ES2622870T3 - Aparato quirúrgico que incluye un contrafuerte quirúrgico - Google Patents

Aparato quirúrgico que incluye un contrafuerte quirúrgico Download PDF

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ES2622870T3
ES2622870T3 ES09252794.4T ES09252794T ES2622870T3 ES 2622870 T3 ES2622870 T3 ES 2622870T3 ES 09252794 T ES09252794 T ES 09252794T ES 2622870 T3 ES2622870 T3 ES 2622870T3
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jaw
buttress
surgical
body portion
surgical stapling
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Lee Olson
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Covidien LP
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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
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
    • A61B17/10—Surgical instruments, devices or methods, e.g. tourniquets for applying or removing wound clamps, e.g. containing only one clamp or staple; Wound clamp magazines
    • A61B17/105—Wound clamp magazines
    • 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
    • A61B17/072—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
    • A61B17/07292—Reinforcements for staple line, e.g. pledgets
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
    • A61B17/11—Surgical instruments, devices or methods, e.g. tourniquets for performing anastomosis; Buttons for anastomosis
    • A61B17/115—Staplers for performing anastomosis in a single operation
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
    • A61B17/11—Surgical instruments, devices or methods, e.g. tourniquets for performing anastomosis; Buttons for anastomosis
    • A61B17/115—Staplers for performing anastomosis in a single operation
    • A61B17/1155—Circular staplers comprising a plurality of staples
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
    • A61B2017/0046—Surgical instruments, devices or methods, e.g. tourniquets with a releasable handle; with handle and operating part separable
    • A61B2017/00473—Distal part, e.g. tip or head
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
    • A61B2017/00831—Material properties
    • A61B2017/00862—Material properties elastic or resilient

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  • Health & Medical Sciences (AREA)
  • Life Sciences & Earth Sciences (AREA)
  • Surgery (AREA)
  • Heart & Thoracic Surgery (AREA)
  • Engineering & Computer Science (AREA)
  • Biomedical Technology (AREA)
  • Nuclear Medicine, Radiotherapy & Molecular Imaging (AREA)
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  • Veterinary Medicine (AREA)
  • Surgical Instruments (AREA)

Abstract

Un contrafuerte quirúrgico en combinación con un aparato grapador quirúrgico, comprendiendo: un aparato grapador quirúrgico (10) comprendiendo un efector de extremo (40) teniendo una primera mordaza (50) y una segunda mordaza (60), teniendo la primera mordaza (50) ranuras para sujetadores, teniendo la segunda mordaza (60) cavidades para sujetadores, y teniendo cada una de la primera y segunda mordazas (50, 60) lados y bordes de lados; y un contrafuerte quirúrgico (100, 200) comprendiendo: una porción de cuerpo (110, 210) definiendo una longitud y una anchura, teniendo la porción de cuerpo (110, 210) lados, un extremo distal y un extremo proximal, en donde la porción de cuerpo (110, 210) cubre sustancialmente una porción de al menos algunas de las ranuras para sujetadores de la primera mordaza (50) del efector de extremo (40) o de las cavidades para sujetadores de la segunda mordaza (60) del efector de extremo; al menos una banda (120, 220) conectada al extremo distal de la porción de cuerpo (110, 210) para rodear una porción del efector de extremo; caracterizado por que: el contrafuerte (100, 200) comprende además una faldilla lateral elástica (130, 230) extendiéndose transversalmente más allá de los bordes laterales de la primera mordaza (50) o de la segunda mordaza (60), y estando aplicada a los lados de la primera mordaza (50) o de la segunda mordaza (60).

Description

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DESCRIPCION
Aparato quirurgico que incluye un contrafuerte quirurgico
Antecedentes
Campo tecnico
Esta solicitud se refiere a una combinacion de un contrafuerte quirurgico y un aparato grapador quirurgico para ser usada durante la operacion del aparato grapador para aplicar una pluralidad de sujetadores quirurgicos al tejido corporal.
Antecedentes de la tecnica relacionada
Conforme los costos medicos y hospitalarios continuan aumentando, los cirujanos se esfuerzan constantemente por desarrollar tecnicas quirurgicas avanzadas. Los avances en el campo quirurgico se relacionan frecuentemente con el desarrollo de tecnicas operativas que implican procedimientos quirurgicos menos invasivos y reducen el trauma general del paciente. De esta manera, la duracion de las estancias hospitalarias puede reducirse significativamente y, por tanto, los costos hospitalarios y medicos se reducen tambien.
Aunque la descripcion presente incluye, pero no esta limitada a su uso en la cirugfa endoscopica, la cirugfa endoscopica ha realizado un gran avance en los ultimos anos reduciendo la invasividad de los procedimientos quirurgicos. En general, la cirugfa endoscopica implica la incision a traves de las paredes del cuerpo, por ejemplo, la visualizacion y/u operacion de los ovarios, el utero, la vesfcula biliar, los intestinos, los rinones, el apendice, etc. Existen muchos procedimientos quirurgicos endoscopicos comunes como la artroscopia, laparoscopia (pelviscopia), gastroentroscopia y laringobroncoscopia, solo por nombrar algunos. Tfpicamente, se utilizan trocares para crear las incisiones a traves de las que se realiza la cirugfa endoscopica. Los tubos de trocar o los dispositivos de canula se extienden hacia dentro y se dejan en el sitio en la pared abdominal para proporcionar acceso a las herramientas quirurgicas endoscopicas. Se inserta una camara o endoscopio a traves de un tubo de trocar de diametro relativamente grande que es situado en general en la incision umbilical y permite la inspeccion visual y la ampliacion de la cavidad corporal. El cirujano puede realizar entonces procedimientos de diagnosis y terapeuticos en el sitio quirurgico con la ayuda de instrumentacion especializada, tal como forceps, cuchillas, aplicadores y similares que estan disenados para ser aplicados a traves de canulas adicionales. Asf, en lugar de una incision grande (tfpicamente 30 cm (12 pulgadas) o mas) que se corta a traves de los musculos principales, los pacientes sometidos a cirugfa endoscopica reciben incisiones mas atractivas desde el punto de vista cosmetico, de entre 5 y 10 milfmetros de tamano. La recuperacion es, por tanto, mucho mas rapida y los pacientes requieren menos anestesia que en la cirugfa tradicional. Ademas, debido a que el campo quirurgico se ha ampliado mucho, los cirujanos pueden diseccionar los vasos sangumeos y controlar la perdida de sangre de mejor manera. Las perdidas de calor y agua se reducen considerablemente como resultado de unas incisiones mas pequenas. A fin de abordar las necesidades espedficas de los procedimientos endoscopicos y/o quirurgicos laparoscopicos, se han desarrollado dispositivos de grapado quirurgico endoscopico y se describen en, por ejemplo, las patentes de los EE.UU. N° 5.040.715 (Green, y otros); 5.307.976 (Olson, y otros); 5.312.023 (Green, y otros); 5.318.221 (Green, y otros); 5.326.013 (Green, y otros); y 5.332.142 (Robinson, y otros).
