JP6233147B2 - Indwelling snare ligation device - Google Patents

Description

The present invention relates to an indwelling snare ligation apparatus for connecting an indwelling snare placed in the body in an unligated state to a distal end portion of a sheath by an operation from outside the body and ligating a ligation target in the body.

  Recently, lesions such as tumors (polyps) in body cavities such as the stomach and intestine have been treated with high frequency by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). For the purpose of preventing bleeding from the defect or perforation after excision of the lesion using a scalpel or the like, the base of the lesion is ligated in advance using an indwelling snare to reduce blood flow to the lesion. After blocking, a procedure for excision of the lesion has been performed. In addition, by a similar method, a technique of ligating and suturing a defect portion or a perforated portion after excision of a lesion portion using an indwelling snare has been performed.

  As an indwelling snare used for such a procedure, both ends of a strand made of a resin such as nylon are connected and molded into a substantially loop shape, and a part of the strand is brought close to be substantially parallel, A cylindrical ring is slidably fitted to the close part. A relatively large (substantially circular) loop formed on one side of the ring serves as a ligation loop for ligating the lesion, and a relatively small (substantially U-shaped) loop on the other side. It becomes a connection loop connected to the ligating apparatus. By sliding the ring from the position fitted on the coupling loop to the ligation loop side, a part of the ligation loop (base end side) is drawn into the ring, and the diameter of the ligation loop is reduced. Can ligate body tissues.

  As an indwelling snare ligation apparatus, for example, as described in Patent Document 1 below, a driving wire is further inserted into an inner sheath inserted into an outer sheath, and a protruding hook is formed on the side of the driving wire. The thing which provided the front-end | tip member which has is proposed. Outside the body, hook the hook into the snare connection loop (second loop) and operate the drive wire so that the ring does not slide to the ligation loop (first loop) side. By pulling in, it is connected to the distal end of the inner sheath, and in this state, the entire indwelling snare is retracted into the outer sheath to be received in the distal end of the outer sheath.

  In this state, when the distal end of the sheath is transported to the vicinity of the body tissue to be treated and the outer sheath is slid to the proximal end side to expose the ligation loop, the ligation loop returns to its original shape due to its own elasticity. Restore to (substantially circular shape). The distal end of the inner sheath is slid to the distal end side with respect to the drive wire in a state where the ligating loop is positioned so that the lesioned portion passes through the inner side of the ligating loop as appropriate. As a result, the ring is slid, the diameter of the ligation loop is reduced, and the body tissue can be ligated.

Japanese Utility Model Publication No. 6-17712

  By the way, during such a procedure, the indwelling snare may fall off from the distal end of the sheath in an unligated state before completing ligation of the body tissue due to an operation error or the like. Thus, when the unligated indwelling snare is indwelled in the body, in the prior art, it is very difficult to hook the tip member hook to the indwelling snare connection loop, so the sheath is once pulled out of the body, In reality, a new indwelling snare is connected to the distal end of the sheath and the same operation is performed again.

  When the indwelling snare is used to sew (stitch) a defect in a body tissue, the indwelling snare is actively removed from the distal end of the sheath without being ligated (disconnected), After placing the clip at the appropriate position surrounding the defect and clipping (fixing) the clip to the body tissue at multiple locations in the ligation loop, reconnect the indwelling snare to the distal end of the sheath, Although there is a request to perform a procedure of sliding and ligating, it is difficult to meet such a request with the conventional technology.

The present invention has been made in view of the above points, and an indwelling snare placed in the body in an unligated state is connected to the distal end portion of the sheath by an operation from outside the body, thereby ligating the body . An object of the present invention is to provide an indwelling snare ligation apparatus capable of easily performing a technique for ligating a ligament.

