KR20160077140A - Methods and Devices For Soft Tissue Dissection - Google Patents

Abstract

A mechanism for differentiating composite tissue is disclosed, which includes a handle, a central longitudinal axis, and a elongate member, wherein the differential excision member (DDM) is configured to be rotatably attached to the distal end of the elongate member. The DDM includes a mechanism configured to rotate the DDM about at least one tissue-engaging surface, a first torque point disposed at a first side of the axis of rotation, and an axis of rotation to move the tissue-engaging surface in at least one direction relative to the tissue. . The mechanism includes a first torque point member configured to vibrate the DDM and at least one force transmission member attached to the motion source. The tissue-binding surface is configured to selectively bond with the complex tissue such that the at least one soft tissue within the complex tissue is destroyed but the hard tissue within the complex tissue is not destroyed.

Description

Methods and Devices for Soft Tissue Dissection < RTI ID = 0.0 >

Priority application

This application claims priority from U.S. Provisional Patent Application No. 61 / 687,587 entitled " Instrument for Soft Tissue Dissection "filed April 28, 2012; U.S. Provisional Patent Application No. 61 / 744,936 entitled " Instrument for Soft Tissue Dissection "filed on October 6, 2012; And U.S. Provisional Patent Application No. 61 / 783,834 entitled " Instruments, Devices, and Related Methods for Soft Tissue Dissection "filed on March 14, 2013, , Filed on April 29, 2013, entitled " Instruments, Devices, and Related Methods for Soft Tissue Dissection ", filed April 29, 2013, This application is a continuation-in-part of copending application Ser. No. 13 / 872,766, the entirety of which is incorporated herein by reference in its entirety.

Field of invention

FIELD OF THE INVENTION [0002] The field of the present disclosure relates to methods or devices used to excise tissue during surgery or other medical procedures.

Doctors are often required to sever or separate tissue during surgical procedures. Two techniques are commonly used: (1) "sharp resection" using a cutting instrument to cut tissue, where the surgeon cuts with scissors, scalpels, electrosurgery, or other slicing instruments; and (2) .

The advantage of sharp cutting is that the cutting tool easily cuts through any tissue. The cutting itself is indiscriminate, so that it cuts any tissue to which it is applied. This is also a disadvantage of sharp ablation, particularly when the first tissue is buried and thereby obscured by the second or more generally the tissue, when attempting to isolate the first tissue without damaging it. For example, accidental amputation of blood vessels, nerves, or organs is not uncommon for most experienced physicians, and can lead to serious, even life-threatening intra-operative complications, Lt; / RTI >

Therefore, isolation of the first tissue embedded in another tissue is frequently performed by blunt dissection. In blunt dissection, blunt instruments are used to move through the tissue, to force separation of the two tissues, or to separate tissues by rupture rather than amputation. Almost all surgeries require blunt dissection of tissue to expose target structures such as blood vessels to be ligated or nerve bundles to be avoided. Examples of thoracic surgery include hysterectomy for lobectomy and sequestration of blood vessels during exposure of the lymph nodes.

Blunt dissection may be performed by inserting a blunt probe or instrument, by inversion of the forceps (i.e., widening), and by pulling the tissue by a forceps or rubbing by a "swap cutter" (e.g., surgical gauze held in a forceps) Including a variety of ways to rupture. When necessary, sharp resection is used carefully to cut tissue that resists rupture during blunt dissection.

A general purpose is to rupture or destroy tissue such as thin films and mesenteric membranes from the target structure without rupturing or destroying the target structure or critical structures such as peripheral blood vessels or nerves. Physicians utilize different mechanical behaviors of tissue, such as the different stiffness of adjacent tissues or the presence of a plane of soft tissue between hard tissues. Frequently, the objective is to isolate a mechanically robust target tissue composed of closely packed fibrous components embedded in a mechanically soft tissue composed of loosely packed fibrous components (for example, collagen, reticuline, and loose retinas of elastin) . Adherently packed fibrous tissue includes tissue composed of closely packed collagen and other fibrous connective tissue, usually with a highly organized anisotropic distribution of fibrous components, often in a hierarchical composition. Examples include blood vessels, nerve sheaths, muscles, fascia, bladder, and tendons. The loosely packed fibrous tissue has a much smaller number of fibers per unit volume or is composed of less structured material such as fat and mesentery. The fibrous component includes fibers, fibrils, filaments, and other filament-like components. When tissue is referred to as "fibrous ", extracellular filamentous components, such as proteins that are polymerized into linear structures of variable and varying complexity to form collagen and elastin-extracellular matrix, are typically referred to. As mentioned in the previous paragraph, the density, orientation, and texture of the fibrous component largely determine the mechanical behavior of the tissue. Sometimes, tissue is referred to as "tough, fibrous tissue" which indicates that fibrous or filamentous components are densely packed to form a substantial fraction of the tissue mass. However, all tissues are somewhat fibrous, and fibers and other filamentous extracellular components are present in virtually all tissues.

What is important for this explanation is that soft tissue tears more easily than hard tissue, so blunt dissection tries to proceed by applying enough force to rupture soft tissue but not tear hard tissue.

Blunt ablation can be difficult and often takes time. It is not easy to judge the strength of a soft tissue that ruptures but does not rupture hard tissue that is closely juxtaposed. Therefore, the blood vessel can be ruptured. The nerve may be stretched or ruptured. In response, the physician attempts a careful, sharp ablation, but the blood vessels and nerves, especially the smaller side branches, can be severed. This leads to an increased risk of complications such as long and tedious ablation, bleeding, air leakage from the lungs, and nerve damage.

Doctors frequently use forceps for blunt dissection. 1A and 1B show a conventional forceps 10 of the prior art. Figure 1A shows a clamp 10 in a closed position for clamping tissue 34 between opposing first and second clamping elements 30,31. Figure IB shows the forceps 10 in an open position forcing the tissue 34 apart. A first finger combiner 20 and an opposing second finger combiner 21 are used to actuate the mechanism. The first finger combiner 20 drives the first gripper element 30 and the second finger combiner 21 drives the second gripper element 31. [ The pivot 40 attaches the first and second gripping elements 30 and 31 to form a scissor similarity action to move the first gripping element 30 and the second gripping element 31 together or away Whereby the tissue 34 is clamped between the two clamping surfaces 35 and 36 or the tissue 34 is clamped by the expansion of the first clamping element 30 and the second clamping element 31. Frequently, a latching clasp 50 is used to lock the first and second clamping elements 30 and 31 together.

Laparoscopic and thoracoscopic (collectively referred to herein as "endoscopy") instruments use similar actions. 2 shows an example of an endoscopic forceps 110 of the prior art. A first finger combiner 120 and an opposing second finger combiner 121 are used to actuate the mechanism. The first finger combiner 120 is rigidly mounted to the instrument body 150. The second finger combiner 121 drives the opposing clamping elements 130, 131. The pivot 140 attaches the two gripper elements 130 and 131 so that the action of the second finger combiner 121 moves the gripper elements 130 and 131 together thereby causing the two gripper surfaces 135 and 131 to move, 136). 1, the endoscopic forceps 110 can be used to forcibly separate tissue. The clamp elements 130, 131 are closed, inserted into the tissue, and then opened to rupture the tissue.

For each instrument that is the forceps 10 or endoscope forceps 110, the physician closes the forceps, pushes the closed forceps into the tissue, and then uses the force applied by the jaw opening of the forceps Performs blunt dissection by opening the forceps inside the tissue and rupturing the tissue. Thus, the physician proceeds to abstain the tissue by a combination of pushing the forceps into the tissue and opening the jaw.

Blunt dissection is generally used for soft and slippery tissues, and the smooth, manual surface of most surgical instruments slides easily along the tissue, undermining the ability of the instrument to grab tissue. In addition, the physician has only limited control that can be poked, moved sideways, or separated. Improved instruments for blunt dissection that can differentiate soft tissue without destroying the hard tissue will greatly facilitate many surgeries.

The disclosed embodiment includes a method and apparatus for blunt dissection that differentially destroys a patient's soft tissue without destroying the patient's hard tissue. In one embodiment, a differential ablation mechanism for differential ablation of complex tissue is disclosed. The differential ablation device includes a handle, a central longitudinal axis, and a elongate member having a proximal end and a distal end. The differential ablation device also includes a discriminating ablation member configured to be rotatably attached to the distal end, wherein the discrimination ablation member has at least one tissue-engaging surface, a first torque point disposed on a first side of the axis of rotation of the discriminating ablation member, And a mechanism configured to mechanically rotate the differential ablation member about the axis of rotation such that the at least one tissue-engaging surface moves in at least one direction relative to the composite tissue. The mechanism includes at least one force transmitting member having a distal end and a proximal end, and the distal end is attached to the first torque point member. The proximal end of the at least one force transmitting member is attached to a motion source configured to vibrate the discriminating ablation member. In addition, the at least one tissue-engaging surface is such that when the discriminating ablation member is pressed into the patient's complex tissue by a physician, at least one tissue-engaging surface moves across the complex tissue and at least one tissue- The at least one soft tissue destroys, but is configured to selectively bind to the complex tissue such that the hard tissue within the complex tissue is not destroyed.

Figures 1A and 1B show an example of the prior art. Figure 1A shows a forceps used to grip tissue.
Figure IB shows an exemplary clamp used in blunt dissection to segment tissue.
2 shows a prior art laparoscopic forceps.
Figures 3A-3F illustrate an exemplary differential ablation mechanism. Figs. 3A to 3C show a discrimination ablation mechanism having a rotatable discriminating member in a shell. Fig. Figs. 3d-1 to 3d-3 show a front view and a side view of the discriminating member; Fig. 3d-1 is a side view of the discriminating member, Fig. 3d-2 shows an enlarged view of the surface of the discriminating member, and Fig. 3d-3 shows a front view of the same discriminating member. Figures 3e-1 through 3e-4 illustrate four different types of discriminating ablation members, discriminating ablation member type I, type II, type III, and type IV, respectively. Figures 3F-1 and 3F-2 show the differential ablation members, including the tissue to be ablated, in front and side views, respectively.
Figures 4A-4F illustrate how an exemplary differential ablation mechanism disrupts the soft tissue within the composite tissue, but not the hard tissue, thereby exposing the hard tissue. Figures 4d-4f illustrate how the differential ablation member combines with and disrupts tissue having a diffused fibrous component, but can not combine with fibrous components and destroy it.
Figures 5A-5C illustrate the tissue joining end of a different exemplary differential ablation device including a ablation wheel mounted within the envelope. Figures 5A-5B show a mechanism with one configuration of ablation wheels, Figures 5C-1 and 5C-2 show other configurations with different configurations of ablation wheels; Figure 5c-1 shows the ablation wheel in its exploded view from the appliance, and Figure 5c-2 shows the ablation wheel in its position.
Figures 6a to 6d illustrate how the axis of rotation of the differential ablation member may have many different orientations for differentiating ablation mechanisms, including differential ablation mechanisms with flexible or refractive elongate members, And illustrate different configurations of an exemplary differential ablation member.
Figures 7a and 7b illustrate an exemplary differential ablation device using ablation wires or other discriminating ablation members instead of ablation wheels.
Figures 8A-8C illustrate an exemplary differential ablation mechanism using a flexible belt as the discriminating ablation member.
Figs. 9A to 9C show how changing the exposure of the tissue-engaging surface of the discriminating ablation member changes the behavior of the discrimination ablation mechanism, in particular the range of exposure angles of the tissue-engaging surface.
Figs. 10A-10C illustrate how changing the exposure of the tissue-engaging surface of the discriminating ablation member changes the direction of the frictional forces on the tissue and the angle of the strain on such tissue.
Figs. 11A and 11B show an example differential discrimination mechanism having a water outlet diverging to the side of the discriminating ablation member.
Figure 12 shows an exemplary differential ablation mechanism with two opposing flexible belts that generate opposing frictional forces to reduce torque on the differential ablation mechanism.
Figure 13 illustrates an exemplary differential ablation mechanism that may have a plurality of components positioned within the envelope, including a suction line, a water tube, and a light emitting diode.
Figures 14-1 to 14-3 illustrate how the elongate members of the exemplary differential ablation mechanism can be deflected by the bendable region to facilitate placement of the discriminating ablation member; Fig. 14-1 shows the elongated member of the differential ablation mechanism at the straight line position 1, Fig. 14-2 shows the elongated member of the differential ablation mechanism bent at 45, Fig. 14-3 shows the elongated member bent at 90 And shows the elongated member of the discrimination ablation mechanism.
Figs. 15A-15E illustrate different exemplary discriminating members showing various important dimensions and features of a discriminating member; 15A shows a top view of an exemplary discriminating member that rotates relative to a rotational joint; 15B-1 to 15B-3 show the discriminating member as shown in FIG. 15A; 15B-1 shows the differential ablation member in a side sectional view; Fig. 15B-2 shows an enlarged view of the tip of the discriminating member shown in Fig. 15B-1, Fig. 15B-3 shows an enlarged view of the surface of the discriminating member shown in Fig. 15B-2, 15C illustrates another embodiment of a differentiating member having a wavy tissue-engaging surface; 15D shows a perspective view of the discriminating member shown in Fig. 15C; Fig. Fig. 15E-1 shows an end view of the discriminating member shown in Fig. 15C, Fig. 15E-2 shows an enlarged view of the tissue engaging surface of the discriminating member shown in Fig. 15E- 15E-1 and 15E-2. As shown in Fig.
Figures 16-1 to 16-3 illustrate one exemplary means for varying the attack level of the discriminating ablation member; Fig. 16-1 shows a discriminating member having a somewhat sharp but still non-sharpened feature, Fig. 16-2 shows a discriminating member having a rounded feature more than that shown in Fig. 16-1 , Fig. 16-3 shows the discriminating member having the feature more dull than the discriminating member shown in Fig. 16-1 or Fig. 16-2.
FIGS. 17A, 17B-1, and 17B-2 illustrate how a feature such as the wavy shape of the tissue-engaging surface creates a tissue-engaging surface having a variable attack angle when moving over tissue; Fig. 17A shows the differentiation ablation member having a lobed configuration, Fig. 17B-1 shows the same different ablation member impinging on the tissue, Fig. 17B-2 shows the attack angle of the tissue- Fig. 3 is an enlarged view of the lobe of the lobe-shaped discrimination member shown in Fig.
Fig. 18 shows how the relative arrangement of the center of gravity and the center of gravity of the vibratory differential ablation member can cause the discrimination ablation mechanism to vibrate.
19A-19D illustrate how an exemplary discriminating ablation member or an enclosure surrounding it deforms tissue in a direction perpendicular to the direction of movement of the tissue-engaging surface. Figure 19d shows how such a strain aligns the fibrous components within the tissue to facilitate their destruction by the tissue-engaging surface.
Figure 20 further illustrates how an example differential ablation member destroys tissue, including how the different ablation members deform tissue and fibrous components such as interstitial fibers.
Figures 21A-21C-4 illustrate how the relative movement of the discriminating ablation mechanism shell and differential ablation member alter the wedge angle to produce more or less strain in tissue; 21 (a) shows a side view of the discriminating member having a thin ablation wheel and enclosed within the envelope; Figures 21b-1 and 21b-2 further illustrate respectively a front view and an enlarged view of the covered differential ablation member of Figure 21a, respectively; Figs. 21C-1 to 21C-4 show four different positions of the sheath covering the differential ablation member of the differential ablation mechanism.
Figure 22 shows an example of an exemplary reciprocating mechanism for a discriminating member using a scotch yoke mechanism to convert the rotation of the shaft into the reciprocating vibration of the discriminating member.
Figs. 23A to 23C further illustrate the scotch yoke mechanism shown in Fig. 22. Fig.
24A and 24B further illustrate the scotch yoke mechanism shown in FIG.
25A-25D further illustrate the scotch yoke mechanism shown in Fig. 22, including how more of the differential ablation member can be covered to reduce trauma to the patient's tissue.
Figures 26A-1, 26A-2, 26B-1, and 26B-2 illustrate how an exemplary differential ablation member can be equipped with a retractable blade to allow differential excision mechanisms to perform sharp ablation of tissue FIG. Figures 26A-1 and 26B-1 show side views, Figures 26A-2 and 26B-2 show a top view, Figures 26A-1 and 26A-2 illustrate the differential ablation member in which the retractable scalpel is withdrawn, and Figures 26B-1 and 26B-2 illustrate the same differential ablation member in which the retractable scalpel is extended.
Figs. 27A and 27B illustrate how the example differential discriminating member can be provided with a tightening member to allow the discriminating ablation mechanism to act as a clamp. Fig.
Figure 28 shows an exemplary discriminating member having a tissue-engaging surface and a side surface.
29A to 29E-2 show an enlarged view of a tissue-engaging surface and a side surface of the discriminating member of Fig. 28, wherein the tissue-engaging surface is composed of a series of alternating bones and protrusions; Fig. Figure 29c-2 shows an enlarged view of the corner of the protrusion shown in Figure 29c-1; 29e-1 and 29e-2 illustrate two alternative versions of the arrays of projections and valleys that form the surface of the differential ablation member.
Figures 30A-30D illustrate how the lateral surfaces of the differential ablation members of Figures 28 and 29A-29C align and deform the tissue comprising the interstitial fibrous component and how the deformation of the interstitial fibrous component facilitates their alignment , And facilitates rupture by protrusion after entering the valley.
Figure 31 further illustrates from different drawings how the fibrous component of the tissue enters the valley and then is deformed and ruptured by the protrusion.
Figure 32 shows an exploded view of a complete exemplary differential ablation instrument.
33A to 33C show an enlarged view of the discriminating member of the discrimination ablation mechanism of Fig. 32, and emphasize how the scraper yoke mechanism allows the revolving shaft to drive the reciprocating vibration of the discriminating member.
Figure 34 shows an exploded view of another exemplary differential ablation mechanism having a retractable blade.
Figs. 35A to 35C-2 show an enlarged view of the discriminating member of the differential excision mechanism of Fig. 34, including how such a mechanism may be used to change the amplitude of the vibration of the discriminating member; 35A shows an exploded view of an exemplary differential ablation mechanism; 35B shows details of an assembly of an exemplary discriminating member; 35C-1 and 35C-2 show how the angular amplitude of the discriminating ablation member can be controlled by the longitudinal position of the cam housing main body.
36A-1, 36A-2, 36B-1, 36B-2, 36B-3, and 36B-4 show a retractable hook with a more aggressive tissue- Illustrate an exemplary retractable blade that is a hook with a sharp elbow that allows for slicing; 36A-1 shows the hook extending from the differential ablation member, Fig. 36A-2 shows the hook retracted into the differential ablation member, Figs. 36B-1 and 36B-2 show the extended hook, 36b-3 and 36b-4 show the retracted hooks; Figs. 36B-1 and 36B-3 show the discriminating member in the fixed position, and Figs. 36B-2 and 36B-4 show the actively vibrating discriminating member.
37-1, 37-2, 37-3, and 37-4 illustrate how the retractable hooks shown in Figs. 36A and 36B can be used to quickly and safely divide thin film structures such as the peritoneum and; 37-1 illustrates a hook extending from a tip of a fixed differential ablation member while the differential ablation mechanism is suspended by a physician on a patient's tissue; Fig. 37-2 illustrates a hook extending from a vibrating differential ablation member to a tissue surface Figure 37-3 shows a fixed differentiating member in which an elongated hook engages the edge of the tissue sac, Figure 37-4 shows a vibrating hook with an elongated hook, Quot ;.
Fig. 38 shows a complete example discriminating ablation instrument having a pistol grip and the ability to rotate the instrument insertion tube to rotate the plane of vibration of the discriminating ablation member.
Figure 39 illustrates how an exemplary differential ablation device can be fitted in the arm of a surgical robot and optionally equipped with an electrically conductive patch for electrocautery.
Figures 40-1 and 40-2 illustrate an exemplary laparoscopic version of a differential ablation instrument having an electromechanical actuator at its origin, relative to the abutment, at a linear position and a bend position, respectively.
41 shows one exemplary version of a differential ablation mechanism driven by a flexible drive shaft.
Figures 42A-42E show a perspective view and an exploded view of an embodiment of a differential ablation instrument in the form of a thin pencil grip specially designed for open surgery.
43A to 43C show different embodiments of several mechanisms capable of driving the vibration of the discriminating member.
44A-44C illustrate different embodiments of a differential ablation mechanism and a mechanism for protecting tissue that is ablated from a large mass.
45A-45G illustrate a method for using differential discrimination mechanisms to separate tissue planes without damaging blood vessels and other anatomical structures within the tissue plane.
Figs. 46A-1, 46A-2, 46B-1, 46B-2, 46C-1 and 46C-2 show mechanisms for tunneling by means of a differential excision mechanism combined with an endoscope.
47A-47D illustrate another device for tunneling by a differential ablation device associated with an endoscope, including sub-components for improving ablation and improving the endoscope's clock.

