JP4749412B2 - Minimally invasive tissue retraction and surgical instruments and methods - Google Patents

Description

  The present invention relates to an instrument and method for retracting a tissue in a minimally invasive procedure and performing surgery via the retracted tissue.

  Conventional surgical procedures for lesions in the body can cause severe trauma to the intervening tissue. These procedures often require long incisions, extensive muscle ablation, prolonged tissue retraction, tissue denervation and vascular blockage. These procedures require several hours of operating room time and can require several weeks for post-operative recovery time due to tissue destruction during the surgical procedure. In some cases, these invasive procedures lead to permanent scarring and pain that can be more serious than the pain that leads to surgical intervention.

  Since it is necessary to make a minimal incision in tissues such as muscle tissue, the development of percutaneous procedures has resulted in significant improvements in reducing recovery time and postoperative pain. For example, minimally invasive surgical techniques are desirable for spinal and neurosurgical applications because of the need to access sites within the body and the risk of damaging living intervening tissue. Although the development of minimally invasive surgery is an advance in the right direction, there remains a need for further development in minimally invasive surgical instruments and methods.

  The present invention is directed to methods and instruments for performing surgery on a patient. One particular application relates to instruments and methods for retracting tissue in minimally invasive spinal surgery. Further specific applications include percutaneous tissue retractors that provide access to a patient's surgical site. Another particular application includes surgical methods performed through tissue percutaneously opened at any site within a patient's body. Other applications of the invention will become further apparent from the following description of the illustrated embodiments.

  To assist in understanding the principles of the present invention, reference will now be made to the embodiments illustrated in the drawings and specific language will be used to describe the same. However, it will be understood that it does not limit the scope of the invention. Such alterations and further modifications of the illustrated apparatus and described methods, as well as any such additional applications of the principles of the invention as illustrated herein, will generally be apparent to those skilled in the art to which the invention pertains. It is thought to be conceived.

  The present invention includes one or more techniques such as laminectomy, laminectomy, intervertebral canal resection, spine arthrotomy, discectomy, interbody fusion, spinal nucleus or intervertebral disc replacement, graft tissue insertion, etc. Instruments and methods for performing percutaneous surgery, such as spinal cord surgery, are provided. Surgery is performed through working channels or passages provided by the retractor through the patient's skin and tissue. The surgical site at the working end of the retractor is an observation instrument mounted on the retractor, an observation instrument positioned on the retractor, and / or via an observation system such as a lateral fluoroscope. Can see. The retractor increases the dimensions of the working channel to allow easy access to the working space at the distal end of the retractor and to minimize trauma to the tissue surrounding the retractor. It can be moved in situ. The retractor can be used in any surgical approach to the spine, such as anterior, posterior, posterior median, lateral, posterior lateral, and / or anterolateral approaches, and in areas other than the spine.

  In FIG. 1, a retractor 20 is shown that includes a first portion 22 and a second portion 42. The first portion 22 has a distal end 24 and an opposing proximal end 26. The second portion 42 has a distal end 44 and an opposing proximal end 46. Although the distal ends 24 and 44 can be angled to facilitate insertion, non-tilted ends are also contemplated. The first portion 22 is adjacent to or adjacent to the second portion 42 along the adjacent one of the longitudinal edge 25 of the first portion 22 and the longitudinal edge 45 of the second portion 42. Can be meshed and positioned. A working channel 50 is formed between the first portion 22 and the second portion 42. A working channel 50 extends between the distal ends 24 and 44 and the proximal ends 26 and 46 where it opens.

  The retractor 20 can be inserted into the patient's skin and tissue to provide a working channel 50 to the surgical site. The retractor 20 is believed to be inserted into the skin and tissue with the working channel 50 insertion configuration as shown in FIG. In the inserted configuration, the working channel 50 is substantially surrounded or restricted by the first portion 22 and the second portion 42. After insertion into the patient, the working channel 50 can be enlarged by separating the first portion 22 and the second portion 42. Separating the first portion 22 and the second portion 42 increases the size of the working channel 50 from the proximal ends 26 and 46 to the distal ends 24 and 44.

  In the insertion configuration of FIG. 1, the working channel 50 is limited or substantially surrounded by the first portion 22 and the second portion 42. The working channel 50 can be sized to allow one or more surgical instruments and / or transplanted tissue to pass to a surgical site within a patient in an inserted configuration. During surgery, it may be desirable to allow further access to a site within the patient's body that is farther than the site provided through the working channel 50 in the inserted configuration. The first portion 22 and the second portion 42 can be moved away from each other to enlarge the working channel 50. In the enlarged configuration of the working channel 50, at least a space is formed between the adjacent longitudinal edges 25 and 45 of the first portion 22 and the second portion 42. The space between adjacent longitudinal edges 25 and 45 exposes an enlarged working channel 50 to the patient's skin and tissue between the separated first and second portions 22 and 42. . The surgeon can also access this exposed tissue along with one or more instruments and / or transplanted tissue via the enlarged working channel 50. It is further contemplated that a shield, protector, or tissue retractor can be placed within the enlarged working channel 50 to maintain the exposed tissue away from the enlarged working channel 50.

  The first portion 22 includes a semi-cylindrical body 23 that extends between a distal end 24 and a proximal end 26. The collar 28 extends around the proximal end 26 and forms a lip that extends around the outer surface of the body 23. The first portion 22 includes a first bracket member 39 that extends from the proximal end 26. The second portion 42 includes a semi-cylindrical body 43 that extends between the distal end 44 and the proximal end 46. The collar 48 extends around the proximal end 46 of the second portion 42 and defines a lip that extends around the outer surface of the body 43. The second portion 42 includes a second bracket member 40 that extends from the proximal end 46.

  A first alignment member 30 may be provided to connect the first side of the first portion 22 to the second portion 42 with the proximal ends 26 and 46 adjacent. A second alignment member 31 opposite the first alignment member 30 is provided to abut the proximal ends 26 and 46 along another side of the retractor 20 so that the other of the first portions 22 Can be coupled to the second portion 42. A retaining member 38 can be positioned around the bracket members 39 and 40 to hold the first portion 22 and the second portion 42 adjacent to each other. In one embodiment, alignment members 30 and 31 are provided in holes 43 (only one is shown in FIG. 2) formed in the other part of the retractor when the retractor 20 is in the insertion configuration. Pin that is slidably received inside. The alignment members 30 and 31 maintain the first portion 22 and the second portion 42 in the longitudinal direction with respect to each other during and after insertion. The retaining member 38 is resiliently biased to engage the bracket members 39 and 40 and to maintain the first portion 22 and the second portion 42 adjacent to each other during and after insertion. Can do. If it is desirable to separate the first portion 22 and the second portion 42, the retaining member 38 can be removed from the bracket members 39 and 40.

  Other configurations for aligning the first portion 22 and the second portion 42 with each other and releasably connecting are also conceivable. Examples of such configurations include, for example, dovetail connections, fasteners, threaded coupling members, clamping members, snap rings, compression bands, straps, ball detent mechanisms, and detachably mating cams or tabs. Examples of suitable retaining members include clamps, clips, bands, straps, hooks, ties, sleeves, connecting members and / or fasteners. As shown in FIG. 3, the holding member 38 includes a tightening mechanism 35 and can urge the holding member 38 to engage with the bracket members 39 and 40. The tightening mechanism 35 supports one or both of the bracket members 39 and 40, securely attaches the retaining member 38 thereto, and quickly removes the retaining member 38 from the bracket members 39 and 40. Can be included.

  Bracket members 39 and 40 extend from, and are integrally formed with or attached to, the collars 28 and 48 of the first portion 22 and the second portion 42, respectively. Bracket members 39 and 40 can also be provided as a single bracket on one of collars 28 and 48 instead of or in addition to bracket members 39 and 40. Bracket members 39 and 40 extend away from working channel 50 and can be connected to one end of a flexible or articulatable arm 41 (FIG. 7). The opposite end of arm 41 (not shown) can be attached to an operating table or other support device. The arm 41 supports the retractor 20 within the patient, and can further manipulate and reposition the retractor 20 during surgery. It is further contemplated that two or more flexible arms 41 can be provided to engage the retractor portions 22 and 42, respectively, after the working channel 50 has been enlarged.

