CH717179B1 - Training device for the training of minimally invasive doctors. - Google Patents

Abstract

The invention relates to a training device (1) for doctors, comprising a carrier plate for supporting exercise elements and a plurality of pivotally mounted receptacles arranged at a distance from the carrier plate for passing through and fastening surgical instruments, the receptacles (11) being mounted on a column (3) are movably arranged in the x, y and z direction and can be locked in a set position.

Description

The subject of the invention is a training device for the training of minimally invasive doctors according to the preamble of patent claim 1.

[0002] Laparoscopy (= abdominal endoscopy) is generally understood as a method for examining the abdomen (ancient Greek: lapara = abdomen (cavity)). It is used for diagnostics and to carry out minimally invasive operations, i.e. operations using keyhole technology. Laparoscopy is performed with a laparoscope or an endoscope. Originally, the abdominal cavity was directly inspected via a tube with a lens system (optics). Today it is a video camera system in which images from the abdominal cavity are transmitted digitally to a monitor. The “scopy” (ancient Greek: skopia = observe) can also be performed in other body cavities and regions (e.g. chest cavity: thoracoscopy, etc.) In minimally invasive surgery (MIS) or (especially for the abdominal cavity) laparoscopic surgery (MIS under video-assisted laparoscopy), both the camera (endoscope) and the required (especially long) surgical instruments are inserted through sleeves (trocars) via small incisions in the inserted into the abdominal cavity.

Operating with these specially long instruments under video monitoring represents a considerable challenge for every surgeon and therefore requires lengthy and intensive training. The following difficulties must be overcome and appropriate compensation mechanisms must be learned: Fine and targeted work with extended instruments: After the handle, a mechanical translation in a mostly 33cm long shaft leads to different tools at the tip of the instrument (clamps, scissors, spreading tool, etc.). Significantly changed haptics: The sensors of the hand and fingers to tissues and organs (also via classic "short" instruments that are held directly in the hand) differ significantly from the sensory perception of laparoscopic instruments. It is greatly reduced or increased in laparoscopic surgery. changes. The fabric and layer feel is also significantly limited. Stereotactic, 3-dimensional vision, experience and action: The basic problem of the new laparoscopic surgical technique is that a 3-dimensional body and a 3-dimensional handicraft is depicted in a 2-dimensional video image. This makes stereotactic vision with the eyes impossible. Substitute compensation mechanisms must be developed and learned in order to compensate for this deficit. Analogous to this, the 3-dimensional experience and action is extremely difficult due to the lack of visual control and requires intensive training. The "feeling/sensing" in which 3-dimensional position a body is in the abdominal cavity and how to move such a body 3-dimensionally, optimally vectorially, is initially very poorly developed and requires long training. Finally, a good surgeon can recognize how a body is positioned in space and in which vectorial direction (3-dimensional sum vector of the x,y,z plane) he has to move this body for optimal surgical preparation (rotation, translation). Overview and orientation (macro signals): The area displayed on the monitor during a laparoscopic operation usually only corresponds to a fraction of the entire abdominal cavity. The target region should be optimally represented by the magnifying effect of the camera system like a magnifying glass. However, the overview resp. limited overview. This can affect orientation due to the lack of landmarks (fixed points) and the ability to receive "macro signals". "Macro signals" are impressions that are received unconsciously, analyzed and forwarded to the brain with the appropriate priority. "Receiving macro signals" is a learned subconscious ability to "keep the whole picture in mind" and to react to certain stimuli. In this way, alarm signals are also subconsciously received at the edge of the field of vision and alert the surgeon if something is wrong outside of his focus. Reduced available space: In some cases, the patient must be positioned in extreme positions (head high/down) in order to obtain sufficient space for the operation. Here, due to the force of gravity, the mobile intestine is relocated to lower-lying areas of the abdominal cavity. Physical laws: In laparoscopic surgery, e.g. T new physical laws relevant or known ones have a new, different degree of effectiveness: leverage, hypomochlion, shear/friction forces, Fulcrum effect (fulcrum effect), triangulation, working and manipulation angles, coaxial and lateral position to the patient, degrees of freedom of the instruments, interference, etc.). All of these influences initially make the operation difficult and must be re-learned and implemented in the surgical procedure.

