicates a need for a smaller staple 110 height (i.e. less than about 2.5 mm or the dimpling position as seen in FI. 7 E)
- the actuation mechanism of the stapling instrument operates a second drive member that is operatively coupled to rod sled 136 , as discussed hereinabove.
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Abstract
A surgical device for applying a plurality of surgical staples is provided. The device includes a staple fastening assembly attached to a surgical instrument. The staple fastening assembly includes a pair of cooperating jaws, a jaw operating mechanism, and a gap sensor. A staple magazine having a plurality of staples and an anvil member having a plurality of staple pockets are attached to the jaws. The staple magazine includes a staple crimping cam and a staple dimpling cam that are operatively coupled to the surgical instrument. The jaw operating mechanism is operatively connected to a drive assembly in the surgical instrument for moving the jaws for automatically setting a tissue gap between the cooperating jaws. The gap sensor cooperates with the jaw operating mechanism for controlling staple formation.
Description
- This application is a continuation of U.S. patent application Ser. No. 13/778,735, filed Feb. 27, 2013, which is a divisional of U.S. patent application Ser. No. 13/343,743, filed Jan. 5, 2012, now U.S. Pat. No. 8,403,198, which is a continuation of U.S. patent application Ser. No. 12/529,576, filed Sep. 2, 2009, now U.S. Pat. No. 8,205,780, which is a National Stage Application of PCT/US2008/057599, filed on Mar. 20, 2008 under 35 USC §371(a), which claims priority to, and the benefit of, U.S. Provisional Patent Application Ser. No. 60/919,381, filed on Mar. 22, 2007. The entire contents of each of the above applications are hereby incorporated by reference.
- Technical Field
- The present disclosure relates to surgical fastener apparatus. More particularly, the present disclosure relates to apparatus for forming variable height surgical fasteners to body tissue in surgical procedures.
- Background of Related Art
- Surgical devices wherein tissue is first grasped or clamped between opposing jaw structure and then joined by means of surgical fasteners are well known in the art. In some instruments, a knife is provided to cut the tissue which has been joined by the fasteners. The fasteners are typically in the form of surgical staples.
- Instruments for this purpose may include two elongated members which are respectively used to capture or clamp tissue. Typically, one of the members carries a cartridge which houses a plurality of staples arranged in at least two lateral rows while the other member includes an anvil which defines a surface for forming the staple legs as the fasteners are driven from the cartridge. Generally, the stapling operation is effected by a pusher which travels longitudinally through the cartridge carrying member, with the pusher acting upon the staples for sequentially ejecting them from the cartridge. A knife may travel with the pusher between the staple rows to longitudinally cut and/or open the stapled tissue between the rows of staples.
- A later stapler disclosed in U.S. Pat. No. 3,499,591 applies a double row of staples on each side of the incision. This is accomplished by providing a cartridge assembly in which a cam member moves through an elongate guide path between two sets of staggered staple carrying grooves. Staple drive members are located within the grooves and are positioned in such a manner so as to be contacted by the longitudinally moving cam to effect ejection of the staples. Other examples of staplers are disclosed in U.S. Pat. Nos. 4,429,695; 5,065,929; and 5,156,614.
- The present disclosure is directed towards a staple fastening assembly for use with a surgical instrument to apply surgical staples. The staple fastening assembly includes cooperative first and second jaws, a jaw operating mechanism, and a staple driving assembly. One jaw is generally elongate and includes a staple magazine. The staple magazine may be fixedly attached or releasably attached to the jaw and includes a plurality of staples arranged in at least one row. A first tissue contacting surface is defined on one face of the staple magazine and includes a plurality of retention slots corresponding to the number of staples included in the staple magazine. It is contemplated that multiple rows of staples may be provided and arranged in columns. The retention slots may be longitudinally aligned or offset from one another. Each retention slot is configured and adapted for releasably receiving its respective staple. Each staple includes first and second substantially parallel legs connected by a backspan forming substantially right angles to each of the legs.