  When the working channel 50 of the retractor 20 is in the insertion configuration, the opposing edges 25 of the first portion 22 are adjacent to each of the opposing edges 45 of the second portion 42. Various interfaces between the edges 25 and 45 are conceivable. For example, in FIG. 4, in the insertion configuration of the working channel 50, the edge 25 (only one is shown) of the first portion 22 is all or part of the adjacent edge 45 of the second portion 42. The structure which touches along is shown. FIG. 5 is another embodiment of the first portion 22 having an outer recess 27 along each edge 25 (only one is shown). Each of the edges 45 can include an inner recess 47. The edges 25 and 45 can thus be combined and touched with each other in the recesses 27 and 47 in the inserted configuration of the working channel 50. In FIG. 6, the edge 25 (only one is shown) of the first portion 22 is located inside the adjacent edge 45 of the second portion 42 relative to the working channel 50. Overlapping arrangements that can be shown are shown. It is also conceivable that the edge 45 can be arranged inside the edge 25. Further, the edge 25 may be inside the edge 45 on one side of the retractor 20, and the other edge 45 may be inside the other edge 25 on the other side of the retractor 20. Conceivable. Other configurations allow for a gap between adjacent ones of edges 25 and 45.

  The body 23 has a perimeter along the distal end 24 that can be approximately the same as the perimeter of the body 23 at the proximal end 26. The body 43 of the second portion 42 includes a perimeter along the distal end 44 that can be approximately the same as the perimeter of the body 43 adjacent the proximal end 46. The bodies 23 and 43 can have a semi-circular cross section and form a generally circular cross section of the working channel when placed adjacent to each other as shown in FIG. Other cross-sectional shapes of the first portion 22 and the second portion 42 are also contemplated, such as, for example, a polygonal shape with any open side, a curved shape, or a combination of curved / polygonal shapes.

  Proximal from the collar 28 of the first portion 22 is a first engagement member 32 having a head portion 36 with a recess 33 formed thereunder. Proximal from the collar 48 of the second portion 42 is a second engagement member 52 having a head portion 56 with a recess 53 formed thereunder. Head portions 36 and 56 are engaged by screwing, engaged with each other and spring biased toward collars 28 and 48, or alternatively engaged with individual collars 28 and 48, and The height of the individual recesses 33 and 53 can be increased or decreased to be adjustable to receive and connect the separating device therein. Further, it is contemplated that the engagement members 32 and 52 can be non-adjustable, and a separation device configured to engage adjacent engagement members 32 and 52 is contemplated.

  As will be discussed further below, the first portion 22 and the second portion 42 are separated from the first portion 22 and the second portion 42 by applying a separating force to enlarge the working channel 50. The instrument separating the two portions 42 can engage or disengageably engage the engagement members 32 and 52. Such an instrument can also detachably or non-engageably engage the first portion 22 and the second portion 42. Such an instrument can further maintain the first portion 22 and the second portion 42 in an initial insertion configuration and / or an expanded configuration of the working channel 50. Other means may be used in addition to the separating instrument to maintain the first portion 22 and the second portion 42 in one or both of the initial insertion configuration and the expanded configuration of the working channel 50. . For example, when no separation instrument is attached, the member can extend between and be coupled to the engagement members 32 and 52 and / or the retractor portions 22 and 42, respectively.

  Engaging members 32 and 52 are positioned on lateral extensions 29 and 49 of collars 28 and 48, respectively. Lateral extensions 29 and 49 extend laterally far enough so that the separating device can engage the engagement members 32 and 52 without interfering with the working channel 50.

  It is contemplated that the body 23 can have a thickness 39 (FIG. 4). The body 43 of the second portion 42 can have a thickness 59 (FIG. 4) that can be the same as, greater than, or less than the thickness 39 of the first portion 22. To separate and maintain the body tissue when the retractor is first inserted and when the tissue is retracted by moving the first portion 22 and the second portion 42 away from each other, The bodies 23 and 43 can have sufficient rigidity between their distal and proximal ends. The first thickness 39 and the second thickness 59 are sufficient to resist the first portion 22 and the second portion 42, respectively, to bend or bend under the force exerted by the retracted tissue. Rigidity can be provided. Furthermore, the main body 23 has a depth 37 from the edge 25 to the midpoint of the wall surface of the main body 23 extending between the edges 25. Depth 37 may provide a section modulus or moment of inertia that sufficiently resists the bending, bending, and / or deflection forces applied during such movement in the direction of movement of first portion 22. Similarly, the body 43 has a depth 57 from the edge 45 to the midpoint of the wall surface of the body 43 extending between the edges 45 and is applied during the movement in the direction of movement of the second portion 42. A section modulus or moment of inertia that sufficiently resists bending, bending, and / or bending forces.

  In one particular embodiment, the first portion 22 and the second portion 42 are each made from surgical grade stainless steel. Other materials including plastics, metals, and alloys, such as, for example, spring steel, shape memory metals and alloys, and aluminum are also contemplated for the first portion 22 and the second portion 42.

  In the first insertion configuration, the working channel 50 has a generally circular cross section along the retractor 20 as shown in FIGS. The working channel 50 has a first width 51 in the direction of movement of the first portion 22 relative to the second portion 42 and the other of the adjacent edges 25 and 45 from one pair of adjacent edges 25 and 45. And a second width 55 extending to the pair. In the illustrated embodiment, the first width 51 and the second width 55 can be substantially the same because the working channel 50 has a generally circular cross-section in the initial insertion configuration. In the expanded configuration, as shown in FIGS. 2 and 9, the second width 55 remains substantially the same as in the initial insertion configuration of the retractor 20, but the first width 51 is the first portion. Increased by separation of 22 and second portion 42.

  Various forms of working channel 50 are possible. In the initial insertion configuration, the working channel 50 can have a cylindrical shape whose cross-sectional shape is, for example, circular, oval, elliptical, polygonal, or a combination of polygonal / curved shapes. In the expanded configuration, working channel 50 has a cylindrical or frustoconical shape whose cross-sectional shape is, for example, oval, elliptical, circular, curved, polygonal, or a combination of polygonal / curved. be able to.

One particular application of the retractor 20 is in spinal surgery. After insertion of the retractor 20, the first portion 22 and the second portion 42 may be separated primarily in one direction in order to retract the muscle and tissue along the path 62 ( FIGS. 8, 9 ) . Conceivable. For example, the first portion 22 and the second portion 42 of the retractor 20 may be separable initially or primarily in the axial direction of the spinal column. The fibers of the muscle tissue adjacent to the spine have an orientation that extends generally in the axial direction of the spinal column. Separating the body portions 23 and 43 of the retractor 20 can also separate the muscle tissue along the fibers, thus minimizing the amount of separation and resulting cleavage and trauma to the muscle tissue. Can be suppressed. Further, in other techniques using the retractor 20, it is contemplated that the working channel 50 can be initially expanded in a direction other than along the spinal axis, or in a range other than the spine. Also contemplated are embodiments of the retractor 20 in which the working channel 50 is expanded in approximately one direction or in all directions.

  7-9, an example method for positioning the retractor 20 through the patient's skin 60 and tissue 68 will now be described. An incision is made in the skin 60 adjacent to the accessed site of the patient's anatomy. For example, in spinal surgery, an incision can be made at the vertebral level at a site that allows access to the disc space between adjacent vertebrae or one or more vertebrae by the desired approach. Prior to insertion of the retractor 20, the skin 60 and tissue 68 can be continuously expanded by a dilator set 66 that can include a guide wire and / or one or more tissue dilators that increase dimensions. . Tissue dilators are inserted one on top of the other to form a pathway 62 through the skin 60 and tissue 68 to the surgical site in the patient. In such a procedure, the retractor 20 is positioned over the last inserted dilator to form a pathway 62 in the skin and tissue. When the guidewire and dilator (if used) are removed therefrom, the working channel 50 through the retractor 20 provides access to the working space 64 at the distal end of the retractor 20.

  For the entire procedure or a particular procedure during the procedure, the surgeon may increase the size of the working channel 50 to facilitate access to the working space 64 below the distal end of the retractor 20, or the working space. It may be desirable to increase the size of 64. The first portion 22 and the second portion 42 of the retractor 20 can be separated from their insertion configuration to a separation configuration in which the working channel 50 is expanded as shown in FIG. In the expanded configuration, the first portion 22 and the second portion 42 can be moved laterally and / or can be pivoted away from each other by a separation instrument. An example of a separation device is a separation device 70 that extends between and is coupled to the engagement members 32 and 52. The adjacent portions of the edges 25 and 45 are separated by the space 69 to expose the working channel 50 along the path 62 to the skin and tissue, while at the same time the first portion 22 and the second portion 42. Holds the tissue outside the surgical area. In the expanded configuration, the working channel 50, and thus the pathway 62, is expanded by the penetrating skin 60 and tissue 68 formed by the first portion 22 and the second portion 42. As the dimensions of the working space 64 are increased, trauma to the tissue and skin along the path 62 can be minimized.