Basic medical-technical specifications:

[0004] Special training is required so that these skills and abilities are not first learned on the patient. The setting and the possibilities of such a technical training unit should cover as many of these criteria as possible: 1. Bi-manual training 2. Training of eye-hand coordination 3. Adaptation of the new relevant physical conditions in laparoscopic handling 4. Training of sensorimotor compensation mechanisms. Mastery of fine and targeted work despite overly long instruments. Be familiar with the changed feel. 5. Training in 3-dimensional vision, experiencing (imagining) and acting 6. Orientation and adequate ability to act under limited space. Training in laparoscopic handling, even with limited space and cramped conditions.

[0005] This results in basic equipment-technical specifications: The training device itself should technically enable the medical-technical criteria mentioned under points 1 - 6 to be able to be trained optimally. This requires the following adjustment, installation and setting options: In general, the training device should contain the following components: 1. A central fixation for modular application of training elements, 2. At least two holding devices for trocars for inserting laparoscopic instruments that hold any point of a training element ( from both instruments) in an intersection of usually optimal a max. radius of 15-20cm (rarely up to 25cm on one side) can reach (central, lateral, above, below), 3. Optional (but desirable) a "video camera Monitor” system.

In order to gain basic knowledge of the laparoscopic surgical procedure and, in the course, a high level of expertise in the necessary abilities and sensorimotor skills/skills, devices are already known with which the surgeon can train the activities outside the human body that are necessary during the operation. In the simplest form of such devices, two surgical instruments are each inserted through a hole into a box in which an artificial sample organ can be processed on the screen using image acquisition with a camera (WO 99/42978, WO 2005/037057). However, such training devices are unsatisfactory.

[0007] Most of the training devices available on the market have (in some form) more or less great limitations on the actual need of a training device for surgeons. The following list reflects the current reality: Training units or (artificial) organs to be processed are often fixed to a permanently mounted plate in a horizontal or inclined plane, so that it is not possible to feel resistance on the instruments as it exists in reality Usually there are only possibilities to use 2-dimensional training units In most devices, the instruments are stored in ball sockets or the like in the wall or the lid of a box, so that their position is uniquely fixed. The holding devices for the instruments in the boxes practically never correspond to the conditions when instruments are passed through the elastic abdominal wall and are given resistance to longitudinal displacement as well as to rotary or pivoting movements depending on their position. There is usually a fixed working direction with the instruments, since the training box is on a table: = the instruments run from top to bottom. However, this contradicts many and very common operations (e.g. operations on the gallbladder, hernia, rectum, etc.: here, due to the extreme positioning of the patient, the direction of the overly long instruments often runs from bottom to top. Most training boxes are closed box systems without direct control and supervision of the training element. Rarely are there open systems, but then without the possibility of camera-monitor training. If a camera is available, the setting options are extremely limited. The most common camera position in a box only allows one viewing direction: diagonally from top to bottom, in the middle. A training tool can practically never be adjusted from the height of the working level in such a way that it would also be optimal for very small or very large people, which is always possible in the operating room (with the height-adjustable tables).

An object of the present invention is to create a new, innovative, needs-adapted and optimal training device (tools) for the training of minimally invasive surgical techniques for the fields of surgery, gynecology, urology, thoracic surgery, orthopedics, etc., which the surgeon essentially provides realistic conditions that he finds again later when used on patients.

