JP6084100B2 - Ultrasonic treatment device - Google Patents

Description

  The present invention relates to an ultrasonic treatment apparatus.

  2. Description of the Related Art Conventionally, an apparatus for treating a tissue using ultrasonic waves is known (see, for example, Patent Documents 1 and 2). The apparatus of Patent Document 1 generates frictional heat in fat by ultrasonically vibrating the tip of the probe in contact with fat, and the fat is dissolved and emulsified in physiological saline by this frictional heat. It removes fat from the body. The apparatus of Patent Document 2 is a method of cauterizing a tissue such as a myocardium in a non-contact manner by focusing ultrasonic waves radiated from a spherical radiation surface on a focal point away from the radiation surface. It has a mechanism to move to

Japanese Patent Publication No. 06-020462 JP 2012-187257 A

  However, since each of the devices of Patent Documents 1 and 2 can only deal with a specific application, it corresponds to a situation where a plurality of tissues having different appropriate treatment methods are mixed, such as when treating a myocardium covered with fat. There is a problem that it is difficult to do.

  That is, since the apparatus of Patent Document 1 is a system that transmits ultrasonic vibrations to a relatively wide range of tissues by directly contacting the probe with the tissues, the influence on the tissues is large. Therefore, although it is effective for the treatment of fat on the assumption that it is removed from the body, it is not suitable for the treatment of the myocardium that requires minimally invasiveness. On the other hand, since the ultrasonic wave locally acts on only the tissue in the vicinity of the focal point, the apparatus of Patent Document 2 can perform a minimally invasive treatment. However, since it is difficult to remove a relatively large amount of fat, the myocardium must be cauterized over the fat, and the focal point of the ultrasonic wave irradiated to the myocardium is shallow by the thickness of the fat. turn into.

  This invention is made | formed in view of the situation mentioned above, Comprising: It aims at providing the ultrasonic treatment apparatus which can perform the treatment of the some structure | tissue from which the appropriate treatment system differs continuously.

In order to achieve the above object, the present invention provides the following means.
The present invention provides an elongated main body, a first ultrasonic vibrator that is provided at a distal end of the main body and generates a first ultrasonic vibration, and the first ultrasonic wave generated by the first ultrasonic vibrator. A first treatment means having a transmission member for transmitting the ultrasonic vibration to the tissue, a second ultrasonic vibrator provided at the distal end of the main body and generating a second ultrasonic vibration, a second treatment means having a radiating surface for radiating an ultrasonic wave toward the tissue by ultrasonic vibration of said second generated by the second ultrasonic transducer, said first treatment section and the second and a driving switching unit for alternatively driving the treatment unit, the first treatment unit and the second treatment means, that are coupled together at the position of the first section of the ultrasonic vibration ultrasonic A treatment device is provided.

  According to the present invention, the first treatment means is used, and the first ultrasonic vibration generated by the first ultrasonic transducer is transmitted to the tissue around the first transmission member via the first transmission member. By transmitting to, the tissue can be crushed or dissolved by applying mechanical vibration to the tissue. In addition, the second treatment means is used to irradiate the tissue with the second ultrasonic vibration generated by the second ultrasonic transducer as an ultrasonic wave from the radiation surface, thereby giving high energy to the tissue. The tissue can be cauterized.

  In this case, since the first treatment means and the second treatment means for treating the tissue in different manners are provided in a single body, the two treatment means are switched according to the tissue to be treated. By properly using each part, it is possible to continuously perform treatment of a plurality of tissues having different appropriate treatment methods.

In the above-mentioned invention, it may have a treatment portion that is ultrasonically vibrated integrally with the first ultrasonic transducer and is brought into contact with the tissue.
By doing in this way, the 1st treatment means can be made into the contact type composition which makes a treatment part contact tissue, and makes ultrasonic vibration act on this tissue directly.