En muchos procedimientos quirurgicos, incluyendo aquellos involucrados en la cirugfa abierta y endoscopica, es frecuentemente necesario grapar tejido. Esto es especialmente diffcil en la cirugfa endoscopica debido a las pequenas aberturas a traves de las que se debe realizar el grapado de los tejidos. Los instrumentos para este proposito pueden incluir dos miembros alargados que se utilizan respectivamente para capturar o fijar el tejido. Los dispositivos quirurgicos en donde el tejido es primero apresado o fijado entre una estructura de mordazas en oposicion y luego unido por sujetadores quirurgicos son bien conocidos en la tecnica. Tfpicamente, uno de los miembros lleva un cartucho con sujetadores que aloja una pluralidad de grapas dispuestas en al menos dos hileras laterales mientras que el otro miembro tiene un yunque que define una superficie para formar patas de grapa conforme las grapas son impulsadas desde el cartucho de grapas. Los sujetadores tienen tfpicamente la forma de grapas quirurgicas, pero tambien se pueden utilizar sujetadores polimericos de dos partes. En general, la operacion de grapado se realiza mediante barras de leva o cunas que se desplazan longitudinalmente a traves del cartucho de grapas, las barras de leva actuan sobre los tirantes de grapas para expulsar secuencialmente las grapas del cartucho de grapas. Una cuchilla puede desplazarse entre las hileras de grapas para cortar longitudinalmente y/o abrir el tejido grapado entre las hileras de grapas. Tales instrumentos se describen, por ejemplo, en la patente de los EE.UU. N° 3.079.606 y la patente de los EE.UU. N° 3.490.675.
Una grapadora posterior descrita en la patente de los EE.UU. N° 3.499.591 aplica una doble hilera de grapas a cada lado de la incision. Esto se realiza proporcionando una unidad de carga desechable en la que un miembro de leva se mueve a lo largo de una trayectoria de grna alargada entre dos conjuntos de ranuras escalonadas que llevan grapas. Los miembros de accionamiento de las grapas estan situados dentro de las ranuras y estan dispuestos de tal manera que entran en contacto con el miembro de leva que se mueve longitudinalmente para efectuar la eyeccion de las grapas del cartucho de grapas de la unidad de carga desechable. U.S. Surgical, el cesionario de la solicitud presente, ha fabricado y comercializado instrumentos de grapado endoscopico durante varios anos. Ejemplos de
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tales instrumentos incluyen los instrumentos Multifire ENDO GIA * 30 y Multifire ENDO GIA * 60. Otros ejemplos de tales grapadoras se describen en las patentes de los EE.UU. N° 4.429.695 y 5.065.929.
En las grapadoras del tipo general descrito anteriormente, resulta convencional proporcionar ranuras de yunque separadas en cada posicion para la formacion de grapas. Esto hace que sea necesario mantener una alineacion relativamente estricta entre el conjunto de sujetadores de la grapa y el yunque para asegurar que las grapas entran correctamente en las ranuras del yunque para realizar un remachado apropiado. La importancia de mantener una buena alineacion entre el relativamente movible conjunto de sujetadores de las grapas y el conjunto de yunque puede contribuir a la complejidad del instrumento y a su costo de fabricacion y de mantenimiento. Es importante que cada grapa sea formada correctamente ya que una grapa incompleta o impropiamente formada puede dejar un espacio en el cierre de la herida. Actualmente, el material de contrafuerte quirurgico se usa tambien en combinacion con estos instrumentos como refuerzo para lmeas de grapas para promover aun mas una formacion de grapas apropiada, a la vez que reduce la torsion/malformacion causada por desalineacion o por tejido inusual mientras se minimiza la dependencia de tolerancias de fabricacion estrictas. Estos instrumentos han proporcionado beneficios clmicos significativos. Sin embargo, es posible realizar mejoras, por ejemplo, reduciendo la complejidad de fabricacion y/o aplicacion.
La patente de los EE.UU. US 6 704 210 B1 (el preambulo de la reivindicacion 1 esta basado en este documento) describe una banda de pelfcula sellante de bioprotesis para una grapadora quirurgica. La banda de pelfcula sellante es fijada a una grapadora quirurgica pasando una mordaza de la grapadora a traves de unas aberturas formadas en los extremos de la banda. En una realizacion alternativa, un extremo de la banda esta asegurado de manera liberable a unos pasadores de una mordaza de la grapadora.
La patente de los EE.UU. US 5 902 213 A describe un conjunto de refuerzo para ser montado en un instrumento grapador quirurgico para impedir el desplazamiento de las grapas activadas de un tejido quirurgico grapado. El conjunto de refuerzo comprende una estructura de soporte y un material de refuerzo o de soporte del tejido fijado removiblemente a la estructura de soporte por una unica longitud de filamento continuo. El material de refuerzo o de soporte es fijado en su sitio en la mordaza de la grapadora por medio del filamento continuo.
Compendio
La invencion presente esta definida en la reivindicacion independiente 1 y ciertas caractensticas opcionales de la invencion presente estan definidas en las reivindicaciones dependientes.