The disclosed embodiment includes a method and apparatus for blunt dissection that differentially destroys a patient's soft tissue without destroying the patient's hard tissue. In one embodiment, a differential ablation mechanism for differential ablation of complex tissue is disclosed. The differential ablation device includes a handle, a central longitudinal axis, and a elongate member having a proximal end and a distal end. The differential ablation device also includes a discriminating ablation member configured to be rotatably attached to the distal end, wherein the discrimination ablation member has at least one tissue-engaging surface, a first torque point disposed on a first side of the axis of rotation of the discrimination ablation member, And a mechanism configured to mechanically rotate the differential ablation member about the axis of rotation thereby causing at least one tissue-engaging surface to move in at least one direction relative to the composite tissue. The mechanism includes at least one force transmitting member having a distal end and a proximal end, and the distal end is attached to the first torque point member. The proximal end of the at least one force transmitting member is attached to a motion source configured to vibrate the discriminating ablation member. In addition, the at least one tissue-engaging surface is such that when the discriminating ablation member is pressed into the patient's complex tissue by a physician, the at least one tissue-engaging surface moves across the complex tissue and the at least one tissue- And is configured to selectively couple with the complex tissue such that the at least one soft tissue destroys but not the hard tissue within the complex tissue.

Specifically, a "discrimination ablation apparatus" is disclosed. The term "discrimination" is used because differential discrimination mechanisms can destroy soft tissues while avoiding the destruction of hard tissues. The effector end of the differential ablation mechanism can be pressed against tissue consisting of hard and soft tissue, and the soft tissue is much more easily destroyed than hard tissue. Thus, when the differential ablation mechanism is pushed into the complex tissue, the differential ablation mechanism destroys the soft tissue, thereby exposing the hard tissue. This differential action is automatic and is a function of the device design. Much less attention is paid to the operator for blunt dissection than traditional methods, and the risk of accidental damage to the tissue is greatly reduced.

For purposes of the present application, "soft tissue" is defined as various soft tissues that are separated, ruptured, removed, or otherwise typically destroyed during blunt dissection. A "target tissue" is defined as a tissue that is isolated during blunt dissection, such as a blood vessel, bladder, urethra, or nerve bundle, and its integrity is preserved. "Hard tissue" is defined as a mechanically stronger tissue, usually comprising one or more layers of coherent packed collagen or other extracellular fibrous matrix. Examples of hard tissues include blood vessel walls, nerve fiber sheaths, fascia, tendons, ligaments, bladder, pericardium, and many others. "Composite tissue" is an organization of soft tissue and hard tissue, and may include a target tissue.

Figures 3a, 3b, and 3c show the effect end of a differentiating ablation device 300 that is capable of differentially destroying the soft tissue without destroying the hard tissue. In this embodiment, the ablation member includes a ablation wheel 310 that rotates about a shaft 320 that is retained within cavity 331 within enclosure 330. Figure 3A shows the separated parts. Figures 3b and 3c show two different views of the assembly. The ablation wheel 310 is rotated by one of several mechanisms such as a motor or a manually actuated drive with appropriate transmission means. The ablation wheel 310 has a tissue-engaging surface 340 that grasps and destroys the soft tissue but does not destroy the hard tissue. Examples of tissue-engaging surface 340 and ablation wheel 310 include a surface covered by a diamond grinding wheel or grinding stone or a small projection or protrusion (further defined below) from the surface. The envelope 330 covers a portion of the ablation wheel 310 so that only a portion of the ablation wheel 310 is exposed. In use, ablation wheel 310 rotates at a speed in the range of about 60 to about 25,000 rpm or about 60 to about 100,000 rpm, and the speed is operator selectable. In addition, the direction of rotation of the ablation wheel 310 may be reversed by the operator. Alternatively, ablation wheel 310 may oscillate (reciprocating vibration) at a frequency in the range of about 60 to about 20,000 cycles per minute in one embodiment. In another embodiment, ablation wheel 310 may vibrate (reciprocating vibration) at a frequency in the range of about 2,000 to 1,000,000 cycles per minute.

The ablation wheel 310 is an example of a " Differential Dissecting Member "(hereinafter" DDM ") that is capable of differentially destroying a soft tissue but not a hard tissue. FIG. 3D shows a side view, a front view, and a perspective view of one embodiment of the DDM 350 separated from the rest of the differential ablation mechanism 300 for clarity. The DDM 350 is comprised of a body 360 having a rotational axis 365 about which the body 360 rotates. The rotation may be oscillatory (i.e., back and forth) or continuous. The body 360 has an outer surface 361 with a tissue engaging surface 370 distributed over at least a portion of the outer surface 361 of the body 360. The tissue non-engaging surface 371 is the portion of the outer surface 361 that is not covered by the tissue engaging surface 370. In this embodiment, the portion of the outer surface 361 that is in contact with the tissue, and in particular the tissue-engaging surface 370, should not have features that are sharp enough to cut tissue and should therefore be free of knives (such as scalpels or scissors) , No sharp-edged teeth (such as saw blades), no sharp corners, no sharp-edge grooves (such as a drill bit or arthroscope), where sharp edges have a curvature of less than 25 μm do. A typical maximum dimension of a DDM is between approximately 3 mm and approximately 20 mm. Alternatively, a small version for microsurgery can be measured between approximately 2 mm and approximately 5 mm.

The tissue-engaging surface 370 is further constructed of a plurality of protrusions 375 (shown in exploded detail in Figures 3d-1 to 3d-3) from the outer surface 361 of the body 360, The protrusion 375 of the body 360 has a protrusion length 380 measured from the bone to the peak in a direction substantially perpendicular to such a local region of the outer surface 361 of the body 360. Different protrusions 375 on the tissue-engaging surface 370 may all have the same protrusion length 380, or they may have different protrusion lengths 380. The protrusion 375 preferably has a protrusion length 380 of less than about 1 mm. Alternatively, for some embodiments, the protrusion length may be greater than about 1 mm and less than about 5 mm. Collectively, all protrusions 375 on the tissue-engaging surface 370 have an average protrusion length (P _avg ). The protrusions 375 are preferably separated by a gap 385 that spans a distance of about 0.1 to about 10 mm.

Referring now to Figures 3d-1 to 3d-3, Figures 3d-1 to 3d-3 show a front view and a side view of the discriminating member. Fig. 3d-1 is a side view of the discriminating member, Fig. 3d-2 shows an enlarged view of the surface of the discriminating member, and Fig. 3d-3 shows a front view of the same discriminating member. The body 360 of Figures 3d-1 to 3d-3 may optionally be shaped such that the tissue engaging surface 370 is located at a variable distance from the rotational axis 365. [ The placement radius R can be measured from the rotational axis 365 to any point on the tissue engaging surface 370 in a plane perpendicular to the rotational axis 365. [ Thus, there will be a maximum batch radius (R _max) with the smallest place radii (R _min) and a maximum length with the shortest length, as shown in Fig. 3d-1 through 3d-3 and 3e-1 through Fig. 3e-4 As noted, R _min exceeds zero so long as the tissue-engaging surface 370 does not completely cover the surface 361 of the DDM 350. Thus, if the body 360 is shaped such that the tissue engaging surface 370 is positioned at a variable distance from the rotational axis 365, (R _max - R _min ) will exceed zero. In some embodiments of the DDM, this relationship (R _max - R _min ) is greater than about 1 mm. In another embodiment, this relationship (R _max - R _min ) exceeds P _avg . Alternatively, Fig. 3d-1 to, as shown in the example of Fig. 3 and Fig. 3d-3e-1 through Fig. 3e-4, R _min is more typically at least 5% lower than R _max. A typical size for the DDM is R _min> approximately 1mm and R _max <but approximately 50mm; Smaller versions for micro-ablation can have smaller dimensions of R _min > about 0.5 mm and R _max < about 5 mm.

Referring now to Figures 3e-1 through 3e-4, four different embodiments of the DDM are shown in side elevation, and the axis of rotation 365 is perpendicular to the plane of the ground. The cross-sectional profile of the DDM in a plane perpendicular to the axis of rotation 365 is important, as will be discussed in the following paragraphs. Four scenarios for the cross-sectional profile of DDM are shown below.

DDM Type I: The section profile can be any shape except for round or circular wedges. The rotation axis 365 is located at any point in the cross section as shown in Figs. 3d-1 to 3d-3 yielding the result P _avg <(R _max - R _min ). As shown in Figures 3d-1 to 3d-3, the DDM Type I includes irregular cross-sectional profiles including regular cross-sectional profiles and various asymmetric, wave / wave / wave boundaries, cutouts, can do. In this example, the DDM type I oscillates reciprocally between two end positions (dashed contours). Alternatively, the movement may be rotary.

DDM Type II: Section profile is a circle or circle wedge. The rotation axis 365 is located at any point in the cross section to yield a result P _avg < (R _max - R _min ) (i.e., the rotation axis 365 is not near the center of the circle).

DDM type III: The cross-sectional shape is a circle or circle wedge. The rotational axis 365 is located at any point within the cross-section sufficiently close to the distal center to yield a result P _avg ~ (R _max - R _min ) (i.e., the rotational axis 365 is generally in the center of the circle) .

DDM type IV: The cross-sectional shape includes the center of the cross-sectional shape, so that a regular repeating feature on the periphery, such as a wavy shape, yielding a result P _avg <(R _max - R _min ) no matter where the rotational axis 365 is located . Type I DDM and Type IV DDM are closely related in that the axis of rotation 365 can be anywhere within the cross-sectional shape and still yield the result P _avg <(R _max - R _min ).

The wave, wave, or any regular repeating feature of the DDM does not include perforations or holes in the tissue-engaging surface 370, and therefore the perforation walls do not significantly contact the tissue. For example, the suction passageway disclosed in U.S. Patent No. 6,423,078 includes a hole in the abrasive surface that serves as the tissue-engaging surface of the abrasive member. These holes do not include the features described for DDM because the holes only act as fluid ports within the tissue-engaging surface and the walls of the suction passages are not supported on the tissue. Nevertheless, the DDM disclosed herein may include such a suction passage.

DDMs of types I through IV may also include any of a variety of shapes from the plane of the ground. As described above, the cross-sectional profile of the DDM in a plane perpendicular to the rotation axis 365 is important. Thus, the ablation wheel 310 of Figs. 3A-3C is an example of DDM type III.

Figures 3f-1 and 3f-2 show a DDM 390 similar to the DDM 350 shown in Figures 3d-1 to 3d-3. The DDM 390 has a first end and a second end 392 with the first end 391 facing away from the composite structure 399 and the DDM 390 being rotated about the axis of rotation 365 by a mechanism And is rotatably coupled with a mechanism (not shown). The mechanism may include a powered drive and a manual drive. The second end portion 392 faces the composite structure 399 and has a semi-elliptical shape formed by three orthogonal half-axes: longitudinal axis (A), first-half axis (B), and second- The longitudinal axis A lies in the direction of the line connecting the first end 391 and the second end 392; The short half axis C is parallel to the rotation axis 365 (i.e., A is perpendicular to the rotation axis 365); The short half axis B is perpendicular to the long half axis (A) and the short half axis (C). Half ellipses can have a range of shapes (eg, there can be different relationships between the lengths of the three half axes, including A = B = C, A ≠ B ≠ C, A> B and A> ). In one embodiment, A> B> C was found to be very effective for DDM.

Figures 4A-4C illustrate how the effector end of the differential ablation device 300 can be used for ablation of complex tissue composed of soft and hard tissues, where the DDM is the ablation wheel 310. In Figure 4a, the operator initiates rotation of the ablation wheel 310, as indicated by arrow 410, before or during contact with the soft tissue 400. [ In Figure 4b, the operator then presses the exposed tissue-engaging surface 340 of the ablation wheel 310 into the volume of the soft tissue 400 for blunt dissection to reach the internal target tissue 420. Arrows 430 and 440 in FIG. 4B illustrate two possible operator run movements of the discrimination ablation mechanism 300. Only a portion of the tissue engaging surface 340 of the ablation wheel 310 that is exposed to the exterior of the envelope 330 contacts the soft tissue 400 and thereby exposes the soft tissue 400 in contact with the tissue engaging surface 340, Destroy the part. The exposed moving portion of the tissue-engaging surface 340 can be removed without additional action by the physician (e.g., without the doctor forcibly rubbing the differential ablation device 300 against the soft tissue 400) The tissue may simply be destroyed by the application of the rotating ablation surface 340 of the ablation wheel 310 to any portion of the soft tissue 400; When the ablation wheel 310 contacts the hard tissue of the target tissue 420, it does not destroy the target tissue 420. Pushing the ablation wheel 310 into the soft tissue 400 as indicated by the arrowhead on arrow 430 is a "plunge" and the ablation wheel 310 will not destroy the hard tissue, 420 may not be destroyed, it may be pushed into the soft tissue 400 without looking into it. Other movements of the differential ablation mechanism 300, including orthogonal movement, curvilinear motion, and other 3D motion, relative to arrows 430 and 440 may be used to ablate soft tissue 400. Once the target tissue 420 is exposed, the differential ablation mechanism 300 may be withdrawn and expose the target tissue 420, as shown in FIG. 4C.

Figures 4d-4f illustrate how one embodiment of DDM breaks soft tissue but not hard tissue. 4D shows a cross-sectional view of the DDM as ablation wheel 310 with a tissue engaging surface 340 having protrusions 375. Fig. The ablation wheel 310 moves in and out of the plane of the ground while the shaft 320 (not shown) is substantially parallel to the plane of the ground. Thus, the protrusion 375 moves through the plane of the ground. Figure 4d further illustrates the volume of soft tissue 400 that is substantially maintained in place as ablation wheel 310, tissue engaging surface 340, and protrusion 375 move through the plane of the paper. Given the movement of the protrusion 375 relative to the generally fixed soft tissue 400, the ablation wheel 310 breaks the soft tissue 400. In detail, the soft tissue 400 is composed of a fibrous component 401 and a gel-like material 402. (The soft tissue is often composed of a fibrous component 401, such as a small bundle of collagen fibers and fibers, and a thin film component, for example, an extracellular material in which a thin film is dispersed in a water-swellable gel material.) The protrusions 375 (E.g., at points 450 and 451) with the individual fibrous component 401 and then sweep through the gel-like material 402 to engage it; The fibrous component 401 is then ruptured by the relative movement of the soft tissue 400 with the protrusion 375 on the ablation wheel 310 through the plane of the ground. If the ablation wheel 310 is pushed deeper into the tissue 400, the protrusion 375 will engage and fracture a much deeper fibrous component. Thus, soft tissue 400 with dispersed components can be ablated by DDM.

FIG. 4E shows how, in contrast to FIG. 4D, the closely packed fibrous tissue can resist ablation by ablation wheel 310. FIG. The hard tissue 403 is composed of a fibrous component 401 that is frequently packed in parallel, crossed, or other closely packed arrays (e.g., fascia and vein walls) or in tightly packed 2D and 3D meshes, and the gel material 402 ) Covers the array of fibrous component (401). 4E, the hard tissue 403 is composed of a gel-like material 402 (spot area) that thinly coats a layer of closely packed fibrous component 401, the filament of the fibrous component having a long axis thereof perpendicular to the plane of the paper And thus the cross section of the fibrous component 401 is shown in a circular shape. In this image, the ablation wheel 310 reciprocates left and right on the ground, as indicated by arrow 405, to sweep the protrusions 375 over the surface of the hard tissue 403. Due to the close packing of the fibrous component 401 within the hard tissue 403, the protrusions 375 can not engage and engage separately with the fibrous component 401, thus imparting sufficient stress to rupture the fibrous component 401 Can not. The gel material 402 also acts as a lubricant so that the protrusions 375 tend to slip in the closely packed fibrous component 401 of the hard tissue 403. [ Finally, any compliance of the surface of the hard tissue 403 exposed to the ablation wheel 310 prevents the tension in the hard tissue 403 or the fibrous component 401, so that the hard tissue 403 is removed from the ablation wheel 310). &Lt; / RTI &gt; The hard tissue 403 is therefore resistant to fracture by DDM by a combination of fibrous, adhesive fill of the plate-like component 401, lubrication of this component by the gel-like material 402, and conformity of the hard tissue 403.

The movement of the DDM can be rotary or oscillatory, as described above. The speed of the point on the DDM over a particular area of the tissue strongly affects the ability of the DDM to destroy such tissue. Figure 4f shows the ablation wheel 310 sweeping left and right within the plane of the paper on soft tissue 400 (as shown by bi-directional arrow 460) by contact point 470. The translational velocity of the contact point 470 is determined by the rotational speed of the DDM and the distance 480 separating the contact point 470 from the center of rotation (not shown). For rotational movement, the translational movement speed is equal to 2 [pi] D [omega], where D is the distance (480) and [omega] is the rotational frequency in revolutions per second. For oscillatory motion, the translational velocity is D? 2X, where D is the distance (480),? Is the oscillation frequency in cycles per second, and X is the sweep angle in radians. For a differential ablation device, the distance 480 ranges from about 1 mm to about 40 mm; The rotational speed ranges from about 2 rotations per second to about 350 rotations per second; The vibration frequency ranges from about 2 Hz to about 350 Hz; The sweep angle is in the range of 2 DEG to 270 DEG. Thus, the translational speed of the contact point 470 on the discriminating ablation can range from about 1 mm per second to about 60,000 mm per second. In one embodiment, oscillatory motion with a frequency of approximately 100 Hz, sweeping at a distance 480 of approximately 15 mm and approximately 45 degrees, yielding approximately 2400 mm per second is highly effective for a plurality of soft tissues. This is because the speed of the operator-initiated movement (as shown in FIG. 4) is always less than the speed of the contact point on the DDM during ablation, which allows the physician to be careful during ablation and slow his mechanism (usually much less than 100 mm per second) It is because we move it. In addition, movement of the DDM is described throughout this document as arising from rotational motion (continuous rotation or reciprocation, i.e., back and forth oscillation). However, as described above, any movement of the DDM may be used, including a linear movement to the tissue such that the tissue-engaging surface of the DDM properly engages the tissue.

DDM can be forced to move to almost any other organ or tissue that is composed of or covered by blood vessel walls, pleura, pericardium, esophagus, bladder, and adherent filled fibrous tissue, and DDM can be used to remove such hard tissues under light manual pressure It will not be significantly destroyed. Conversely, DDM can be forced to move to the mesentery or other soft tissues, and the soft tissues will quickly disintegrate under light manual pressure. The differentiating ablator equipped with any one of the various DDMs as disclosed herein quickly ablates between the planes of the lobes by the present inventor and removes the internal thoracic artery away from the inner wall of the thorax, The esophagus was removed from the surrounding tissues, not through the fiber bundles, but through the large muscles between them, cutting away the fascia and tendons away from the muscle fibers, washing the resected fascia, To remove the pockets into the tissue, and to separate the tissue planes in many different tissues. The availability of discrimination is broad and thus has many potential uses. Importantly, due to the composition of skin and surgical gloves, the skin or surgical gloves are not severed or destroyed by DDM, even when significant pressure is applied. The inventors have demonstrated that vibratory DDM of the type disclosed herein can be held against a ball of a face without any effect. The differential resector is therefore inherently safe to use, which simplifies its use during surgery, especially when the physician's finger is near the ablation point.

DDM is preferably formed from a rigid material such as a metal or rigid polymer (e.g., Shore A of 70 or greater) rather than a mild polymer and elastomer (e.g., less than 70 Shore A). The use of a rigid material prevents the protrusion from the tissue-engaging surface from deflecting away from the tissue, as may occur if a soft material is used. The DDM or its component parts may be machined from bulk material, constructed by stereolithography, or by any one of the means known in the art (e.g., injection molding) or by any such method known in the art As shown in Fig.