  The first portion 22 and the second portion 42 pivot or rotate away from each other about their proximal ends so that the working channel 50 is located at the distal end of the retractor 20 adjacent to the working space 64. From the skin 60 through the skin 60 to the proximal end of the retractor 20 can be provided with a tapered configuration. The tapered working channel allows the surgeon more access to the working space 64 and makes it more visible and minimizes tissue retraction. The tapered working channel 50 further allows for more precise angular measurements of instruments and transplanted tissue placed through the working channel 50 and further selects the positioning of the instrument and implanted tissue within the working channel 50. And for positioning a device and a graft tissue adjacent to the inner wall surfaces of the separated first and second portions 22 and 42 for a plurality of devices and the graft tissue. Increases the available space in the work space 64 for orienting.

  A viewing instrument can be positioned within or adjacent to the working channel 50 to facilitate the surgeon viewing the working space 64 and the surgical site. For example, the viewing element of the endoscope can be attached to the proximal end of the retractor 20 with a scope portion extending along the working channel 50. A viewing element of the microscope can be positioned on the proximal end of the retractor 20 to view the working space 64 and the surgical site. Other imaging techniques such as side fluoroscopy can be used alone or in combination with an endoscope or microscope viewing element. Further, for use in surgical procedures within the workspace via the retractor 20, a nerve root retractor, tissue retractor, tweezers, cutter, drill, scraper, reamer, separator, bone forceps, tap, cautery instrument It is contemplated that other instruments, such as irrigation and / or suction instruments, lighting instruments, inserter instruments, can be attached to the proximal end of the retractor 20. Such viewing instruments and other instruments can be used with the working channel 50 in the initial insertion and / or expansion configuration.

  Referring now to FIG. 7, further details regarding an embodiment of the instrument 70 that separates the first portion 22 and the second portion 42 are provided. The instrument 70 includes a shelf portion 72 and a body portion 74. The shelf portion 72 includes a foot portion 76 that can be releasably engaged with the engagement member 52, and the body portion 74 has a foot portion 78 that can be releasably engaged with the engagement member 32. Including. The shelf portion 72 includes an extension 80 that is received through the housing 82 of the body portion 74. The housing 82 includes a pinion 84 that is rotatably mounted therein and engages the teeth 86 of the extension 80. The pinion 84 can be rotated by a tool or manually by a surgeon and rotated so that the shelf portion 72 moves relative to the body portion 74, thereby moving the foot portions 76 and 78 away from each other. The working channel 50 is enlarged by separating the first portion 22 and the second portion 42. Stop member 88 may be provided at any position along or along the end of extension 80 to prevent excessive separation of first portion 22 and second portion 42.

  Referring now to FIGS. 10 and 11, another embodiment of the retractor 20 is shown in which the retractor portions 22 and 42 are simultaneously separable from and swivel relative to each other to enlarge the working channel 50. It is. The collar 28 includes an extension 300 that extends generally from the body 23 of the first portion 22 in the direction of separation of the first portion 22 from the second portion 42. The collar 48 includes an extension 302 that extends generally from the body 43 of the second portion 42 in the direction of separation of the second portion 42 from the first portion 22. In the insertion configuration of FIG. 10, extension 300 extends distally from collar 28 at angle 304 and extension 302 extends distally from collar 48 at angle 306. Engaging members 32 and 52 extend proximally from extensions 300 and 302, respectively.

  In FIG. 11, the working channel 50 has been expanded by applying a lateral separation force as indicated by arrows 312 and 314, for example, with the separation instrument 70 described above or the instrument 220 described below. A lateral separation force separates the first portion 22 from the second portion 42. A lateral separation force is applied to the engagement members 32 and 52 on the angled extensions 300 and 302. Angled extensions 300 and 302 pivot distal ends 24 and 44 when angled extensions 300 and 302 are rotated or pivoted in the direction in which lateral forces 314 and 316 are applied. Or they tend to rotate away from each other. As a result, edges 25 and 45 form an angle 307 therebetween, providing an elliptical truncated-conical working channel 50 that is enlarged between distal ends 24 and 44 and proximal ends 26 and 46. The distal ends 24 and 44 are separated by a distance 308 at the edges 25 and 45, which is greater than the distance 310 separating the edges 25 and 45 adjacent to the proximal ends 26 and 46.

  Referring now to FIG. 12, the retractor 20 with another embodiment of the instrument 90 separating the first portion 22 and the second portion 42 is shown. The instrument 90 includes a rotary separator 92 and a lateral separator 110. The rotary separator 92 operates to rotate or pivot the first portion 22 and the second portion 42 relative to each other about their proximal ends 26 and 46 to separate the distal ends 24 and 44 from each other. Is possible. Lateral separator 110 is operable to separate first portion 22 and second portion 24 from each other by laterally separating proximal ends 26 and 46 and distal ends 24 and 44. . As discussed further below, the instrument 90 is disposed adjacent to one of the edges 25 and 45 and extends laterally from the first portion 22 and the second portion 42, respectively. The engagement member (not shown) of the portion 22 and the second portion 42 can be connected. The rotary separator 92 and the lateral separator 110 cause the first portion 22 and the second portion 42 to pivot and then laterally separate, or laterally separated and then pivoted. In addition, it can be operated continuously. The rotary separator 92 and the lateral separator 110 can also be operated to simultaneously pivot / rotate and separate the first portion 22 and the second portion 42 laterally.

  The rotary separator 92 includes a first handle 94 and a second handle 96. The first handle 94 is attached to the first connecting member 98, and the second handle 96 is attached to the second connecting member 100. The first connecting member 98 of the rotary separator 92 is non-rotatably connected to the engaging member on the side surface of the first portion 22, and the second connecting member 100 of the rotary separator 92 is connected to the second portion 42. It is non-rotatably connected to the side engaging member. The first portion 22 and the second portion 42 move the first handle 94 toward the second handle 96 in the direction of the arrow 105, and move the second handle 96 toward the first handle 94. By moving in the direction of arrow 106, they can be swung or rotated away from each other. By moving the handles 94 and 96 in the direction of the arrows 105 and 106, the proximal ends of the coupling members 98 and 100 are rotated toward each other so that the first part 22 and the second part 42 pivot or rotate. Bring. Handles 94 and 96 rotate in the direction of arrow 108 to move connectors 94 and 96 away from the proximal end opening of working channel 50 and provide clear access thereto for the surgeon. It can be pivotally connected.

  The transverse separator 110 extends laterally from the retractor 20 across the separation direction of the first portion 22 and the second portion 42. The lateral separator 110 includes a first handle 112 and a second handle 114. The first connecting member 116 is pivotally connected to the first handle 112 at the center thereof, and the second connecting member 118 is pivotally connected to the second handle 114 at the center thereof. The connecting members 116 and 118 are rotationally connected at their distal ends to respective side engaging members extending from the first portion 22 and the second portion 42. The first connector 120 extends between one end of the first handle 112 and the opposite end with respect to the second connecting member 118, and is pivotally connected at these ends. The second connector 122 extends between one end of the second handle 114 and the opposite end to the first connecting member 116, and is pivotally connected at these ends. The first coupling member 116 includes a first tab 134 that rotatably receives a side engagement member extending from the first portion 22. The second coupling member 118 includes a second tab 136 that rotationally receives a side engagement member extending from the second portion 42.

  The first connector 120 includes a first groove 124, and the second connector 122 includes a second groove 126. The locking pin 128 extends through the grooves 124 and 126 and connects the connectors 120 and 122 together. To laterally separate the first portion 22 from the second portion 42, the locking pin 128 is loosened, thus allowing the connectors 120 and 122 to move relative to each other. The first handle 112 is moved toward the second handle 114 in the direction of the arrow 130, and the second handle 114 is moved toward the first handle 112 in the direction of the arrow 132. At the same time as the first connector 120 pushes the second connecting member 118 outward, the second handle 114 pulls the second connecting member 118 outward. Similarly, at the same time as the second connector 122 pushes the first connecting member 116 outward, the first handle 112 pulls the first connecting member 116 outward. The connecting members 116 and 118 are thus laterally separated from each other. Since this separates the first portion 22 and the second portion 42, the edges 25 and 45 are laterally spaced from each other at the same relative distance between the proximal ends 26 and 46 and the distal ends 24 and 44. Displaced. Thereafter, the locking pin 128 can be screwed together to tighten the connector members 120 and 122 together to prevent the lateral separator 110 from moving further. Moving the handles 112 and 114 in the direction of the opposing arrows 130 and 132 causes the first portion 22 and the second portion 42 to move toward each other, and when swung, causes the handles 94 and 96 to move relative to each other. By moving toward each other, the first portion 22 and the second portion 42 are pivoted toward each other, the working channel 50 is reduced, and the retractor 20 can be more easily removed from the incision.