- The second jaw is generally elongate and movable throughout a plurality of positions between an open position and a closed position. An anvil member is disposed on the second jaw and includes a second tissue contacting surface. The second tissue contacting surface includes a plurality of staple pockets wherein the number and arrangement of staple pockets corresponds to the number and arrangement of retention slots in the staple magazine. The second tissue contacting surface is oriented such that it is in juxtaposition with the first tissue contacting surface and defines a tissue gap therebetween.
- Each staple pocket includes a pair of staple forming grooves for capturing the legs of each staple. The staple forming grooves are substantially symmetrical about an intermediate point and have opposing inclined surfaces. A substantially lemniscate channeling surface is formed about a perimeter of each staple pocket. Each staple forming groove urges one leg of each staple towards the other leg while maintaining lateral separation of the legs during and after staple formation.
- The jaw operating mechanism is disposed in a housing that is attached to a proximal portion of the staple fastening assembly. The jaw operating mechanism includes a cam rotatably mounted to the housing, a cable, and a spring that are cooperatively coupled to one another. An approximating mechanism in the surgical instrument is operatively coupled to the jaw operating mechanism to cause proximal motion of the spring. Proximal movement of the spring is coupled to the cam via the cable. In one embodiment, the cam has an eccentric outer surface for maintaining contact between at least a portion of the outer surface of the cam and an outer surface of the second jaw. The cam may include an anti-reverse assembly (i.e. self-locking) to permit counter-clockwise rotation of the cam while inhibiting clockwise rotation of the cam. Configured thusly, counter-clockwise rotation of the eccentric cam continuously urges the second jaw towards the first jaw during proximal movement of the spring. The dimensions of the cam and the cable, as well as the dimensions and material selected for the spring, contribute towards the tissue capturing characteristics of the jaw operating mechanism. It is desirable for the jaws to capture and hold tissue in position while minimizing trauma to the tissue. Advantageously, the combination of the cam, the cable, and the spring allows for automatic adjustment of the tissue gap to accommodate different thicknesses of tissue during stapling operations.
- Embodiments of the presently disclosed surgical instrument are described herein with reference to the drawings, wherein:
-
FIG. 1 is a side cross-sectional view of a staple fastening assembly in accordance with an embodiment of the present disclosure in an open position; -
FIG. 2 is a side cross-sectional view of the staple fastening assembly ofFIG. 1 in an intermediate position; -
FIG. 3 is a side cross-sectional view of the staple fastening assembly ofFIG. 1 in a closed position; -
FIG. 4 is a top plan view of a staple magazine of the staple fastening assembly ofFIG. 1 ; -
FIG. 5 is an exploded perspective view of a staple driving assembly showing the relationship among the several components; -
FIG. 6 is a bottom plan view of an anvil member; -
FIG. 6A is a top plan view of a staple pocket; -
FIG. 7A is a side view of an unformed staple; -
FIG. 7B is a side view of the staple ofFIG. 7A formed to a first configuration in accordance with the present disclosure; -
FIG. 7C is a side view of the staple ofFIG. 7A formed to a second configuration in accordance with the present disclosure; -
FIG. 7D is a side view of the staple ofFIG. 7A formed to a third configuration in accordance with the present disclosure; -
FIG. 7E is a side view of the staple ofFIG. 7A formed to a fourth configuration in accordance with the present disclosure; -
FIG. 7F is a plan view of the staple ofFIG. 7B showing an overlap between first and second legs of the staple; -
FIG. 8A is an enlarged side view of a staple pocket, an unformed staple, a staple sled, and a rod sled; -
FIG. 8B is an enlarged side view of the components ofFIG. 8A showing the staple formed into a first configuration; and -
FIG. 8C is an enlarged side view of the components ofFIG. 8B showing a backspan of the staple being dimpled by the dimpling rod. - Embodiments of the presently disclosed surgical instrument will now be described in detail with reference to the drawings, in which like reference numerals designate identical or corresponding elements in each of the several views. As used herein, the term “distal” refers to that portion of the instrument, or component thereof which is further from the user while the term “proximal” refers to that portion of the instrument or component thereof which is closer to the user.