The protrusions on the tissue-engaging surface of the DDM can be made by one of several means. The protrusions can be formed by coating a tissue-bonded surface with a grit similar to sandpaper using a grit that is rougher than 1000 but finer than 10 on the Coated Abrasive Manufacturers Institute standard. The grit may comprise particles comprised of diamond, stonemason, metal, glass, wool, or other materials known in the art. The protrusions may be formed into the surface of the material that constitutes the DDM by sanding, sand blasting, machining, chemical processing, charge processing, or other methods known in the art. The protrusions can be molded directly into the surface of the DDM. The protrusions can be formed on the surface by stereolithography. The protrusions can be irregularly shaped like particles of a grit, or can be regularly shaped with a defined polygonal, curved, or inclined surface. The protrusion may be elongate, and the major axis of such protrusion may have an angle with respect to the tissue engaging surface. The protrusions have a cross-sectional shape when viewed from above the tissue-engaging surface, which may be circular, polyhedral, or composite. The cross-sectional shape of the protrusion can be oriented with respect to the moving direction of the DDM.

Keeping tissues moist helps the discrimination. A well-wetted hard tissue is better lubricated, greatly reducing fracture by DDM. Conversely, well-wetted soft tissues are water-swollen and gentle so as to separate the spacing of individual fibers and to facilitate their rupture by being joined by protrusions from the tissue-engaging surface of the DDM. Wetting of the tissue can be accomplished by one of several means, including simply passing tissue through physiological saline during ablation. Perfusion can be performed by procedures already in use at the time of surgery, such as a perfusion line, or by one of the devices described below. In addition, wetting of the tissue-bound surface of the tissue and also the DDM reduces clogging by the destroyed tissue of the tissue-bonded surface.

5A and 5B illustrate another embodiment of the effect end of a differentiation ablation device 500 having DDM type III configured as a circular cylinder 510. Fig. 5A shows a circular cylinder 510 in which the shaft 520 is separated from the shell 530. The tissue-engaging surface 540 covers the side of the circular cylinder 510. A bi-directional arrow indicates rotation about the rotation axis 575. Figure 5B shows both components configured for use where only a limited portion of the tissue-engaging surface 540 is exposed.

Figures 5c-1 and 5c-2 illustrate another embodiment of the effector end of a differential excision mechanism having a different configuration for the sheath and DDM, where different DDM type III. Figures 5c-1 and 5c-2 illustrate a differential ablation instrument 550 with a ablation wheel 560, wherein the shaft 570 is separate from the sheath 580. [ The tissue engaging surface 590 covers the periphery of the ablation wheel 560. A double-headed arrow indicates a rotation axis 575. Figure 5c-2 shows both components configured for use where only a limited portion of the tissue-engaging surface 590 is exposed. This configuration is problematic because the envelope 580 makes it difficult to position the tissue engaging surface 590 relative to the tissue and the envelope 580 blocks the operator's field of view.

6A shows an embodiment of a differential ablation device 600 including a handle 610 for an operator. The handle 610 is connected to a elongate member 620 that includes a first end 621 coupled to the handle 610 and a second end 622 coupled to the DDM 630. [ The elongate member 620 is short enough to allow better manual control of the DDM 630 on the instrument for open surgery or it may be long enough to allow the differential ablation mechanism 600 to be a laparoscopic instrument. A drive mechanism for rotating the DDM 630, such as a rotating drive shaft for a scotch yoke or a crank / slider, can be easily adapted to any elongated member 620, or any device capable of driving the DDM 630, do. The DDM 630 is configured to rotate about the rotational axis 630 of the type III &lt; RTI ID = 0.0 &gt; (III) &lt; / RTI &gt; rotatably mounted on the elongate member 620 at the second end 622 such that the DDM 630 is reciprocally oscillated about its rotational axis 640, DDM (the axis of rotation 640 is perpendicular to the plane of the sheet of Fig. 6A). The first end 621 and the second end 622 form a centerline 650 of the elongate member 620. The tangential line 651 of the centerline 650 and the rotational axis 640 as the centerline 650 approaches the second point 622 is at a time 670 (not shown - perpendicular to the plane of the drawing) . In this example, the time 670 is 90 degrees (i.e., the rotation axis 640 is aligned at right angles to the tangent line 651). Rather than the handle 610, the first end 621 of the elongate member 620 may be attached to the arm of the robot for robotic surgery. The DDM can be easily adapted to any other device that can move or rotate the DDM.

Fig. 6B shows another embodiment of a differentiation ablation device 601 with a similar but rotational axis parallel to the centerline. The handle 610 is connected to a elongate member 620 that includes a first end 621 connected to the handle 610 and a second end 622 connected to the type III DDM 631. [ The DDM 631 is rotatably mounted to the elongate member 620 at the second end 622 such that the DDM 631 reciprocally oscillates about its rotational axis 640. [ The rotation axis 640 is parallel to the plane of the paper of Fig. 6B. The first end 621 and the second end 622 form a centerline 650 of the elongate member 620 by a tangent line 651 when the centerline 650 approaches the second end 622 . Thus, the axis of rotation 640 is aligned parallel to the tangent line 651 (i.e., the time 670 is 0 °). (Again, the time 670 is not shown in FIG. 6B because the time is 0 °). Thus, the differentiation ablation device 601 is similar to the differentiation ablation device 550 of FIG. 5C, Thus having similar limitations, including difficulty in locating the tissue-engaging surface of the DDM 631 relative to the tissue without interrupting the operator's field of view.

6C shows a differential embodiment with a curved centerline 650 and a curved elongate member 620 with a tangent line 651 to a centerline 650 as the centerline 650 approaches the second point 622. [ And shows another embodiment of the resection mechanism 603. The rotational axis 640 is perpendicular to the tangent line 651, forming a time 670, which in this example is 90 [deg.]. The elongate member 620 may be similarly bent, joined, deflected, or made of a plurality of parts. In all cases, the time 670 is formed by the tangential line of the centerline when the rotational axis and centerline of the DDM approach the second point 622. [

FIG. 6D shows another embodiment of a differential ablation mechanism 604 similar to the differential ablation mechanism 602 of FIG. 6B. The handle 610 is connected to a elongate member 620 that includes a first end 621 connected to the handle 610 and a second end 622 connected to the type III DDM 631. The DDM 631 is rotatably mounted to the elongate member 620 at the second end 622 such that the DDM 631 reciprocally oscillates about its rotational axis 640. [ The rotation axis 640 is parallel to the plane of the paper of Fig. 6D. The first end 621 and the second end 622 form a centerline 650 of the elongate member 620 by a tangent line 651 when the centerline 650 approaches the second point 622 . Thus, the rotational axis 640 is aligned at an angle other than zero relative to the tangent line 651 (i.e., the time 670 is between 0 [deg.] And 90 [deg.]). In a preferred embodiment, the time 670 is not equal to 0 DEG for the reason described for the differential ablation mechanism 603 of FIGS. 5C and 6B.

7A and 7B show another embodiment of the effector end of the differential ablation mechanism 700 using the ablation wire 710 as the DDM. Figure 7a shows an assembled device. The ablation wire 710 lies at a distance 725 from the backing surface 726 of the sheath 730 and the ablation wire 710 emanates from the first pillar 720 over the gap 722, 730 at the end of the second column 721. The ablation wire 710 is a continuous loop of wire that is driven such that the exposed section of the ablation wire 710 moves in the direction indicated by the arrow 723 across the gap 722 in Fig.

7B shows a schematic side view of this embodiment of a discrimination ablation mechanism 700 showing the loop and drive mechanism of the ablation wire 710. As shown in Fig. The ablation wire 710 is a continuous loop that passes over the first idler bearing 750 received in the first post 720 and then emanates from the first post 720. The ablation wire 710 moves in the direction of the arrow 723 to move across the gap 722 and into the second post 721 where it passes over the second idler bearing 751. The loop of ablation wire 710 further travels back into envelope 730 where it passes over drive wheel 760 that is rotated by a motor in the direction of, for example, a curved arrow 724. Thus, the rotation of the drive wheel 760 drives the ablation wire 710. The resection wire 710 may be a flexible linear element having any cross-sectional shape, so instead of being a wire of circular cross-sectional shape, the resection wire 710 may be a flexible flattened surface having an outwardly facing surface with a tissue- It can be a belt. Similarly, ablation wire 710 may be a flexible cord having a larger diameter than the wire allows rotation on idler bearings 750, 751; The flexible cord has a tissue-engaging surface. The distance 725 between the ablation wire 710 and the backing surface 726 may be arbitrarily large or small and the distance 725 may be arbitrarily large or small such that the resection wire 710, the backing surface 726, May be large enough to create a substantial area surrounded by the first column 720 and the second column 721 so as to surround the target tissue to be removed. In contrast, the distance 725 may be zero, where the ablation wire 710 travels along the surface of the sheath 730, or in some receiving grooves that support the ablation wire 710 from the rear. Such receiving grooves may have a semicircular cross-sectional shape so that only a portion of the cross-sectional shape of the resection wire 710 may be exposed to the tissue being cut. In addition, the shape of the backing surface 726 may be flat, may be finely or predominantly curved, and the curved surface may have a convex region, a concave region, or a combination.

8A-8C illustrate the effect end of a differential ablation device 800 using a flexible belt as a DDM. Figure 8a shows the separated parts. The flexible belt 840 has an outer tissue engaging surface 850. The flexible belt 840 moves over the idler wheel 810 that rotates about the shaft 820, all of which are received within the envelope 830.

Figure 8B shows the assembled effector end of the differential ablation device 800 where only a limited portion of the tissue engaging surface 850 of the flexible belt 840 is exposed.

8C shows a top view of a schematic diagram of one example of how a flexible belt, such as the flexible belt 840, can be driven. An idler wheel 810 and a drive wheel 860 are mounted within the shell 830. The flexible belt 840 wraps around the idler wheel 810 and drive wheel 860. The drive wheel 860 is powered to rotate so that the flexible belt 840 is driven in the direction indicated by the curved arrows 870. The tissue-engaging surface 850 exposed to the outside of the sheath 830 is then used to destroy the tissue. The drive wheel 860 may be driven by one of several mechanisms, such as a motor, a hand crank, and the like. The drive wheel 860 and the idler wheel 810 do not need to be employee-type cylinders, and their rotation axes need not be parallel.

The extent of exposure of the tissue-engaging surface outside the sheath may be greater or less than that shown in the previous example. In fact, changing the exposure changes the different aspects of the behavior of the differential ablation device.

First, larger exposures increase the exposed areas of the tissue-engaging surface, which increases the amount of tissue destructed per unit time and increases the surface area of the tissue being removed. Thus, reducing the exposure allows for a more precise removal of the tissue, but reduces the total amount of material removed. Second, increasing the exposure changes the angle of the exposed tissue-engaging surface. 9A-9C, which illustrate a schematic planar schematic view of the effector end of the differentiating ablation device 800 with successively limited exposure of the tissue-engaging surface 850 as controlled by the opening 900 in the shell do. The opening 900 is the largest in Fig. 9A and the smallest in Fig. 9C. As the exposure is limited, the range of angles of the arrows perpendicular to the tissue-engaging surface 850 decreases. In Fig. 9A, the tissue-engaging surface 850 fractures on the anterior and lateral sides. In Fig. 9c, the tissue-engaging surface 850 fractures only at the front. Thus, when the tissue-engaging surface 850 is applied to tissue, different contact directions are applied, depending on the angle of the exposed tissue-engaging surface.

Second, this increased exposure angle of the tissue-engaging surface 850 also changes the angle at which the contacting surface of the tissue is deformed and the torque on the instrument. Consider FIGS. 10A-10C showing the friction on the tissue 400 produced by application of the tissue-engaging surface 1010.

In Fig. 10A, the tissue-engaging surface 1010 is moving in the direction of arrow 1020. Fig. This creates a frictional force in the direction of the arrow 1030. The larger the contact area, the greater the frictional force. Frictional forces pull tissue 400 laterally (in the direction of arrow 1030) to shear tissue 400 and move tissue-engaging surface 1010 in a direction opposite to arrow 1020. When the tissue engaging surface 1010 is mounted on the instrument 1060 at a distance from the point 1040 where it is held by the operator, the frictional force exerts a torque 1050 relative to the point 1040. This torque may cause the end 1070, opposite the point 1040 of the instrument 1060, to be pulled away from the desired point of application, making control of ablation more difficult. Thus, limiting the extent of exposure of the tissue-engaging surface improves control by reducing frictional forces and reducing torque on the handle.

10B illustrates how the circular tissue-engaging surface 850 is perpendicular to the tissue-engaging surface 850 and creates a frictional force in different directions depending on the contact area of the tissue 400 on the circular tissue- Lt; / RTI &gt; The resulting multidirectional shear forces on the tissue 400 produce a more complex strain pattern within the tissue 400. As in FIG. 10A, the frictional force still produces a net upward force 1080 on the tip of the sheath 830; This does not create a net left / right force on the tip of the sheath 830 (into and out of the tissue 400). Fig. 10c shows that reducing the exposure of the tissue-engaging surface 850 by narrowing the opening 900 makes the frictional forces on the tissue more one-dimensional, thereby simplifying the strain pattern in the tissue.

Despite this description of the friction to tissue, as described above for wet tissue, DDM as described herein has unusual qualities that are effective when having low friction for composite tissue. The tissue non-bonding surface and the tissue bonding surface are also effective when the entire DDM is completely immersed in a lubricant such as a surgical lubricant or a hydrogel lubricant.

During surgery, it is desirable to minimize unintentional delivery of tissue to other parts of the body. The destroyed pieces of tissue may adhere to the tissue-engaging surface of the differential ablation mechanism disclosed herein. Unintentional transport can be minimized in two ways. First, narrowing and controlling the shape of the opening 900, as shown in Figs. 10b and 10c, may be advantageous if the debris of the fractured tissue that adheres to the tissue-engaging surface 850 is stacked on the envelope, It means that it will be transported only to the streets. Similarly, if the debris adheres to the tissue-engaging surface 850 but is removed in a tangential direction away from it by inertia, narrowing the opening 900 will reduce the surface area available for adhesion, the time available for adhesion, Thereby reducing the distance that can be reached. Second, the tissue-engaging surface 850 can be made resistant to tissue adhesion. Surface treatment of the tissue-engaging surface 850 may be accomplished by any of a number of techniques known in the art, such as chemical treatment, deposition, sputtering, and the like. For example, fluoridation of the tissue-engaging surface 850 by one of several known methods (e.g., immersion coating, chemical laminating, chemical cross-linking such as by silane, etc.) And tissue adhesion by carbon-based hydrophobic tissue components. In one embodiment, a diamond / carbide coated tissue bonded surface could be used, which was found to cause the tissue to become less attached to such a surface.

Transport of the material may also be reduced by the use of oscillatory (reciprocal) movement of the DDM, rather than continuous one-way movement or continuous rotation movement. Vibration prevents transport over a distance exceeding a vibration distance that can span only a few degrees of rotation (e.g., 5 to 90 degrees). Any number of mechanisms, such as a scotch yoke or crank / slider, may be used to drive the reciprocating oscillatory movement by the rotary motor.

Tissue adhesion is also a problem because it reduces the effectiveness of the tissue-engaging surface 850. [ Clogging of tissue-engaging surface 850 creates a thick coating of material on tissue-engaging surface 850, making the tissue-engaging surface much less effective in ablating soft tissue. As above, making the surface resistant to adhesion by tissue reduces this problem. Fluorinated tissue-bonded surfaces and diamond / carbide tissue-bonded surfaces are not easily clogged, especially when destroying adipose tissue.

Clogging is also reduced, as described above, if the tissue is wet, or if the tissue-engaging surface 850 is cleaned with water. 11A and 11B show a discrimination ablation device 1100 in which a first array of three water outlets 1111 emits from the outer sheath 830 on the side of the tissue engaging surface 850. Fig. A second array of three water outlets 1112 emanates on opposite sides of the tissue-engaging surface 850. Other arrangements of water outlets are possible. 11A shows a three-dimensional model in a perspective view. 11B shows that the water tube 1121 transfers another fluid such as water or physiological saline from the inside to the one side of the shell 830 to the water outlet 1111 and the second water tube 1122 transfers the fluid from the inside Out to the water outlet 1112, to the other side of the outer skin 830. In this way, The water outlets 1111 and 1112 emanate from opposite sides of the opening 900 to provide fluid on both sides of the tissue-engaging surface 850. The liquid emanating from the water outlet can selectively transport the physiologically active substance dissolved or suspended in the liquid. The biologically active material may include various drug compounds (antibiotics, anti-inflammatory agents, etc.) and active biological molecules (e.g., cytokines, collagenases, etc.).

Proper alignment of the tissue-engaging surface 850 creates a frictional force on the tissue that can be advantageously used during blunt dissection. 12 shows a differential ablation device 1200 having two opposed flexible belts 1201 and 1202 exposed in an aperture 1230. The ablation ablation device 1200 shown in FIG. Each belt is configured with a flexible belt 1201 running on the idle 1211 and a flexible belt 1202 running on the idler 1212 and the flexible belts 1201 and 1202 ) Circulate in opposite directions with respect to each other. The flexible belt 1201 and the flexible belt 1202 are positioned in the same direction as shown by the arrows 1203 and 1204 but in the same direction as shown by the arrows 1271 and 1272, ), It proceeds in the opposite direction. Thus, the flexible belt 1201 creates a net force 1251 downward and the flexible belt 1202 creates a net force 1252 upwardly on the envelope 1220, whereupon such forces 1251, 1252 ) Are erased, leaving little or no net force on the envelope 1220. This eliminates any torque of the discrimination ablation device 1200 (as described in FIG. 10A), making it easier for the operator to control. In addition, opposing movement directions 1271 and 1272 of the flexible belts 1201 and 1202 produce opposing frictional forces on the tissue 1205 during ablation, thereby creating a frictional force in the region identified by the bi-directional arrow 1260 The tissue 1205 is pulled out. This pulling action may facilitate blunt dissection by rupturing the tissue within the area of the bi-directional arrow 1260. It should be noted that the gap 1280 between the flexible belts 1201 and 1202 within the envelope 1220 may be varied and may be reduced to zero to allow the flexible belts 1201 and 1202 to contact. The contact between the flexible belts 1201 and 1202 can help the drive mechanism to match the speed of movement of the flexible belts 1201 and 1202. In fact, friction between the flexible belts 1201 and 1202 may allow one belt, e.g., 1201, to drive 1202 in another belt, in this example. Thus, the motor can, for example, actively drive the flexible belt 1201 and the flexible belt 1202 is then driven by the flexible belt 1201. This can simplify the drive mechanism for the two belts.

Figure 13 shows how the envelope 1330 of the differential ablation mechanism 1300 accommodates different components and allows greater functionality. The ablation wheel 810 is exposed in the opening 900. Fig. Suction lines 1301 and 1302 are connected in front of the shell 1330 near the tissue engaging surface 850 so that water tubes 1121 and 1122 emanate through any debris or water outlets 1111 and 1112 from the fracture. Such as a fluid from a fluid reservoir. A light emitting diode (LED) can be placed on the envelope 1330 to better illuminate the area for blunt ablation; For example, LEDs 1311 and 1312 are powered by cables 1313 and 1314, respectively, and light from LEDs 1311 and 1312 directly illuminates the tissue in the breakdown region.

14-1 to 14-3 illustrate how elongated member 1410 of differential discrimination mechanism 1400 can achieve variable bending of elongate member 1410 to facilitate placement of DDM 1420 by the user And can be refracted by the bendable region 1430 to be able to bend. Fig. 14-1 shows the elongated member of the differential resection mechanism at the position 1 of the straight line, Fig. 14-2 shows the elongated member of the differential resecting mechanism bent at 45, Fig. 14-3 shows the elongated member bent at 90 And shows the elongated member of the discrimination ablation mechanism. In position 1 (Fig. 14-1), elongate member 1410 is straight. In position 2 (FIG. 14-2) and then in position 3 (FIG. 14-3), elongate member 1410 includes a bendable region 1420 such that DDM 1420 moves from position 1 toward face 3 to position laterally Lt; RTI ID = 0.0 &gt; 1430 &lt; / RTI &gt; The bendable region 1430 can be a refractory joint or any other mechanism that allows bending.