The indwelling snare ligation apparatus according to the present invention comprises:
A ligation loop for ligating a ligation target in the body and a coupling loop on which a ring is externally fitted, and the ring is slid from an unligated state located in the coupling loop to the ligation loop side Thus, a ligation device for indwelling snare that ligates a ligation target in the body using an indwelling snare adapted to reduce the diameter of the ligation loop,
A tubular sheath;
A drive wire inserted through the sheath;
An operating portion provided at a proximal end of the sheath and sliding the drive wire with respect to the sheath;
A pair of arm portions that are attached to the distal end of the drive wire and are arranged so as to open in a substantially C shape as they go to the tip thereof, and claws formed by bending the tip portions of the arm portions inwardly The elastic body has a portion, and the sheath is slid toward the proximal end side with respect to the drive wire, so that the sheath protrudes from the distal end of the sheath and is opened by its own elasticity. A connecting hook which is buried in the distal end of the sheath and closed by sliding to the distal end side with respect to
The connecting loop of the indwelling snare placed in the body in an unligated state is gripped by closing the connecting hook and the connecting loop is pulled into the distal end of the sheath. To the distal end side of the sheath by slidably moving the indwelling snare to the distal end of the sheath, and the sheath to the drive wire so as to further retract the coupling loop into the sheath. The ring is slid to the ligation loop side by the distal end portion of the sheath by sliding toward the distal end side.

  The indwelling snare ligation apparatus according to the present invention may further include a lock portion that detachably attaches the proximal end of the sheath to the operation portion.

According to the indwelling snare ligation apparatus according to the present invention, the indwelling snare placed in the body in an unligated state is connected to the distal end (tip) portion of the sheath, and the ligation target in the body is connected. There is an effect that it can be easily ligated.

It is a top view which shows the whole structure in the state which does not reduce the diameter of the ligation loop of the indwelling snare of embodiment of this invention. It is a top view which shows the whole structure in the state which diameter-reduced the ligation loop of the indwelling snare of embodiment of this invention. It is a top view which shows the whole structure of the ligation apparatus for indwelling snares of embodiment of this invention. It is a top view which shows the structure by the side of the sheath of the lock | rock part of the indwelling snare ligation apparatus of embodiment of this invention. It is a top view which shows the structure by the side of the base part of the lock | rock part of the indwelling snare ligation apparatus of embodiment of this invention. It is an end elevation which shows the structure by the side of the base part of the lock | rock part of the indwelling snare ligation apparatus of embodiment of this invention. In embodiment of this invention, it is a top view which shows the state before connecting the indwelling snare indwelled in the body in the unligated state to the distal end of the sheath of the indwelling snare ligation apparatus. In embodiment of this invention, it is a side view which shows the state before connecting the indwelling snare indwelled in the body in the unligated state to the distal end of the sheath of the indwelling snare ligation apparatus. In embodiment of this invention, it is a side view which shows the state just before connecting the indwelling snare indwelled in the body in the unligated state to the distal end of the sheath of the indwelling snare ligation apparatus. In embodiment of this invention, in order to connect the indwelling snare indwelled in the body in the unligated state to the distal end of the sheath of the indwelling snare ligation apparatus, a side view showing a state in which the connecting loop is gripped by the connecting hook It is. In embodiment of this invention, it is a side view which shows the state which connected the indwelling snare indwelled in the body in the unligated state to the distal end of the sheath of the indwelling snare ligation apparatus. In embodiment of this invention, it is a side view which shows the state which diameter-reduced the ligation loop of the indwelling snare connected with the distal end of the sheath of the indwelling snare ligation apparatus.

  First, a configuration of an indwelling snare that is a target of the indwelling snare ligation apparatus according to the present embodiment will be described with reference to FIGS. 1 and 2. Indwelling snare 1 is a high-frequency treatment of lesions such as tumors (polyps) in body cavities such as the stomach and intestine by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). For the purpose of preventing bleeding from the defect or perforation after excision of the lesion using a scalpel or the like, the base of the lesion is ligated in advance using an indwelling snare to reduce blood flow to the lesion. After blocking, it is used to excise the lesion. The indwelling snare 1 is also used when ligating and suturing a defective part or a perforated part after excising a lesioned part by the same method.