En una realizacion, el aparato grapador quirurgico incluye un alojamiento, un efector de extremo que tiene una primera y una segunda mordazas y al menos un contrafuerte quirurgico. Una pluralidad de sujetadores esta dispuesta en las ranuras para sujetadores de la primera mordaza, y hay dispuestas bosas para los sujetadores en la segunda mordaza. El al menos un contrafuerte quirurgico tiene una porcion de cuerpo y al menos una banda conectada a un extremo distal de esta para ser conectada al efector de extremo. La al menos una banda rodea una porcion del efector de extremo. La porcion de cuerpo del al menos un contrafuerte quirurgico esta configurada y dimensionada para cubrir sustancialmente al menos algunas de las ranuras para sujetadores de la primera mordaza.
El al menos un contrafuerte quirurgico incluye una porcion elastica. La porcion elastica se extiende transversalmente mas alla de los bordes laterales de al menos una de la primera o de la segunda mordazas del efector de extremo. La porcion elastica del aparato grapador quirurgico puede estar configurada y dimensionada para permanecer fijada al efector de extremo a continuacion del disparo del aparato grapador quirurgico.
El aparato grapador quirurgico puede incluir ademas al menos una segunda banda conectada a un extremo proximal del al menos un contrafuerte quirurgico para ser conectada a un extremo proximal del efector de extremo. La al menos una segunda banda del aparato grapador quirurgico puede estar configurada y dimensionada para permanecer fijada al efector de extremo a continuacion del disparo del aparato grapador quirurgico.
El aparato grapador quirurgico puede incluir ademas una configuracion de gancho dispuesta en el extremo proximal de al menos una de la primera o de la segunda mordaza del efector de extremo. La al menos una segunda banda esta configurada y dimensionada para aplicar la configuracion de gancho.
Al menos la porcion de cuerpo del al menos un contrafuerte quirurgico del contrafuerte quirurgico incluye una pluralidad de perforaciones. Las perforaciones pueden estar dispuestas a lo largo del penmetro de la porcion de cuerpo del contrafuerte quirurgico.
Al menos la porcion de cuerpo del al menos un contrafuerte quirurgico puede estar hecha de materiales degradables seleccionados del grupo que comprende: materiales de colageno naturales, catgut o tripa de gato o resinas sinteticas incluyendo las derivadas de carbonatos de alquileno incluyendo carbonato de trimetileno, carbonato de tetrametileno; caprolactona, valerolactona, dioxanona, poliantudridos, poliesteres, poliacrilatos, polimetilmetacrilatos, poliuretanos, acido glicolico, acido lactico, glicolida, lactida, polihidroxibutiratos, poliortoester, polihidroxialcanoatos, homopolfmeros de estos y copolfmeros de estos.
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Al menos la porcion de cuerpo del al menos un contrafuerte quirurgico puede estar hecha de materiales no degradables seleccionados del grupo que comprende: poliolefinas, incluyendo polietileno, polidimetilsiloxano, polipropileno, copolfmeros de polietileno y polipropileno y mezclas de polietileno y polipropileno; polietileno de peso molecular ultra elevado, poliamidas; poliesteres incluyendo tereftalato de polietileno; politetrafluoroetileno; esteres de polieter incluyendo polibutester; glicol de eter de politetrametileno; 1,4-butanodiol; poliuretanos; y combinaciones de estos; seda; algodon, lino y fibras de carbono.
El contrafuerte quirurgico incluye una porcion de cuerpo que define una longitud y una anchura. La porcion de cuerpo tiene un extremo distal y uno proximal. La porcion de cuerpo esta configurada y dimensionada para cubrir sustancialmente una porcion de al menos una de las ranuras de los sujetadores de la primera mordaza de un efector de extremo del aparato grapador quirurgico o las cavidades para sujetadores de la segunda mordaza del efector de extremo del aparato grapador quirurgico. Al menos una banda esta conectada al extremo distal de la porcion de cuerpo. La al menos una banda esta configurada y dimensionada para rodear una porcion del efector de extremo.
Al menos una porcion de la porcion de cuerpo del contrafuerte quirurgico puede incluir una pluralidad de perforaciones. Al menos una porcion de las perforaciones del contrafuerte quirurgico puede estar dispuesta a lo largo del penmetro de la porcion de cuerpo.
La al menos una banda del contrafuerte quirurgico puede estar configurada y dimensionada para permanecer fijada al efector de extremo a continuacion del disparo del aparato grapador quirurgico.
En una realizacion se proporciona un aparato grapador quirurgico que tiene un alojamiento y un efector de extremo que incluye una primera y una segunda mordazas y al menos un contrafuerte quirurgico. Una pluralidad de sujetadores esta dispuesta en ranuras para sujetadores de la primera mordaza. En la segunda mordaza hay dispuestas cavidades para sujetadores. El al menos un contrafuerte quirurgico tiene una porcion de cuerpo y al menos una banda conectada a un extremo distal de este para ser conectada al efector de extremo. La al menos una banda rodea una porcion del efector de extremo. La porcion de cuerpo del al menos un contrafuerte quirurgico esta configurada y dimensionada para cubrir sustancialmente al menos algunas de las cavidades para sujetadores de la segunda mordaza.
Se describe un metodo para fijar un contrafuerte quirurgico a una mordaza de un aparato grapador quirurgico. El metodo incluye el paso de: proporcionar un contrafuerte quirurgico. El contrafuerte quirurgico incluye una porcion de cuerpo que define una longitud y una anchura; La porcion de cuerpo tiene extremos distal y proximal, en donde la porcion de cuerpo esta configurada y dimensionada para cubrir sustancialmente una porcion de al menos una de las ranuras para sujetadores de la primera mordaza de un efector de extremo del aparato grapador quirurgico o las cavidades para sujetadores de la segunda mordaza del efector de extremo del aparato grapador quirurgico; al menos una banda conectada al extremo distal de la porcion de cuerpo, en donde la al menos una banda esta configurada y dimensionada para permanecer fijada al efector de extremo a continuacion del disparo del aparato grapador quirurgico; y una porcion elastica conectada a los lados de la porcion de cuerpo. El metodo incluye ademas los pasos de fijar la al menos una banda al extremo distal de al menos una de las primera o segunda mordazas del efector de extremo; extender la porcion elastica transversalmente mas alla de al menos un borde lateral de al menos una de las primera o segunda mordazas; y fijar selectivamente al menos una segunda banda al extremo proximal de al menos una de las primera o segunda mordazas del efector de extremo.