Further, in the above invention, the first ultrasonic transducer is a bolt fastening in which the piezoelectric element and the elastic body arranged on both sides of the piezoelectric element are integrally fastened by a bolt penetrating the piezoelectric element. It is a Langevin type (BLT) vibrator, and the transmission member is a straight rod-like member fixed to one end of the bolt-clamped Langevin vibrator and arranged coaxially with the bolt, and its distal end is used as the treatment part It may act.
By doing so, the first ultrasonic vibration generated by the BLT vibrator can be efficiently transmitted to the treatment portion, and the treatment efficiency of the tissue by the first treatment means can be improved.

Further, in the above invention, the radiation surface is a concave curved surface arranged outward of the main body, and the second treatment means focuses the ultrasonic wave focused at a position away from the main body. You may radiate | emit from a radiation | emission surface.
By doing in this way, an ultrasonic wave can be made to act locally and effectively with respect to the treatment object part of the position away from the main body, and the treatment object part can be cauterized without contact.

Moreover, in the said invention, the said transmission member may protrude rather than the said main body, and the said 2nd treatment means may radiate | emit the said ultrasonic wave focused on the position beyond the said transmission member from the said main body.
By doing in this way, even in the configuration in which the approach of the radiation surface to the tissue is restricted by the transmission member, it is possible to cauterize by applying ultrasonic waves to the treatment target site at a position deeper than the surface of the tissue.

Moreover, in the said invention, you may provide the focus moving mechanism which moves the focus of the said ultrasonic wave to the radiation | emission direction of this ultrasonic wave.
In this way, by adjusting the focus position of the focused ultrasound according to the depth of the treatment target site, it can be suitably applied to cauterization of various treatment target sites with different depths from the tissue surface. can do.

Moreover, in the said invention, the said 2nd treatment means may radiate | emit the said ultrasonic wave toward the side of the said main body.
By doing so, the treatment target site can be cauterized by irradiating the tissue with ultrasonic waves in a posture in which the tip of the main body is laid on the tissue surface, so that operability in a particularly narrow treatment space is improved. Can do.

In the above invention, the first treatment means and the second treatment means are coupled to each other at the position of the node of the first ultrasonic vibration so that the first treatment means is driven. It is possible to prevent the second treatment means from being vibrated by the first ultrasonic vibration.

  According to the present invention, there is an effect that a plurality of tissues having different appropriate treatment methods can be successively treated.

1 is an overall configuration diagram of an ultrasonic treatment apparatus according to a first embodiment of the present invention. (A) The longitudinal cross-sectional view of the front-end | tip part of the ultrasonic treatment tool with which the ultrasonic treatment apparatus of FIG. 1 is equipped, (b) The graph which shows the displacement amount of the longitudinal vibration in each position of a 1st ultrasonic transducer | vibrator and a horn. is there. It is a figure explaining the usage method of the ultrasonic treatment apparatus of FIG. It is a figure explaining the usage method of the ultrasonic treatment apparatus of FIG. It is a figure explaining the usage method of the ultrasonic treatment apparatus of FIG. It is a figure explaining the usage method of the ultrasonic treatment apparatus of FIG. (A), (b) It is a longitudinal cross-sectional view of the front-end | tip part of the ultrasonic treatment tool with which the ultrasonic treatment apparatus concerning the 2nd Embodiment of this invention is provided. It is (a) longitudinal cross-sectional view and (b) front view of the front-end | tip part of the ultrasonic treatment tool with which the ultrasonic treatment apparatus which concerns on the 3rd Embodiment of this invention is provided. It is a figure explaining the usage method of the ultrasonic treatment apparatus of FIG. It is a figure explaining the usage method of the ultrasonic treatment apparatus of FIG. It is a figure explaining the usage method of the ultrasonic treatment apparatus of FIG. It is a figure explaining the usage method of the ultrasonic treatment apparatus of FIG.