  As shown in FIG. 1, the indwelling snare 1 is formed into a substantially loop shape (endless shape) by joining both ends of a strand made of resin such as nylon, and a part of the strand is substantially parallel. Are formed so that a relatively large substantially circular loop 11 is formed on one side thereof, and a relatively small substantially U-shaped loop 12 is formed on the other side. . The loop 11 is a ligation loop for ligating body tissue, and the loop 12 is a coupling loop for coupling to a ligation apparatus (distal end of the sheath).

  A substantially cylindrical ring (clamping ring) 13 made of an elastic resin is slidably fitted on a pair of parallel portions 12a and 12b that are substantially parallel to each other of the connecting loop 12. By sliding the ring 13 from the position externally fitted to the parallel portions 12a and 12b of the connecting loop 12 to the ligating loop 11 side, as shown in FIG. End portions) 11a and 11b are drawn into the ring 13 and the ligation loop 11 is reduced in diameter, whereby the body tissue can be ligated.

  As an example, the wire diameter of the strand constituting the indwelling snare 1 is about 0.2 to 0.6 mm, and the ring 13 is externally fitted to the parallel portions 12a and 12b of the connecting loop 12 (unligated state). ), The diameter of the ligation loop 11 is about 2.0 to 40.0 mm. The inner diameter of the ring 13 is preferably slightly smaller than the wire diameter of the strands constituting the indwelling snare 1 when the ring 13 is made of an elastic resin, specifically about 0.1 to 0.5 mm. Yes, the wall thickness is about 0.1 to 1.0 mm.

  As shown in FIGS. 3 to 6, the indwelling snare ligation apparatus 2 includes a connection hook (wing member) 21, a sheath (tube) 22, a drive wire (operation wire) 23, a base-side lock member 25, and a sheath. A lock mechanism having a side lock member 26 and an operation unit having a base portion 27 and a slider portion 28 are roughly provided.

  The sheath 22 is made of a flexible hollow tube, and a simple tube made of resin or the like may be used as the sheath 22, but in this embodiment, a coil tube is used. As the coil tube, a flat wire coil tube formed by spirally winding a long flat plate made of metal (stainless steel) or the like can be used. However, a round wire coil tube or an inner flat coil tube may be used. Note that a wire tube may be used as the sheath 22. The wire tube is a tube made of a hollow stranded wire formed by spirally twisting a plurality of wires (cables) made of, for example, metal (stainless steel) or the like.

  Such a coil tube (or wire tube) is used as the sheath 22 when the ligation apparatus 2 is ultrasonically cleaned using a cleaning liquid, and the cleaning liquid sufficiently penetrates the inside of the tube and is good both inside and outside. This is so that it can be washed.

  A substantially cylindrical tip member 24 is integrally fixed to the distal end of the coil tube of the sheath 22, and the distal end surface of the tip member 24 is in contact with the ring 13 of the indwelling snare 1. Has become a department. However, the tip member 24 may not be provided from the viewpoint of cost, the number of parts, and the like. In this case, the distal end surface of the coil tube serves as a contact portion that contacts the ring 13 of the indwelling snare 1. .

  The drive wire 23 is made of a flexible wire, and a wire rope is used in this embodiment. The wire rope is a rope made of a stranded wire formed by twisting a plurality of wires (cables) made of, for example, metal (stainless steel) or the like. However, the drive wire 23 may be a single wire.

  A connecting hook 21 is integrally attached to the tip (distal end) of the drive wire 23. The connecting hook 21 is a claw formed by bending a pair of arm portions 21a, 21a and tip portions of the arm portions 21a, 21a that are arranged so as to open in a substantially C shape toward each other. The base portions of the arm portions 21a and 21a are integrated with each other and are integrally fixed to the distal end (distal end) of the drive wire 23 by welding or the like.

  The connection hook 21 slides the drive wire 23 toward the distal end side with respect to the sheath 22 (that is, slides the sheath 22 toward the proximal end side with respect to the drive wire 23), thereby distant the sheath 22. On the contrary, it slides so that the drive wire 23 is drawn from the distal end side with respect to the sheath 22 (that is, the sheath 22 is driven to the drive wire). 23), the sheath 22 is buried in the distal end of the sheath 22 and closed.