Figures 15A-15E illustrate different DDMs and illustrate several important dimensions and features of DDMs. 15A shows a top view of an exemplary discriminating member that rotates relative to a rotational joint. 15A shows a top view of a DDM 1500 rotating with respect to a rotational joint 1510. Fig. The operation of the DDM 1500 causes the DDM to move up and down reciprocatingly as shown by the bi-directional arrows 1506 so that the tissue-engaging surface 1520 (the pebble-shaped cross-section) pivots through an arc having a radius R _A. . The vibration of the DDM 1500 can be swung through a range of ± 90 °. The tissue-engaging surface has a minimum radius (R _S ) within the plane of rotation (plane perpendicular to the plane of rotation, here the plane of the plane).

Figure 15B shows a cross-sectional view of two successive enlarged roads. (Thus, the DDM 1500 vibrates in and out of the ground in this figure.) Figures 15b-1 through 15b-3 illustrate the differential ablation member as in Figure 15a; Fig. 15B-1 shows the differential cutting member in a side sectional view, Fig. 15B-2 shows an enlarged view of the tip of the discriminating member shown in Fig. 15B-1, Fig. 3 is an enlarged view of the surface of the different discriminating member. The first side 1530 and the tissue engaging surface 1520 are bonded at a first margin 1540 having a radius of curvature R _E and the second side 1531 and tissue engaging surface 1520 are bonded at a radius of curvature R _E joining the second margin section (1541) having a R _E), wherein the first margin portion 1540 and a second radius of curvature of the free portion 1541 will be different, but the first free portion (1540) and the 2 The margin 1541 should be large enough not to be sharp. The tissue-engaging surface 1520 is then created by a projection 1550 having a maximum length L _max defined as the maximum length of the feature from the innermost bone to the outermost peak.

15C shows a different DDM 1501 having a wavy tissue-engaging surface formed by surface features 1560. Fig. Here, the surface feature 1560 is a convex lobe, but the surface feature 1560 can be any regular or repeating feature on the tissue-engaging surface 1520 having a minimum radius of curvature R _S. In addition, the surface feature may have a profile that is not in the plane of rotation, as shown in Figures 15d and 15e. Fig. 15D shows a perspective view, and Fig. 15E shows an end view. Fig. 15E-1 shows an end view of the discriminating member shown in Fig. 15C, Fig. 15E-2 shows an enlarged view of the tissue engaging surface of the discriminating member shown in Fig. 15E- 15E-1 and 15E-2. As shown in Fig. 15E-1 through 15E-3 illustrate successively enlarged sections of the DDM 1502 taken along a 45 [deg.] Angle. The DDM 1502 has a surface feature 1570 with a profile in a plane that is 45 degrees to the plane of rotation. As in the DDM 1501 of Figure 15C, the tissue-engaging surface 1520 of the DDM 1502 has a protrusion 1550 with a maximum length L _max . In one embodiment, R _A may be between approximately 1 mm and approximately 100 mm. In one embodiment, R _S may be between approximately 0.1 mm and approximately 10 mm. In one embodiment, R _E can be between about 0.05 mm and about 10 mm, so that the cutting edge is not present in the tissue. Alternatively, for some embodiments of DDM, R _S and R _E may be as small as about 0.025 mm.

The DDM may have a wavy, notched, or tissue-bonded surface with a wave-like profile so that the attack angle of the tissue-binding surface to the surface of the tissue varies as the tissue-binding surface passes over a given point in the tissue. In fact, the attack angle varies for any DDM, e.g., DDM Type I, Type II, or Type IV, with P _avg <(R _max - R _min ). The changing angle of attack makes the resection more aggressive, with more aggressive DDMs destroying hard tissue better, and less aggressive DDMs less able to destroy such identical tissues.

Figures 16-1 through 16-3 illustrate alternative means by which DDMs with different attack levels can be created, i.e., the aggressiveness of DDMs can be designed. The DDM 1600 has a tissue engaging surface 1620 that rotates about a rotational axis 1610 and retains the protrusions 1622. These protrusions (Figure 16-1) are more pointed but have a tip (which is not sharp enough to still cut). DDM 1640 has a tissue-engaging surface 1650 that retains projections with rounded tips 1652 (Fig. 16-2). DDM 1680 has a tissue-engaging surface 1690 that retains projections with a much rounded tip 1692 (Figure 16-3). DDM 1600 is more aggressive than DDM 1640, which is more aggressive than DDM 1680.

Figure 17A illustrates one embodiment of a DDM 1700 having a wavy tissue-engaging surface 1710 and a center of rotation 1720. [ Thus, DDM 1700 is an example of DDM type IV. The back and forth vibration of the DDM 1700 as shown by the bi-directional arrow 1730 causes the corners of the wavy portion to retain a different attack angle on the tissue-engaging surface 1710 as each wavy feature passes over the tissue. Causing the tissue-engaging surface 1710 to move over the tissue.

FIGS. 17B-1 and 17B-2 illustrate the operation of DDM 1700 for tissue 1750. FIG. 17B-1 shows the same differential ablation member impacting on the tissue, and Fig. 17B-2 is an enlarged view of the lobe of the lobed differentiation ablation member detailing the attack angle of the tissue-engaging surface for tissue. The attack angle (angle between the tangent to the tissue-engaging surface 1710 at the point of travel and the point of contact) is shown at two points P ₁ , P ₂ on the tissue-engaging surface 1710. θ ₁ is smaller than θ ₂ . By using a circular tissue-joining component 1805 having a similar function with the rotation center 1820 that is not the center of the tissue-joining surface 1810 and the circular tissue-joining component 1805, a DDM (E.g., DDM type II). The back and forth oscillations of the tissue-engaging component 1805 as shown by the double-headed arrow 1830 are such that the attack angle changes at each point on the tissue-engaging surface 1810 on the periphery of the circular- Causing the tissue-engaging surface 1810 to move over the tissue such that the engaging surface 1810 moves.

18 shows another important point particularly for the accelerated movement of the DDM relative to the tissue 1850, wherein acceleration occurs when the DDM is loaded or dripped, the vibratory DDM is decelerated after sweeping in one direction and swept in the opposite direction . The DDM 1800 is mounted with its center of gravity 1870 displaced from the center of rotation 1820. Solid line bi-directional arrow 1830 shows rotation about rotation center 1820 and dotted bi-directional arrow 1840 shows movement of center of gravity 1870. The force to accelerate the mass of the DDM 1800 and the distance between the center of gravity 1870 and the center of rotation 1820 produce a moment about the center of rotation 1820 causing the discriminator to vibrate. This moment will cause the handle of the discriminating abrader with the DDM 1800 attached thereto to shake. A DDM made of more dense materials will make the shaking worse. Thus, in order to reduce the shaking of the handle, it may be advantageous to make the DDM from a less dense material such as a rigid polymer rather than a metal. Conversely, the counterbalance moment can be arranged through an appropriate distribution of mass in the DDM to place the center of gravity on the rotational axis.

The entire surface of the DDM can be a tissue-bonded type. Alternatively, a selected portion of the surface may be tissue-bonded. This may be advantageous to limit the ablation effect to one region of the surface of the DDM, for example, a forward facing surface. 19A-19D illustrate a differential ablation instrument 1900 with DDM, a ablation wheel 1910 similar to that shown in Figs. 3A-3C; The tissue-engaging surface is limited to the thin tissue-bonding strip 1920 around the outer periphery of the ablation wheel 1910 that rotates about the rotational axis 365. [ The remaining portion includes a tissue non-engaging surface 1930, which is laterally disposed on each side of the tissue engaging strip 1920, on the exposed surface of the ablation wheel 1910, and optionally is smooth as glass, Or have a much smoother surface that can not bind to the fibers in the tissue. Figure 19b shows how ablation wheel 1910 is inserted into envelope 1940 and is urged in direction 367 by an operator. As shown in FIG. 19C, the tissue non-engaging surface 1930, which is smoother than the tissue engaging strip 1920, reduces the destruction of the tissue 1950 after the tissue is separated by the tissue engaging strip 1920. The envelope 1940 further protects the tissue 1950 from fracture by the ablation wheel 1910 as it is further penetrated into the tissue 1950 in the pressing direction 367.

Fig. 19d shows additional important actions of the tissue non-engaging surface 1930 and the skin 1940. Fig. When there is a moving component 1901 to the pressing direction 367 (not shown) into the tissue 1950 of the differential ablation device 1900, this wider portion of the differential ablation device 1900 Surface 1930 and sheath 1940) may force or separate the recently separated portions of tissue 1950 to wedge and align and deform fibrous components 1980 of tissue 1950 to tension them Align them at right angles to the movement of the tissue-bonding strip 1920. Such strain within the fibrous component (1980) promotes the ability of the protruding portion of the tissue-binding material in the tissue-bonding strip (1920) to grasp and rupture the individual fibers.

As tissue binding strip 1920 moves past tissue 1950 and moves in (through) a direction perpendicular to the plane of the paper surface, the protrusions on the tissue bonding strip 1920 on the inner surface of the tissue 1950, (1950), including rupturing the component (1980) (e.g., collagen or elastin fibers). Such fibrous component (1980) frequently has irregular alignment (i.e., irregular orientation) within the soft tissue. When the tissue 1950 is broken, however, the discrimination ablation device 1900 is configured so that when the residual tissue-engaging surface 1930 and the sheath 1940 are pushed into the discrete tissue 1950, To move the tissue 1950 including the tissue 1950 in the direction of the arrows 1960 and 1961 to align the previously irregularly oriented fibers and to deform the material at the point of contact of the tissue- 1901) into the tissue (1950). This localized region of strain aligns and deforms uncut fibrous component 1980 in a direction perpendicular to the direction of movement of tissue bond strip 1920, as shown by bi-directional arrow 1970 ), Which facilitates the gripping of the fibrous components and increases the likelihood that they will be severed by protrusions from the tissue binding strip 1920. The tissue non-engaging surface 1930 and the sheath 1940 may function as wedges if they are angled with respect to each other as shown in Figures 19c and 19d or if they have a wider width than the tissue engaging surface 1910 will be. In one embodiment, the second stage half axis C is a substantial fraction of the first stage half axis B (e.g., 0.2B < C < 0.8B in one embodiment) The shape is an effective shape for wedge action.

Alignment of the fibers as described in the previous paragraph can greatly change the way DDM performs. Alignment can be achieved by the physician manually or by deforming the tissue in the appropriate direction with a separate instrument. Alignment may be achieved by DDM as described in the previous paragraph by a smooth portion on the tissue-engaging wheel, such as the tissue-free engaging surface 1930 of Figures 19c-19d, By a sheath, or by a separate mechanism on the DDM.

Figure 20 shows details of one version of the destruction of tissue segments within a human patient. The patient's area of interest 2000 is shown in a circular window, showing a cross-sectional view through two juxtaposed volumes, i.e., a tissue segment A juxtaposed to the tissue segment B; The juxtaposition occurs within the region 2010 that is bridged by the interstitial fibers 2012 and the tensed interstitial fibers 2015 and also associated with the interrupted interstitial fibers 2020. A DDM 2030 having a tissue engaging surface 2034 further having protrusions 2032 and a smooth tissue non-engaging surface 2033 is shown within the circular window. In this figure, the DDM 2030 reciprocates with respect to the axis 2036 such that the movement of the fiber-engaging protrusions 2032 is in and out of plane of the ground (i.e., reciprocating toward and away from the observer).

Each of the tissue segment A and the tissue segment B is arranged parallel to the tissue segment surface 2005 and the tissue segment surface 2006 to form a tissue segment A and a tissue segment B (B) comprises a tissue segment surface 2005 and a tissue segment surface 2006, each of which consists of relatively closely packed fibers forming a thin film covering the hard tissue. Surface 2005 of tissue segment A and surface 2006 of tissue segment B are also three-dimensional curves. The tissue surface 2005 and the tissue segment surface 2006 may be positioned such that the tissue segment surface 2005 and the tissue segment surface 2006 are located locally, In the region 2010, which is generally juxtaposed in a parallel manner, and frequently come into substantial contact with each other.

Within such regions 2010, tissue segment surface 2005 and tissue segment surface 2006 are relatively loose interstitial fibers 2012 running at substantially right angles to two juxtaposed tissue segment surfaces 2005, Are fixed to each other by a group of. This lean mass of interstitial fibers 2012 may originate from (or be a member of) a group of fibers comprising a more closely packed woven surface forming the tissue segment surfaces 2005, 2006. For example, a given fiber constituting a portion of the tissue segment surface 2005 may proceed along such surface for a distance before it rotates and continues across the region 2010, whereby a population of interstitial fibers 2012 And can be continuous up to the tissue segment surface 2006 across the region 2010 where it can be rotated and woven into it to thereby form the fibers of the fibers of the tissue segment surface 2006 Become a member of a group. The definition of an interstitial fiber 2012 thus defines the ability to cross, bridle, traverse, or otherwise connect (or closely) the tissue segment surface 2005 and tissue segment surface 2006 to the juxtaposed area 2010 And &lt; / RTI &gt; The interstitial fibers 2012 may be the same type of fibers that make up the tissue segment surface 2005 and tissue segment surface 2006 of tissue segment A and tissue segment B in one embodiment. In another embodiment, the interstitial fibers 2012 may be of a different type and the interstitial fibers 2012 may be strongly or weakly bonded, either directly or indirectly, to the tissue segment surface 2005 and the tissue segment surface 2006.

In each case, all associated fibers can mechanically transmit forces (by tension) along the surface of each individual tissue segment, or interstitially between the two tissue segments, or both. For example, the tensile state of the fibers constituting the interstitial fibers 2010 and the tissue segment surface 2005 and the tissue segment surface 2006 may be determined by, for example, 2041) on forces acting on tissue segment (A) and tissue segment (B) when wedging into these tissue segments and forcing them apart. For example, the fibers 2010 are resistant to tensile strains resulting from movement of the tissue segment surface 2005 in direction 2040 to each other and from movement of tissue segment surface 2006 in direction 2041, In addition, such resistance varies with the mechanical properties of the fibers. The distance between the tissue segment A and the tissue segment B is greater than the distance between the tissue segment A and the tissue segment 2010. For example, (As shown by arrow 2030) until it can be broken as shown by the interstitial fibers 2020, which are then first straightened as tensed interstitial fibers 2015, ). The most common fiber type in man is collagen, which has a fracture strain of about 5% over its unstressed normal length. When tissue segment A and tissue segment B are separated and moved as shown by arrow 2030, the collagen fibers, where the inflexible interstitial fibers 2012 are first (as in strained fibers 2015) ) It will be strained. When the two tissue segments (A, B) are moved farther apart, the collagen fibers will stretch by about 5%. Crucially, at this point, if the tissue segment A is moved further than 5% beyond the tension from the tissue segment B, the tense interstitial fibers 2015 are broken or the tensed fibers 2012 are not broken , The tissue segment itself may rupture, which is a detrimental consequence to the patient.

The physician must separate, separate or otherwise move the tissue segments very often with respect to each other to gain access to the various areas within the patient, so that the physician will be able to access the fibers corresponding to the &lt; RTI ID = Transform the group constantly. Current practice is to cut the interstitial fibers to free one tissue segment from other tissue segments, or by applying a dull force (by opening the jaws, forcing the tissue segments apart, and thus rupturing the interstitial fibers) ) &Lt; / RTI &gt; interstitial fibers as a whole. The general complexity is to cut tissue segments while attempting to cut only the interstitial fibers by sharp resection, or to rupture smaller or larger portions of tissue segments while attempting blunt dissection of the interstitial fibers. Each approach first strains the interstitial fibers 2010, then stretches them and then applies strain to rupture them. It is now clear that the result of the above close connection with the tissue segment surfaces 2005, 2006 of the interstitial fibers 2010 (air leaks and bleeding of the segments of the lung, for example) is now clear: , It is necessary to distinguish the forces required to cause the interstitial fibers to break.

An embodiment of the differential ablation mechanism disclosed herein generates an initial separation movement of the tissue segments A and B juxtaposed by the collision of the smooth surface 2033 to expose the individual interstitial fibers 2010 to a tension Making these fibers much more vulnerable to fracture and taking advantage of the opportunity provided by this now tense interstitial fibers 2015 as well as allowing them to protrude from the protrusions 2032 of the tissue engaging surface 2034 of the discriminating ablation member 2030. [ Specifically by allowing them to be properly encountered, joined, and converted into broken interstitial fibers 2020 by local collision of the fibers. In this way, DDMs with smooth-tissue non-engaging surfaces and / or sheaths will limit the extent of the ablation effect to only those fibers in the soft tissue that connect adjacent regions of the hard tissue and still preserve such hard tissue, And the effect can be greatly increased.

21A-21C-4 illustrate another differential ablation device 2100 using a very thin ablation wheel 2110 as the DDM. The ablation wheel 2110 is substantially entirely enclosed within the envelope 2120 to achieve a very thin tissue engaging surface 2009 as shown in Figure 19D and the envelope 2120 protects the tissue being ablated And acts to apply a preliminary stress.

Fig. 21A shows a side view, and Fig. 21B shows a front view. 21 (a) shows a side view of the discriminating member having a thin ablation wheel and enclosed within the envelope; Figs. 21B-1 and 21B-2 respectively show a front view and an enlarged view thereof, respectively, of the covered different discriminating member in Fig. 21A. The cutting wheel 2110 is mounted on the first pillar 2130 and the second pillar 2131 (shown in the side view of FIG. 21B-1) by the rotating axle 2135. The rotating axle 2135 rotates freely in the first pillar 2130 and the second pillar 2131, but is firmly fixed to the excavation wheel 2110. The sprocket 2140 is also fixedly secured to the axle 2135. The sprocket 2140 is rotated by the drive belt 2150. Thus, the drive mechanism 2160 includes a first pillar 2130 and a second pillar 2131, an axle 2135, a sprocket 2130, and a sprocket 2130 to rotate the cutout wheel 2110 within the shell 2120 in the direction of arrow 2161. [ A belt 2140, and a drive belt 2150. Alternative drive mechanisms can be used, and movement can be rotary or oscillatory. The first clearance 2111 and the second clearance 2112 of the ablation wheel 2110 are preferably not sharp, as shown in the enlarged portion of FIG. 21B-2. (The first clearance 2111 and the second clearance 2112 are similar to the first clearance 1540 and the second clearance 1541 in Figs. 15B-1 to 15B-3.) The sharp margin You can destroy more aggressively than a rounded margin; Nevertheless, a sharp margin can be used if more aggressive destruction or destruction is required. Also, one margin can be sharper than the other if it requires differential destruction or destruction. For example, the first margin 2111 may be square or sharp, and the second margin 2112 may be rounded to achieve more aggressive destruction or destruction on the side of the first margin 2111 .

The envelope 2120 substantially encircles the ablation wheel 2110 leaving only a small portion of the ablation wheel 2110 exposed as the tissue engaging surface 2111 and determining the tissue strain at the fracture point of the ablation wheel 2110 To form a wedge angle (?). The larger wedge angle (?) Deforms the tissue more as the DDM 2100 is pushed into the tissue. Figures 21C-1 through 21C-4 illustrate the DDM 2100 with the envelope 2120 in four different positions. The envelope 2120 can be moved independently of the drive mechanism 2160 and the ablation wheel 2110 and the envelope 2120 can move in the direction of the bi-directional arrow 2190. Therefore, at position 1 (Fig. 21C-1), only a thin portion of the ablation wheel 2110 is exposed. In position 2 (FIG. 21C-2), sheath 2120 is moved in the direction of arrow 2191 leaving the thinner portion of ablation wheel 2110 exposed and also creating a larger wedge angle?. In position 3 (Fig. 21c-3), sheath 2120 has been moved in the direction of arrow 2192 so that sheath 2120 completely surrounds ablation wheel 2110. Fig. Thus, ablation wheel 2110 can no longer destroy tissue. In this position, ablation wheel 2110 effectively acts as a smooth, flat, blunt probe. In position 4 (FIG. 21C-4), sheath 2120 is moved in the direction of arrow 2193 to increase the exposure seen at position 1 or position 2 of ablation wheel 2110 and decrease wedge angle? .