Descripcion breve de los dibujos
Los aspectos, caractensticas y ventajas anteriores asf como otras particularidades de la descripcion presente se haran mas evidentes a la luz de la detallada descripcion siguiente cuando se toman conjuntamente con los dibujos adjuntos, en los que:
La Figura 1 es una vista en perspectiva de una grapadora quirurgica endoscopica que incluye un contrafuerte quirurgico segun la descripcion presente;
La Figura 2 es una vista en perspectiva que ilustra un efector de extremo ejemplar durante una operacion de aplicacion de sujetadores cuando los sujetadores son disparados secuencialmente;
La Figura 3 es una vista en perspectiva del efector de extremo que ilustra un contrafuerte quirurgico fijado a la primera y segunda mordaza de estas segun la invencion presente;
La Figura 4 es una vista en perspectiva desde abajo de la segunda mordaza de la Figura 3;
La Figura 5A es una vista en perspectiva del contrafuerte quirurgico segun la invencion presente;
La Figura 5B es una vista en alzado lateral del contrafuerte quirurgico de la Figura 5A;
La Figura 5C es una vista en alzado por delante del contrafuerte quirurgico de las Figuras 5A y 5B;
La Figura 6 es una vista en perspectiva en despiece ordenado de una realizacion de un aparato grapador quirurgico segun la descripcion presente que incluye una unidad de carga de un solo uso que tiene un contrafuerte quirurgico
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con la unidad de carga de un solo uso separada del extremo distal del aparato grapador quirurgico.
Descripcion detallada de las realizaciones
Se describen realizaciones particulares de la invencion presente haciendo referencia a los dibujos adjuntos. Segun se muestra en los dibujos y segun se describe a lo largo de la descripcion siguiente, y como es tradicional cuando se hace referencia al posicionamiento relativo en un objeto, la expresion “proximal “se refiere al extremo del aparato que esta mas cerca del usuario y la expresion “distal”, se refiere al extremo del aparato que esta mas alejado del usuario. En la descripcion siguiente, no se describen en detalle funciones o construcciones bien conocidas para evitar que se obscurezca la descripcion presente con detalles innecesarios.
Haciendo referencia ahora a los dibujos, en los que numeros de referencia similares identifican partes identicas o sustancialmente similares a lo largo de las diversas vistas, la Figura 1 ilustra un aparato grapador quirurgico 10. Segun la descripcion presente, un aparato grapador quirurgico 10 incluye un alojamiento 20 y un miembro alargado 30 que se extiende desde el alojamiento 20. Un efector de extremo 40 esta dispuesto en un extremo del miembro alargado 30. El efector de extremo 40 incluye una primera y una segunda mordazas 50, 60. Segun se muestra en la Figura 2, hay una pluralidad de sujetadores 70 dispuestos en ranuras para sujetadores 80 y formados en cavidades para sujetadores 90 (no mostradas). Las ranuras para sujetadores 80 estan dispuestas en una de la primera o la segunda mordazas 50, 60. Las cavidades para sujetadores 90 estan dispuestas en la otra mordaza primera o segunda 50, 60.
Segun se ilustra en las Figuras 3 y 4, se muestra un primer contrafuerte quirurgico 100 dispuesto sobre o fijado a la primera mordaza 50 y se muestra un segundo contrafuerte quirurgico 200 dispuesto sobre o fijado a la segunda mordaza 60. Haciendo referencia a las Figuras 5A - 5C, cada contrafuerte quirurgico 100, 200 incluye una porcion de cuerpo respectiva 110, 210 que tiene al menos una banda distal 120, 220 dispuesta en un extremo distal de esta para conectar de forma removible el contrafuerte quirurgico 100, 200 a un extremo distal de las mordazas respectivas 50, 60 del efector de extremo 40. Adicionalmente, cada contrafuerte quirurgico 100, 200 tiene una banda proximal 122, 222 dispuesta en su extremo proximal para conectar de manera removible el contrafuerte quirurgico 100, 200 a un extremo proximal de las mordazas 50, 60 respectivas del efector de extremo 40. Cada banda 120, 220, 122, 222 esta configurada y dimensionada para rodear una porcion del efector de extremo 40.
Segun se usa en la memoria presente, el contrafuerte quirurgico 100, 200 incluye una almohadilla, tapa, contrafuerte o estructura de refuerzo de la lmea de grapas.
Cada porcion de cuerpo 110, 210 define una longitud y una anchura y esta configurada para cubrir sustancialmente al menos una porcion de la superficie de trabajo de la primera o de la segunda mordazas 50, 60 respectivas del efector de extremo 40 del aparato grapador quirurgico 10. Cada contrafuerte quirurgico 100, 200 puede estar configurado y dimensionado para cubrir al menos una porcion de las ranuras para sujetadores 80 o las cavidades para sujetadores 90 de las primera y segunda mordazas 50, 60 respectivas. Como tal, en el uso, la porcion de cuerpo 110, 210 del contrafuerte quirurgico 100, 200 proporciona un refuerzo a la lmea de sujetadores para la pluralidad de sujetadores 70 a continuacion del disparo del aparato grapador quirurgico 10.
Las bandas distales 120, 220 estan fijadas en el extremo distal de las porciones de cuerpo 110, 210 de tal manera que permanecen fijadas a las mordazas 50, 60 respectivas del efector de extremo 40 despues de un disparo del aparato grapador 10. Por ejemplo, cada banda distal 120, 220 esta configurada y dimensionada para envolver un extremo distal de una mordaza 50, 60 respectiva del efector de extremo 40. Por el contrario, una banda proximal 122, 222 esta configurada y dimensionada para envolver un extremo proximal de las mordazas 50, 60 respectivas. En una realizacion, segun se ilustra en la Figura 3, la banda proximal 122 del contrafuerte quirurgico 100 puede estar configurada para aplicar una configuracion de gancho 55 dispuesta en el extremo proximal de la primera mordaza 50. De manera similar, la banda proximal 222 del contrafuerte quirurgico 200 puede estar configurada para aplicar la configuracion de gancho 55 dispuesta en el extremo proximal de la primera mordaza 50.