- An example of a surgical stapling apparatus is disclosed in U.S. Pat. No. 5,480,089 to Blewett, currently owned by and assigned to United States Surgical, a division of Tyco Healthcare, the contents of which are hereby incorporated by reference in their entirety. Referring to
FIG. 1 , a staple fastening assembly, shown generally as 100, includes a fixedfirst jaw 104, a moveablesecond jaw 140, and ajaw operating mechanism 160. In one embodiment,staple fastening assembly 100 is adapted for use in connection with endoscopic or laparoscopic stapling instruments as are known in the art. -
First jaw 104 includes astaple magazine 120 having a firsttissue contacting surface 122. A plurality ofretention slots 124 is included instaple magazine 120 where they are arranged inrows 126 on first tissue contacting surface 122 (seeFIG. 4 ). Eachrow 126 generally extends along a longitudinal axis offirst jaw 104. Firsttissue contacting surface 122 is generally elongate. Eachretention slot 124 is configured for receiving astaple 110 and a staple ejector assembly. The staple ejector assembly includes astaple ejector 132, a dimpling rod 138 (seeFIG. 5 ), astaple sled 134, and arod sled 136. It is contemplated thatstaple magazine 120 may be removably attached tofirst jaw 104. In a configuration wherestaple magazine 120 is a removable structure, once its complement ofstaples 110 have been expended, it may be removed and anew staple magazine 120 is attached tofirst jaw 104. Eachstaple magazine 120 includes a full complement ofstaples 110 and at least one staple driving assembly 130 (shown inFIG. 5 and discussed in detail below). -
Staple magazine 120 includes a plurality of longitudinal channels 128 (seeFIGS. 3 and 4 ) that are adapted for slidably receivingstaple sled 134 androd sled 136. The number ofchannels 128 corresponds to the number ofrows 126 ofstaples 110 included instaple magazine 120. In one embodiment,staple magazine 120 include at least tworows 126 ofstaples 110, although the procedure being performed, characteristics of the tissue to be fastened, and other considerations are factors in determining the number ofrows 126, as well as the number ofstaples 110, included in eachstaple magazine 120. Eachrow 126 in the plurality of rows has an identical quantity ofstaples 110. - Referring now to
FIGS. 5 and 8A-8C , in conjunction withFIGS. 1-3 ,staple driving assembly 130 is shown and it includes astaple ejector 132,staple sled 134,rod sled 136, and adimpling rod 138. Eachstaple sled 134 is operatively coupled to a drive mechanism (not shown) of the surgical stapling instrument using structures that are known in the art. An example of such an instrument that includes a drive mechanism and an actuation mechanism is disclosed in U.S. Pat. No. 6,669,073 to Milliman et al., currently owned by and assigned to United States Surgical, a division of Tyco Healthcare, the contents of which are hereby incorporated by reference in their entirety. In embodiments that include a plurality ofrows 126, staple sleds 134 are operatively coupled to the drive mechanism such that their longitudinal travel is synchronized for ejecting acolumn 127 of staples 110 (seeFIG. 4 ) substantially simultaneously during an actuation sequence. Operation of the drive mechanism results in proximal and distal movement of the respective cams in response to actuation of the actuation mechanism. -
Staple sled 134 is a generally elongate structure having a pair ofinclined surfaces staple magazine 120.Inclined surfaces passage 135 c therebetween.Passage 135 c is substantially flat and dimensioned for slidably receivingrod sled 136.Rod sled 136 is a generally inclined structure having a substantially similar incline to that ofstaple sled 134. Further still,staple ejector 132 includes a pair oflegs inclined surfaces body 132 d ofstaple ejector 132 and is dimensioned for slidably receivingdimpling rod 138. - Upon actuation of the actuation mechanism,
staple sled 134 is driven throughstaple magazine 120 in a generally distal direction by the drive mechanism. As it translates throughstaple magazine 120,staple sled 134 sequentially engages eachstaple ejector 132.Staple sled 134 andstaple ejector 132 have engaging surfaces with complementary angles such that distal horizontal motion ofstaple sled 134 results in vertical motion ofstaple ejector 132 which, in turn, drivesstaple 110 in a generally vertical direction towardsanvil member 142. During distal movement ofstaple sled 134,rod sled 136 remains stationary in a proximal region of the magazine. In instances where a staple height of less than about 2.5 mm is desirable, as determined bytissue gap 102, the actuation mechanism actuates the drive mechanism and drivesrod sled 136 distally as will be discussed in detail hereinafter. - With reference to