Figure 22 illustrates the distal end of a reciprocating mechanism, here a differentiator 2210, including one embodiment of a scotch yoke. The distal end of the discrimination cutter 2210 includes a housing 2212 that additionally includes a pivot bearing 2214, a motor shaft bearing 2216, and a shaft drum bearing 2218. 22 also shows a motor shaft 2220, a shaft drum 2222 coaxially fixed to the motor shaft 2220 and a shaft drum 2222 that is parallel but not coaxial to the motor shaft 2220, Lt; RTI ID = 0.0 &gt; 2224 &lt; / RTI &gt; An outer surface 2231 that is associated with the differential ablation housing 2212 and that forms the body of the DDM 2230, a tissue engaging surface 2232 that forms at least a portion of the outer surface 2231, (DDM) 2230 further comprising a hollow DDM pin actuator 2236 that further includes a DDM pivot shaft 2234 that fits into the drive pin 2224 and that effectively captures the driver pin 2224. In this embodiment, The internal three-dimensional shape of the hollow DDM pin follower 2236 is shown here as a prism, so that in the view shown in Figure 22, the cross-sectional shape is similar to the hourglass, and perpendicular to the figure, have.

23A, 23B, and 23C illustrate the DDM 2230 of FIG. 22 (see FIG. 22), which is perpendicular to the axis of rotation of the shaft drum 2222, through the narrowest portion of the waist portion of the hollow DDM pin follower 2236 ). &Lt; / RTI &gt; The shape of the DDM pin follower 2236 is rectangular in this view; The height of the rectangle is equal to or greater than the diameter created along the circular path 2237 of the driver pin by the outer diameter of the driver pin 2224. In this figure, The width of the rectangle in this figure corresponds to the outer diameter of the driver pin 2224. The DDM 2230, including the hollow DDM pin follower 2236, rotates about an axis 2233 of the shaft 2234. Thus, the position of the hollow DDM pin follower 2236 and the rotational position of the DDM 2230 are determined by the rotational position of the actuator pin 2224.

In operation, referring to Figure 22 with Figures 23A-23C, a motor (not shown) rotates the motor shaft 2220, which rotates the drum 2222 about its rotational axis, (2224) to move around a circular path (2237) having a plane perpendicular to the axis of rotation of the drum (2222). As in the Scotch yoke, the rectangular hollow DDM pin actuator 2236 converts the circular path 2237 of the actuator pin 2224 to a linear movement 2238 of the hollow DDM pin actuator 2236; When the pin follower 2236 is positioned a certain distance away from the axis 2233, the DDM 2230 levers against the axis 2233 and thus moves the rotation path 2237 to the linear movement 2238, Into a reciprocating motion of the DDM 2230 that rotates relative to the DDM pivot shaft 2234 held by the cam 2214. [ The pattern of reciprocal movement of the DDM 2230 includes the shape of the hollow DDM pin follower 2236, the 3D angle of the driver pin 2224, the axis 2233 through which the shaft 2234 rotates, 2233 by changing the distance between the motor and the motor, and also by changing the rotational speed of the motor.

The DDM 2230 of Figure 22 may have a reciprocating movement 2250, 2251, as shown in the side view of Figures 24A and 24B. The illustrated vibration sequence shows the extreme position of the DDM 2230 as the actuator pin 2224 moves around the circular path 2237 when it is provided with a rotational movement 2299 from a motor (not shown). The action of the tissue-engaging surface 2232 of the DDM 2230 on the surface of the tissue to be ablated is best illustrated in the edge view of Fig.

The surgeon who is operating within the patient wants to create a minimal possible trauma to the tissue that is not the focus of the procedure or simply within the path to the target tissue. 25A-25C illustrate an internal pivot shaft 2510, an internal motor shaft 2550, an internal driver drum 2522, a driver pin 2524, and the like, which protrude perpendicularly (i.e., observerly) A DDM 2520 reciprocating (in the plane of the ground) with respect to the internal pivot shaft 2510, a tissue-bonded DDM surface 2534, a smooth DDM surface 2518, a substantially circular DDM area 252, 2514, 2516, a jacket clearance 2517, and an envelope-DDM gap 2514. The DDM assembly 2500 includes a cover 2516, Overall, by the entire outer surface of the DDM assembly 2500 included as one, the overlying DDM assembly 2500 presents a nearly continuous smooth surface to the patient's tissue. In this regard, beyond the limited range of tissue-bonded DDM surfaces 2534, the entire differential ablation mechanism with DDM assembly 2500 acts only as a polished probe.

Once activated, the DDM 2520 reciprocates in the housing 2512 with respect thereto. At the corner of the housing 2512 closest to the DDM 2520 is a shell clearance 2517. Between the sheath margin 2517 and the DDM 2520, a sheath-DDM gap 2514 is found. In one embodiment, the differential ablation device with DDM assembly 2500 includes means for preserving the smooth characteristics of the exterior of the differential ablation device. Thus, the envelope-to-DDM gap 2514 is sufficient to allow any relative movement of the DDM 2520 to the housing 2512 to enlarge the envelope-to-DDM gap 2514, thereby presenting a sharp edge to the tissue. . Alternatively, a portion of the DDM 2520 may collide with the housing 2512. Also, in one embodiment, the envelope-to-DDM gap 2514 is always kept as small as possible. To facilitate this, the DDM 2520 is in this respect a circular DDM area (not shown) formed as part of the mass of the DDM 2520 having a circular cross-section with a center coinciding with the axis of the built-in pivot shaft 2510 2516). This circular DDM region 2516 defines a portion of the outer surface of the DDM 2520 through the sheath margin 2517 at a distance forming the sheath-DDM gap 2514 during the reciprocal movement of the DDM 2520, do. This conserves the envelope-to-DDM gap 2514 to a constant value (i. E., The envelope-to-DDM gap 2514 is greater than the DDM 2514) because the circular DDM area 2516 preserves the same radius of the DDM 2520 over the rotation angle. 2520). &Lt; / RTI &gt; Thus, differential discrimination mechanisms with such a DDM assembly always present a continuous smooth surface to the tissue at all times.

Figure 25d illustrates a DDM 2520 reciprocating with the housing 2512, the internal pivot shaft 2510 (see Figures 25a-25c), a tissue-bonded DDM surface 2534, a smooth DDM surface 2518, Shown is a perspective view of a generally covered DDM assembly 2500 showing a DDM area 2516, a casing margin 2517, and a sheath-DDM gap 2514. [

Sharp ablation is frequently performed alternately with blunt ablation when the target tissue is exposed. This occurs when a thin film or large fibrous component that resists blunt dissection is encountered and the physician must be cut to further penetrate into the tissue. Current practice requires the physician to use a lane instrument for blunt dissection (e.g., an inactive electrosurgical scalpel) or to replace the instrument while exposing the target tissue. Use of lane instruments reduces the ease of blunt dissection and increases the potential risk to target tissue. Replacement is time consuming and distracts attention to many minimally invasive procedures, such as during laparoscopic and thoracoscopic procedures, where the instrument must be guided to the next site through a narrow opening in the body. Differential ablation devices can have sharp ablation components that can be selectively activated by a physician, thereby eliminating the need for device replacement while still providing the physician with the optimal device.

Figures 26A-1 and 26A-2 illustrate one embodiment of a differential ablation instrument 2600, similar to the differential ablation instrument 2000 as shown in Figure 20, but also including a retractable scalpel blade covered during blunt ablation. A plan view and a side view of the example, respectively. Figures 26A-1 and 26B-1 show side views, Figures 26A-2 and 26B-2 show a top view, Figs. 26A-1 and 26A-2 show differentiation ablation members in which a retractable scalpel is withdrawn. The retractable scalpel blade may protrude outward by the surgeon for a sharp resection and then retract before proceeding to subsequent blunt resection. The discrimination ablation mechanism 2600 has a elongated member composed of a sheath 2620 to which the DDM 2610 is rotatably mounted by a rotary axle 2635. On one side of the DDM 2610 there is a slot 2612 and a retractable scalpel blade 2622 is placed under which the retractable scalpel blade 2622 is completely covered by the envelope 2620. Retractable scalpel blade 2622 is actuated by a retraction mechanism (not shown) controlled by the physician. The actuation of the retractable scalpel blade 2622 can be controlled manually by a slider, by electrical actuation (such as a solenoid), or by any suitable mechanism controllable by an operator.

Figs. 26B-1 and 26B-2 illustrate a differential ablation device 2600 in which a retractable scalpel blade 2622 is extended for sharp ablation. Figures 26b-1 and 26b-2 show the same differential ablation member with the retractable scalpel extended. Retractable scalpel blade 2622 is one example of a sharp ablation tool. In another embodiment, the differentiating member 2600 may include an electrosurgical blade, an ultrasonic cutter, or other sharp cutting tools such as a fracture hook. In another embodiment, the discrimination ablation mechanism 2600 may include a tool for powerful destruction, such as an electrocautery blade or an electrosurgical head. Additionally, instead of retracting, the retractable scalpel blade 2622 or other suitable tool may be used for one of several mechanisms, such as pop-out, spread, or a different mechanism known in the art And can be selectively exposed.

27A and 27B illustrate a differential excision mechanism 2700 similar to the differential excision mechanism 2600 shown in Figs. 26A and 26B, but having a gripping member for allowing the differential excision mechanism 2700 to also function as a forceps, Respectively, of a second embodiment of the present invention. The discrimination ablation mechanism 2700 has a DDM 2710 rotatably attached to a mechanism shaft 2720 and is rotated by a powered mechanism (not shown). The push rod 2730 is inside the instrument shaft 2720 and is activated by a mechanism present in the handle (not shown) and is manually activated by the operator. When DDM 2710 is active, it oscillates back and forth as indicated by arrow 2740. When the operator turns off the action of the DDM 2710 the operator then pushes the plunger jaw 2750 with the control horn 2760 that causes the plunger jaw 2750 to rotate about the pivot point 2770 to open the push rod 2730 ). &Lt; / RTI &gt; The opposing jaw to the forceps is the DDM 2710. The operator can then grasp and release the object between the forceps jaw 2750 and the DDM 2710 by pushing or pulling the push rod 2730.

Figures 28 and 29A-29D illustrate another embodiment of DDM. Indeed, this embodiment has provided great discriminating action through complex tissue and rapid ablation. For this embodiment of the DDM, the protrusion of the tissue-engaging surface is formed by the bone cut into the surface of the DDM. 28, the DDM 2800 has a first end 2810 and a second end 2820 and a center axis 2825 connects the first end 2810 and the second end 2820. The first end 2810 is coupled to a drive mechanism (not shown) that moves away from the composite tissue (not shown) to be cut and moves the DDM 2800 to sweep the second end 2820 along the direction of movement . Here the mechanism vibrates the DDM 2800 about a rotational axis 2830 perpendicular to the central axis 2825 such that the direction of movement 2840 is the arc of movement lying within a plane perpendicular to the rotational axis 2830 . The second end 2820 has a tissue-facing surface 2850 facing the composite tissue including at least one tissue-engaging surface 2860 and at least one lateral surface 2870.

The movement of DDM 2800 in this example is reciprocal (back and forth) vibration, but other DDMs may have continuous rotation or linear movement. The rotation is preferably between 2,000 and 25,000 cycles per minute, but may range from 60 cycles per minute to 900,000 cycles per minute, all of which are well below the ultrasound. In certain embodiments, speeds of 300 to 25,000 cycles per minute have been found to be highly effective.

29A-29E-2 show enlarged views of the tissue-facing surface 2850 of the DDM 2800 of FIG. 29A shows a perspective view of a tissue-facing surface 2850 where components are identified. FIGS. 29B-29D show different views of a tissue-facing surface 2850 in which the geometric features of the shape are better illustrated, particularly with respect to the components of the tissue-facing surface 2850. Figure 29c-2 shows an enlarged view of the corner of the protrusion shown in Figure 29c-1; 29e-1 and 29e-2 illustrate two alternative versions of the arrays of projections and valleys that form the surface of the differential ablation member. Finally, Figures 29e-1 and 29e-2 illustrate different embodiments of some of these components. The tissue-facing surface 2850 includes a tissue-mating surface 2860 and two side surfaces, a first side surface 2871 disposed on one side of the tissue-mating surface 2860, And a second side surface 2872 disposed on the second side surface 2872. [ Referring to Figs. 29A, 29C-1 and 29C-2, the tissue-engaging surface 2860 is formed such that the intersection of at least one trough 2910 and at least one protrusion 2920 is at right angles to the movement direction 2840 An alternating series of at least one rib 2910 arranged along the direction of movement 2840 which is the arc of movement on the tissue-facing surface 2850 to form at least one bony edge 2930 oriented to have a directional component And one protruding portion 2920. As shown in Fig.

Bone corners 2930 should not be sharp, for example, it should not be able to cut composite tissue, especially hard tissue. For example, the point on the bony edge 2930 should not have a radius of curvature (R _C ) that is less than approximately 0.025 mm (Figure 29c-1, see also an enlarged view). The radius of curvature (R _C) is similar to the radius of curvature (R _E) of the curvature radius of the surface, such as (R _S) and the corner shown in Fig. Tests have shown that edges with a radius of curvature (R _c ) of about 0.050 mm or greater can also be effective. In addition, the radius of curvature (R _c) can be varied along the length of the bone edge (2930). In the embodiment shown in Figure 29a to Figure 29d, the radius of curvature (R _c) is a bone edge (2930) is the most distant from the rotational axis (2830) the smallest, the first lateral surface (2871) and a second lateral surface (2872). Further, the minimum radius of curvature of the bone edge (2930) (R _c) may be different for the bone edges, and even on the opposite side of the same bone marrow for different edges in the same DDM.

The protrusion 2920 in the DDM 2800 may be formed by subtractive fabrication in one embodiment. In fact, the valleys 2910 have a longitudinal axis A perpendicular to the rotational speed 2830 and aligned parallel to the central axis 2825 (i.e., toward the composite structure) (see FIG. 28) 29B-29C-1 and 29C-2, having a second-half axis C parallel to the rotation speed 2830 . Thus, the protrusion 2920 is the remaining semi-elliptical surface and has side surfaces 2971, 2972 and a continuous protruding top portion 2940. Thus, the tissue-engaging surface 2860 is created by the lateral limitations of the ribs 2910 in this embodiment and spans the tissue-facing surface between the ribs 2910 that form the protrusions 2920. In other embodiments, the protrusions may be formed by other means, and thus may have more differently shaped protrusions over the top of the protrusions that are not formed as residues of the surface. For example, in one embodiment, the protrusions can be effectively formed from the surface, thus enabling more complex protrusion tops.

Referring to Figures 29A, 29C and 29C-2, each bone 2910 may have a first bone side 2911, a second bone side 2912, and a bottom 2913, where The first bone side 2911 and the second bone side 2912 lie on opposite sides of the bone 2910. The rib bottom 2913 may be straight or curved, and may be two-dimensional or three-dimensional. For example, the bottom of the valleys in the DDM 2800 is a straight line aligned parallel to the rotational speed 2830. The first bone side 2911 and the second bone side 2912 rise from the bottom 2913 to the bottom edge 2930. The transition from the bottom of the valley may be gradual and indefinite, as in valley 2910 in DDM 2800, or the transition may be polyhedral. The rib 2910 may be curved in two dimensions in a straight line in a direction parallel to the rib bottom 2913 (and also parallel to the rotation axis 2830). However, the bone side may be any shape including a three-dimensionally curved surface.

The corners of the corrugations are formed by the intersections of the corrugation walls with the top of the protrusions. Thus, the corners of the cores can have different shapes, depending on the shape of the corners and the top of the protrusions. Bone corners 2930 on DDM 2800 follow a three-dimensional curve, and thus are not zero and have curvature and twist (as defined mathematically in geometry) that varies along the corners of the bone. The bony corners may have curvature and twist that change smoothly (such as bony corners 2930), or the bony corners may bend.

Figure 29c-1 shows an enlarged view of the corners of the corners in a plane perpendicular to the corners of the corners. Protruding upper 2920 and a valley side (here, 2911 or 2912) has to be rounded in cross section having a radius of curvature (R _c) described above (that is, the "round", as the machine manufacturer description) within this plane To form a conical angle (?). Ppulgak circle (Γ), but may form an angle of less than a sharp appearance, 90 ° on the first cross section, sharpness is determined by the radius of curvature (R _c) of the edge. The angular cone angle? May vary along the length of the coronal edge, such as for the DDM 2800 where the cone angle? Is the smallest at a point on the coronal edge most distant from the rotational axis 2830. In one embodiment, a cone angle of about 30 [deg.] To about 150 [deg.] May be effective.

The bone has a length, a width and a depth, a bone length is a length of the bottom of the bone, a bone width is a distance separating the bone corners of one bone measured at the longest separation distance of the bone corners, (E.g., peak-groove height) from the bottom to the bottom of the valley. Typical dimensions for the bone include a bone length of 0.25 mm to 10 mm, a bone width of 0.1 mm to 10 mm, and a bone depth of 0.1 mm to 10 mm. In one embodiment, a bone length of approximately 3 mm, a bone depth of approximately 3 mm, and a bone width of approximately 2 mm were found to be highly effective.

When the DDM has a plurality of valleys, such as the DDM 2800, the valleys may be parallel like the valleys 2910 of the DDM 2800 with all of the parallel valley bottoms 2913, Or may not be parallel to the bottom of the valleys that are placed at variable angles relative to each other.

The ribs 2910 of the DDM 2800 have a single channel (a space defined by the rib side and the bottom of the rib); The bones may have a plurality of intersecting channels so that the bottom of the bones can branch, multiply or form a network on the tissue-engaging surface. 29E-1 and 29E-2 show a top view of two DDMs, with the left DDM 2980 having parallel troughs 2981 with a trough bottom not parallel to the rotational speed, and the right DDM 2990 Has a net 2991 of a plurality of intersecting bones that are both at different angles with respect to the rotational speed and to each other.

As described above, the tissue-facing surface 2850 of the DDM 2800 has a longitudinal axis A perpendicular to the rotational axis 2830 and parallel to the central axis 2825, a first end half axis B, And a second half-axis (C) parallel to the axis of rotation (2830). The tissue-facing surface 2850 may have an oval shape in one embodiment where A > B > C. However, any relationship is possible between the lengths of the half-axes. For example, in another embodiment, DDM with A = B = C can be made (e.g., the tissue-facing surface is hemispherical).

The first side surface 2871 and the second side surface 2872 of the DDM 2800 are semi-elliptical continuous bodies. As such, they are angled relative to one another to align and deform the fibrous components of the composite tissue to form a wedge as previously shown in Figures 19d and 20, allowing the protrusions to break through the fibrous component.

30A shows the situation of a first tissue area 3011 surrounded by a first thin film 3016 and a second tissue area 3012 surrounded by a second thin film 3017. Fig. The first thin film 3016 and the second thin film 3017 are abutted in the tissue plane 3020. The first thin film 3016 and the second thin film 3017 are formed of densely packed fibrous components and thus include hard tissue. The interstitial material across the tissue plane from the first thin film 3016 to the second thin film 3017 comprises a fibrous component 3030. This fibrous component 3030 is less densely packed, and thus the interstitial material comprises soft tissue. As the tissue facing surface 2850 is pressed into the tissue plane 3020 in the direction of the arrow 3050 to separate the two tissue regions 3011 and 3012 the first side surface 2871 and the second side surface 2871 2872 are positioned in the tissue regions 3011, 3012 to define a first diffusing force 3041 and a second diffusing force 3042 that align and deform the fibrous components 3030 in the protrusion upper portion 2940 (see Figures 29c-1 and 29c- 3012, respectively. This is because the fibrous component 3030 enters the valley 2910 and is caught by the protrusion 2920 as the tissue facing surface 2850 rotates about the rotational axis 2830 and moves from the plane of the ground . In addition, since the protruding top portion 2940 is continuous with the lateral side surfaces, the further lateral areas of the protruding top portion 2940 also apply additional spreading forces 3043 and 3044 that separate the tissue regions 3011 and 3012, 3030). &Lt; / RTI &gt;

FIGS. 30B-30D illustrate how the curvatures of the first side surface 2871 and the second side surface 2872 can be varied to make the DDM more or less aggressive. Consider the first DDM 3060 of Figure 30B. As illustrated in Figure 30A, the laterally more regions of the protruding upper portion 2940 apply diffusive forces 3043 and 3044 that diverge adjacent tissue regions. In addition, the first side surface 2871 and the second side surface 2872 apply a first spreading force 3041 and a second spreading force 3042, respectively. As the first angle 3065 formed by the diffusive forces 3043 and 3044 approaches 180 ° (as shown for DDM 3061 in Figure 30C), the wedge action of the lateral regions of the protruding upper portion 2940 Lt; / RTI &gt; (Note that angle 3065 is similar to wedge angle [omega] described in Figs. 21A-21C.) As protrusions 2920 also slip sideways (to the left and right in this view) However, there is a tendency to abstain or destroy the hard tissue. 30A, the first side surface 2871 and the second side surface 2872 define diffusive forces 3041 and 3042 forming a second angle 3066 (in effect, a second wedge angle?), Respectively . If the second angle 3066 is similar to the first angle 3065 (as shown for DDM 3060 in FIG. 30B), then these surfaces combine to create a single wedge surface. As shown in Figure 30C, if the second angle 3066 'is greater than the first angle 3065 (i.e., the side surfaces 2871, 2872 are more or less parallel), the second angle 3066' Little or no. Conversely, if the second angle 3066 "is less than the first angle 3065 (i.e., the side surfaces 2871 and 2872 are more or less perpendicular), as in FIG. 30D, ) Has a larger wedge action. DDMs such as 3061 have proven to be more effective in ablating tissue planes with dominant collagen fibers across the tissue plane, from one surface to another.