Segun se ilustra en la Figura 5A, cada contrafuerte quirurgico 100, 200 incluye una pluralidad de perforaciones 114, 214 formadas a lo largo del penmetro respectivo de las porciones de cuerpo 110, 210. De esta manera, durante el uso, una zona central de las porciones de cuerpo 110, 210 puede ser separada a lo largo de las perforaciones 114, 214 despues de su fijacion al tejido. Se contempla ademas que las perforaciones 114, 214 puedan ser reemplazadas por lmeas o ranuras de grosor reducido y no necesariamente puedan penetrar completamente a traves de las porciones de cuerpo 110, 210.
Haciendo referencia de nuevo a las Figuras 3-4, 5B y 5C, cada contrafuerte quirurgico 100, 200 incluye unas faldillas laterales elasticas 130, 230 que se extienden transversalmente mas alla de al menos un borde lateral de las porciones de cuerpo respectivas 110, 210 de cada contrafuerte quirurgico 100, 200. Se contempla que las faldillas laterales 130, 230 puedan estar fijadas o adheridas a los lados de las mordazas 50, 60 respectivas.
Se preve que al menos las porciones de cuerpo 110, 210 del contrafuerte quirurgico 100, 200 pueden estar hechas de materiales degradables, absorbibles y/o reabsorbibles. Se pueden usar materiales tales como colageno naturales, catgut o tripa de gato o resinas sinteticas incluyendo las derivadas de carbonatos de alquileno incluyendo carbonato de trimetileno, carbonato de tetrametileno; caprolactona, valerolactona, dioxanona, poliantudridos,
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poliesteres, poliacrilatos, polimetilmetacrilatos, poliuretanos, acido glicolico, acido lactico, glicolida, lactida, polihidroxibutiratos, poliortoester, polihidroxialcanoatos, homopoKmeros de estos y copolfmeros de estos.
Ademas, tambien se contempla que al menos las porciones de cuerpo 110, 210 del contrafuerte quirurgico 100, 200 pueden estar hechas de materiales no degradables, no absorbibles y/o no reabsorbibles. Pueden ser usados materiales tales como poliolefinas, incluyendo polietileno, polidimetilsiloxano, polipropileno, copolfmeros de polietileno y polipropileno y mezclas de polietileno y polipropileno; polietileno de peso molecular ultra elevado, poliamidas; poliesteres incluyendo tereftalato de polietileno; politetrafluoroetileno; esteres de polieter incluyendo polibutester; glicol de eter de politetrametileno; 1,4-butanodiol; poliuretanos; y combinaciones de estos; seda; algodon, lino y fibras de carbono.
Haciendo referencia a la Figura 6, una realizacion de la descripcion presente concibe un aparato grapador quirurgico 10 que incluye una unidad de carga de un solo uso 150, que en algunas realizaciones es desechable. Al disparar el aparato grapador quirurgico 10, cada banda distal 120, 220, cada banda proximal 122, 222 y cada faldilla lateral elastica 130, 230 son separadas colectivamente de las porciones de cuerpo 110, 210 respectivas cuando la primera o segunda mordaza 50, 60 respectiva es retirada del sitio quirurgico a continuacion del disparo del aparato grapador quirurgico 10.
Se contempla tambien un metodo para fijar un contrafuerte quirurgico 100, 200 a una mordaza 50, 60 de un aparato grapador quirurgico 10. Segun la descripcion presente, el metodo incluye los pasos de proporcionar un contrafuerte quirurgico 100, 200 segun la invencion presente; fijar al menos una banda distal 120, 220 al extremo distal de una mordaza 50, 60 respectiva del efector de extremo 40; extender transversalmente al menos una porcion de las faldillas laterales elasticas 130, 230 del contrafuerte quirurgico 100, 200 mas alla de al menos un borde lateral de al menos una de las primera o segunda mordazas 50, 60; y fijar selectivamente una banda proximal 122, 222 a un extremo proximal de la primera o segunda mordaza 50, 60 respectiva. Se contempla que las faldillas laterales elasticas 130, 230 puedan estar adheridas a la primera o segunda mordazas 50, 60.
Durante la operacion de un aparato grapador quirurgico 10, que incluye al menos un contrafuerte quirurgico 100, 200, la primera y la segunda mordazas 50, 60 son impulsadas contra el tejido de un paciente y el aparato grapador quirurgico 10 es disparado para desplegar los sujetadores 70 a traves de las ranuras para sujetadores 80. Despues de disparar, los sujetadores 70 pasan a traves de las ranuras para sujetadores 80 y las patas de los sujetadores 70 penetran a traves de una primera capa de tejido, a traves de las porciones de cuerpo 110, 210 del contrafuerte quirurgico 100, 200, a traves de una segunda capa de tejido y son formadas contra las cavidades para los sujetadores 90, fijando de esta manera la porcion de cuerpo 110, 210 del contrafuerte quirurgico 100, 200 al tejido. Coincidiendo con esto, una cuchilla (no mostrada) dispuesta trasladablemente dentro del efector de extremo 40 corta a traves del tejido apretado entre las mordazas 50, 60, a traves de al menos una porcion de la porcion de cuerpo 110, 210 del contrafuerte quirurgico 100, 200. En ciertas realizaciones, la cuchilla puede estar configurada y dispuesta para cortar a traves de las bandas proximales 122, 222, que estan dispuestas distalmente de la cuchilla antes del disparo. Las perforaciones 114, 214 dispuestas en la porcion de cuerpo 110, 210 permiten que una zona central de las porciones de cuerpo 110, 210 del contrafuerte quirurgico 100, 200 se desaplique o libere del efector de extremo 40, mientras que cada banda distal 120, 220, banda proximal 122, 222, y las faldillas laterales elasticas 130, 230 permanecen fijadas. La zona central de la porcion de cuerpo 110, 210 de los contrafuertes quirurgicos 100, 200 permanece fijada al tejido por medio de los sujetadores 70. Las bandas distales 120, 220 y las faldillas laterales elasticas 130, 230 permanecen fijadas a las respectivas mordazas 50, 60 del efector de extremo 40 cuando el efector de extremo 40 es retirado.