  If the driving wire 23 is held at a fixed position and the sheath 22 is pushed out, the pair of arms 21a and 21a of the connecting hook 21 can be freely opened and closed with the position of the connecting hook 21 kept constant ( Holding or releasing). As the connection hook 21, one made of a metal such as stainless steel can be used.

  The proximal end (base end portion) of the sheath 22 through which the drive wire 23 is inserted is connected to the distal end of the base portion 27 via a luer lock mechanism having a base side lock member 25 and a sheath side lock member 26. It is fixed.

  As shown in FIG. 4, the sheath-side lock member 26 includes a substantially cylindrical pipe portion 26a and a flange-like (substantially convex annular) flange that is integrally fixed to the base end side of the pipe portion 26a. It has a portion 26 b and is integrally fixed to the proximal end of the sheath 22. As the sheath side lock member 26 (the pipe portion 26 a and the flange portion 22 b), those made of metal such as stainless steel can be used, and the pipe portion 26 a is fixed to the sheath 22 by welding to the proximal end of the sheath 22. You can do that.

  As shown in FIGS. 5 and 6, the base side lock member 25 includes a fixed lock member 251 and a rotation lock member 252. The fixed lock member 251 has a through hole 251a and a protrusion 251b at the center thereof. A concave neck (not shown) is formed at the base end of the protrusion 251b. The rotation lock member 252 is formed of a substantially cylindrical member having one end surface opened and the other surface closed, and a female screw portion 252a is formed inside thereof. A through hole (not shown) is formed in the central portion of the other closed surface of the rotation lock member 252 and the portion of this through hole is loosely fitted to the neck portion of the protrusion 251b, thereby rotating the rotation lock member 252. Is rotatably attached to the fixed lock member 251 in a state in which the protrusion 251a is prevented from coming off.

  The protrusion 251b of the base-side lock member 25 is inserted into a through hole (not shown) inside the sheath-side lock member 26, and the rotation lock member 252 is rotated so that the flange portion 26b is screwed into the female screw portion 252a. Thus, the sheath 22 can be detachably attached to the base portion 27.

  A slider portion 28 is slidably attached to the base portion 27, and the proximal end of the drive wire 23 passes through the respective through holes of the sheath side lock member 26 and the base side lock member 25, and the slider portion. 28, and is detachably fixed to the slider portion 28 via a lock screw 29.

  By sliding the slider portion 28 toward the distal end side with respect to the base portion 27, the connecting hook 21 provided at the distal end of the drive wire 23 is pushed out from the distal end of the sheath 22, and is substantially due to its own elasticity. Open the legs in a C shape. On the contrary, by sliding the slider portion 28 toward the proximal end side with respect to the base portion 27, the connection hook 21 provided at the distal end of the drive wire 23 is buried from the distal end of the sheath 22. Housed inside the sheath 22.

  Next, the usage method of the indwelling snare ligation apparatus 2 will be described with reference to FIGS. As an example, indwelling snares after excision of lesions in internal tissues using a high-frequency knife etc. by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), etc. A case where ligation and suturing is performed by using the above will be described.

  As shown in FIG. 7, first, the indwelling snare 1 in an unligated state is placed alone (arranged) so that the ligation loop 11 is positioned around the defect B to be sutured in the body tissue A. To do. The indwelling snare 1 can be transported from the outside of the body to the defect B through a treatment instrument guide tube of an endoscope using a dedicated transport device or a conventional ligation device shown in Patent Document 1. Next, using a plurality of endoscope clips C, the ligation loop 11 of the indwelling snare 1 is clipped (fixed) to the body tissue A around the defect B at a plurality of appropriate locations. Clipping of the clip C can be performed through a treatment instrument guide tube of an endoscope using a known clip device.

  Next, the sheath 22 of the indwelling snare ligation apparatus 2 according to the present embodiment described above is inserted through the treatment instrument guide tube of the endoscope, and the distal end of the sheath 22 of the indwelling snare 1 in an unligated state is inserted. It is located in the vicinity of the connecting hook 12. During this insertion operation, the slider portion 28 is slid toward the proximal end side with respect to the base portion 27, and the connecting hook 21 provided at the distal end of the drive wire 23 is buried from the distal end of the sheath 22. In a state of being accommodated in the sheath 22.