(First embodiment)
Hereinafter, an ultrasonic treatment apparatus 100 according to a first embodiment of the present invention will be described with reference to FIGS. 1 to 6.
As shown in FIG. 1, the ultrasonic treatment apparatus 100 according to the present embodiment uses an ultrasonic treatment device 1, a drive unit 30 that drives the ultrasonic treatment device 1, and an ultrasonic wave propagation medium as an ultrasonic wave. A medium supply unit 50 that supplies the vicinity of the distal end of the treatment instrument 1 is provided as a main configuration.

  The ultrasonic treatment tool 1 has a rigid distal end portion 3 and is flexible as a whole, an elongated insertion portion (main body) 2, an operation portion 4 provided on the proximal end side of the insertion portion 2, and described later. Tubes 5 and 6 connected to balloons 11 and 12 are provided.

  FIG. 2A is a cross-sectional view showing the configuration of the distal end portion 3 of the ultrasonic treatment instrument 1. As shown in FIG. 2A, the distal end portion 3 includes a rigid outer cylinder 7, a first ultrasonic transducer (first treatment means) 8 accommodated in the outer cylinder 7, A straight rod-shaped horn (transmission member, first treatment means) 9 extending from the tip of the first ultrasonic transducer 8 to the outside of the tip of the outer tube 7 along the longitudinal direction of the outer tube 7, A second ultrasonic transducer (second treatment means) 10 provided at the distal end and balloons 11 and 12 provided on the side surface and the distal end surface of the outer cylinder 7 are provided.

  The outer cylinder 7 is connected to a first portion 7a that accommodates the first ultrasonic transducer 8 and the tip of the first portion 7a, and the first ultrasonic transducer 8 is ultrasonicated as will be described later. And a second portion 7b held at the position of the vibration node. The 1st part 7a and the 2nd part 7b consist of SUS (stainless steel), PEEK (polyetheretherketone) resin, etc. which have high affinity with respect to a biological body.

  The first supersonic vibrator 8 is a bolt-clamped Langevin type (BLT) vibrator, and includes piezoelectric elements 8a and electrodes 8b alternately stacked in the longitudinal direction of the outer cylinder 7, and the piezoelectric elements 8a and 8b. Two elastic bodies 8c and 8d sandwiching the laminated body in the longitudinal direction, and a bolt 8e for fastening the laminated body and the elastic bodies 8c and 8d together.

  The piezoelectric element 8a is made of a piezoelectric material such as PZT (titanium zircoate). The positive and negative electrodes 8b are alternately arranged, the positive electrode 8b is connected to the common (+) BLT vibrator cable 8f, and the negative electrode 8b is connected to the common (-). A BLT vibrator cable 8g is connected. The piezoelectric element 8a and the electrode 8b are annular, and a hole through which the bolt 8e passes in the stacking direction is formed at the center.

  The first elastic body 8c, the bolt 8e, and the horn 9 positioned on the front end side of the laminate are made of a single member and made of a metal material such as titanium. The second elastic body 8d is a metal material such as aluminum, and constitutes a nut fastened to the base end portion of the bolt 8e. A second elastic body 8d is fastened to a base end portion of a bolt 8e penetrating the center of the laminated body, and the laminated body is firmly tightened from both sides by the first elastic body 8c and the second elastic body 8d. The expansion and contraction deformation of the piezoelectric element 8a is transmitted to the horn 9 with high efficiency via the two elastic bodies 8c and 8d. An insulator 8h made of alumina or the like is sandwiched between the laminate and the elastic bodies 8c and 8d in order to electrically insulate the horn 9 and the laminate.

  The first ultrasonic transducer 8 configured in this way is applied with an alternating voltage from the drive unit 30 to the electrode 8b via the cables 8f and 8g, whereby the longitudinal vibration (first vibration) in the longitudinal direction of the outer cylinder 7 is obtained. 1 ultrasonic vibration). The longitudinal ultrasonic vibration generated by the first ultrasonic vibrator 8 is transmitted from the proximal end to the distal end of the horn 9 extending on the extension line of the bolt 8e, so that the distal end portion of the horn 9 is elongated. It is designed to vibrate ultrasonically in the direction.