The following preferably applies: a. The tool must be sufficiently stable and heavy to withstand tensile forces during training. b. The dimensions of the tool must be large enough to allow different training modules of different sizes and shapes to be used. c. The tool must take into account the geometric locations (effective radius of the laparoscopic instruments or their working length: max. 33 cm). i.e. The working height of the tool (basic training level) must be adjustable so that people of different heights can use it optimally e. The tool must have a fixation system that allows different modular training units to be deployed and used. f. The tool must be designed for both 2-dimensional (i.e. planar) and 3-dimensional (i.e. spatial, physical) training units, g. The tool must be designed in such a way that the following elements can be adjusted and fixed as required: • Basic training level (target (= exercise/training unit) and trocar holder): Must be forward/down resp. can be tilted up/back • Trocar holder: Adjustable in height to the basic training level, in the lateral (horizontal) angles to the right and left of the target, in the inclination (vertical) to the target and in the distance to the target • Training unit holder (target): Must forward/ down resp. be tiltable up/back h. (Optional) video camera monitor system: A training tool can be closed (then a camera system is needed) or open (= training can be directly viewed/observed). It is optimal if both options are available in one training device (at the beginning direct stereotactic view of the training action, later training via monitor: 2D image transferred to a 3D action and observation). When using a camera system, it is extremely important that this camera can be used extremely flexibly. It must be ensured that with an optimal training device (including 3-dimensional training units), the camera can show the training from any perspective: from above, from both sides, from below and from all oblique directions in between. The camera should not obstruct the laparoscopic instruments or get in the way. It must also not obstruct the view of the training element (as a direct visual 3D control) or the monitor.

[0010] This object is achieved by a training device according to the features of patent claim 1. Advantageous configurations of the training device are defined in the dependent claims.

[0011] The basic medical-technical specifications as well as the specifications for the technical equipment described in the introduction have been implemented to the greatest possible extent in the present invention.

The training device is characterized by its unique selling point in the implementation of all relevant needs of a surgeon to a realistic training simulation of a minimally invasive operation. He achieves this through a combination of all relevant setting options for the training units, the instrument holder, the camera positioning and the working level, as well as the implementation and realization of the didactically important possibility of knowledge-relevant training units both in a plan, 2-dimensional form and in a physical, 3 - dimensional form to be able to implement. All of this is monitored by a highly flexible camera system with the highest image quality and almost real-time transmission.

Thus, all relevant senso-motor skills can be realistically trained by the appropriate training units.

[0014] During training on the present training device, the surgeon is given the feeling and thus the routine of being able to train relevant sensory-motor skills on the one hand and, in a figurative sense, on the other hand, a non-rigid object (an organ or tissue corresponding to the conditions in a real operation).

In order to be able to set a suitable realistic angular position between two surgical instruments, the instruments are mounted on swivel arms whose mutual angular position can be adjusted. Both the angle between the two pivoting arms and the position of the pivoting arms in relation to the standing position of the surgeon can be adjusted. For this purpose, the pivoting arms are attached pivotably on a common axis or on axes lying next to one another.

Furthermore, the resistance to the axial displaceability of the surgical instruments can be adjusted, i.e. the resistance to axial displacement, as occurs on the human body through the abdominal wall, can be adjusted.

Furthermore, the pivoting of the surgical instruments can also be adapted to reality on the articulated axial guide of the surgical instruments, i.e. pivoting is not possible without resistance, but suitable means are provided to adapt the pivoting forces to the realistic conditions.

Another advantage of the training device according to the invention is that the position of the attachment and guidance of the surgical instruments to the distance to the training units (to the body part to be operated on), here to the training units attached to the support plate, can be adjusted. It is therefore also possible to adjust to the patient's individual proportions, such as the thickness of the abdominal wall to be penetrated.

The support plate can also be placed in an inclined position to give the surgeon the opportunity to perform operations from different angle perspectives, as is often the case inside the body.

A three-dimensionally movable mounting of the support plate for the training unit to be processed makes it possible to realistically specify the conditions as they exist when operating on organs in the abdominal cavity. In particular, the non-rigid mounting of the training units to be processed (simulated body parts) offers the surgical instruments or the surgeon real spatial conditions and counteracts corresponding forces. For example, during training (corresponding to a preparation on an organ), parts of the training tool (organ/tissue) can try to avoid the manipulation, so that the surgeon has to follow the evasive part. Not only in the axial direction to the surgical instrument, but three-dimensionally, since the tools are not held on a rigid plate.

To achieve this, the support plate is mounted on a ball joint, for example, or the connection between the support plate and a support arm for the support plate is made of an elastic material such as rubber, such that deflection on all sides by the surgical instrument on the body executed force takes place. If two instruments are used, as is customary, forces are introduced by both instruments, which always lead to a displacement or evasion of the object to be operated on.