Mientras usa una unidad de carga de un solo uso 150, el usuario puede retirar la unidad de carga de un solo uso 150 o porciones de esta del aparato grapador quirurgico 10 y disponer posteriormente la unidad de carga de un solo uso 150 en su totalidad o porciones de esta. Si se necesita una aplicacion adicional, un usuario puede reemplazar la unidad de carga 150 de un solo uso gastada o disparada montando una nueva unidad de carga de un solo uso 150 en el aparato grapador quirurgico 10. El usuario puede repetir a continuacion un proceso de sujecion.
En general, las grapadoras lineales, incluyendo los dispositivos abiertos y endoscopicos, pueden tener dos miembros alargados que se utilizan respectivamente para capturar o apretar el tejido. Tfpicamente, uno de los miembros lleva un cartucho de grapas que aloja una pluralidad de grapas dispuestas en al menos dos hileras laterales mientras que el otro miembro tiene un yunque que define una superficie para formar las patas de grapa cuando las grapas son impulsadas desde el cartucho de grapas. En general, la operacion de grapado se realiza mediante barras de leva que se desplazan longitudinalmente a traves del cartucho de grapas, las barras de leva actuan sobre los tirantes de las grapas para expulsar secuencialmente las grapas del cartucho de grapas. Una cuchilla puede desplazarse entre las hileras de grapas para cortar longitudinalmente y/o abrir el tejido grapado entre las hileras de grapas. Dicho instrumento se describe, por ejemplo, en la patente de los EE.UU. N° 6.202.914.
Algunas grapadoras aplican una hilera doble de grapas a cada lado de la incision. Esto se realiza proporcionando una unidad de carga desechable en la que un miembro de leva se mueve a traves de un camino de grna alargado entre dos conjuntos de ranuras escalonadas portadores de grapas. Los miembros de accionamiento de grapas estan situados dentro de las ranuras y estan dispuestos de tal manera que se ponen en contacto con el miembro de leva que se mueve longitudinalmente para efectuar la eyeccion de las grapas desde el cartucho de grapas de la unidad
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de carga desechable. Un ejemplo de una grapadora de este tipo es descrito en la patente de los EE.UU. N° 5.065.929.
Algunos de los instrumentos descritos anteriormente fueron disenados para ser usados en procedimientos quirurgicos convencionales en donde los cirujanos tienen acceso manual directo al sitio operativo. Sin embargo, en procedimientos endoscopicos o laparoscopicos, la cirugfa se realiza a traves de una pequena incision o por medio de una canula estrecha insertada a traves de pequenas heridas de entrada en la piel. A fin de abordar las necesidades espedficas de los procedimientos quirurgicos endoscopicos y/o laparoscopicos, se han desarrollado dispositivos de grapado quirurgicos endoscopicos y se describen en, por ejemplo, la patente de los EE.UU. N° 5.865.361.
En otro ejemplo, se contempla que el contrafuerte quirurgico este configurado para ser usado con dispositivos de sujecion quirurgicos para aplicar simultaneamente un grupo de sujetadores quirurgicos, por ejemplo, grapas u otros tipos de sujetadores que son conocidos en la tecnica. Tales dispositivos son usados para unir tejidos corporales tales como, por ejemplo, paredes intestinales y gastricas con hileras paralelas, separadas, de sujetadores alineados longitudinalmente. Estos dispositivos de sujecion quirurgicos reducen el tiempo de cierre de la herida en un procedimiento quirurgico.
Tfpicamente, estos dispositivos incluyen un soporte del sujetador dispuesto en un lado del tejido a ser unido, y un conjunto de yunque paralelo al soporte del sujetador al otro lado del tejido a ser sujetado. El soporte del sujetador es movido linealmente hacia el conjunto de yunque para que el tejido quede apretado entre ellos. Los sujetadores son accionados desde el soporte del sujetador para que los extremos de los sujetadores pasen a traves del tejido y forman sujetadores acabados conforme hacen contacto con el conjunto de yunque, produciendo de esta manera un grupo de sujetadores acabados en el tejido. Los sujetadores pueden ser de una o dos piezas y estan hechos de metal, polfmeros no absorbibles, o polfmeros bioabsorbibles tales como poliglicolide, polilactide, y copolfmeros de estos.
La patente de EE.UU. N° 5.137.198 adjudicada a Nobis y otros ("Nobis") describe un dispositivo de aplicacion de sujetadores que incluye un cartucho que se hace avanzar hacia un conjunto de yunque mediante un mecanismo de avance. El mecanismo de avance incluye un primer miembro de actuacion para hacer que el cartucho avance hacia el conjunto de yunque a un ritmo acelerado y un segundo miembro de actuacion separado del primer miembro de actuacion para hacer que el cartucho avance incrementalmente hacia el conjunto de yunque.
Tfpicamente, estos dispositivos de aplicacion de sujetadores incluyen una barra de tirante que se hace avanzar a lo largo de una carrera predeterminada para interactuar con y eyectar los sujetadores del cartucho. Al menos un actuador esta situado dentro del cartucho entre el extremo distal de la barra de tirante y los sujetadores de tal manera que la barra de tirante hace avanzar los actuadores para que esten acoplados a los sujetadores. La longitud de los actuadores puede ser variada para facilitar la eyeccion de sujetadores de diferentes tamanos desde un dispositivo de aplicacion de sujetadores que tiene una carrera de barra de tirante fija. Tales instrumentos han sido descritos, por ejemplo, en la patente de los EE.UU. N° 5.964.394.
Se contempla ademas que el contrafuerte quirurgico pueda ser configurado para su uso en un aparato grapador circular, o en un aparato grapador semicircular. El contrafuerte quirurgico incluye una faldilla elastica en la periferia circunferencial del aparato grapador que es impulsada elasticamente sobre el yunque y/o la porcion de cuerpo tubular del aparato grapador. El contrafuerte quirurgico es retenido en el aparato grapador por medio de la elasticidad de la faldilla elastica y/o la friccion. El contrafuerte quirurgico puede ser liberado del aparato grapador utilizando perforaciones alrededor de la porcion de cuerpo del contrafuerte quirurgico y/o por medio de la operacion de la cuchilla del aparato grapador.