Here, the outer peripheral surface of the first elastic body 8c located at the node of the longitudinal vibration is fixed to the inner peripheral surface of the second portion 7b of the outer cylinder 7, and the first ultrasonic transducer 8 is generated. The outer cylinder 7 is not vibrated by the ultrasonic vibration. Also, as shown in FIG. 2 (b), the length from the tip of the horn 9 to the first elastic body 8c so that the tip of the horn 9 is located at the antinode of the longitudinal vibration where the displacement is maximum, The length from the first elastic body 8c to the base end of the bolt 8e is substantially the same.

  The 1st elastic body 8c, the volt | bolt 8e, and the horn 9 have the flow path 13 penetrated in a longitudinal direction inside. The flow path 13 is connected to a medium supply unit 50 via a water supply pipe 14 connected to the base end of the bolt 8e, and a medium (for example, water or physiological saline) supplied from the medium supply unit 50 is supplied. The horn 9 is discharged from a discharge port 13a opened at the tip.

  The second ultrasonic transducer 10 is a focused ultrasonic transducer having a radiation surface 10a that is disposed toward the front of the tip 3 and has a concave curved surface. A hole through which the horn 9 passes is formed at the center of the second ultrasonic transducer 10, and the gap between the inner peripheral surface of the hole and the outer peripheral surface of the horn 9 is such that the horn 9 is in the longitudinal direction. The seal member 16 is slidable.

  The second ultrasonic transducer 10 is connected to a (+) focused ultrasonic transducer cable 10b and a (−) focused ultrasonic transducer cable 10c, and is connected from the drive unit 30 via these cables 10b and 10c. By applying the alternating voltage, ultrasonic vibration (second ultrasonic vibration) is generated, and the focused ultrasonic wave U is radiated from the radiation surface 10a. The focused ultrasonic wave U radiated from the radiation surface 10a is focused on a focal point F disposed at a position away from the radiation surface 10a in front of the outer cylinder 7. At the focal point F, the temperature rises as the energy density of the ultrasound increases locally, and the tissue is cauterized. Here, the shape of the radiation surface 10 a is set so that the focal point F is disposed at a position beyond the tip of the tip 3 and beyond the tip of the horn 9.

  The balloons 11 are substantially circular, and a plurality (two in the illustrated example) are arranged in the circumferential direction of the outer cylinder 7 substantially equally. The balloon 12 has a cylindrical shape, and is provided along the periphery of the distal end surface of the outer cylinder 7 so as to surround the radiation surface 10a of the second ultrasonic transducer 10. The tubes 5 and 6 connected to the balloons 11 and 12 extend along the outer cylinder 7 to the proximal end side of the outer cylinder 7, and a syringe 15 containing fluid (for example, air or water) is connected to the proximal end. Has been.

  The drive unit 30 is connected to the front panel via the connection ports 31 and 32 to which the vibrator cables 8f, 8g, 10b, and 10c are connected, and the vibrator cables 8f, 8g, 10b, and 10c. An output adjustment dial 33 that adjusts the level of the alternating voltage applied to the ultrasonic transducer 8 or the second ultrasonic transducer 10, and a first output display that displays the level of the alternating voltage set by the dial 33. A window 34, a second output display window 35, a drive changeover switch (drive changeover unit) 36 that switches the application target of the alternating voltage between the first ultrasonic transducer 8 and the second ultrasonic transducer 10; The first foot switch 37 and the second foot switch 38 for turning on / off the supply of the alternating voltage to the first ultrasonic transducer 8 or the second ultrasonic transducer 10, and the foot switches 37, 38 And a connection port 39, 40 to be continued.

  The medium supply unit 50 includes, on the front panel, a connection port 51 to which the water supply pipe 14 is connected, a foot switch 52 for turning on / off the supply of the medium to the water supply pipe 14, and a connection port 53 to which the foot switch 52 is connected. And a display window 54 for displaying on / off of the medium supply by the foot switch 52.