Using an illustrated embodiment, the training device is described below. It shows: Figure 1 a perspective view of a training device for the training of surgeons, Figure 2 a perspective view of the training device without the support plate and the camera, Figure 3 a perspective rear view of the training device with the support plate, Figure 4 a perspective detailed view of a swivel arm for an instrument holder and the adjustable elements, Figure 5 shows a perspective detailed view of the support plate with a fictitious body part on a tripod and Figure 6 shows a vertical section through the support plate in Figure 5.

[0023] Reference number 1 designates a training device. This includes a column 3 which is fastened to a base plate 5 . Two swivel arms 9 are attached to the column 3 with a sliding bracket 7 . The pivoting arms 9 are pivotably arranged on separate pivoting axes or preferably on a common axis A. The swivel arms 9 carry receptacles 11 for surgical instruments 13 at their ends. A camera arm 17 can be arranged at the upper end of the column 3, at the end of which a camera 19 or a mirror which directs an image to a camera not shown in the figures is attached.

The support plate 15 rests on a tripod 21 which carries the support plate 15 at its upper end and at its lower end on a base 23 which is pivotable about a horizontal pivot axis B and lockable. The base 23 can be pivoted and locked in the set position by a first lever 25 . The base 23 is also guided around a further horizontal axis C on a circular path section. For this purpose, the axis C is arranged in a shaft 27 to which two guide plates 29 are fastened as a pair of supports. The base 23 is fastened to these guide plates 29 . The shaft 27 can be pivoted and locked by a second lever 31 . With the guide plates 29, the height of the base 23 and thus of the support plate 15 attached thereto can be adjusted with respect to the base plate 5.

In the base 23 a bore 33 is formed, in which the tripod 21 for the support plate 15 is received. The support plate 15 is mounted in an articulated manner at the upper end of the stand 21 by a bearing element 35, with which the support plate 1 is pivotably mounted in all directions.

The bearing element 35 can consist, for example, of a ball at the upper end of the tripod 21 and a socket on the underside of the support plate 15. Of course, these two elements can also be arranged in reverse, i.e. the socket sits on the stand 21 and the ball is connected to the support plate. Alternatively, the bearing element 35 can also be constructed from a rod section made of rubber or an elastic plastic (not shown). Furthermore, there is preferably a connecting element 53 between the edge area of the support plate 35 and the stand 21 in order to hold it in a basic position, for example at right angles to the stand 21, when no forces are acting on the surface of the support element 35. The connecting element 53 can consist of elastic cords or straps which are attached to the support plate 15 and the stand 21 (FIGS. 5, 6).

Of course, the three-dimensional pivotability of the carrier element 35 could also be effected by a universal joint as a bearing element 35.

The support plate 15 serves as a support for training models such as hoses as an imitation of blood vessels, three-dimensional structures with different strength or hardness, for example, simulating other body parts in the human body where 13 operations must be carried out with the surgical instruments. These bodies generally simulate body parts to be operated on in order to make incisions and practice stitches to close the incisions, but also to singe areas of body parts such as small veins or to treat them with laser light and so on. The simulated body parts 55 on the carrier plate 15 can be firmly connected to it and the entire carrier plate 15 is replaced for each exercise or the body parts 55 can be removed individually and are temporarily attached to the surface of the carrier plate 15 with fastening means such as screws, velcro or other elements held during their surgical processing.

The position or the engagement angle between the two or more surgical instruments 13 can be set and adjusted more or less as desired. The pivoting arms 9 can be pivoted about the axis or axes A and the respective suitable pivoting position or the angle between the pivoting arms 9 can be determined individually and is reproducible if, for example, the locking and guiding element 37 consists of a partially circular plate 41. As shown in FIGS. 1 to 3, this can be T-shaped, with a slot 44 being formed in the leg 43 in the shape of a circular arc, through which the locking screws 45 can be passed.

Furthermore, the receptacles 11 for the surgical elements 13 are articulated on a slide 47 which is arranged to be displaceable and lockable radially along the swivel arms 9 . The receptacles 11 are carried by support arms 49 which are pivotably and lockably fastened with a joint 51 on the slide 47 so as to be pivotable. A corresponding scale can be printed on the support arms 49 for reproducible swivel arm alignment. The joint 51 on the slider 47 is pivotably mounted about a vertical axis D.