Los dispositivos de grapado quirurgicos para aplicar un grupo anular de grapas o sujetadores al tejido son bien conocidos en la tecnica. Estos dispositivos incluyen tfpicamente medios para controlar la separacion entre el conjunto de sujetadores y el miembro de yunque en el extremo distal del aparato. El conjunto de sujetadores incluye generalmente un grupo circular de sujetadores tales como grapas, anillos de anastomosis y similares, mientras que el miembro de yunque incluye medios para completar la anastomosis circular, tfpicamente un grupo de miembros de cubeta que sujetan las grapas despues de que las grapas son expulsadas del conjunto de sujetadores, o puede incluir un miembro de bloqueo para el anillo de anastomosis. Los medios para avanzar o retraer el yunque respecto al conjunto de sujetadores incluyen tfpicamente un mecanismo del tipo de tuerca de aletas en un extremo proximal del instrumento o un mando giratorio, ambos se aplican a una disposicion de engranaje de tornillo sin fin en el mecanismo de mango para lenta, metodicamente, hacer que avance el miembro de yunque hacia el conjunto de sujetadores.
Son bien conocidos en la cirugfa gastrica y esofagica los dispositivos quirurgicos de grapado para aplicar un grupo anular de grapas, asf como los dispositivos para completar una anastomosis quirurgica por medio de la provision de anillos de anastomosis, por ejemplo, en la reconstruccion gastrica clasica o modificada formada tfpicamente de extremo a extremo, de extremo a un lado, o de lado a lado. En el uso, el instrumento es situado dentro del lumen de un organo tal como el estomago, esofago o intestino para realizar la anastomosis. El tejido es situado entre el yunque y el conjunto de sujetador y es tfpicamente cosido, por ejemplo, mediante una sutura de cadena de bolsa. A
continuacion, el miembro de yunque se hace avanzar hacia el conjunto de sujetadores mediante el giro del conjunto de mando giratorio o tuerca de aletas en el extremo proximal del instrumento para mantener el tejido entre el miembro de yunque y el conjunto de sujetadores. Conforme las grapas o los sujetadores son expulsados del conjunto de sujetadores, una cuchilla circular sigue tfpicamente la aplicacion de las grapas para extirpar el tejido no 5 deseado en el sitio de la anastomosis. El instrumento es retirado a continuacion del lumen del organo.
Los mecanismos de cierre asociados con estos tipos de dispositivos de grapado o sujecion utilizan tfpicamente una disposicion compleja de engranaje de tornillo sin fin o de miembro de apoyo de tornillo para abrir y cerrar el espacio entre el yunque y el conjunto de sujetadores. Estos dispositivos generalmente proporcionan un mando giratorio o conjunto del tipo de aleta distanciado del sujetador o del miembro de tirante de grapa, y el mecanismo de engranaje 10 de tornillo sin fin esta dispuesto para transformar el movimiento giratorio del mando en un movimiento longitudinal del miembro de yunque hacia el miembro de tirante de grapas. Para efectuar este movimiento, el cirujano debe apresar el dispositivo con una mano mientras gira el mando o conjunto del tipo de aleta con la otra mano Tales instrumentos se describen, por ejemplo, en la patente de los EE.UU. N° 5.915.616.
Aunque varias realizaciones de la descripcion han sido mostradas en los dibujos, no se pretende que la descripcion 15 se limite a ellas. Por tanto, la descripcion anterior no debe interpretarse como limitadora, sino meramente como ejemplificadora de realizaciones preferidas. Por tanto, el alcance de las realizaciones debe ser determinado por las reivindicaciones adjuntas, en lugar de por los ejemplos presentados.

Claims (13)

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    REIVINDICACIONES
    1. Un contrafuerte quirurgico en combinacion con un aparato grapador quirurgico, comprendiendo:
    un aparato grapador quirurgico (10) comprendiendo un efector de extremo (40) teniendo una primera mordaza (50) y una segunda mordaza (60), teniendo la primera mordaza (50) ranuras para sujetadores, teniendo la segunda mordaza (60) cavidades para sujetadores, y teniendo cada una de la primera y segunda mordazas (50, 60) lados y bordes de lados; y
    un contrafuerte quirurgico (100, 200) comprendiendo:
    una porcion de cuerpo (110, 210) definiendo una longitud y una anchura, teniendo la porcion de cuerpo (110, 210) lados, un extremo distal y un extremo proximal, en donde la porcion de cuerpo (110, 210) cubre sustancialmente una porcion de al menos algunas de las ranuras para sujetadores de la primera mordaza (50) del efector de extremo (40) o de las cavidades para sujetadores de la segunda mordaza (60) del efector de extremo;
    al menos una banda (120, 220) conectada al extremo distal de la porcion de cuerpo (110, 210) para rodear una porcion del efector de extremo;
    caracterizado por que:
    el contrafuerte (100, 200) comprende ademas una faldilla lateral elastica (130, 230) extendiendose transversalmente mas alla de los bordes laterales de la primera mordaza (50) o de la segunda mordaza (60), y estando aplicada a los lados de la primera mordaza (50) o de la segunda mordaza (60).
  2. 2. La combinacion del contrafuerte y del aparato grapador quirurgico segun la reivindicacion 1, en donde la al menos una banda (120, 220) comprende una porcion elastica sobre el contrafuerte (100, 200).