Referring again to Figure 30A, Figure 30A also illustrates an important aspect of DDM. The DDM will automatically follow the tissue plane. Because of the tendency of the tissue plane to be defined by the hard tissue (e. G., Thin film, catheter, etc.) and to be carried by the soft tissue, the DDM does not move into the hard tissue by its differential action and moves into the soft tissues, Or with no tissue at all. This means that when the operator does not need to have a detailed understanding of the anatomical structure as required by the current practice or conversely if the tissue plane is distorted by the tumor or the tissue is swollen or swollen, This means allowing the surgeon to confidently remove uncertain anatomical structures.

Figure 31 shows an end view of a tissue-facing surface 2850 that engages and breaks the fibrous component 3030 shown in Figure 30A to stretch it. Three fibrous components (the first fibrous component 3031, the second fibrous component 3032 and the third fibrous component 3033) have three protrusions (first protrusions 2921, second protrusions 2922, And the third projection 2923). The tissue-facing surface 2850 rotates to generate a movement direction 2840, which is a movement arc as shown by the arrow 3100. The first fibrous component 3031 entered directly into the first trough 2911 and was not yet caught by the first projecting portion 2921. The second fibrous component 3032 entered the second trough 2912 at an earlier point in time and was deformed by being caught by the second trough 2922. The third fibrous component 3033 entered the third trough 2913 at a much earlier point in time and was much more deformed by being caught by the third trough 2923. Ultimately, all three fibrous components 3031, 3032, 3033 will be deformed and fractured.

Figure 31 shows an important aspect of the design of the DDM 2800. Because the corrugations extend from one side surface 2871 to the opposite side surface 2872, each trough creates an open space that spans across the end of the DDM 2800, and into which the deformed fibrous component enters So that the fibrous component is easily caught by the protrusions.

It is important to note that the DDM 2800 does not have an array of small protrusions that provide any portion of its surface texture, as described above. Rather, all surfaces of the DDM 2800 are smooth, and preferably have a low friction surface. The shape and configuration of the surface features of the DDM 2800 is responsible for the ability to differentially ablate complex tissue. In fact, DDM 2800 works best when all of its surfaces in contact with tissue are well lubricated, for example, with surgical lubricants.

Figure 32 shows an exploded view of one embodiment of a complete differential ablation instrument. The differential ablation device 3200 includes a mechanism insertion tube 3290 having a first end 3291 attached to the instrument handle 3212 as a whole and a second end 3293 to which the DDM 3292 is rotatably mounted And an instrument handle 3212. Instrument handles 3212 are assembled from an upper housing 3220 and a lower housing 3230 that include an upper battery cover 3222 that is held together by appliance housing bolts 3236. [ In the upper housing 3220 and the lower housing 3230, a motor 3260 and a battery pack 3270 are included. Within the upper housing 3220 there is a switch port 3224 through which a switch 3282 (which may be an instantaneous switch or a on-off switch) for providing power from the battery pack 3270 to the motor 3260, Lt; / RTI &gt; A printed circuit board 3280 is further provided that includes a power level adjustment portion 3281 (which may be any convenient component but is shown here as a linear potentiometer) and is mounted within the surface of the upper housing 3220 Lt; / RTI &gt; switch cover 3284, as shown in FIG. Also included are a forward spring battery connector 3272 and a rear spring battery connector 3274 that guide power from the battery pack 3270. The upper housing 3220 further includes a tool insertion tube support 3226 for coaxially fixing and orienting the tool insertion tube 3290 in the vicinity of the motor 3260.

The lower housing 3230 also provides access to and locks the battery pack 3270 and the integral lower battery cover 3232 and the motor housing section 3234 are secured to the upper housing 3230 using the three instrument housing bolts 3236. [ Gt; 3220 &lt; / RTI &gt; The motor housing section 3234 holds and holds the motor 3260 coaxially with the instrument insertion tube 3290 passing through the instrument insertion tube support 3226. The motor 3260 is urged forward by the motor housing section 3234 against the motor collar 3264 whose inner diameter leaves space for the motor shaft coupler 3262. [ The motor shaft coupler 3262 is fixedly mounted on the end of the shaft of the motor 3260 with the help of the motor shaft coupler bolts 3266 and also grips the first end 3295 of the drive shaft 3294. The drive shaft 3294 is rotated by a motor 3260 which is concentric with the mechanism insertion tube 3290. The drive shaft 3294 also has a second end 3297 of the drive shaft 3294 that is supported concentrically by a shaft bearing 3296 mounted on the second end 3293 of the instrument insertion tube 3290. [ The DDM 3292 is rotatably mounted on the shaft bearing 3296 such that the drive shaft 3294 rotates the DDM 3292. The DDM 3292, the shaft bearing 3296, the drive shaft 3294, and the instrument insertion tube 3290 collectively form the DDM assembly 3299, described below.

33A, 33B, and 33C illustrate details of the DDM assembly 3299, including how the DDM 3292 is assembled with other components, such that the motor 3260 drives the vibration of the DDM 3292 / RTI &gt;

Referring now to Figure 33A, the DDM 3292 of this embodiment includes a tissue bearing surface 3322 on the first end 3321 and a shaft bearing grip 3324 on the second end 3323. [ The shaft bearing grip 3324 also has two pivot pins 3325. The DDM 3292 is partially hollow and has a shaft bearing cavity 3326 that allows the shaft bearing 3296 to be fitted therein. Shaft bearing cavity 3326 also presents cam follower cavity 3328. The shape of the cam follower cavity 3328 may be rectangular in that it is much narrower in one direction and forms a slot. Shaft bearing 3296 has a bore 3336, a shaft bearing tip 3332, a threaded bearing end 3338, and two pivot pin holes 3334. The threaded shaft bearing end 3338 threaded into a threaded shaft bearing mount 3342 on the second end 3293 of the instrument insertion tube 3290. The bore 3336 can have a diameter greater than the diameter 3385 of the drive shaft 3294 anywhere along its length except for the shaft bearing tip 3332, Lt; RTI ID = 0.0 &gt; 3294 &lt; / RTI &gt; The second end portion 3297 of the drive shaft 3294 is deformed to include the main shaft section 3352 and the camshaft section 3354. The various subcomponents of these components allow their assembly and operation, as can be seen in Figures 33b and 33c.

Referring now to FIG. 33B, drive shaft 3294 is shown coaxially fitted within shaft bearing 3296 and instrument insertion tube 3290 of DDM assembly 3299. Which aligns the threaded bearing end 3338 of the shaft bearing 3296 into a threaded shaft bearing mount 3342 located at the second end 3293 of the instrument insertion tube 3290. The shaft bearing tip 3332 receives the drive shaft 3294 to prevent misalignment to the DDM 3292. The second end 3293 of the drive shaft 3294 diverges from the shaft bearing tip 3332 to expose the camshaft section 3354 fully. When the instrument insertion tube 3290, the shaft bearing 3296 and the drive shaft 3294 are assembled, the DDM 3292 is configured such that (a) the pivot point pin 3325 is positioned in the pivot pin hole 3334 and (b) the camshaft section 3354 is inserted into the cam follower cavity 3328. As shown in Fig.

33C shows the assembled DDM assembly 3299. FIG. The DDM 3292 is fitted over a shaft bearing 3296 threaded into a threaded shaft bearing mount 3342 of a mechanism insertion tube 3290 coaxially surrounding the drive shaft 3294. It can be seen that the pivot pin 3325 on the shaft bearing grip 3324 is fitted into the pivot pin hole 3334 of the shaft bearing 3296. This arrangement, in combination with the shaft bearing cavity 3326, allows the hollow DDM 3292 to rotate freely on the pivot pin 3325. Rotation of the drive shaft 3294 causes the camshaft section 3354 to rotate within the cam follower cavity 3328 to drive the DDM 3292 to vibrate relative to the pivot pin hole 3334 and move the tissue- As indicated by bi-directional arrow 3377. &lt; RTI ID = 0.0 &gt;

32 and 33A-33C, the physician grasps the differential ablation instrument 3210 by the instrument handle 3212 and moves the distal tip presenting the DDM 3292 toward the ablated composite tissue . The physician selects the power level by sliding the power level adjustment portion 3281 to the desired position and then places his thumb on the switch 3282 and presses the switch to close it. When the switch 3282 is closed, the motor 3260 is turned on and rotates the motor shaft coupler 3262 and eventually the drive shaft 3294. The drive shaft 3294 is configured to rotate about the axis of the shaft bearing 3296 and the shaft bearing 3296 such that the camshaft section 3354 of the drive shaft 3294 oscillates rotationally within the cam follower cavity 3328 of the shaft bearing cavity 3326 of the DDM 3292, Particularly coaxially by the shaft bearing tip 3332, in a very precise manner. The cam follower cavity 3328 is rectangular and has an oblong shape that occurs in a direction perpendicular to the axis of the rotational joint formed by the pivot pin 3325 and the pivot pin hole 3334 in the embodiment shown in Figures 33A- It has the narrowest dimension. In this embodiment, the narrowest dimension of the cam follower cavity 3328 now only permits passage of the camshaft section 3354 of the rotating drive shaft 3294 tightly. The rotational vibration of the camshaft section 3354 collides against the long wall of the cam follower cavity 3328 such that the entire DDM 3292 is displaced by the pivot pin 3325 and the pivot pin hole 3334 Causing it to rotate through oscillating arc 3377 lying in a plane perpendicular to the axis. In this embodiment, the amplitude of the oscillating arc 3377 that the tissue-facing surface 3322 of the discriminating ablation member 3292 is pivoted is determined by the diameter 3385 of the drive shaft 3294 from which the camshaft section 3354 is cut, Is a function of the distance 3379 separating the facing surface 3322 and the pivot pin hole 3334. The frequency of the vibration matches the frequency of the rotational vibration of the motor 3260. The operator can control the vibration frequency of the tissue-facing surface 3322 by changing the position of the power level adjusting portion 3281. [ It should be noted that this mechanism for converting the rotation of the motor 3260 and the rotation of the drive shaft 3294 into the vibration of the DDM 3292 is similar to the scatch yoke shown in Figures 22 to 25C.

Discrimination ablation mechanism 3200 is one example of an implementation of DDM, and many variations are possible. For example, the vibration of the DDM can be driven by a crank-slider mechanism with a slider moving back and forth longitudinally inside the instrument insertion tube. Alternatively, the motor may be positioned adjacent to the DDM, the motor shaft directly driving the DDM, and only electrical wires for feeding the motor proceed along the instrument insertion tube. In addition, since the DDM is well adapted to the end of the tube, extending the instrument insertion tube significantly allows differentiation ablation mechanisms, such as differential ablation mechanism 3200, to be a laparoscopic instrument, for example. Differential ablation devices with instrument insertion tubes as long as 36 cm can be used, but longer or shorter tubes are easily accommodated in the design. DDM as disclosed herein can be readily adapted to the arms of a surgical robot, such as the Da Vinci Surgical Robot from Intuitive Surgical (Sunnyvale, Calif., USA). DDM can be made very small; For example, an effective differential ablation mechanism may be formed in which a DDM and instrument insertion tube is inserted through a 5 mm hole, such as a surgical port, to enable minimally invasive surgery. These small devices are easily formed.

In addition, a discriminating member, in which the driving shaft is replaced by a flexible driving shaft, and the instrument insertion tube is curved, may be used. This creates a differential ablation device with a curved instrument insertion tube, as shown in Figure 6c. Refraction of the instrument insertion tube is also possible, for example using a drive shaft with a universal joint or other bendable coupler at the refracting portion.

As previously disclosed, additional functionality may be added to the end of the discrimination ablation mechanism. E.g,

FIGS. 11B and 13 show how the design of the DDM allows fluid to be delivered to the DDM for perfusion, or how the inhalation can be applied to clean the surgical site, or how the light source illuminates the surgical site Lt; RTI ID = 0.0 &gt; DDM &lt; / RTI &gt;

Figures 26a-26d disclose differential discrimination devices with retractable cutting blades that can be sharpened for cutting or can be powered by electrosurgical generators (single-pole or double pole) for electrosurgery.

27A and 27B show how the design of the DDM allows the DDM to be adapted to function as a forceps.

Additional functionality can easily be added to differential discrimination mechanisms. For example, a jacket holding any size patch or DDM on the side of the DDM can be fed so that the patch can be used for electrocautery. To simplify manufacturing, the drive shaft may be used to conduct electricity from the handle to the DDM. The design of the DDM allows the forceps shown in Figures 27A and 27B to be used as scissors instead. Additional functionality can include a video camera for imaging or ultrasound surgery for sharp ablation. The improved design of DDM allows many of these additional functionality to be combined together within a discrimination ablation mechanism. The advantage realized from combining the functionality with the DDM at the working end of the differential ablation device is that it reduces the number of instruments needed by the physician for the procedure; Simplify planning for inventory and support personnel for hospitals; And most importantly, slowing the surgery and reducing the instrument exchange during surgery, which is a major cause of surgical complications. This is especially true in laparoscopic and robotic surgery, which frequently requires placement of the instrument in the body through a small incision, by an airtight port.

34 shows a perspective view of an embodiment of an assembled differential ablation device. The differential ablation mechanism 3400 includes a mechanism insertion tube 3490 having a first end 3491 attached to the instrument handle 3412 as a whole and a second end 3493 to which the DDM 3492 is rotatably mounted And an instrument handle 3412. The instrument handle 3412 is assembled from a lower housing 3430 that includes an upper housing 3420 that includes an upper battery cover 3422 and a lower battery cover 3432. A motor 3460 and a battery 3470, which can be selectively assembled into the battery pack, are enclosed in the upper housing 3420 and the lower housing 3430. Within the upper housing 3420 is a switch 3482 (which may be an instantaneous switch or on-off switch) for providing power from the battery pack 3470 to the motor 3460. The flexible switch cover 3484 mounted within the surface of the upper housing 3420 allows access to the internal power level adjustment portion 3581 (Fig. 35A). The upper housing 3420 includes a retractable blade hook control button 3499 (fixed by a control button bolt 3498) and a mechanism for coaxially directing the tool insertion tube 3490 near the motor 3460 And further includes an insertion tube support 3426.

Fig. 35A shows an exploded view of the discrimination ablation mechanism 3400. Fig. The differential ablation mechanism 3400 includes a mechanism insertion tube 3490 having a first end 3491 attached to the instrument handle 3412 as a whole and a second end 3493 to which the DDM 3492 is rotatably mounted And an instrument handle 3412. The instrument handle 3412 is assembled from a lower housing 3430 that includes an upper housing 3420 and a lower battery cover 3432 that includes an upper battery cover 3422 that is held together by instrument housing bolts 3536 . In the upper housing 3420 and the lower housing 3430 a motor 3460 and a battery 3470 shown here as battery type CR123A (3V each, 18V for all six batteries 3470) are included, Battery type and voltage can be used. In some embodiments, a total of as low as 3V was used. Within the upper housing 3420 there is a switch port 3524 through which a switch 3482 (which may be a momentary switch or a on-off switch) for providing power from the battery pack 3470 to the motor 3460, Lt; / RTI &gt; A printed circuit board 3580 is provided that further includes a power level adjustment portion 3581 (which may be any convenient component, but is shown here as a linear potentiometer), and is mounted on the surface of the upper housing 3420 Lt; / RTI &gt; switch cover 3484, as shown in FIG. In addition, a front spring battery connector 3572 and a rear spring battery connector 3574 for guiding power from the battery 3470 are included. The upper housing 3420 further includes a tool insertion tube support 3426 for coaxially fixing and orienting the tool insertion tube 3490 in the vicinity of the motor 3460. [ The instrument insertion tube retaining bolt 3527 fixes the instrument insertion tube 3490 in the instrument insertion tube support 3426.

The lower housing 3430 also provides access to the battery 3470 and secures it and the integral lower battery cover 3432 and motor housing section 3534 are secured to the upper housing 3420 using the three appliance housing bolts 3536. [ ). &Lt; / RTI &gt; The motor housing section 3534 holds and secures the motor 3460 coaxially with the instrument insertion tube 3490 passing through the instrument insertion tube support 3426. The motor 3460 is urged forward by the motor housing section 3534 against the motor spring 3562 whose inner diameter leaves space for the motor shaft coupler 3562. [ The motor shaft coupler 3562 is fixedly mounted on the end of the shaft of the motor 3460 with the help of the motor shaft coupler bolts 3566 and also grips the first end 3595 of the drive shaft 3494. The motor 3460 may slide longitudinally back and forth within the motor housing section 3534 under the control of the retractable blade hook control button 3499. [ The motor 3460 further includes a power connection plate 3569 that operatively slides against the spring-loaded motor power contact 3563 mounted on the circuit board 3580. Further, on the circuit board 3580, an adjustable power contact pressure control bolt 3561 is mounted. Normally, the spring 3567 holds the motor 3460 rearward. The spring motor power contact 3563 mounted on the printed circuit board 3580 aligns with and presses against the power connection plate 3569 on the motor 3460 and thus urges against the battery pack 3470 Power can drive motor rotation. Pushing the retractable blade hook control button 3499 forward allows the motor 3460 to slide forward. The power connection plate 3569 is connected to the battery pack 3470 when the motor 3460 is slid far enough forward toward the insertion tube second end 3493 to disconnect the connection with the spring motor power contact 3563. [ Is shorter than the entire range of movement of the motor 3460 under the influence of the retractable blade hook control button 3499 so that the power is automatically blocked from the power.

The drive shaft 3494 also has a second end 3597 which passes through and is supported concentrically by the shaft bearing 3496 mounted on the second end 3493 of the instrument insertion tube 3490. [ 35B, the second end 3597 of the drive shaft 3494 includes a cam holder retainer 3555 (which operates inward from the tip of the second end of 3597), a cam retainer driver 3554, and And further includes a shaft bearing clearance section 3552. The DDM 3492 is rotatably mounted on the shaft bearing 3496 such that the drive shaft 3494 rotates the DDM 3492 by reciprocating vibration. The DDM 3492, the shaft bearing 3496, the cam receiver 3596, the cam holder retainer 3555, the drive shaft 3494, and the instrument insertion tube 3490 collectively refer to the DDM assembly 3598 ).

35B illustrates details of the DDM assembly 3598, including how the DDM 3492 is assembled with other components to drive the motor 3460 to reciprocating vibration of the DDM 3492. [ The DDM 3492 of this embodiment includes a tissue bearing surface 3522 on the first end 3521 and a shaft bearing grip 3524 on the second end 3543. The shaft bearing grip 3524 further comprises two pivot pin holes 3525. The DDM 3492 can be partially hollow to have a shaft bearing cavity 3526 that allows the shaft bearing 3496 to fit internally. Shaft bearing cavity 3526 further provides cam holder cavity 3548 shaped to allow cam holder 3596 to slide easily therein. In this embodiment, the tissue-facing surface 3522 of the DDM 3492 further includes retractable blade slots 3506. Shaft bearing 3496 has two insertable pivot pins 3535 that fit into bore 3536, shaft bearing tip 3532, threaded bearing end 3538, and threaded bore 3534. The threaded shaft bearing end 3538 threads into a threaded shaft bearing mounting 3542 on the second end 3493 of the instrument insertion tube 3490. The bore 3536 can have a diameter greater than the diameter 3585 of the drive shaft 3494 anywhere along its length except for the shaft bearing tip 3532, RTI ID = 0.0 &gt; 3494 &lt; / RTI &gt; The second end 3497 of the drive shaft 3494 is modified to include a main shaft section 3552, a camshaft section 3554, and a cam holder retainer 3555. The cam receiver 3596 further includes a cam receiver main body 3502, a cam receiver chamber 3505, and a retractable blade 3501. Retractable blade 3501 may additionally include hook 3504 and tissue engaging surface 3503. The tissue-engaging surface 3503 of the retractable blade 3501 may be more aggressive or less aggressive than the tissue-engaging surface of the DDM 3492. [ The various subcomponents of these components allow their assembly and operation, as disclosed elsewhere in this document.