  Thereafter, as shown in FIGS. 7 and 8, the slider portion 28 is slid to the distal end side with respect to the base portion 27, and the connecting hook 21 provided at the distal end of the drive wire 23 is sheathed. When pushed out (protruded) from the distal end of 22, the pair of arm portions 21a, 21a are opened in a substantially C shape by their own elasticity (see FIG. 8).

  Next, as shown in FIG. 9, the connection loop 12 of the indwelling snare 1 is brought close to a position where the pair of arms 21 a and 21 a of the connection hook 21 can be gripped. In this state, when the base portion 27 is slid to the distal end side with respect to the slider portion 28 while preventing the position of the slider portion 28 from changing, the sheath 22 moves to the distal end side, and the sheath 22 moves far away. The pair of arm portions 21a, 21a of the connecting hook 21 protruding from the rear end are closed while being pulled into the inside.

  Accordingly, as shown in FIG. 10, the connection loop 12 is gripped by the pair of arm portions 21 a and 21 a (claw portions 21 b and 21 b) of the connection hook 21 without shifting the position of the indwelling snare 1. The In this state, when the base portion 27 is further slid to the distal end side with respect to the slider portion 28, the connecting loop 12 held by the pair of arm portions 21a and 21a is drawn inward from the distal end of the sheath 22. As shown in FIG. 11, the distal end surface of the sheath 22 abuts against the end surface of the ring 13. As a result, the indwelling snare 1 is connected to the distal end of the sheath 22 of the ligating apparatus 2 while remaining in an unligated state.

  Here, since the indwelling snare 1 is clipped to the body tissue by the clip C, its position cannot be moved. For example, when the indwelling snare 1 is not clipped to the body tissue, in this connected state, The indwelling snare 1 can be moved to an appropriate position.

  Next, when the base portion 27 is further slid to the distal end side with respect to the slider portion 28, the connecting loop 12 is further drawn inside the sheath 22, and the ring 13 is ligated by the distal end surface of the sheath 22. 11, the base ends 11 a and 11 b of the ligation loop 11 are drawn into the ring 13, and the diameter of the ligation loop 11 is reduced as shown in FIG. 12 (see also FIG. 2). . Thereby, the portion clipped by the clip C of the body tissue A is sewn together with the diameter of the ligation loop 11, and the defect B can be finally stitched.

  When the suturing is completed, when the base portion 27 is slid toward the proximal end side with respect to the slider portion 28 while preventing the position of the slider portion 28 from changing, the sheath 22 moves to the proximal end side, and the sheath 22 moves. The connecting hook 21 and the connecting loop 12 protrude (expose) from the distal end of the pair 22, and the pair of arms 21a, 21a of the connecting hook 21 are opened by their own elasticity, and the holding of the connecting loop 12 is released. Thus, the ligating apparatus 2 can be separated from the indwelling snare 1 in the ligated state.

  The connection loop 12 of the indwelling snare 1 in a ligated state is cut and collected by a high-frequency knife or the like as necessary.

  According to the above-described embodiment, the connection loop 12 of the indwelling snare 1 placed in the body in an unligated state is arranged in a pair of substantially C-shapes that can be opened and closed at the distal end of the sheath 22. Since the indwelling snare 1 is connected by being gripped by the connecting hook 21 having the arm portions 21a and 21a and being drawn into the inside from the distal end of the sheath 22, the position and posture of the indwelling snare 1 The connecting operation can be easily performed without changing the distance. Accordingly, the indwelling snare 1 placed in the body in an unligated state can be easily connected to the distal end portion of the sheath 22 and ligated to the body tissue without being taken out of the body.

  Further, according to the above-described embodiment, since the proximal end of the sheath 22 is detachable from the base portion 27 and the proximal end of the drive wire 23 is detachable from the slider portion 28, the sheath 22 and The drive wire 23 can be removed from the operation part (base part 27, slider part 28) as needed, and each can be cleaned independently.