  First and second adjustment mechanisms 102 and 104 are provided to finely incrementally adjust the rotational positioning of the first portion 22 and the second portion 42, respectively. The first adjustment mechanism 102 extends through the first tab 134 and engages the first connecting member 98. When the first adjustment mechanism 102 is screwed toward the first tab 134, the end of the first adjustment mechanism 102 pushes the first connection member 98, thereby causing the first connection member 98 and the first connection member 98 to move. A handle 94 pivots or rotates the associated first tab 134 along the first portion 22. The adjustment mechanism 102 can also engage the first coupling member 98 to maintain the first portion 22 in the pivoted or rotated position provided via the first handle 94. Similarly, the second adjustment mechanism 104 extends through the second tab 136 and engages the second connecting member 100. When the second adjustment mechanism 104 is screwed toward the second tab 136, the end of the second adjustment mechanism 104 pushes the second connection member 100, thereby causing the second connection member 100 and the second connection member 100 to move. A handle 96 pivots or rotates the associated second tab 136 along the second portion 42. The second adjustment mechanism 104 can also engage the second coupling member 100 to maintain the second portion 42 in the pivoted or rotated position provided via the second handle 96.

  In use, the resistance to the wound provided by the tissue can prevent the distal ends 24 and 44 from separating to the extent of the proximal ends 26 and 46 when a separating force is applied by the lateral separator 110. Using a rotary separator 92, the distal ends 24 and 44 are separated from each other to provide the desired separation between the edges 25 and 45 along the length of the first portion 22 and the second portion 42. Can be provided.

  Referring now to FIG. 13, the retractor 20 with another embodiment of the instrument 140 separating the first portion 22 and the second portion 42 is shown. Instrument 140 includes a rotary separator 142 and a lateral separator 160. The rotary separator 142 operates to rotate or pivot the first portion 22 and the second portion 42 relative to each other about their proximal ends 26 and 46 to separate the distal ends 24 and 44 from each other. Is possible. Lateral separator 160 is operable to separate first portion 22 and second portion 24 from each other by laterally separating proximal ends 26 and 46 and distal ends 24 and 44. . The rotary separator 142 and the lateral separator 160 cause the first portion 22 and the second portion 42 to pivot and then laterally separate, or to laterally separate and then pivot. In addition, it can be operated continuously. The rotary separator 142 and the lateral separator 160 can also be operated to simultaneously pivot / rotate and separate the first portion 22 and the second portion 42 laterally.

  The rotary separator 142 includes a first handle 144 and a second handle 146. The first handle 144 has a first connecting member 148 and the second handle 146 has a second connecting member 150. The first connecting member 148 includes a groove 149 that receives the engaging member 32 of the first portion 22, and the second connecting member 150 includes a groove 151 that receives the engaging member 52 of the second portion 42. The first portion 22 and the second portion 42 move the first handle 144 toward the second handle 146 in the direction of arrow 155 and the second handle 146 toward the first handle 144. By moving in the direction of arrow 156, they can be swung or rotated away from each other. Moving the handles 144 and 146 in the direction of the arrows 155 and 156 may cause the connecting members 148 and 150 to move away from each other, causing the first portion 22 and the second portion 42 to pivot or rotate relative to each other. it can.

  The lateral separator 160 includes a first handle 162 and a second handle 164. The first connector 166 is pivotally connected to the first handle 162 at the center thereof, and the second connector 168 is pivotally connected to the second handle 164 at the center thereof. Connectors 166 and 168 are pivotally connected at their distal ends to the first handle 144 and the second handle 146, respectively, of the rotary separator 142.

  The first connector 170 extends between one end of the first handle 162 and the opposite end with respect to the second connector 168, and is pivotally connected at these ends. The second connector 172 extends between one end of the second handle 164 and the opposite end with respect to the first connector 166, and is pivotally connected at these ends. The first connector 166 includes a first locking member 152 that is pivotally connected thereto and extends through the first handle 144 and is releasably engageable therewith. The second connector 168 includes a second locking member 154 that is pivotally connected thereto and extends through the second handle 146 and is releasably engageable therewith. The locking members 152 and 154 selectively engage the handles 142 and 144 at any one of a number of positions where the first portion 22 and the second portion 42 have been rotated or pivoted by the rotary separator 142. The position can be maintained.

  The first connector 170 includes a first groove 174 and the second connector 172 includes a second groove 176. The locking pin 178 extends through the grooves 174 and 176 and connects the connectors 170 and 172 to each other. To laterally separate the first portion 22 from the second portion 42, the locking pin 178 is loosened, thus allowing the connectors 170 and 172 to move relative to each other. The first handle 162 is moved in the direction of the arrow 180 toward the second handle 164, and the second handle 164 is moved in the direction of the arrow 182 toward the first handle 162. At the same time as the first connector 170 pushes the second connecting member 168 outward, the second handle 164 pulls the second connecting member 168 outward. Similarly, at the same time as the second connector 172 pushes the first connecting member 166 outward, the first handle 162 pulls the first connecting member 166 outward. The connecting members 166 and 168 move the connecting portion 148 laterally away from each other. Accordingly, lateral movement of the handles 162 and 164 separates the connected first and second portions 22 and 42 so that the edges 25 and 45 are at the proximal ends 26 and 46 and the distal ends. Between 24 and 44 is displaced laterally relative to each other. Thereafter, the locking pin 178 can be screwed in to tighten the connector members 170 and 172 so that the lateral separator 160 does not move further. By moving the handles 162 and 164 in the direction of arrows 180 and 182, the first portion 22 and the second portion 42 are moved toward each other, reducing the spacing therebetween, and the retractor 20 is removed from the incision. Removed more easily.

  In use, the resistance to the wound provided by the tissue can prevent the distal ends 24 and 44 from separating to the extent of the proximal ends 26 and 46 when a separating force is applied by the lateral separator 160. Using rotary separator 142, distal ends 24 and 44 are separated from each other to provide the desired separation between edges 25 and 45 along the length of first portion 22 and second portion 42. Can be provided.

  Instrument 140 is positioned over the proximal end opening of working channel 50. In order to provide the surgeon with clear access to the working channel 50, the instrument 140 can be removed from the retractor 20, and the guide mechanism 190 is provided with the first portion 22 and the second obtained with the instrument 140. The lateral and rotational positioning of the portion 42 can be maintained. The guide mechanism 190 includes a guide member 200 having a groove 202 formed therein. The guide member 200 extends along the one side between the first portion 22 and the second portion 42, and the first portion 22 and the second portion 42 are connected thereto. Furthermore, it is conceivable that a second guide member can be provided on the other side of the retractor 20.

  The first connecting member 192 is movably attached to the groove 202 of the guide member 200 adjacent to the first portion 22, and the second connecting member 214 is adjacent to the second portion 42. It is movably attached to the groove 202. The first portion 22 includes a first ear 208 that extends from a collar 28 that is pivotally connected at one end 194 of the first connecting member 192. The other end of the first connecting member 192 is a cam mechanism that can be releasably engaged with the guide member 200 so as to maintain the positioning of the first portion 22 along the guide member 200. There is a stop mechanism 196. The second portion 42 includes a second ear 210 that extends from a collar 48 that is pivotally connected at one end 212 of the second connecting member 214. The other end of the second connecting member 214 is a cam member that can be removably engaged with the guide member 200 so as to maintain the position of the second portion 42 along the guide member 200. There is a stop mechanism 216.

  A first adjustment mechanism 198 and a second adjustment mechanism 206 are provided to finely and incrementally adjust the rotational positioning of each of the first portion 22 and the second portion 42. The first adjustment mechanism 198 extends through the first ear 208 and engages the first connecting member 192. When the first adjustment mechanism 198 is screwed toward the first ear 208, the end of the first adjustment mechanism 198 engages with the first connecting member 192, and the first portion 22 is moved to the guide member. Maintain in a swiveled position with respect to 200. The first adjustment mechanism 198 can also be operated by the surgeon to finely adjust the pivot position of the first portion 22 relative to the guide member 200 and the second portion 42. The second adjustment mechanism 206 extends through the second ear 210 and engages the second connecting member 214. When the second adjustment mechanism 206 is screwed toward the second ear portion 210, the end of the second adjustment mechanism 206 engages with the second connecting member 214, and the second portion 42 is guided to the guide member. Maintain in a swiveled position with respect to 200. The second adjustment mechanism 206 can also be operated by the surgeon to adjust the pivot position of the second portion 42 relative to the guide member 200 and the first portion 22.