The DDM 3492 is fitted over a shaft bearing 3496 which is threaded into a threaded shaft bearing mount 3542 of the instrument insertion tube 3490 coaxially surrounding the drive shaft 3494. It can be seen that the pivot pin hole 3525 on the shaft bearing grip 3524 is fitted onto the pivot pin 3535 of the shaft bearing 3496. This arrangement, in combination with the shaft bearing cavity 3526, allows the DDM 3492 to rotate freely on the pivot pin 3535. Rotation of the drive shaft 3494 causes the camshaft section 3554 to rotate within the cam receiver 3596 to drive the DDM 3492 to oscillate reciprocally relative to the pivot pin hole 3525 and cause the tissue- In the lateral direction. The tissue-facing surface 3522 may have a tissue-engaging surface (not shown here) to allow it to act as a DDM.

In operation, the doctor holds the differential ablation instrument 3400 by the instrument handle 3412 and directs the distal tip presenting the DDM 3492 toward the ablative composite tissue. The physician selects the power level by sliding the power level adjustment portion 3581 to the desired setting and then places his thumb on the switch 3482 and presses the switch to close it. When the switch 3482 is closed, the motor 3460 is turned on and rotates the motor shaft coupler 3562 and eventually the drive shaft 3494. The drive shaft 3494 is configured to allow the camshaft section 3554 of the drive shaft 3494 to rotate about the axis of the shaft bearing 3496 such that the camshaft section 3554 of the drive shaft 3494 vibrates rotationally within the cam receiver chamber 3505 of the cam receiver 3502 captured within the DDM 3492. [ And in particular by the shaft bearing tip 3532, in a very precise manner. The rotational vibration of the camshaft section 3554 collides against the wall of the cam receiver chamber 3505 of the cam receiver 3502 constituted as a scotch yoke as described above and the pivot pin 3535 and the pivot pin hole 3525, Causing the entire DDM 3492 to rotate through a vibrating arc placed in a plane perpendicular to the axis of the rotational joint formed by the rotating joint. The doctor may extend the retractable blade 3501 by pushing the retractable blade hook control button 3499 forward. The forward movement of the retractable blade hook control button 3499 causes the motor 3460 and the power connection plate 3569 to move forward so that the spring force from the spring motor power contact 3563 to the power connection plate 3569 to cut off power to the motor and prevent vibration of the DDM 3492. [ At the same time, the forward movement of the motor 3460 pushes the drive shaft 3494 forward toward the second end 3493 of the instrument insertion tube 3490. The forward movement of the drive shaft 3494 eventually pushes the cam holder retainer 3555 against the upper portion of the cam retainer chamber 3505 inside the cam retainer main body 3502, Further pushing upward along blade 3548 and extending retractable blade 3501 from retractable blade slot 3506. Thus, the forward movement of the retractable blade hook control button 3499 causes the motor 3460 to stop and the retractable blade 3501 to extend from the DDM 3492. When the retractable blade hook control button 3499 is released, the motor spring 3562 pushes the motor 3460 backward to retract the retractable blade 3501 and restore the electrical connection to the motor.

In this embodiment, the amplitude of the oscillation of the tissue-facing surface 3522 of the discriminating ablation member 3492 is greater than the diameter 3585 of the drive shaft 3494 from which the camshaft section 355 is cut and the diameter of the tissue- And the distance 3579 separating the pivot pin hole 3525 from the pivot pin hole 3525. The frequency of the reciprocating vibration of the DDM 3492 relative to the composite structure (cycle per minute) matches the rotation frequency (revolutions per minute) of the motor 3460. The operator can control the vibration frequency of the tissue-facing surface 3342 by changing the position of the power level adjustment section 3581. [ It should be noted that this mechanism for converting the rotation of the motor 3460 and the rotation of the drive shaft 3494 into the vibration of the DDM 3492 is similar to the scatch yoke shown in Figures 22 to 25C.

Figs. 35C-1 and 35C-2 show that the back and forth movement of the drive shaft 3494 and cam receiver main body 3502 also changes the amplitude of the reciprocating vibration of the DDM 3492. Fig. The drive shaft 3494 is shown in a forward position (shifted in the direction of arrow 3595) in Figure 35c-1 and in a forward position (shifted in the direction of arrow 3597) in Figure 35c-2. The distance D from the cam holder main body 3548 and the pivot pin hole 3525 increases to D 'and the distance D from the pivot pin hole 3525 is increased 3599) remains constant (because it is determined by the diameter 3585 of the drive shaft 3494, as described above). As D 'increases, the large angular amplitude of the DDM 3596 in the left frame decreases with the small angular amplitude of the DDM 3592 in the right frame. This effect can be used to reduce the amplitude of the vibration when the retractable blade is extended. It can also be used, for example, to change the amplitude of oscillation during blunt ablation by DDM when the physician desires a narrower oscillation for finer ablation.

36A-1, 36A-2, 36B-1, 36B-2, 36B-3, and 36B-4 are rotatably mounted on the instrument insertion tube 3620 via a rotary joint 3630 Shows the end of the discrimination ablation mechanism 3600 having the DDM 3610. FIG. The differential ablation mechanism 3600 also has a retractable hook 3640 that can be extended or retracted by movement in the direction indicated by the bi-directional arrow 3650. Retractable hook 3640 may be retracted or extended using, for example, the mechanism described in Figures 34, 35A, and 35B. Figure 36A demonstrates how the retractable hook 3640 can be positioned in two configurations. Configuration 1 (Fig. 36A-1) shows retractable hook 3640 in an extended position and configuration 2 (Fig. 36A-2) shows retractable hook 3640 in retracted position. The retractable hook 3640 may have a tip 3670 that may be pointed or rounded and a tissue engaging surface 3660 that may be more aggressive than the tissue engaging surface 3690 of the DDM 3610, Lt; / RTI &gt; Retractable hook 3640 may have an elbow 3680 which may be sharpened for slicing as shown here, or it may be rigid; It can also be serrated, and the sharp areas can be located anywhere within the elbow. In configuration 2, the retractable hook is hidden inside the DDM 3610, and the DDM 3610 alone interacts with the tissue. In configuration 1, the retractable hook 3640 is exposed so that the tissue-engaging surface 3690 (e.g., to disrupt the soft tissue) can be removed from the tissue 3640, depending on how the operator positions the retractable hook 3640 relative to the tissue. Or interact with the tissue such that the tip 3670 interacts with the tissue (e.g., to puncture the tissue), or the elbow 3680 interacts with the tissue (e.g., to slice the tissue) Lt; / RTI &gt; In addition, the retractable hook 3640 can be held in any intermediate position between configuration 1 and configuration 2, including that which can be variably extended by an operator.

36B-1 to 36B-4 illustrate the ends of differentiating ablation mechanisms 3600 and show that the retractable hooks of the DDM 3610 are of an extended configuration (configuration 1) (Fig. 36b-1) or retraction configuration (configuration 2) (Fig. 36B-2), and that the retractable hook 3640 can retract or extend before activation of the vibration of the DDM 3610 or during vibration of the DDM 3610. Fig. Arrow 3601 shows the retractable hook moving from the retraction configuration (lower left frame) to the extended configuration (upper left frame - Fig. 36b-3) when DDM 3610 is not vibrating. Arrow 3602 shows that DDM 3610 can be switched from a fixed (upper left frame) to a vibration (upper right frame - Fig. 36b-4) when retractable hook 3640 is in an extended configuration. Arrow 3603 shows that retractable hook 3640 can be moved from the extended configuration (upper right frame) to the retracted configuration (lower right frame) when DDM 3610 is vibrating. Arrow 3604 shows that DDM 3610 can change from stationary (lower left frame) to vibration (lower right frame) when retractable hook 3640 is in retracted configuration. Retractable hook 3640 may optionally be made of an electrically conductive material, such as stainless steel, to electrically connect to an external surgical electrosurgical generator to allow retractable hook 3640 to act as an electrosurgical hook.

Many abstinence organizations are wrapped in thin films or bags that a physician must divide to approach such tissue. When such a thin film or sac is divided, the surgeon proceeds through such tissue. Figures 37-1 through 37-4 illustrate how the differential ablation mechanism 3600 can be used to safely and quickly segment a thin film 3710 overlying a tissue 3700, such as a peritoneum overlying a bladder, The method is shown in four panels. In the upper left panel (Fig. 37-1), the differential ablation mechanism appears to have retractable hook 3640 approaching the thin film 3710 while remaining in the elongated configuration. 37-2), the tissue-engaging surface 3660 of the retractable hook 3640 is pressed against the membrane 3710 by a doctor and the DDM 3610 is positioned such that the tissue- (Not shown). (Alternatively, retractable hook 3640 may be retained in a retracted configuration and tissue engaging surface 3690 of DDM 3610 may be used to peel thin film 3710. Two tissue engaging surfaces 3660 , 3690) have different attack levels, the physician has the flexibility to select a more aggressive tissue-binding surface or a less aggressive tissue-binding surface to peel the thin film 3710.) Lt; / RTI &gt; Next, as shown in the bottom left panel (Fig. 37-3), the doctor then slides the tip 3670 of the retractable hook 3640 through the opening 3720 under the membrane 3710, Lifting or "tenting &quot; the flap 3730 of the thin film 3710 away from the tissue 3700. The doctor then moves the DDM 3600 in the direction of arrow 3740 and thereby moves the flap 3730 into the elbow 3680 of the sharp retractable hook 3640 to cut the tissue. Finally, as shown in the lower right panel (Fig. 37-4), the doctor makes the DDM 3610 oscillate so that when the doctor continues to move the DDM 3600 in the direction of the arrow 3740, The possible hook 3640 vibrates and causes the sharp edges of the elbow 3680 of the retractable hook 3640 to rapidly move into the thin film 3710. [ This has proven to be an easy, fast and safe method for dividing thin films such as the peritoneum on the bladder and bile ducts without damaging the underlying structures (e.g., bladder, bile duct, or liver) in fresh tissue. The tip 3680 of the retractable hook 3640 can be made sufficiently blunt to not easily penetrate the thin film 3710 or underlying structure; In addition, the arrangement of sharp edges only in the elbow 3680 prevents the critical structure from being exposed to the sharp edges 3680, thereby reducing the likelihood that such critical structures will be severed. Examples of thin films or cysts on critical structures include the liver, bladder, gallbladder, peritoneum overlying the gallbladder artery; And lungs, pulmonary arteries, pulmonary veins, and pleuraes overlying the bronchi.

Retractable hooks may be used in a manner similar to that shown in Figures 37-1 to 37-4 to exclude tied fibrous structures such as scar tissue, fibrous tissue surrounding the fascia, renal artery or vein, and scar tissue. For example, a physician can use the tip of a retractable hook to grasp all or a portion of the fibrous structure, and then push the tissue into the sharp elbow of the hook. The physician can then vibrate the DDM and the hook to use the sharp edges inside the hook to cut the tissue. The advantage of this approach is to apply stresses in the mid-position of the tissue to be segmented. In current practice, physicians simply divide such tissue by a variety of techniques, including grasping the side or end of such tissue and pulling it until it breaks. This can sometimes cause large stresses on the pulled tissue, such as a barrier, leading to an accidental burst of important tissue, such as a barrier (thereby puncturing the bowel). By applying stress more locally and directly to the tissue that is divided (especially in the sharp elbows of the hooks) and by applying stresses (for example, between two pairs of clamps) You can have a greater assurance that the farther tissue is not injured.

It is important to know that this method of dividing tissue by using vibrating hooks does not heat the tissue, in sharp contrast to the extreme heat that arises from current practice using electrocautery. Heat from electrocautery is widely recognized as a major risk to accidental thermal injury of surrounding tissue. Competitive techniques for sharp ablation such as ultrasound ablation (e. G., "Harmonic shear " from Ethicon Endosurgery) have been developed to reduce heat and thereby reduce heat damage to tissue. Nevertheless, local heating remains significant and the risk of thermal damage still exists. In contrast, splitting thin films or excising fibrous structures as described herein with vibrating hooks does not cause heating of the tissue, thus eliminating this major cause of the cardiac trauma.

38 shows one embodiment of a differential ablation instrument 3800 for laparoscopic surgery. It uses a mechanism for vibrating the DDM 3810 shown in Figures 34, 35A, and 35B, including a retractable blade (not shown in this figure because it is in retracted configuration). The discrimination ablation mechanism 3800 uses a pistol grip 3820 having a trigger 3830 for starting / stopping the vibration of the DDM 3810 and a speed control 3840 for controlling the speed of the vibration. A thumb-actuated push button 3850 is used to extend the retractable blade held in its normally retracted configuration by a spring mechanism within the handle 3820. The rotation wheel 3860 can be reached and rotated by the index finger and the rotation of the rotation wheel 3860 is controlled by the instrument insertion tube 3870 so that the vibration plane 3880 of the DDM 3810 can be easily rotated 360 [ And the attached DDM 3810, thereby allowing the physician to orient the oscillating plane 3880 with the tissue plane within the body while maintaining good ergonomics for the handle 3820. [ An indicator 3862 on the rotating wheel 3860 provides a visual signal to the physician about the orientation of the plane of vibration 3880 to the physician and similarly a visual signal such as an embossed stripe is applied to the instrument insertion tube 3870 or DDM May be positioned on the lumen 3810 to provide a visual signal on the camera during laparoscopic observation. The electrical plug 3890 is selectively attached to the electrosurgical generator (controlled by an external foot pedal attached to the electrosurgical generator for control of the electrosurgical generator) and to an external electrosurgical generator for electrification (Alternatively, a push button (not shown) may be located on handle 3820 and used for control of the electrosurgical generator). The differential ablation device 3800 therefore allows the physician to perform blunt dissection (by differential excision), sharp ablation (by retractable hook or electrosurgery), and coagulation (by electrocautery) by a single instrument , Thereby reducing complex instrument exchange for laparoscopic surgery.

39 shows a differential ablation instrument 3900 constructed as a tool attached to the arm of a surgical robot, such as a multi-bias robot from Intuitive Surgical, Inc. The DDM 3610 is rotatably attached to the instrument insertion tube 3910 via a rotary joint 3630. [ Retractable hook 3640 can move between retracted and extended configurations, as indicated by bi-directional arrow 3650. Retractable hook 3640 has an elbow 3680 with a tissue-engaging surface 3660, tip 3670, and sharp edges for sharp ablation. Retractable hook 3640 is optionally electrically conductive and may be electrically connected to an external electrosurgical generator. Similarly, a small electrically conductive patch 3625 on the DDM 3610 or the DDM 3610 may be used for electrocautery. (It should be appreciated that the electrically conductive patch may be located anywhere on the DDM 3610, including the tissue-engaging surface 3690.) When the instrument insertion tube 3910 is positioned between the DDM 3610 and the retractable hook 3610, Is attached to a housing 3920 that includes a motor for driving the vibration of the motor 3640. The housing 3920 is constructed with a socket 3930 having electrical and mechanical connections for connecting to the arms of the surgical robot. The instrument insertion tube 3910 can be made long so that the housing 3920 is located outside the patient's body. Conversely, the instrument insertion tube 3910 may be made shorter, such that the housing 3920 is located within the body, and the inflation section may be positioned in the patient &lt; RTI ID = 0.0 &gt; Within the body of the robot arm.

Within the body of the patient, the arrangement of the miniature motors in the housing closer to the DDM can be achieved by the fact that all connections from the housing to the handle or housing through the diaphragm can be electrical, which requires a design that requires the transmission of mechanical drive through the diaphragm , It facilitates refraction of the instrument insertion tube of the differential resection mechanism. This applies to differential robots designed for surgical robots and laparoscopy.

Figs. 40-1 and 40-2 illustrate an embodiment of such an apparatus as an end of the laparoscopic differentiation resection apparatus 4000. Fig. Figures 40-1 and 40-2 illustrate an exemplary laparoscopic version of a differential ablation instrument having an electromechanical actuator on a circle for a refractive portion, in a linear position and a bending position, respectively. The DDM 3610 is equipped with a retractable hook 3640 and an electrically conductive patch 3625. The DDM 3610 is rotatably attached to the distal instrument insertion tube 4010 which is deflected in the rotational joint 4030 with respect to the proximal instrument insertion tube 4020. A solenoid 4060 having a motor 4040 having a motor shaft 4050 and a solenoid plunger 4070 is mounted inside the distal instrument insertion tube 4010. The rotation of the motor shaft 4050 by the motor 4040 drives the vibration of the DDM 4010 and the retractable hook 3640 as described above. Solenoid 4060 is rigidly attached to distal instrument insertion tube 4010 and solenoid plunger 4070 is attached to motor 4040 that freely slides within distal insertion tube 4010. Thus, when solenoid 4060 is activated, the solenoid plunger moves up and down (in the direction indicated by arrow 4080), thereby moving motor 4040, motor shaft 4050, and retractable hook 3640 (As indicated by arrow 4080). Flexible conductor ribbon 4090 supplies the power and signals needed to drive motor 4040 and solenoid 4060. The refraction of the laparoscopic differential resection mechanism 4000 in the rotational joint 4030 allows the distal instrument insertion tube 4010 to bend against the proximal instrument insertion tube 4020, as shown in the right panel. The movement of the distal instrument insertion tube 4010 relative to the proximal instrument insertion tube 4020 is accomplished by various mechanisms such as a control horn driven by a push-pull rod operated by a manual mechanism within the handle of the laparoscopic differential ablation mechanism 4000 Lt; / RTI &gt; This configuration of the actuators (i. E., Motor 4040 and solenoid 4060) and flexible conductive ribbon 4090 facilitates the transfer of complex action across the refractory at the rotational joint 4030, And will require complex mechanical parts that are large and prone to failure.

41 is a thin, flexible instrument insertion tube for use in surgical procedures such as Single-Insight Laparoscopic Surgery (SILS) or Natural Openoffice Translumenal Endoscopic Surgery (NOTES) 4110, respectively. The actuation mechanism is similar to the DDM 3492 and the retractable hook 3596 of Figures 35a and 35b is the same as that shown in Figures 35a and 35b; The rigid instrument insertion tube 3490 and the rigid drive shaft 3494 are replaced by the flexible instrument insertion tube 4110 and the flexible drive shaft 4120 and the retractable hook 3596 is connected to the electrosurgical hook 4130, . The flexible drive shaft 4120 may be rotated (as shown by bi-directional arrow 4160) to drive the oscillation of the DDM 3492 or may be used to retract and extend the electrosurgical hook 4130 (As shown by bi-directional arrow 4162). The multiple lumen flexibilizer insertion tube 4110 may be used to reduce the movement of the flexible drive shaft 4120 within the flexible instrument insertion tube and thereby to extend and retract the electrosurgical hook 4130 And provides greater authority for the push-pull mechanism of the flexible drive shaft 4120. The flexible wire 4140 can also move within the flexible insertion tube 4110 to allow electrical conduction to the electrosurgical hook 4130 and the flexible wire 4140 and electrosurgical hook 4130 Is connected to the cam holder body 3502 by brazing welding 4150 or other suitable mechanism. Accordingly, the discrimination ablation mechanism 4100 can perform blunt dissection, electrosurgical sharp ablation, and electrocautery by a control unit located on a handset outside the body, or electrosurgical or electrocautery by a foot pedal.

Figures 42A-42E illustrate differentiation with a slender pencil grip handle that can be easily rotated in the hand, enabling 360 [deg.] Rotation of the rotational plane of the DDM 4250 relative to the central longitudinal axis 4299 of the differential ablation mechanism 4200 A perspective view and an exploded view of one embodiment of a resection mechanism 4200. FIG.

42A and 42B show the differential excision mechanism 4200 in a perspective view assembled in FIG. 42A and a perspective view exploded in FIG. 42B. The discrimination ablation device 4200 has a generally cylindrical handle 4210 having a longitudinal central axis 4299. In use, the distal end 4201 of the handle 4210 faces the tissue being cut, and the proximal end 4202 faces away from the composite tissue. Parallel to the longitudinal axis 4299 with a proximal end 4222 attached to the distal end 4201 of the handle 4210 and a distal end 4221 towards the tissue to be excised at the distal end 4201, (4220). The DDM 4250 attaches to the distal end 4221 of the elongate member 4220. In this embodiment, the cylindrical handle 4210 is hollow with a clamshell configuration to accommodate a mechanism 4260 configured to mechanically rotate the DDM 4250, as described in the following paragraphs.