  3. 3. La combinacion del contrafuerte y del aparato grapador quirurgico segun la reivindicacion 1 o la reivindicacion 2, en donde al menos la porcion de cuerpo (110, 210) esta hecha de materiales seleccionados del grupo que comprende: materiales de colageno naturales, catgut o tripa de gato o resinas sinteticas incluyendo las derivadas de carbonatos de alquileno incluyendo carbonato de trimetileno, carbonato de tetrametileno; caprolactona, valerolactona, dioxanona, polianhudridos, poliesteres, poliacrilatos, polimetilmetacrilatos, poliuretanos, acido glicolico, acido lactico, glicolida, lactida, polihidroxibutiratos, poliortoester, polihidroxialcanoatos, homopolfmeros de estos y copolfmeros de estos, poliolefinas, incluyendo polietileno, polidimetilsiloxano, polipropileno, copolfmeros de polietileno y polipropileno y mezclas de polietileno y polipropileno; polietileno de peso molecular ultra elevado, poliamidas; poliesteres incluyendo tereftalato de polietileno; politetrafluoroetileno; esteres de polieter incluyendo polibutester; glicol de eter de politetrametileno; 1,4-butanodiol; poliuretanos; y combinaciones de estos; seda; algodon, lino y fibras de carbono.
  4. 4. La combinacion del contrafuerte y del aparato grapador quirurgico segun la reivindicacion 1, en donde:
    la primera mordaza (50) tiene un extremo distal y lados;
    una pluralidad de sujetadores (70) esta dispuesta en las ranuras de los sujetadores (80) de la primera mordaza (50), y
    las cavidades para sujetadores son cavidades formadoras de sujetadores dispuestas en la segunda mordaza (60); y
    la banda (120) esta conectada a la primera mordaza (50) y esta rodeando el extremo distal de la primera mordaza (50);
    la faldilla lateral elastica (130) se extiende transversalmente mas alla de los bordes laterales de la primera mordaza (50), y esta aplicada a los lados de la primera mordaza (50); y
    la porcion de cuerpo (110) del contrafuerte quirurgico (100) cubre sustancialmente al menos algunas de las ranuras para sujetadores (80) de la primera mordaza (50).
  5. 5. La combinacion del contrafuerte y del aparato grapador quirurgico segun la reivindicacion 4, en donde la banda (120) comprende una porcion elastica.
  6. 6. La combinacion del contrafuerte y del aparato grapador quirurgico segun la reivindicacion 4 o la reivindicacion 5, en donde la banda (120) y la faldilla lateral elastica (130) estan configuradas y dimensionadas para permanecer fijadas a la primera mordaza (50) a continuacion del disparo del aparato de grapado quirurgico (10).
  7. 7. La combinacion del contrafuerte y del aparato grapador quirurgico segun una cualquiera de las reivindicaciones 4 a 6, en donde al menos la porcion de cuerpo (110) del contrafuerte quirurgico (100) esta hecha de:
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    materiales degradables seleccionados del grupo que comprende materiales de colagenos naturales, catgut o tripa de gato o resinas sinteticas incluyendo las derivadas de carbonatos de alquileno incluyendo carbonato de trimetileno, carbonato de tetrametileno; caprolactona, valerolactona, dioxanona, poliantudridos, poliesteres, poliacrilatos, polimetilmetacrilatos, poliuretanos, acido glicolico, acido lactico, glicolida, lactida, polihidroxibutiratos, poliortoester, polihidroxialcanoatos, homopoKmeros de estos y copolfmeros de estos; o
    materiales no degradables seleccionados del grupo que comprende poliolefinas, incluyendo polietileno, polidimetilsiloxano, polipropileno, copolfmeros de polietileno y polipropileno y mezclas de polietileno y polipropileno; polietileno de peso molecular ultra elevado, poliamidas; poliesteres incluyendo tereftalato de polietileno; politetrafluoroetileno; esteres de polieter incluyendo polibutester; glicol de eter de politetrametileno; 1,4-butanodiol; poliuretanos; y combinaciones de estos; seda; algodon, lino y fibras de carbono.
  8. 8. La combinacion del contrafuerte y del aparato grapador quirurgico segun una cualquiera de las reivindicaciones 4 a 7, comprendiendo ademas una segunda banda (122) conectada a un extremo proximal del contrafuerte quirurgico (100) para realizar la conexion a un extremo proximal de la primera mordaza (50).
  9. 9. La combinacion del contrafuerte y del aparato grapador quirurgico segun la reivindicacion 8, en donde la segunda banda (122) esta configurada y dimensionada para permanecer fijada al efector de extremo (40) despues de disparar el aparato grapador quirurgico (10).
  10. 10. La combinacion del contrafuerte y del aparato grapador quirurgico segun la reivindicacion 8 o la reivindicacion 9, comprendiendo ademas una configuracion de gancho (55) dispuesta en el extremo proximal de la primera mordaza (50) del efector de extremo (40), en donde la segunda banda (122) esta aplicada a la configuracion de gancho (55).
  11. 11. La combinacion del contrafuerte y del aparato grapador quirurgico segun una cualquiera de las reivindicaciones 4 a 10, en donde la porcion de cuerpo (110) del contrafuerte quirurgico incluye una pluralidad de perforaciones (114).
  12. 12. La combinacion del contrafuerte y del aparato grapador quirurgico segun la reivindicacion 11, en donde las perforaciones (114) estan dispuestas a lo largo del penmetro de la porcion de cuerpo (110) del contrafuerte quirurgico (100).
  13. 13. La combinacion del contrafuerte y del aparato grapador quirurgico segun una cualquiera de las reivindicaciones 4 a 12 comprendiendo un contrafuerte quirurgico adicional (200) conectado a la segunda mordaza (60); comprendiendo dicho contrafuerte quirurgico adicional (200): una porcion de cuerpo (210) definiendo una longitud y una anchura, teniendo la porcion de cuerpo (210) lados, un extremo distal y un extremo proximal; en donde el contrafuerte quirurgico adicional (200) comprende ademas una faldilla lateral elastica (230) extendiendose transversalmente mas alla de los bordes laterales de la segunda mordaza (60), y aplicandose a los lados de la segunda mordaza (60); y
    en donde el contrafuerte quirurgico adicional (200) comprende una banda (220) conectada al extremo distal de la porcion de cuerpo (210), estando la banda (220) conectada a la segunda mordaza (60) y rodeando el extremo distal de la segunda mordaza (60); y
    la porcion de cuerpo (210) del contrafuerte quirurgico adicional (200) cubre sustancialmente al menos algunos de las cavidades formadoras de sujetadores de la segunda mordaza (60).
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US10617419B2 (en) 2020-04-14

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