Next, the operation of the ultrasonic treatment apparatus 100 configured as described above will be described by taking as an example a case where a treatment target site existing inside the myocardium is treated.
In order to treat a treatment target site existing inside the myocardium using the ultrasonic treatment apparatus 100 according to the present embodiment, the position of the treatment target site is specified by a diagnostic device (not shown), and then the ultrasonic treatment tool 1 is inserted. As shown in FIG. 3, the part 2 is inserted into the space between the pericardium A and the heart (pericardial cavity), and the distal end portion 3 is arranged in the vicinity of the treatment target site B.

  Next, the first ultrasonic transducer 8 is selected by the drive changeover switch 36 of the drive unit 30, and the first portion (treatment unit) of the horn 9 is in contact with the fat D covering the surface of the myocardium C. , The tip of the horn 9 is ultrasonically vibrated. As a result, as shown in FIG. 4, the fat D is dissolved by the frictional heat generated between the tip of the horn 9 and the fat D, the fat D is removed from the myocardium C, and the fat D is covered. Exposed myocardium C is exposed.

  Next, by supplying fluid from the syringe 15 into the balloons 11 and 12 through the tubes 5 and 6, as shown in FIG. The balloons 11 and 12 are fully inflated until supported by C. Thereby, the front-end | tip part 3 is positioned with respect to the treatment object site | part B so that the focus F of the focused ultrasound U may correspond to the treatment object site | part B. FIG. At this time, the cylindrical balloon 12 inflated on the distal end surface of the distal end portion 3 comes into contact with the myocardium C and the fat D, whereby a sealed space is formed around the horn 9.

  Next, the foot switch 52 is stepped on, and the medium E is supplied from the medium supply unit 50 to the sealed space around the horn 9 through the water supply pipe 14 and the flow path 13, and the sealed space is filled with the medium E. Next, the second ultrasonic transducer 10 is selected by the drive changeover switch 36, the second foot switch 38 is stepped on, and the second ultrasonic transducer 10 is ultrasonically vibrated to be focused on the treatment target site B. Irradiation of the ultrasonic wave U is started. The focused ultrasonic wave U radiated from the radiation surface 10a of the second ultrasonic transducer 10 propagates through the medium E and the myocardium C and is focused on the treatment target site B at a position deeper than the surface of the myocardium C. Thereby, the treatment target part B inside the myocardium C can be locally heated, and only the treatment target part B can be selectively cauterized.

  As described above, according to the present embodiment, the contact-type first composed of the first ultrasonic transducer 8 and the horn 9 suitable for dissolving the fat D is attached to the distal end portion 3 of the single insertion portion 2. Both the treatment means and the non-contact type second treatment means composed of the second ultrasonic transducer 10 suitable for cauterization inside the myocardium C are provided. Therefore, there is an advantage that the treatment target site B inside the myocardium C can be treated in a minimally invasive manner by the second treatment means while efficiently removing the fat D using the first treatment means. In addition, since two treatments having different methods can be continuously performed using the single ultrasonic treatment tool 1, there is an advantage that the procedure can be simplified.

  Further, when the myocardium C is cauterized over the fat D, the ultrasonic waves are refracted between the myocardium C and the fat D due to the difference in acoustic impedance between the myocardium C and the fat D, and The position may deviate from the design value. In contrast, according to the present embodiment, the fat D is sufficiently removed to expose the myocardium C, and then the focused ultrasound U is irradiated to the myocardium C, thereby preventing the position of the focus F from being shifted, and the treatment target. There is an advantage that the focused ultrasonic wave U can be accurately applied to the part B.

(Second Embodiment)
Next, an ultrasonic treatment apparatus according to the second embodiment of the present invention will be described with reference to FIG.
In the present embodiment, differences from the first embodiment will be mainly described, and the same components as those in the first embodiment will be denoted by the same reference numerals and description thereof will be omitted.