  Referring now to FIG. 14, another embodiment of an instrument 220 that separates the first portion 22 and the second portion 42 of the retractor 20 is shown. The instrument 220 includes a first handle 222 that is pivotally coupled to a second handle 224 about a pin 226. The first handle 222 includes a distal portion 223 having a connecting member 228. The connecting member 228 includes a groove 230 that receives the engaging member 32 of the first portion 22 therein. Second handle 224 includes a distal portion 225 having a connecting member 232. The coupling member 232 includes a groove 234 that receives the engagement member 52 of the second portion 42 therein. The locking member 236 is pivotally connected at one end to the first handle 222, extends through the groove 238 of the second handle 224, and is detachably locked thereto.

  In use, the instrument 220 is attached to the retractor 20 with connecting members 228 and 232 that are engaged with the engaging members 32 and 52, respectively. Handles 222 and 224 are moved toward each other in the direction indicated by arrows 240 and 242 to move connecting members 228 and 232 away from each other. Next, the first portion 22 and the second portion 42 are separated from each other.

  The retractor 20 can be adapted to guide the first portion 22 and the second portion 42 during separation and maintain the separation provided by the instrument 220. In the illustrated embodiment, the collar 28 of the first portion 22 has opposing first ears 240 and second ears 242 that extend toward the second portion 42 beyond the adjacent edges 25. including. The second portion 42 includes a first guide member 246 that can be positioned over the first ear 240 and a second guide member 250 that can be positioned over the second ear 242. The first guide member 246 includes a groove 248, and the second guide member 250 includes a groove 252. The first cam locking mechanism 254 extends through the groove 248 and connects the first ear 240 to the first guide member 248. The second cam locking mechanism 256 extends through the groove 252 and connects the second ear 242 to the second guide member 250.

  As shown in FIG. 14, the first cam locking mechanism 254 includes a lever 258 that holds the locking body 260 with respect to the first ear 240 and the first guide member 246. Similarly, as shown in FIG. 14, the second cam locking mechanism 256 includes a lever 262 that holds the locking body 264 with respect to the second ear 242 and the second guide member 250. If it is desired to move the first portion 22 and / or the second portion 42, the levers 258 and 262 are rotated to engage and disengage the locked stops 260 and 264, respectively. The instrument 220 can then be used to apply a separation force, or the first portion 22 and the second portion 42 can be moved toward each other and easily removed from the incision.

  It is contemplated that the guide members 246 and 250 may be curved or arcuate to follow the path of the connecting members 228 and 232 when the connecting members 228 and 232 are separated by the handles 222 and 224. Thus, the first portion 22 and the second portion 42 are simultaneously swiveled / rotated by the instrument 220 and separated laterally. Further, it is contemplated that one or more guide members between the first portion 22 and the second portion 42 can be configured to provide only a lateral separation path or only a rotational separation path. Other embodiments contemplate a guide member that provides a combination of rotational and lateral separation paths.

  It is contemplated that the various retractors 20 for spinal surgery can be provided as kits with lengths ranging from 20 mm to 100 mm increasing in increments of 10 or 20 mm. It is further contemplated that the retractor 20 can be provided as a kit with various working insertion configurations, such as an initial insertion width 55 of 14, 16, 18, 20, 21, or 25 mm. However, it should be understood that the present invention contemplates that the retractor 20 can have other lengths and diameters and can be provided as a kit of different increment units. The appropriate length of the retractor 20 depends on the desired surgical site depth beneath the patient's skin, the surgical anatomy, and the patient's anatomy. These factors in the selection of the retractor can be assessed by X-ray or other known imaging techniques by pre-operative planning performed prior to surgery, and with different lengths and working channel dimensions. The instrument can be made available and can be adjusted during the surgical procedure if necessary.

  With reference to FIGS. 15 and 16, another embodiment of a retractor 320 is shown. The retractor 320 includes a first retractor portion 322 and a second retractor portion 342. First portion 322 includes a body 323 that extends between a distal end 324 and an opposing proximal end 326. Second portion 342 includes a body 343 that extends between distal end 344 and opposing proximal end 346. The distal ends 324 and 344 can be beveled or tapered distally to facilitate insertion, although non-tilted ends are also contemplated. The first portion 322 is adjacent to the second portion 342 along the longitudinal edges 325 and 327 of the first portion 322 and adjacent to the longitudinal edges 345 and 347 of the second portion 342. Or mesh with it. As mentioned above, other configurations between adjacent edges are also conceivable. Furthermore, it is contemplated that the longitudinal edges can be spaced from each other in the insertion configuration. A working channel 350 is formed between the first portion 322 and the second portion 342. A working channel 350 extends between the distal ends 324 and 344 and the proximal ends 326 and 346 where it opens.

  The retractor 320 can be inserted into the patient's skin and tissue to provide a working channel 350 to the surgical site. The retractor 320 is believed to be inserted into the skin and tissue with the insertion form of the working channel 350 as shown in FIGS. In the inserted configuration, the working channel 350 is substantially surrounded or restricted by the first portion 322 and the second portion 342. After insertion into the patient, the working channel 350 can be enlarged by separating the first portion 322 and the second portion 342 from each other along an axis 321 extending therebetween. Separating the first portion 322 and the second portion 342 increases the size of the working channel 350 from the proximal ends 326 and 346 to the distal ends 324 and 344.

  In the insertion configuration shown in FIGS. 15-18, the working channel 350 is limited or substantially surrounded by the first portion 322 and the second portion 342. The bodies 323 and 343 can be configured as described above with respect to the body of the retractor 20 portion. The working channel 350 has dimensions that allow one or more surgical instruments and / or grafted tissue to pass through to the surgical site in the patient's body in the inserted configuration, although smaller dimensions are also contemplated. During surgery, it may be desirable to allow further access to a site in the patient's body that is farther than the site provided through the working channel 350 in the inserted configuration. Accordingly, the first portion 322 and the second portion 342 are movable away along the axis 321 so as to enlarge the working channel 350.

  The first portion 322 includes a body 323 with a semi-cylindrical body that extends between a distal end 324 and a proximal end 326. The collar 328 extends around the proximal end 326 and forms a lip that extends around the outer surface of the body 323. Second portion 342 includes a body 343 having a semi-cylindrical body extending between distal end 344 and proximal end 346. The collar 348 extends around the proximal end 346 of the second portion 342 and defines a lip that extends around the outer surface of the body 343. Further, it is contemplated that the first portion 322 and the second portion 342 may or may not include a collar and / or lip. The first portion 322 and the second portion 342 may also include a bracket member that is positioned within the patient while engaging an external arm that supports the retractor 320.

  Extending from the collar 328 of the first portion 322 is a first engagement member 332 having a head portion 336 in which a recess 333 is formed. Extending from the collar 348 of the second portion 342 is a second engagement member 352 having a head portion 356 in which a recess 353 is formed. Engaging members 332 and 352 can be integrally formed with collars 328 and 348, respectively, or can be removably engaged therewith. As discussed further below, the first portion 322 and the second portion 342 are separated from the first portion 322 and the second portion 342 to apply a separating force to expand the working channel 350. The instrument that separates the portion 342 can engage or disengageably engage the engagement members 332 and 352. Such an instrument can also detachably or non-engageably engage the first portion 322 and the second portion 342. Engagement members 332 and 352 extend laterally from portions 322 and 342 so that the separation instrument can easily engage engagement members 332 and 352 without the separation instrument interfering with working channel 350. Such an instrument can also maintain the first portion 322 and the second portion 342 in the initial insertion configuration during and after insertion. The separation instrument can further maintain an expanded configuration of the working channel 350 in situ.

  Recesses 333 and 353 are adapted to receive an engagement arm of a separation instrument that is engageable with portions 322 and 342. In the illustrated embodiment, the engagement members 332 and 352 extend laterally from and protrude proximally above the collars 328 and 348, respectively. Engaging members 332 and 352 extend along each other and touch each other when portions 322 and 342 are in the inserted configuration. Other forms of engagement members are also contemplated, such as non-linear engagement members that extend away from each other when portions 322 and 324 are in the insertion configuration, engagement members that do not contact each other when in the insertion configuration.

  Recesses 333 and 353 open laterally and receive respective engagement arms of the separating device. The recess 333 includes a keyway opening 335 and a receiving port 337 communicating with the opening 335. The receptacle 337 is enlarged with respect to the opening 335 and is shaped to receive a portion of the engagement arm of the separation instrument positioned therein. Similarly, the recess 353 includes a keyway opening 355 and a receiving port 357 communicating with the opening 355. The receptacle 357 is enlarged with respect to the opening 355 and is shaped to receive a portion of the engagement arm of the separating instrument positioned therein. Openings 335 and 355 and receptacles 337 and 357 are open along the proximal side of engagement members 332 and 352, respectively, to facilitate placement of the engagement arms of the separating device. Other forms of recesses 333 and 353 are also contemplated, such as any other form of recess that is suitable to receive at least a portion of an enclosed, uniform, or engaging arm. Still other embodiments contemplate engagement members 332 and 352 that do not include a recess, but are shaped to receive or engage each of the engagement arms of the separation device.