The receptacle 11 for the surgical instrument 13 is further pivotable about a substantially horizontal axis E at the upper end of the support arm 49. Furthermore, the surgical instrument 13 can be displaced axially in the receptacle 11 . It follows that the surgical instrument 13 can be pivoted on the pivot arm 9 about the horizontal axis A, radially displaceable on the pivot arm 9, pivoted on the slider 47 about a vertical axis D and pivoted about a horizontal axis on the joint 51 and further the axis E is pivotably mounted at the end of the support arm. This means that the surgical element 13 can essentially assume any desired position and thus the surgeon can also carry out all the necessary processing inside the human body with two instruments. During an operation, only the ability to pivot the pivoting arms and the support arms 49 is preferably preset.

Both the support plate 15 with its bearing element 35 and the swivel arms 9 can be moved together with the bracket 7 in the vertical direction on the column 3 and thereby the altitude can be adjusted. All of this enables the surgeon to use the training device 1 to practice all surgical interventions that occur on the human body.

As shown in the figures, the training device 1 can be used "on sight", i.e. the surgeon can directly see the position of the instruments with which he simulates operations. Of course, the view of the support plate 15 can also be covered, so that the simulated operation is recorded with a camera 19 and transmitted to a screen, not shown in the figures, as is the case with real operations on humans.

Legend of the reference numbers

1 training device 3 column 5 base plate 7 bracket 9 swivel arms 11 receptacle 13 surgical instrument 15 support plate 17 camera arm 19 camera 21 tripod 23 base 25 1st lever 27 shaft 29 guide plates 31 2nd lever 33 bore 35 bearing element 37 locking and guiding element 39 Plate 41 leg 43 scale 44 slot 45 locking means 47 slide 49 support arm 51 hinge 53 connecting element 55 body part

Claims (14)

1. Training device for training minimally invasive physicians, for example surgeons, gynecologists, urologists, in the handling of laparoscopic surgical instruments, comprising a support plate for supporting exercise elements, in particular for simulating organs and tissues, several at a distance from the support plate Arranged pivoted mounts for passing through and for attaching surgical instruments, characterized in that the receptacles (11) for the surgical instruments (13) are arranged on a column (3) so that they can be moved in the x, y and z directions and can be locked in the claimed set position. 2. Training device according to claim 1, characterized in that the receptacles (11) for the instruments (13) are arranged on the ends of pivoting arms (9) and that the pivoting arms (9) are pivotable about vertical axes. 3. Training device according to claim 2, characterized in that the pivot arms (9) have the vertical axes as a common pivot axis or as separate pivot axes A. 4. Training device according to one of claims 2 or 3, characterized in that an angle between the swivel arms (9) is adjustable and lockable. 5. Training device according to claim 4, characterized in that the angle set between the swivel arms (9) can be locked on a locking and guiding element (37) with locking means (45) and can be adjusted on a scale (43). 6. Training device according to one of claims 1 to 5, characterized in that a distance of the receptacles (11) in relation to the column (3) with a slide (47) is radially adjustable. 7. Training device according to claim 6, characterized in that each receptacle (11) is fixed at the upper end of a respective support arm (49), which support arm (49) is connected at its lower end to the slide (47). 8. Training device according to claim 7, characterized in that the support arm (49) is connected to the slide (47) by a joint (51), the joint (51) being pivotable about a vertical axis D on the slide (47). is hinged. 9. Training device according to claim 8, characterized in that the support arm (49) is articulated and lockable about a horizontal axis on the joint (51). 10. Training device according to one of claims 7 to 9, characterized in that the receptacle (11) is elastically movably connected to the support arm (49). 11. Training device according to one of claims 1 to 10, characterized in that the carrier plate (15) is mounted three-dimensionally movable for receiving fictitious body parts. 12. Training device according to claim 11, characterized in that the carrier plate (15) is mounted on a ball joint or on an elastically pivotable support arm. 13. Training device according to claim 12, characterized in that the ball joint is rigidly attached to a pivotable support arm. 14. Training device according to claim 13, characterized in that the support arm is mounted axially adjustable.