  The ultrasonic treatment apparatus according to the present embodiment is different from the first embodiment in that it includes a focal point moving mechanism that moves the position of the focal point F of the focused ultrasonic wave U in the front-rear direction. That is, as shown in FIG. 7A, the outer cylinder 7 that holds the second ultrasonic transducer 10 and the first ultrasonic transducer 8 that is accommodated in the outer cylinder 7 include A fixing screw 17 is further provided so as to be relatively movable in the longitudinal direction and for fixing the longitudinal position of the outer cylinder 7 and the first ultrasonic transducer 8.

  The 1st elastic body 8c has the outer peripheral surface fitted to the internal peripheral surface of the 2nd part 7b of the outer cylinder 7, and the 1st elastic body 8c is on the internal peripheral surface of the 2nd part 7b. By moving along the longitudinal direction, the outer cylinder 7 and the first ultrasonic transducer 8 are relatively moved in the longitudinal direction. Accordingly, as shown in FIGS. 7A and 7B, the focal point F of the focused ultrasonic wave U can move in the front-rear direction with respect to the tip of the horn 9.

  Screw holes 18 penetrating in the wall thickness direction are formed at two positions of the outer cylinder 7 facing each other in the radial direction. By fastening a fixing screw 17 into the screw hole 18, The sound wave vibrator 1 is fixed to the outer cylinder 7 at the position of the first elastic body 8c.

Next, the operation of the ultrasonic treatment apparatus configured as described above will be described.
In order to treat the treatment target site B inside the myocardium C using the ultrasonic treatment apparatus according to the present embodiment, first, the fixing screw 17 is loosened, and the outer cylinder 7 and the first ultrasonic transducer 8 are moved in the longitudinal direction. By moving the relative position, the focal point F is changed to a desired position, and the fixing screw 17 is tightened at the position to fix the outer cylinder 7 and the first ultrasonic transducer 8 to each other. Next, as in the first embodiment, after specifying the position of the treatment target site B, the ultrasonic treatment instrument is inserted into the pericardial cavity, and as shown in FIG. 3 to FIG. Remove and cauterize the site B to be treated.

  In this case, according to the present embodiment, in addition to the effects of the first embodiment, the position of the focal point F of the focused ultrasound U is changed in accordance with the depth of each treatment target site B, whereby the myocardium C There is an advantage that the treatment target site B can be surely cauterized by appropriately applying the focused ultrasonic wave U to any treatment target site B located at various depths.

(Third embodiment)
Next, an ultrasonic treatment apparatus according to the third embodiment of the present invention will be described with reference to FIGS.
In the present embodiment, differences from the first embodiment will be mainly described, and the same components as those in the first embodiment will be denoted by the same reference numerals and description thereof will be omitted.

  The ultrasonic treatment apparatus according to the present embodiment is different from the first embodiment in that the focused ultrasonic wave U is emitted to the side of the distal end portion 3. That is, as shown in FIGS. 8A and 8B, the second ultrasonic transducer 10 radiates so that the central axis of the focused ultrasonic wave U is orthogonal to the longitudinal direction of the outer cylinder 7. It is provided on the side surface of the outer cylinder 7 with the surface 10a facing radially outward.

Next, the operation of the ultrasonic treatment apparatus configured as described above will be described.
In order to treat the treatment target site B inside the myocardium C using the ultrasonic treatment apparatus according to the present embodiment, after the position of the treatment target site B is specified, the insertion unit 2 is placed in the heart as in the first embodiment. As shown in FIG. 9, the distal end portion 3 ″ is placed in the vicinity of the treatment target site B. Next, as shown in FIG. 10, the distal end portion of the horn 9 is ultrasonically vibrated. This dissolves and removes the fat D. Next, as shown in Fig. 11, the balloon 3 is sufficiently inflated so that the focal point F of the focused ultrasound U coincides with the treatment target site B. Is positioned with respect to the treatment target site B.

  Next, the medium E is supplied from the medium supply unit 50 to the periphery of the tip 3 ″ via the water supply pipe 14 and the flow path 13, and the space between the second ultrasonic transducer 10 and the fat D is filled with the medium E. Next, as shown in Fig. 12, the second ultrasonic transducer 10 is ultrasonically vibrated to irradiate the focused ultrasonic wave U to the treatment target site B and cauterize the treatment target site B.