FIGS. 2 and 3 , agap sensor 106 is disposed in a proximal portion ofstaple fastening assembly 100.Gap sensor 106 is a generally elongate structure having a throughhole 109 disposed near one end. Further still,gap sensor 106 is fixedly attached tosecond jaw 140 and slidably received in anopening 105. Adimple window 103 is disposed near a proximal portion offirst jaw 104 and is configured for slidably receiving adimpling rod driver 107.Dimpling rod driver 107 is operatively coupled to the actuation mechanism and engagesstaple dimpling cam 136 whendimple window 103 is aligned withdimpling rod driver 107.Gap sensor 106 is configured and dimensioned such thatdimpling window 103 is aligned withdimpling rod driver 107 only whentissue gap 102 indicates that a staple height of less than about 2.5 mm is desired. - In an embodiment having a staple height of less than about 2.5 mm,
staple sled 134 leads rod sled 136 (FIG. 5 ) during their travel throughstaple magazine 120. Asstaple sled 134 translates distally throughstaple magazine 120,rod sled 136 follows it after a predetermined time delay.Rod sled 136 is guided along its path bypassage 135 c ofstaple sled 134. Therefore,staple sled 134 ejectsstaple 110 and drives it againstanvil member 142 to form a staple having a height of about 2.5 mm as discussed above. Oncestaple 110 has been driven intostaple pocket 150, and beforestaple sled 134 passes staple ejector 132 (i.e. the delay between the sleds),sled 136 engagesdimpling rod 138. Asrod sled 136 translates distally withstaple sled 134, itcontacts dimpling rod 138 causing vertical motion thereof to engagebackspan 116.Rod sled 136 drivesdimpling rod 138 such that it forms a depression in the center ofbackspan 116 and further increasing the holding strength of the formedstaple 110. - As shown in
FIG. 4 ,staple magazine 120 may have a plurality ofrows 126 whereretention slots 124 in eachrow 126 may be longitudinally offset fromretention slots 124 in anadjacent row 126. Sinceretention slots 124 are longitudinally offset,staple crimping cams 134 are operatively arranged and synchronized to eject thefirst staple 110 from eachrow 126 and advancing sequentially towards a distal end ofstaple magazine 120 and sequentially ejectingstaples 110 from eachrow 126. - As shown in
FIGS. 1-3 ,second jaw 140 is spaced apart fromfirst jaw 104 defining atissue gap 102 therebetween.Second jaw 140 is moveable through a plurality of positions between an open position and a closed position. In one embodiment,first jaw 104 andsecond jaw 140 are substantially parallel to one another throughout the plurality of positions. During operation, discussed in detail below, ofstaple fastening assembly 100,second jaw 140 is moved towardsfirst jaw 104 byjaw operating mechanism 160 that maintains a substantially parallel relationship betweenjaws - Referring to
FIG. 1 ,jaw operating mechanism 160 is disposed in ahousing 170 and includes acam 162, acable 164, and aspring 166.Cam 162,cable 164, andspring 166 are operatively connected to one another. A proximal portion ofsecond jaw 140 is disposed withinhousing 170 and secured thereto. In particular,spring 166 is operatively coupled to an approximating mechanism (not shown) of the stapling instrument by structures as are known in the art. The approximating mechanism causesspring 166 to move proximally. Sincecable 164 is operatively connected tospring 166, this proximal movement ofspring 166 results in proximal movement ofcable 164 and counter-clockwise rotation ofcam 162. - At least a portion of
cam 162 contacts anouter surface 146 ofsecond jaw 140 and it is self-locking in the counter-clockwise direction of rotation.Cam 162 has a centrally disposedorifice 163 for rotatably attaching it tohousing 170. Althoughorifice 163 is substantially circular,cam 162 has a generally eccentric shape, particularly along an outside surface, such that counter-clockwise rotation ofcam 162 causes at least a portion ofcam 162 to maintain contact withouter surface 146 thereby urgingsecond jaw 140 towardsfirst jaw 104 during counter-clockwise rotation. Aftercam 162 has rotated a desired amount, it locks in position such that no clockwise rotation is possible (i.e. self-locking), but additional counter-clockwise rotation is possible. A release mechanism, as is known in the art, operatively couplesjaw operating mechanism 160 to the surgical stapling instrument. After a complete actuation sequence, the release mechanism is actuated to unlockcam 162 and permit clockwise rotation ofcam 162. Thusly,second jaw 140 is urged away fromfirst jaw 104 by a biasing mechanism as is known in the art to separate the jaws and allow removal of the surgical stapling instrument. - In one embodiment,