  The indwelling snare ligation apparatus 2 according to the above-described embodiment is connected to the distal end of the sheath 22 without taking out the indwelling snare 1 placed in the body in an unligated state to ligate the body tissue. Therefore, it is not considered to deliver (carry) the indwelling snare 1 from outside the body into the body. In order to enable such delivery, the illustration is omitted, but in addition to the above-described configuration, the sheath 22 is used as an inner sheath, and a tubular outer sheath through which the inner sheath 22 is inserted is slid. What is necessary is just to provide.

  Outside the body, the connection loop 21 of the indwelling snare 1 is gripped by the connecting hook 21 and pulled into the distal end portion of the inner sheath 22, so that the indwelling snare is not moved to the distal end of the inner sheath 22 without sliding the ring 13. In the state where 1 is connected, the entire indwelling snare 1 is accommodated by being pulled into the inside from the distal end of the outer sheath, and delivered (conveyed) to a desired position via the treatment instrument guide tube of the endoscope.

  Thereafter, when the indwelling snare 1 is placed in an unligated state, the indwelling snare 1 connected to the distal end of the inner sheath 22 is slid by sliding the outer sheath toward the proximal end side with respect to the inner sheath 22. By exposing and sliding the drive wire 23 from the inner sheath 22 so that the connecting hook 21 protrudes, the pair of arm portions 21a, 21a of the connecting hook 21 are opened, and the connection of the indwelling snare 1 is released. The indwelling snare 1 can be placed in the body in an unligated state.

  When the outer sheath is additionally provided as described above, the indwelling snare 1 is not placed in the body in an unligated state, but is housed in the outer sheath and transported to a desired position, and then the outer sheath is placed in the inner sheath. The indwelling snare 1 connected to the distal end of the inner sheath 22 is exposed by sliding to the proximal end side with respect to the sheath 22, and the connecting hook 21 is further buried from the distal end of the inner sheath 22. Of course, the desired part of the body tissue may be ligated as it is.

  The embodiment described above is described for facilitating the understanding of the present invention, and is not described for limiting the present invention. Therefore, each element disclosed in the above-described embodiment is intended to include all design changes and equivalents belonging to the technical scope of the present invention.

DESCRIPTION OF SYMBOLS 1 ... Indwelling snare 11 ... Ligation loop 11a, 11b ... Base end part 12 ... Connection loop 12a, 12b ... Parallel part 13 ... Ring 2 ... Indwelling snare ligation device 21 ... Connection hook 21a ... Arm part 21b ... Claw part 22 ... Sheath 23 ... Drive wire 25 ... Base side lock member 251 ... Fixed lock member 252 ... Rotation lock member 26 ... Sheath side lock member 26a ... Pipe part 26b ... Flange part 27 ... Base part 28 ... Slider part A ... Body tissue B ... Deficient part C ... Clip for endoscope

Claims (2)

A ligation loop for ligating a ligation target in the body and a coupling loop on which a ring is externally fitted, and the ring is slid from an unligated state located in the coupling loop to the ligation loop side Thus, a ligation device for indwelling snare that ligates a ligation target in the body using an indwelling snare adapted to reduce the diameter of the ligation loop,
A tubular sheath;
A drive wire inserted through the sheath;
An operating portion provided at a proximal end of the sheath and sliding the drive wire with respect to the sheath;
A pair of arm portions that are attached to the distal end of the drive wire and are arranged so as to open in a substantially C shape as they go to the tip thereof, and claws formed by bending the tip portions of the arm portions inwardly The elastic body has a portion, and the sheath is slid toward the proximal end side with respect to the drive wire, so that the sheath protrudes from the distal end of the sheath and is opened by its own elasticity. A connecting hook which is buried in the distal end of the sheath and closed by sliding to the distal end side with respect to
The outer surface of the sheath is exposed from the proximal end to the distal end,
For detention snare, characterized in that after gripping the detention snare state of non-ligated placed in the body in a state that is not connected to a said indwelling snare ligation apparatus is used for an application to ligating the ligation target Ligating device.   The indwelling snare ligation apparatus according to claim 1, further comprising a lock portion that detachably attaches the proximal end of the sheath to the operation portion.

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