  As shown in FIGS. 19 and 20, an alignment member 330 can be provided along one side of one of the engagement members 332 and 352 (engagement member 352 in the illustrated embodiment). In the illustrated embodiment, the alignment member 330 is rounded that is received in a hole provided in the other of the engagement members 332 and 352 when the engagement members 332 and 352 are positioned adjacent to each other. It is an attached protrusion. The alignment member 330 maintains the first portion 322 and the second portion 342 in the longitudinal direction with respect to each other during and after insertion. Other embodiments contemplate other configurations for aligning and / or releasably connecting the first portion 322 and the second portion 342 to each other. Examples of such configurations include, for example, dovetail connections, fasteners, threaded coupling members, clamping members, snap rings, compression bands, straps, ball detent mechanisms, and detachably mating cams or tabs.

  With reference to FIGS. 17-20, a separation instrument 360 operable to expand the working channel 350 by separating the first portion 322 and the second portion 342 from each other is shown. It is contemplated that the separating instrument 360 includes a lateral separator operable to move the first and second retractor portions linearly away from each other along the axis 321. Further, it is contemplated that the separation instrument 360 includes at least one rotary separator that pivots the distal ends of the first portion 322 and the second portion 342 away from each other along the axis 321. The lateral and rotary separators are selectively used by the surgeon during the surgical procedure to enlarge the working channel 350 and to provide the desired tissue retraction for performing the surgical procedure through the working channel 350. Can be provided. Enlarging the working channel 350 opens the tissue further away from the surgical site distal to the distal ends of the retractor portions 322 and 342, distal to the tissue, bone structure, and retractor 320. Further access to other anatomical spaces located in

  Separation tool 360 includes a first connection assembly 362 movably coupled to a second connection assembly 364. The first connection assembly 362 is further coupled to the first portion 322, and the second connection assembly 364 is coupled to the second portion 342. The first connection assembly 362 and the second connection assembly 364 extend away from the first portion 322 and the second portion 322 and away from the proximal end opening of the working channel 350 to provide a surgical Facilitates access to working channel 350 during the procedure. The first connection assembly 362 and the second connection assembly 364 are operated to move the first portion 322 and the second portion 342 toward and away from each other to separate tissue. Is possible. The first connection assembly 362 and the second connection assembly 364 are further configured to rotate the first portion 322 and the second portion 342 about their proximal ends to separate their distal ends from each other. Lever assemblies 369 and 389, respectively.

  The first connection assembly 362 includes a first engagement arm 372 coupled to the first engagement member 332 of the first portion 322 and a first extension arm 366 extending from the first engagement arm 372. Including. The connecting arm 368 is oriented transversely toward and extending from the end of the first extension arm 366 opposite the first engagement arm 372. The bracket member 376 extends from the connecting arm 368 and can be engaged by, for example, a flexible arm attached to the operating table. The first connection assembly 362 further includes a first intermediate member 367 firmly coupled to the first extension arm 366. The first engagement arm 372 is rotatable with respect to the intermediate member 367. The first attachment member 375 extends from the first engagement arm 372. The first lever arm 374 is pivotally attached to the first attachment member 375 and is movable between a locked position as shown in FIG. 17 and a pivot position as shown in FIG.

  Similarly, the second connection assembly 364 includes a second engagement arm 394 coupled to the second engagement member 352 of the second portion 342 and a second engagement arm 394 extending from the second engagement arm 394. Extension arm 392. The housing 390 extends from the end of the second extension arm 392 that faces the second engagement arm 394. The housing 390 includes a passageway through which the connecting arm 368 is movably received. An adjustment mechanism 399 attached to the housing 390 engages the connecting arm 368 to move the first portion 322 and the second portion 342 toward and away from each other along the translation axis 321. And is operable to translate the connecting arm 368 within the housing 390.

  In the illustrated embodiment, the connecting arm 368 includes a plurality of ratchet teeth 370 formed along it that are engageable by an adjustment mechanism 399. The adjustment mechanism 399 includes a gear 400 with teeth that mesh with the teeth 370 so that the connecting arm 368 in the housing 390 is moved when the handle 398 is rotated. The locking mechanism 402 is spring biased to engage the teeth 370 and maintain the separation of the first portion 322 and the second portion 342 when the handle 398 is disengaged. The locking mechanism 402 can also be lowered down so that its engagement end can be pivoted to disengage the teeth 470 and the first portion 322 and the second portion 342 can move toward each other. .

  The second connection assembly 364 further includes a second intermediate member 393 that is securely coupled to the second extension arm 392. The second engagement arm 394 is rotatable with respect to the intermediate member 393. The second attachment member 397 extends from the second engagement arm 394 along the second intermediate member 393. The second lever arm 396 is pivotally attached to the second attachment member 397 and is movable between a locked position as shown in FIG. 17 and a pivot position as shown in FIG. Intermediate members 367 and 393 can be provided as separate components or can be integral with their respective extension arms.

  As shown in FIGS. 23-24, the first engagement arm 372 and the second engagement arm 394 include feet 378 and 404, respectively. The feet 378 and 404 are slidably and removably received in the recesses 333 and 353 of the engagement members 332 and 352, respectively. In the illustrated embodiment, the feet 378 and 404 extend between the enlarged outer end portions 379 and 405 and the engagement arms 372 and 394 and the enlarged outer end portions 379 and 405, more Including small cross-sectional intermediate transition portions 381 and 407. Intermediate transition portions 381 and 407 are received in intermediate keyway openings 335 and 355, and enlarged outer end portions 379 and 405 are received in receptacles 337 and 357.

  The feet 378 and 404 are configured to cause the lever arms 374 and 396 to rotate the first retractor portion by rotating the engagement arms 372 and 394 about respective axes 371 and 391, as discussed further below. Receivable in recesses 333 and 353 in a manner that can cause rotation of 322 and second retractor portion 342. Further, the separation instrument 360 can be easily removed from the first retractor portion 322 and the second retractor portion 342 to easily clean the instrument assembly after a surgical procedure. In addition, a disposable first portion 322 and second portion 342 may be used, or a set of first portion 322 and second portion 342 may be selected by the surgeon for use with separation instrument 360. It is contemplated that it can be provided in various lengths, shapes, and / or dimensions.

  Intermediate members 367 and 393 each include a locking portion, such as engagement portions 426 and 414 that can engage with lever arm locking assemblies 420 and 408, respectively, as shown in FIGS. Lever arm locking assemblies 420 and 408 include pawls 409 and 421 that are pivotally connected to adjacent ones of mounting members 375 and 397, respectively. For example, as shown in FIGS. 24 and 26, the lever arm locking assembly 420 includes a pivot pin 422 attached to a mounting member 375 about which the pawl 421 can pivot. Similarly, the lever arm locking assembly 408 includes a pivot pin 410 attached to a mounting member 397 about which the pawl 409 can pivot. Intermediate members 367 and 393 are engaging portions 426 and 414, respectively, with which locking members 420 and 408 can engage to maintain the pivoted position of first portion 322 and second portion 342, respectively. Each of them.

  For example, as shown in FIG. 26, an engagement portion 426 is provided along intermediate member 367 oriented toward pawl 421 with respect to intermediate member 367. The pawl 421 includes a proximal handle portion 423 and a distal engagement end 424. The distal engagement end 424 can be positioned in at least one of the recesses provided between the teeth 428 to maintain the pivoted position of the first portion 322. When the lever arm 374 is rotated counterclockwise to pivot the distal end of the retractor portion 322 away from the distal end of the retractor portion 342, the pawl 421 is positioned at the pivoted retractor portion 322. Is moved around the engagement portion 426 and engaged therewith.

  Other embodiments contemplate that the intermediate members 367 and 393 are movable as the respective retractor portions pivot. In such an embodiment, the pawls 409 and 421 do not move or rotate with the rotation of the engagement arm, but remain stationary when it rotates, with adjacent engagement portions of the respective intermediate members 367 and 393. Maintain the engagement.

  In FIG. 24, the first lever arm 374 is shown pivoted to its pivot position on the mounting member 375, and the second lever arm 396 is pivoted to its locked position on the mounting member 397. . In the locked position, the lever arm 396 includes a protrusion 406 that can engage the proximal handle portion of the pawl 409. In the engaged position, the proximal handle portion 413 cannot be moved toward the attachment member 397 to remove its engagement end 412 from the teeth along the engagement portion 414 of the intermediate member 393. Accordingly, the pivot position of the second retractor portion 342 is locked by positioning the lever arm 396 in its locked position, and unless the lever arm 396 is moved to its pivot position, the second retractor portion 342 is I can't move.