cam 162,cable 164, andspring 166 are selected such that tissue T is captured and maintained betweenjaws cam 162,cable 164, andspring 166 captures different thicknesses of tissue T (i.e. each tissue thickness corresponds to a particular tissue gap 102) while minimizing trauma to tissue T asjaws - Referring now to
FIG. 6 , ananvil member 142 is illustrated.Anvil member 142 is generally elongate and includes a plurality of staple pockets 150 (seeFIG. 6A ) disposed on an secondtissue contacting surface 144 where the number and arrangement ofstaple pockets 150 correspond to the number and arrangement ofretention slots 124 in firsttissue contacting surface 122. An example of a staple pocket is disclosed in U.S. Pat. No. 5,480,089 to Blewett. With reference now toFIG. 6A , eachstaple pocket 150 has a first stapleleg forming groove 152 and a second stapleleg forming groove 154 for formingrespective legs FIG. 7A ). Eachstaple forming groove legs - Staple
leg forming grooves intermediate point 156. A substantially lemniscate (figure-eight shaped curve) channelingsurface 158 is also formed in secondtissue contacting surface 144 around a perimeter ofstaple pocket 150. Each channelingsurface 158 forms an angle θ, with respect to a plane defined by secondtissue contacting surface 144, wherein 0°<θ<90°. Eachstaple forming groove surface 158. More particularly, eachstaple forming groove sloped end staple leg backspan 116 ofstaple 110. Sloped ends 152 a, 154 a are longitudinally opposed to one another. - During an actuation sequence,
staple 110 is ejected fromretention slot 124 and directed towardsanvil member 142 thereby drivinglegs staple forming grooves staple 110 contactsstaple pocket 150,staple forming grooves direct legs legs FIG. 7F . In particular, with reference toFIGS. 7B-7D , during formation ofstaple 110,staple forming groove 152, in cooperation with channelingsurface 158, directsleg 112 towardsbackspan 116 alongside and substantially parallel to an unformed portion ofleg 114. Similarly,staple forming groove 154, in cooperation with channelingsurface 158, directsleg 114 towardsbackspan 116 alongside and substantially parallel to an unformed portion ofleg 112. The amount of parallel overlap betweenleg 112 and the unformed portion ofleg 114 is a function oftissue gap 102. Similarly, the amount of parallel overlap betweenleg 114 and the unformed portion ofleg 112 is also a function oftissue gap 102 that is controlled by the thickness of tissue T and operation ofjaw operating mechanism 160. - Thusly, a
larger tissue gap 102 results in alarger staple 110 height (e.g. about 4.8 mm as shown inFIG. 7B ) while asmaller tissue gap 102 yields asmaller staple 110 height (e.g. about 2.5 mm as shown inFIG. 7D ). In one embodiment, the actuation mechanism, in cooperation withstaple magazine 120 andanvil member 142,forms staples 110 having a height of between about 4.8 mm (i.e. the open position of second jaw 140) and about 2.5 mm (i.e. the closed position of second jaw 140) as determined by the thickness of tissue T andtissue gap 102. It is to be understood thatstaples 110 may be formed having any height that is in the range of about 4.8 mm and about 2.5 mm as determined by the thickness of tissue T (an example is illustrated inFIG. 7C ). In instances where tissue T thickness indicates a need for asmaller staple 110 height (i.e. less than about 2.5 mm or the dimpling position as seen in FI. 7E), the actuation mechanism of the stapling instrument operates a second drive member that is operatively coupled torod sled 136, as discussed hereinabove. - It will be understood that various modifications may be made to the embodiments disclosed herein. Therefore, the above description should not be construed as limiting, but merely as exemplifications of preferred embodiments. For example, the staple forming structure disclosed herein can be adapted and configured for use in EEA, TA, and endoscopic staplers with similar effect. Those skilled in the art will envision other modifications within the scope and spirit of the claims appended hereto.