  In this case, according to the present embodiment, in addition to the effects of the first embodiment, the focused ultrasound U is emitted laterally with respect to the longitudinal direction of the distal end portion 3 ″. The treatment target site B can be cauterized in a state where the distal end portion 3 ″ is arranged substantially parallel to the surface. Accordingly, there is an advantage that the operation of the ultrasonic treatment instrument in a narrow treatment space such as a pericardial cavity can be facilitated.

DESCRIPTION OF SYMBOLS 100 Ultrasonic treatment apparatus 1 Ultrasonic treatment tool 2 Insertion part (main body)
3, 3 ′, 3 ″ tip portion 4 operation portion 5, 6 tube 7 outer cylinder 7a first portion 7b second portion 8 first ultrasonic transducer (first treatment means)
8a Piezoelectric element 8b Electrode 8c, 8d Elastic body 8e Bolt 8f (+) BLT vibrator cable 8g (-) BLT vibrator cable 8h Insulator 9 Horn (transmission member, first treatment means)
10 Second ultrasonic transducer (second treatment means)
10a Radiation surface 10b (+) Focused ultrasonic transducer cable 10c (-) Focused ultrasonic transducer cable 11, 12 Balloon 13 Flow path 13a Discharge port 14 Water supply pipe 15 Syringe 16 Seal member 17 Fixing screw 18 Screw hole 30 Drive unit 31, 32, 39, 40 Connection port 33 Output adjustment dial 34, 35 Output display window 36 Drive changeover switch (drive changeover unit)
37, 38 Foot switch 50 Medium supply part 51, 53 Connection port 52 Foot switch 54 Display window A Pericardium B Treatment target part C Myocardium D Fat E Medium

Claims (7)

An elongated body;
A first ultrasonic transducer that is provided at the tip of the main body and generates a first ultrasonic vibration, and transmits the first ultrasonic vibration generated by the first ultrasonic transducer to a tissue a first treatment unit and a transmission member which,
A second ultrasonic transducer that is provided at the tip of the main body and generates a second ultrasonic vibration, and toward the tissue by the second ultrasonic vibration generated by the second ultrasonic transducer. A second treatment means having a radiation surface for emitting ultrasonic waves ,
And a driving switching unit for alternatively driving the first treatment means and the second treatment means,
The first treatment means and the second treatment means, the first ultrasonic treatment apparatus that are coupled together at the position of the node of the ultrasonic vibration.   The ultrasonic treatment apparatus according to claim 1, wherein the transmission member includes a treatment unit that is ultrasonically vibrated integrally with the first ultrasonic transducer and is brought into contact with the tissue. The first ultrasonic vibrator is a bolted Langevin type vibrator formed by integrally fastening a piezoelectric element and an elastic body arranged on both sides of the piezoelectric element with a bolt penetrating the piezoelectric element,
The ultrasonic wave according to claim 2, wherein the transmission member is a straight rod-like member that is fixed to one end of the bolt-clamped Langevin type transducer and is arranged coaxially with the bolt, and the tip portion acts as the treatment portion. Treatment device. The radiation surface is a concave curved surface disposed toward the outside of the main body;
The ultrasonic treatment apparatus according to any one of claims 1 to 3, wherein the second treatment means radiates an ultrasonic wave focused on a position away from the main body from the radiation surface. The transmission member protrudes from the main body;
The ultrasonic treatment apparatus according to claim 4, wherein the second treatment means radiates the ultrasonic wave focused from the main body to a position beyond the transmission member.   The ultrasonic treatment apparatus according to claim 4, further comprising a focal point moving mechanism that moves a focal point of the ultrasonic wave in a radiation direction of the ultrasonic wave.   The ultrasonic treatment apparatus according to claim 1, wherein the second treatment unit emits the ultrasonic wave toward a side of the main body.

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