  In FIG. 24, the first lever arm 374 is shown in its pivoted position and includes a protrusion 418 extending from the first lever arm 374 positioned so as not to contact the pawl 421. In this position, the pawl 421 can pivot about the pin 422 to remove the engagement end 424 from between the teeth 428. The lever arm 374 can then be manipulated to pivot the first retractor portion 322 along the axis 321 to a desired angular position. As the lever arm 374 is pivoted, the locking member 420 is moved therewith to align with another space between the teeth 428. Once the desired orientation of the first portion 322 is obtained, the proximal handle portion 423 can then be disengaged and the locking member 420 can be spring biased or otherwise moved to The engaging portion 426 can be engaged to maintain the pivoted position of the first portion 322. Thereafter, the lever arm 396 can be pivoted on the mounting member 375 to a locking position where the projection 418 engages the pawl 421 so that it does not engage or disengage from the locking portion 426.

  With reference to FIGS. 27-28, a first intermediate retractor assembly 450 that is engageable with a separation instrument 360 is shown. Intermediate retractor assembly 450 is positioned between first retractor portion 322 and second retractor portion 342 to retract and / or maintain tissue from working channel 350 in a direction across axis 321. A retractor blade 452 that can be included. In one surgical approach to the spine, the retractor 320 is oriented such that the retractor portions 322 and 342 are movable along an axis 321 oriented in the direction of the central axis of the spinal column, and the blade 450 is Positioned inside or adjacent to the spinal column relative to other retractor blade portions 322 and 342. Other motion orientations within the incision of the retractor blade and retractor portion are also contemplated.

  The first intermediate retractor assembly 450 includes a blade 452 that extends between a distal end 454 and a proximal end 456. As shown in FIG. 28, the distal end 454 is curved away from the working channel 350 and can be placed over bone or other tissue when positioned within the retracted incision. . The blade 452 can include a flat cross-section between the distal end 454 and the proximal end 456, or can include a convex curvature about or along its longitudinal axis. Can do. The blade 452 can also be provided as a single member or provided in one or more components that are movable relative to each other to lengthen or shorten the blade 452.

The coupling arm 458 is oriented transversely to and extends from the proximal end 456 of the blade 452. Opposite the blade 452, an engagement portion in the form of a first hook member 462 and a second hook member 464 is provided. The lower hook member 464 can be positioned around the connecting arm 368 of the separating instrument 360. The coupling arm 458 has a length such that pressure from the incision tissue against the blade 452 holds the hook member 464 firmly against the coupling arm 368. The upper hook member 462 can serve as a handle that facilitates placing the lower hook member over the coupling arm 368 or removing the intermediate retractor assembly 450. Other configurations for securing the blade 452 to the connecting arm 368 are also contemplated, such as fasteners and components that lift each other.

  As shown in FIGS. 29 and 39, the first intermediate retractor assembly 450 can be further attached by a second intermediate retractor assembly 470. Second intermediate retractor assembly 470 includes a blade 472 extending between a distal end 474 and a proximal end 476. The distal end 474 and the blade portion extending therefrom can be configured as described above with respect to the blade 452. Second coupling arm 478 includes an engagement foot 480 that extends from proximal end 476 and faces blade 472. The engagement foot 480 can be removably attached to the coupling arm 458 of the first intermediate retractor assembly 450.

  The first coupling arm 458 is adapted to receive a pin (not shown) extending from the lower surface of the foot 480 of the second coupling arm 478 and extends therethrough a slotted hole 460 (FIGS. 27- 28). The pin can include an enlarged head that can be positioned within an enlarged portion of the slotted hole 460 such that the slotted hole 460 narrows so that the head is captured within the slotted hole 460. Can slide to the other end. In the illustrated embodiment, the slotted hole 460 narrows so that the pressure from the tissue around the incision pushing the blade 472 maintains the pin of the foot 480 within the narrowed end of the slotted hole 460. The resulting portion expands the opposing retractor blade 472.

  The second coupling arm 478 includes an offset portion 486 that extends in a direction transverse to the first coupling arm 458. The offset portion 486 is connected by an offset member 479 extending therebetween. The offset member 479 can include an arcuate cross section that extends around each of the adjacent retractor portions 322 and 342 so as not to interfere with access to the working channel 350. The retractor blade 472 can maintain tissue retraction and protect tissue disposed along the side of the working channel opposite the retractor blade 452. The first intermediate retractor assembly 450 and the second intermediate retractor assembly 470 provide additional options for tissue retraction and protection that can be readily used with the separation device 360 engaged with the retractor 320. Is provided to the surgeon during the surgical procedure.

  In one surgical procedure, the retractor 320 is engaged with the separation instrument 360 and inserted into the incision. The retractor 320 can be advanced over one or more dilators that dilate the incision or directly into the incision. Thereafter, the separating instrument 360 is operated to linearly move the retractor portions 322 and 342 away from each other along the axis 321 to enlarge the working channel 350. One or both of the lever arms 374 and 396 can be moved and manipulated to their pivot positions to pivot the retractor portions 322 and 342, respectively. As the retractor portion is pivoted, the lever arms each have a protrusion extending therefrom engaging the adjacent pawls 409 and 421 to maintain engagement between the pawl and the adjacent engaging portions 414 and 426. Then, it is moved to the locking position.

  Once the desired separation is obtained, the surgeon has the option of selecting the first intermediate retractor assembly 450. The blade 452 is positioned at the incision between the separated first retractor portion 322 and second retractor portion 342 and the coupling arm 458 is secured to the connecting arm 368. The surgeon has the further option of selecting the second intermediate retractor assembly 470 and positioning the blade 472 within the incision opposite the blade 452. The coupling arm 478 can then be secured to the coupling arm 458. Further adjustment of the spacing and orientation of the retractor portions 322 and 342 can be completed with the separation instrument 360 and / or the lever arms 374 and 396.

  Further, the retractor portions 322 and 342 need not be separated linearly from each other, but can be separated during a surgical procedure only by pivoting one or both along the axis 321. It is done. Once the working channel 350 provides the desired access, the surgeon can remove bone, tissue, disc material, or other objects with the retractor 320. Implanted tissue, such as fusion devices, screws, plates, rods, artificial disks, bone growth materials, and other repair devices, or therapeutic materials may be delivered to the desired site within the patient's body via the retractor 320. it can.

  While the invention has been illustrated and described in detail in the drawings and foregoing description, the same is to be considered as illustrative and not restrictive in character and all modifications and variations that fall within the spirit of the invention. It should be taken into account that it seeks protection of

FIG. 3 is a perspective view of an embodiment of the retractor in an insertion configuration. FIG. 2 is a perspective view of the retractor of FIG. 1 with the first and second portions of the retractor separated from each other. FIG. 11 is a perspective view of another embodiment of a retractor in an insertion configuration. FIG. 4 is a detail view of one form of an adjacent retractor portion in an insertion configuration. FIG. 7 is a detail view of another configuration of adjacent retractor portions in an insertion configuration. FIG. 7 is a detail view of another configuration of adjacent retractor portions in an insertion configuration. FIG. 2 is a plan view of the retractor of FIG. 1 in an insertion configuration with an instrument connected to separate the first and second portions of the retractor. FIG. 8 is a cross-sectional view taken along line 8-8 of FIG. 7 with the retractor inserted over a continuous tissue dilator. FIG. 9 is the retractor of FIG. 8 with the working channel of the retractor enlarged. FIG. 10 is a side view of another embodiment of a retractor in an insertion configuration. 11 is the retractor of FIG. 10 with the working channel enlarged. FIG. 6 is a perspective view of another embodiment of a retractor and an instrument separating a first portion and a second portion of the retractor. FIG. 6 is a perspective view of another embodiment of a retractor and an instrument separating a first portion and a second portion of the retractor. FIG. 6 is a perspective view of another embodiment of a retractor and an instrument separating a first portion and a second portion of the retractor. FIG. 11 is a perspective view of another embodiment of a retractor in an insertion configuration. FIG. 16 is a plan view of the retractor of FIG. 15. FIG. 16 is a plan view of the retractor of FIG. 15 with the separation device engaged. FIG. 18 is a perspective view of the assembly of FIG. 17. FIG. 18 is another perspective view of the assembly of FIG. 17 with the retractor portion separated. FIG. 20 is a plan view of the assembly of FIG. 19. FIG. 20 is a perspective view of the assembly of FIG. 19 with the lever arm being moved to a pivot position. FIG. 22 is a cross-sectional view of a portion of the separation instrument taken along line 22-22 of FIG. 21, showing the lever arm locking assembly when the retractor portion engaged with the lever arm locking assembly is in a non-rotating position; . FIG. 18 is a perspective view of the separation instrument of FIG. 17 removed from the retractor. FIG. 18 is a front view of a portion of the separation instrument of FIG. 17. FIG. 5 is a perspective view of an assembly showing a swiveled retractor portion. FIG. 27 is a cross-sectional view of a portion of the separation instrument taken along line 26-26 of FIG. 25, showing the lever arm locking assembly when the retractor portion engaged with the lever arm locking assembly is in a non-rotating position. . FIG. 20 is a perspective view of the assembly of FIG. 19 showing a first intermediate retractor assembly engaged with a pivoted retractor portion and a separating instrument. It is a top view of the assembly of FIG. FIG. 28 is a perspective view of the assembly of FIG. 27 with a second intermediate retractor assembly engaged with the first intermediate retractor assembly. FIG. 30 is a plan view of the assembly of FIG. 29.