Claims (20)
1-15. (canceled)
16. A surgical apparatus comprising:
a first jaw including retention slots;
a second jaw including pockets, each pocket having a first groove and a second groove; and
a fastener disposed in each of the retention slots, each of the fasteners including first and second legs interconnected by a backspan, the first and second legs each having undeformed portions that are parallel to one another, each of the first grooves configured to direct the first leg of a respective one of the fasteners towards the unformed portion of the second leg and towards the backspan such that a first formed portion of the first leg is positioned alongside and parallel to the unformed portion of the second leg, each of the second grooves configured to direct the second leg of the respective one of the fasteners towards the unformed portion of the first leg and towards the backspan such that a first formed portion of the second leg is positioned alongside and parallel to the unformed portion of the first leg.
17. The surgical apparatus of claim 16 , wherein the first and second legs include second formed portions and the first and second grooves are configured to direct the first and second legs of the respective fastener towards each other while maintaining lateral separation of the second formed portions of the first and second legs.
18. The surgical apparatus of claim 16 , further comprising a first driving mechanism and a second driving mechanism, the first driving mechanism configured to urge each of the fasteners towards a respective pocket and including a first sled and an ejector, and wherein distal longitudinal movement of the first sled through the first jaw causes movement of the ejector towards the second jaw to urge each of the fasteners towards the respective pocket of the second jaw, the second driving mechanism including a second sled and a movable member, wherein distal longitudinal movement of the second sled through the first jaw causes movement of the movable member towards the second jaw, the movable member configured to deform the backspan of each of the fasteners.
19. The surgical apparatus of claim 18 , wherein the moveable member of the second driving mechanism is operable to deform the backspan of each of the fasteners when a distance between the first and second jaws is less than a predetermined value.
20. A surgical apparatus comprising:
a first jaw including a plurality of retention slots;
a second jaw including a plurality of pockets, each of the pockets having a first groove and a second groove; and
a fastener disposed in each of the plurality of retention slots, each of the fasteners including first and second legs, the first groove configured to direct the first leg towards the second leg and the second groove configured to direct the second leg towards the first leg resulting in formed and unformed portions in each of the first and second legs, the formed portion of the first leg positioned alongside and parallel with the unformed portion of the second leg.
21. The surgical apparatus of claim 20 , wherein the first and second grooves are parallel to each other.
22. The surgical apparatus of claim 20 , wherein the first and second grooves are symmetrical about an intermediate point.
23. The surgical apparatus of claim 20 , wherein the first and second grooves each have a sloped end portion.
24. The surgical apparatus of claim 23 , wherein the sloped end portion of the first groove is longitudinally opposed to the sloped end portion of the second groove.
25. The surgical apparatus of claim 23 , wherein the second jaw includes a tissue contacting surface defining a plane and each of the pockets includes a channeling surface around a perimeter of the pocket, the channeling surface forming a first angle with respect to the plane of the tissue contacting surface.
26. The surgical apparatus of claim 25 , wherein first angle is between 0° and 90°.
27. The surgical apparatus of claim 25 , wherein the sloped end portion of the first groove defines a second angle with respect to the plane of the tissue contacting surface and the sloped end portion of the second groove defines a third angle with respect to the plane of the tissue contacting surface, each of the second and third angles being different than the first angle.