Claims (12)

A first retractor portion having a proximal end and a distal end and capable of being positioned within the incision;
A second retractor portion having a proximal end and a distal end and capable of being positioned in an incision opposite the first retractor portion, together with the first retractor portion, The first retractor portion and the second retractor portion in the direction in which the first and second retractor portions are moved from the insertion configuration adjacent to each other to the second configuration in which the first and second retractor portions are separated from each other. A second retractor portion defining an axis extending between the retractor portion and the second retractor portion;
A separating device connected between the proximal end of the first retractor portion and the proximal end of the second retractor portion and offset to one side of the axis, A separation instrument operable to move the retractor portion and the second retractor portion along the axis from the insertion configuration to the second configuration;
An intermediate retractor assembly removably attachable to the separating instrument, the coupling retractor comprising a coupling arm extending from the separating instrument toward the first and second retractor portions to a first retractor blade; An intermediate retractor assembly, wherein one retractor blade is oriented transversely to the coupling arm and can be positioned in an incision between the first and second retractor portions ,
The first retractor portion includes an engagement member that extends laterally from the first retractor portion and engages the separation instrument, and the second retractor portion is the second retractor portion. An engagement member extending laterally from and engaging the separation device;
One of the engaging member of the first retractor portion and the engaging member of the second retractor portion is engaged with the engaging member of the first retractor portion and the second retractor portion. Including at least one alignment member extending toward the other of the mating members;
The other engagement member of the first retractor portion engagement member and the second retractor portion engagement member includes at least one receptacle for receiving the at least one alignment member; A retractor assembly for percutaneous surgery inside a patient comprising :
The separation instrument includes a first connection assembly connected to the first retractor portion and a second connection assembly connected to the second retractor portion, the first connection The assembly and the second connection assembly are movably coupled to each other;
Each of the connection assemblies includes an engagement arm coupled to each of the retractor portions and an extension arm extending from the engagement arm, the engagement arm being rotatable relative to the extension arm. Pivoting the distal end of each of the retractor portions;
The retractor assembly further includes a lever arm assembly coupled to each of the engagement arms, each of the lever arm assemblies being operable to rotate each of the engagement arms about its axis. A lever arm that pivots the distal end of the retractor portion engaged therewith
The retractor assembly is engaged with each of the lever arm assemblies and is operable to maintain a rotated position of the engagement arm coupled to the lever arm assembly. Further comprising an assembly;
Each of the lever arm locking assemblies includes a pawl pivotally coupled to each of the lever arm assemblies, the pawls engaging engagement portions along adjacent ones of the extension arms. Its rotated position can be maintained,
A retractor assembly for percutaneous surgery within a patient . Each of the pawl and the lever arm is pivotally connected to a mounting member extending from the adjacent engagement arm assembly according to claim 1. Each of the lever arms is movable between a swiveling position and a locking position, and in the swiveling position, each of the lever arms extends from the mounting member and is operated to rotate the adjacent engagement arm It is possible, in the locking position, engaging the each pawl of the lever arm, locking the pawl into engagement with the engaging portion of the extension arm and the adjacent, claim 2 Assembly. Each of the lever arms, to urge the engaging end portion opposite of said pawl in engagement with the engagement portion includes a protrusion that engages a proximal handle portion of said pawl, to claim 3 The assembly described. A first retractor portion having a proximal end and a distal end and capable of being positioned within the incision;
A second retractor portion having a proximal end and a distal end and capable of being positioned in an incision opposite the first retractor portion, together with the first retractor portion, A first axis extending between the first retractor portion and the second retractor portion in a direction in which the first retractor portion and the second retractor portion are moved away from each other; A second retractor portion defining:
A separating device connected between the proximal end of the first retractor portion and the proximal end of a second retractor portion and offset to one side of the first axis, Operable to move the first retractor portion and the second retractor portion away from each other along the first axis, wherein the separating instrument comprises a first retractor portion of the first retractor portion; A first engagement arm extending along a second axis transverse to the first axis from the proximal end, and across the first axis from the proximal end of the second retractor portion; A second engagement arm extending along a third axis, wherein each of the engagement arms pivots each of the retractor portions engaged thereto about its proximal end. A portion adjacent to each of said retractor portions rotatable about each said axis No, and separation equipment,
A retractor assembly for percutaneous surgery within a patient comprising :
The retractor assembly further includes a lever arm coupled to the rotatable portion of each of the engagement arms, the lever arm having the rotatable portion about each of the axes of the engagement arms. Operable to rotate, thereby pivoting the retractor portion engaged therewith,
The retractor assembly further comprises a lever arm locking assembly on the rotatable portion of each of the engagement arms, each lever arm locking assembly being a second non-rotatable of the engagement arm. Can be engaged with the engaging part of the main part in a detachable manner,
Each of the lever arm locking assemblies includes a pawl attached to the rotatable portion of each of the engaging arms, each pawl being engageable with the engaging portion, percutaneous within the patient Retractor assembly for surgical operation . 6. An assembly according to claim 5 , wherein each pawl is pivotally connected to a mounting member extending from the rotatable portion of each of the engagement arms. Each of the lever arms is movable between a swiveling position and a locking position, and in the swiveling position, the lever arm extends from each of the mounting members and rotates the rotatable portion of the engagement arm. The set of claim 6 , wherein each of said lever arms engages with each of said pawls and engages with said engaging portion to lock said pawls in said locking position. Solid. Each of the lever arms, to urge the engaging end portion opposite of said pawl in engagement with the engagement portion includes a protrusion that engages a handle portion of said pawl each proximal claim 7 Assembly according to. A first retractor portion having a proximal end and a distal end and capable of being positioned within the incision;
A second retractor portion having a proximal end and a distal end and capable of being positioned in an incision opposite the first retractor portion, together with the first retractor portion, A first axis extending between the first retractor portion and the second retractor portion in a direction in which the first retractor portion and the second retractor portion are moved away from each other; A second retractor portion defining:
A separating instrument connected between the proximal end of the first retractor portion and the proximal end of the second retractor portion and offset to one side of the first axis; A first engagement arm extending from the proximal end of the first retractor portion along a second axis transverse to the first axis; and from the proximal end of the second retractor portion A second engagement arm extending along a third axis transverse to the first axis, each of the engagement arms adjacent to each of the retractor portions rotatable about each of the axes. And a lever arm that extends from the rotatable portion and is operable to rotate the rotatable portion and pivot each retractor portion engaged therewith about its proximal end A separation device comprising:
A retractor assembly for percutaneous surgery within a patient comprising :
The retractor assembly further comprises a lever arm locking assembly attached to each of the engagement arms and operable to maintain a rotational position of the engagement arm;
Each of the lever arm locking assemblies includes a pawl attached to the rotatable portion of each of the engaging arms, each of the pawls being an engaging portion along a non-rotatable portion of each of the engaging arms. A retractor assembly for percutaneous surgery within a patient that is engageable with the device. The assembly of claim 9 , wherein the pawl and the lever arm are each pivotally connected to a mounting member extending from the rotatable portion of each of the engagement arms. Each of the lever arms is movable between a swiveling position and a locking position, in which the lever arm extends from each of the mounting members and rotates each of the rotatable portions of the engagement arm. 11. The lever of claim 10 , wherein each of the lever arms engages with each of the pawls and engages with the engaging portion to lock the pawls in the locked position. Assembly. Each of the lever arms includes a protrusion that engages a proximal handle portion of the pawl adjacent to the pawl that biases an opposing engaging end of the pawl engaged with the engaging portion. 12. An assembly according to claim 11 .

Images