28. A surgical apparatus comprising:
a first jaw including a plurality of retention slots;
a second jaw including a plurality of grooves; and
a plurality of fasteners disposed in the plurality of retention slots, each fastener of the plurality of fasteners including first and second legs interconnected by a backspan, the first and second legs each having undeformed portions that are parallel to each other, wherein each groove of the plurality of grooves is configured to direct the first and second legs of one of the plurality of fasteners towards each other such that each of the first and second legs includes a formed portion, the formed portion of the first leg being parallel to and at least partially overlapping the unformed portion of the second leg.
29. The surgical apparatus of claim 28 , wherein each groove of the plurality of grooves is configured to direct the first leg and the second leg of the fastener towards each other while maintaining lateral separation of the legs.
30. The surgical apparatus of claim 28 , wherein the formed portion of the second leg at least partially overlaps the unformed portion of the first leg.
31. The surgical apparatus of claim 29 , wherein the formed portion of the second leg includes a section parallel to the unformed portion of the first leg.
32. The surgical apparatus of claim 28 , further including a first driving mechanism and a second driving mechanism, the first driving mechanism configured to urge each fastener of the plurality of fasteners towards a respective groove of the plurality of grooves and including a first sled and an ejector, and wherein distal longitudinal movement of the first sled through the first jaw causes movement of the ejector towards the second jaw and urges each fastener of the plurality of fasteners towards a respective groove of the plurality of grooves and the second driving mechanism includes a second sled and a movable member, wherein distal longitudinal movement of the second sled through the first jaw causes movement of the movable member towards the second jaw, the movable member configured to deform the backspan of each fastener of the plurality of fasteners.
33. The surgical apparatus of claim 28 , wherein the formed portion of the first leg is alongside the unformed portion of the second leg.
34. The surgical apparatus of claim 28 , wherein the formed portion of the second leg is alongside the unformed portion of the first leg.
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2008
- 2008-03-20 AU AU2008231109A patent/AU2008231109B2/en not_active Ceased
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- 2008-03-20 US US12/529,576 patent/US8205780B2/en not_active Expired - Fee Related
- 2008-03-20 WO PCT/US2008/057599 patent/WO2008118728A1/en active Application Filing
- 2008-03-20 EP EP17158316.4A patent/EP3195814A1/en not_active Withdrawn
- 2008-03-20 EP EP08744103.6A patent/EP2139411B1/en not_active Revoked
- 2008-03-20 ES ES08744103.6T patent/ES2627617T3/en active Active
- 2008-03-20 CA CA2681186A patent/CA2681186C/en not_active Expired - Fee Related
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2012
- 2012-01-05 US US13/343,743 patent/US8403198B2/en not_active Expired - Fee Related
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2013
- 2013-02-27 US US13/778,735 patent/US9597073B2/en not_active Expired - Fee Related
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2014
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2017
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Publication number | Priority date | Publication date | Assignee | Title |
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US10881400B2 (en) | 2016-11-18 | 2021-01-05 | Olympus Corporation | Medical stapler system |
Also Published As
Publication number | Publication date |
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US8205780B2 (en) | 2012-06-26 |
AU2008231109B2 (en) | 2013-01-10 |
WO2008118728A1 (en) | 2008-10-02 |
CA2681186A1 (en) | 2008-10-02 |
ES2627617T3 (en) | 2017-07-28 |
EP3195814A1 (en) | 2017-07-26 |
US20100006620A1 (en) | 2010-01-14 |
JP5394265B2 (en) | 2014-01-22 |
EP2139411A1 (en) | 2010-01-06 |
JP5685334B2 (en) | 2015-03-18 |
JP2014144365A (en) | 2014-08-14 |
US20120145768A1 (en) | 2012-06-14 |
EP2139411A4 (en) | 2013-08-14 |
EP2139411B1 (en) | 2017-05-03 |
US9597073B2 (en) | 2017-03-21 |
JP2010522035A (en) | 2010-07-01 |
US20130233905A1 (en) | 2013-09-12 |
US8403198B2 (en) | 2013-03-26 |
AU2008231109A1 (en) | 2008-10-02 |
JP2013078621A (en) | 2013-05-02 |
JP5683564B2 (en) | 2015-03-11 |
CA2681186C (en) | 2015-07-21 |
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