Referring now to Figures 42b, 42d, and 42e, Figure 42b illustrates an exploded view of differential ablation instrument 4200; 42D shows an enlarged view of the drive mechanism of DDM 4250; 42E illustrates a simplified diagram of a drive mechanism that emphasizes how the DDM 4250 is driven. The DDM 4250 is rotatably attached to the distal end 4221 of the elongate member 4220 such that the DDM 4250 rotates about the axis of rotation 4252. The DDM 4250 includes a first tissue engaging surface 4251 at the distal end 4221 of the DDM 4250 and a first tissue engaging surface 4251 at the first side 4255 of the rotational axis 4252 of the DDM 4250, (See Fig. 42E). The application of the first force 4270 to the first torque point 4253 produces a moment on the DDM 4250 for the rotational axis 4252 and thus the moment of the DDM 4250 relative to the rotational axis 4252 Directional rotation. There is a second torque point 4254 disposed on the second side 4256 of the axis of rotation 4252 and the application of the second force 4271 occurs in the counterclockwise rotation of the DDM 4250 . Thus, the moment generated by the application of the first force 4270 at the first torque point 4253 produces a reverse torque for the second force 4271 at the second torque point 4254. Thus, alternating application of the first force 4270 and the second force 4271 then drives the vibration (clockwise and then counterclockwise) of the DDM 4250 relative to the axis of rotation 4252. The first force transmitting member 4261 and the second force transmitting member 4262 may be a flexible member such as a cable, a wire, a string, a rope, a tape, a belt, or a chain, or a rigid member such as a push rod or a connecting rod You should know that you can. In the embodiment shown here, the first force transmission member 4261 and the second force transmission member 4264 are flexible tension members such as cables.

The vibration is driven by a motion source 4290 which is powered by the motor 4291. Thus, the motion source 4290 drives the at least one force transmitting member 4261 in a distal and proximal direction relative to the longitudinal axis 4299, thereby driving the first Driving torque point 4253 such that at least one tissue-engaging surface 4251 is configured to selectively engage tissue to be excised and at least one tissue-engaging surface 4251 moves across the tissue to be excised to form at least one Causes the DDM 4250 to oscillate about its rotational axis 4252 so that at least one soft tissue within the tissue where the tissue-engaging surface 4251 of the tissue is resected destroys the hard tissue within the tissue being ablated.

Referring now to FIGS. 42B, 42D, and 42E, mechanism 4260 drives the rotation of DDM 4250. Mechanism 4260 (see Figure 42d in particular) includes at least one force transmitting member 4261 that drives vibration of DDM 4250, as described in the previous paragraph. The first force transmitting member 4261 and the second force transmitting member 4262 are extended substantially parallel to the longitudinal axis 4299 inside the elongate member 4220 as shown in Figs. 42B, 42D, The distal end portion 4264 of the first force transmitting member 4261 is attached to the first torque point 4253 of the DDM 4250 and the distal end portion 4266 of the second force transmitting member 4262 is attached to the DDM 4250. The second torque point &lt; RTI ID = 0.0 &gt; 4254 &lt; / RTI &gt; The proximal end portion 4263 of the first force transmitting member 4261 is attached to the first follower 4231 of the camshaft 4230 and the second force transmitting member 4262 is attached to the first follower 4231 of the camshaft 4230. As shown in Figures 42B and 42D, The proximal end 4265 of the cam shaft 4230 is attached to the second follower 4232 of the camshaft 4230. The first driven member 4231 is placed on the first eccentric cam 4233 (see illustration) on the camshaft 4230 and the second driven member 4232 is mounted on the second eccentric cam 4234 ) (See illustration). The camshaft 4230 rotates about a rotational axis 4235 at right angles to the longitudinal axis 4299 and the first eccentric cam 4233 and the second eccentric cam 4234 rotate about the second axis 4231, Is positioned on opposite sides of the rotation axis 4235 to move 180 degrees out of phase with respect to the follower 4232 (more specifically, see Figs. 42D and 42E). The rotation of the camshaft 4230 alternately pulls the first force transmission member 4261 and the second force transmission member 4262 so that the rotation of the camshaft 4230 Thereby creating a first force 4270 and a second force 4271.

The rotation of the camshaft 4230 is driven by the motor 4291 via the gear train. The motor 4291 is a DC electric motor that forms part of an electrical circuit 4292 (see FIG. 42B) that is powered by at least one battery 4294, Further comprising at least one switch 4296 operatively associated with the motor 4291 and the at least one battery 4294 to at least start and stop the at least one battery 4294. Additional control may be added to allow proportional speed control of the motor 4291 or speed control by an incremental step. The motor 4291 can be one of several types of motors, including a brushless DC motor, a cordless DC motor, a stepper motor, and the like.

The spring mechanism 4280, the compression spring 4281, the compression nut 4282, the lock nut 4283, the inner sleeve 4284, the outer sleeve 4286 and the spring stop 4285 are shown in FIGS. 44c. &Lt; / RTI &gt;

42A to 42C, the switch 4296 is turned on for the motor 4291 which is accessible from substantially any direction with respect to the longitudinal axis 4299 of the handle 4210 of the discrimination ablation mechanism 4200. In this embodiment, Off switch, which is part of the omnidirectional control switch 4298. In this embodiment, the omni-directional control switch 4298 is readily activated with any finger, regardless of the rotational orientation (relative to the longitudinal axis 4299) of the differential ablation mechanism 4200 when the switch 4296 is in the user's hand And five switches 4296 of a radial array distributed about the handle 4210, proximal to the distal end 4201 of the handle 4210, so that the knob 4210 can be positioned. In this embodiment, the radial array of five switches 4296 is made of a soft elastomer (e. G., Silicone rubber) that prevents fluid ingress into the switch 4296 but still permits easy operation of the switch 4296 And is covered by flexible boot 4297. The switch may be momentary acting or latching. There can be any number of switches forming a radial array; They may or may not be in a single plane oriented transversely with respect to the longitudinal axis 4299 and in this case the array of switches may be distributed around and along the longitudinal axis 4299 of the differential ablation mechanism 4200 have. The array of switches may or may not be the same; Each of the switches 4296 may be of any size, shape, type, function (momentary acting, on-off, off, on, off, unipolar, unipolar, dipole, dipole, Analog proportional control), or distance from the longitudinal axis 4299, or any combination thereof. In addition, instead of the array of switches, the omnidirectional control switch 4298 may be a substantially monolithic or torus configuration, for example a first ring conductor that is shielded from and maintained in contact with a second ring conductor Where the physician can apply pressure to this version of the omni-directional control switch 4298 from any direction to cause the first ring conductor to make an electrical connection with the second ring conductor. The first ring conductor or the second ring conductor, or both, may be rigid or flexible. For example, if the second ring conductor forms a rigid ring of small diameter around the longitudinal axis 4299 of the differential ablation mechanism 4200, the second ring conductor is not connected to the first ring conductor and is substantially coaxial with it , &Lt; / RTI &gt; and may be an elastically suspended, large diameter ring. As an example, the physician's finger may displace the rigid second ring conductor away from it until it contacts the first ring conductor, or, alternatively, the second ring conductor may establish contact with the first ring conductor It can be transformed into flexibility. The omnidirectional control switch 4298 may take the form of a power switch that directly controls the flow of electricity to the motor 4291 or the forward forming control switch 4298 may be used to drive a logic circuit that controls the motor 4291 The pseudo-finger input can be converted to a change in resistance, capacitance, or other parameter.

43A-43C illustrate different embodiments for imparting torque and reverse torque on the DDM 4300. Fig. In Figure 43A, the first tension element 4261 and the second tension element 4262 are two halves of a single cable 4302 wrapped around a drive cylinder 4310 attached to the DDM 4300. The single cable 4302 is physically attached to the drive cylinder 4310 by friction, thereby driving the rotation of the drive cylinder 4310. The single end 4301 has a first end 4311 and a second end 4312. The first end 4311 functions as the proximal end of the first force transmitting member and the second end 4312 functions as the second end 4312. [ And acts as a proximal end of the force transmitting member. The first force 4270 and the second force 4271 are connected centrally or eccentrically to the drive pulley 4343 which is rotated by the motor 4342 (as indicated by arrow 4344) 4340 when the rocker arm 4320 is rocked relative to the rocker pin 4323. As shown in Fig.

The application of the first force 4270 rotates the DDM 4300 thereby stretching the linear spring 4350 and when the return force 4271 of the linear spring 4350 decreases as the first force 4270 decreases Another embodiment in which the linear spring 4350 is attached to the second torque point 4254 and the fixed anchor point 4351 to generate a reverse torque is shown in Fig. 43B. Similarly, the reverse torque can be generated by the torsion spring 4360, as shown in Fig. 43C.

Figs. 44A-1 to 44C-1 show different embodiments of the different ablation mechanism and mechanism for protecting the tissue to be excised from a larger mass. 44A-1 and 44A-2 illustrate two difficulties with respect to the construction and use of a differential ablation mechanism 4400 using a tension member as a force transfer member. The DDM 4410 has a tissue-engaging surface 4412 on its distal end and a rotational joint 4414 on its proximal end rotatably connected to the distal end of elongate member 4430. The first tension member 4421 is connected to the first torque point 4423 and the second tension member 4422 is connected to the second torque point 4424 so that the first and second tension members 4421, (4422) generates a back torque around revolute joint (4414) to drive the vibration of DDM (4410). Difficulty # 1: For the first tension member 4421 and the second tension member 4422 to effectively provide a reverse torque to the rotational joint 4414, they must be kept taut. However, other "clearances" within the differential ablation mechanism 4400 may cause poor discrimination of the components, poor performance of the differential ablation mechanism 4400, poor pulling of the first tensile member 4421 or second tensile member 4422, It works or breaks. Difficulty # 2: During the ablation of the tissue 4405, application of the external force F _A to the DDM 4410 can move the discrimination ablation mechanism 4400 to the extreme position, (Or the first or second tension member 4421 or 4422) of the first tension member 4421 at the point 4441 or of the second tension member 4422 at the point 4442 within the elongate member 4430, ) And other contact points between the other components). More broadly, excessive force applied to the DDM of the differential resection mechanism can damage the differential resection mechanism or tissue under resection. Thus, means to prevent damage to the instrument or tissue will be helpful.

Figure 44B shows an embodiment of a discrimination ablation mechanism 4401 that solves this difficulty, including means for preventing damage due to an overload condition. Differential ablation mechanism 4401 includes two overload mechanisms, a first overload mechanism 4477 responsive to a first threshold force F _T1 applied to the DDM 4410 and a second overload mechanism 4477 responsive to a second threshold force And a second overload mechanism 4470 that is responsive to the second overload mechanism (F _T2 ). During the ablation of the tissue 4405, when a force F _A exceeding the first critical force F _T1 is applied to the DDM 4410, the first overload mechanism 4477 is actuated by the differential ablation mechanism 4401, The rotation of the DDM 4410 is stopped to reduce the risk of damage to the tissue 4405. For example, the first overload mechanism 4477 may include a force sensor 4461 that measures the force F _A applied to the DDM 4410. Examples of force sensors 4461 include load cells, strain gauges, and spring loaded electrical contacts. In this example, the overload mechanism 4450 is present in the handle 4411, wherein the elongate member 4413 is attached to the handle 4411, but may be located elsewhere within the elongate member 4413, for example, It is possible. The force sensor 4461 communicates with the electric circuit 4292 via the wire 4462 and when F _T1 exceeds F _{A the} signal is sent to the electric circuit 4292 via the wire 4462, Lt; RTI ID = 0.0 &gt; 4290 &lt; / RTI &gt; There is an alternative means for stopping the rotation of the DDM 4410. [ For example, when the clutch on motor 4290 is overloaded to motor 4290 so that the torque is too large to cause the clutch to slip, or the motor 4290 to be sufficiently small to simply stop when the external force F _A is too large Thereby limiting the torque applied by the motor.

When a force F _A that exceeds the second critical force F _T2 is applied to the DDM 4410, the second overload mechanism 4470 is proximal (in the direction of arrow 4471) away from the tissue 4405 DDM 4410, thereby reducing the external force F _A. It should be noted that the first overload mechanism 4477 and the second overload mechanism 4470 can be activated in response to any force as well as axial forces as shown in Figure 44b. Also, the first critical force F _T1 may be equal to, greater than, or less than the second critical force F _T2 , depending on the desired response. It should also be appreciated that the differential ablation mechanism may have only one of the two overload mechanisms 4470, 4477.

Figures 44c-1 and 44c-2 illustrate one embodiment of a differential ablation mechanism 4402 with a single overload mechanism as described above with respect to Figure 44b. Discriminative resection mechanism 4402 is similar to differential resection mechanism 4401 but now elongate member 4430 is configured to withdraw DDM 4410 proximal to tissue 4405 to provide a second overload mechanism 4470 By another exemplary overload mechanism 4450 that operates in the same manner as the overload mechanism 4450. [ The overload mechanism 4450 includes an outer sleeve 4451 with a first spring stop 4454, an inner sleeve 4452 with a second spring stop 4455 and a compression spring 4453. The outer sleeve 4451 and the inner sleeve 4452 are aligned parallel to the longitudinal axis 4299 of the handle. The DDM 4410 is attached to the inner sleeve 4452 at the rotating joint 4414. [ Inner sleeve 4452 slides proximal freely within outer sleeve 4451. The compression spring 4453 is urged inward by the compressive force 4460 applied to the first spring stop 4454 and the second spring stop 4455 as shown on the left side Causing the sleeve 4452 to slide over the circle inside the outer sleeve 4451. The slide is applied to forces 4462 and 4463 applied by first and second tension members 4421 and 4422, respectively, such that the combined force of force 4462 and force 4463 is equal to compression force 4460 Lt; / RTI &gt; The overload mechanism 4450 thus ensures that the compression spring does not move the inner sleeve 4452 against the outer sleeve 4451 even when any clearance such as the elongation of each of the first tension member 4421 and the second tension member 4422 is accumulated. The above-described difficulty # 1 is solved in terms of adjusting the position of the light source. The right side of Figure 44B shows how the overload mechanism 4450 also alleviates the problem of difficulty # 2. _A moment that is generated for the rotational joint 4414 to move the DDM 4410 to the extreme position and to elongate the second tensile member 4422 when external force F _A is applied to the DDM 4410, At torque point 4424 to create a larger force 4463 on second tension member 4422. [ Thus, an increase in force 4463 increases compressive force 4460 on compression spring 4453. In response, the compression spring 4453 is compressed to allow the inner sleeve 4452 to slide proximal (arrow 4456) within the outer sleeve 4451, thus shorting the overload mechanism 4450. This reduces the size of the force 4463 on the second tensile member 4422 and reduces the size of the differential ablation mechanism 4402 and particularly the second tensile member 4422, Thereby reducing the risk of damage to the skin. It should be noted that other embodiments for recovering DDM in response to an overload are possible. Different configurations of springs, flexible or bendable elongate members, friction pads that slip during overload, and the like are all possible.

42D, the spring mechanism 4280 includes a compression spring 4281, a compression nut 4282, a lock nut 4283, an inner sleeve 4284, and a spring stop 4285. Compression spring 4281 encircles inner sleeve 4284 and extends between compression nut 4282 (serving as first spring stop 482) and spring stop 4285 (serving as second spring stop) Thereby pulling the first tension element 4261 and the second tension element 4262. The strength with which the compression spring 4282 is pulled is set by a compression nut 4282 threaded into the inner sleeve 4284 and advancing the compression nut 4282 downward (relative to the ground) Thereby increasing the strength with which the compression spring 4281 pulls the first tensioning element 4261 and the second tensioning element 4262. [ After proper pulling is established, the compression nut 4282 can be locked by the lock nut 4283. This changes the strength by which the compression spring pulls the first tensioning element 4261 and the second tensioning element 4262, as described in FIG. 44B, so that the compression spring 4281 can effectively reduce the critical force overcome by the external force Means set. Further, the advancing distance of the compression nut 4283 along the inner sleeve 4284 is such that the compression spring can deflect from the mechanism resulting from the elongation of, for example, the first tension element 4261 and the second tension element 4262 Limit the distance that can be removed.

45A-45G illustrate a method for using differential discrimination mechanisms to separate tissue planes without damaging blood vessels and other anatomical structures within the tissue plane. 45A-45G illustrate a method for using differentiation ablation instrument 4530 to ablate and separate two tissues joining in a tissue plane. 45A, the first tissue 4501 and the second tissue 4502 coalesce at a common boundary 4504 and the soft tissue 4505 is attached to the first sac 4506 and the second tissue 4506 of the first tissue 4501 4502 and the second sac 4507 of the second cap 4502. In this example, a single blood vessel 4520 (shown in cross-section) lies within the plane of the common boundary 4504 between the first sac 4506 and the second sac 4507; Is a "penetration" 4510 in which a second blood vessel traverses the common interface 4504 from tissue 4501 to tissue 4502; A single collagen bundle 4515 also traverses the common boundary 4504 from the first tissue 4501 to the second tissue 4502. Thus, if the first tissue 4501 is to be detached from the second tissue 4502 by blunt dissection, the soft tissue 4505 preferably includes a penetrating portion 4510, a collagen bundle 4515, or a blood vessel 4520 Without destroying, it must be destroyed. (The destruction of blood vessels can lead to unnecessary bleeding.) Again, 4505 is a soft tissue typically composed of gelatinous material, mesentery, reticulated fibers, and loosely organized collagen fibrils. The hard tissue includes first and second sacs 4506 and 4507, walls of blood vessels 4510 and 4520, and a collagen bundle 4515, respectively.

Blunt dissection is performed by grasping the first tissue 4501 by the forceps 4540 and by applying a tension to the edge of the common border 4504 in the direction of the arrow 4550 to apply a tension to the edge of the common border 4504, . The application of the tension across the boundary 4504 is important throughout this ablation, since such tension assists the differential action of the differential ablation mechanism 4530, as described above. Discrimination ablation instrument 4530 includes a DDM 4532 with tissue-engaging surface 4533 which heats the inside and outside of the plane of the ground (as indicated by the rotational axis 4535) Is rotatably mounted on the instrument insertion tube 4531 so that the surface 4533 sweeps against the edge of the common boundary 4504. A force 4551 is applied by the operator to push the tissue engaging surface 4533 into the edge of the common interface 4504 thereby causing the ablation of the soft tissue 4505, Followed by separation of the first sac 4506 and the second sac 4507 of the second tissue 4501 and the second tissue 4502, respectively. The tissue engaging surface 4533 does not break and therefore does not cross the sac 4506 or 4507 if the tissue engaging surface 4533 moves up and down due to inaccuracies or misdirected placement of the force 4551 by the operator. Thus, the discrimination ablation mechanism automatically follows the plane between the tissues, defined by the common boundary 4504.

45C, tissue-engaging surface 4533 continues to follow common border 4504 until he collides against blood vessel 4520. In Fig. Again, the tissue-engaging surface 4533 will not destroy the hard tissue including the wall of the blood vessel 4520. Alternatively, the tissue-engaging surface 4533 can be used to reposition the tissue differently depending on whether the soft tissue 4505 is more easily broken above or below the blood vessel 4520, or when the operator pushes the differential ablation mechanism 4530 over or below the blood vessel 4520 (Here, it appears to be moving down the blood vessel 4520), depending on the type of the blood vessel. Since the operator can sense that the tissue engaging surface 4533 collides on the blood vessel 4520 as an increase in resistance to the worker pushing the differential ablation mechanism 4530 into the common boundary 4504, And the progress of the differential resection mechanism 4530 recognizes that the tissue engaging surface 4533 breaks the hard tissue including the wall of the blood vessel 4520 and does not traverse, do.

Blunt dissection continues when the operator continues to apply tension 4536 across common border 4504 by forceps 4540 and push differential discrimination mechanism 4530 into common border 4504, Common boundary 4504. The sacs 4506 and 4507 are positioned such that the tissue engaging surface 4533 traverses the first sac 4506 or the second sac 4507 until the tissue engaging surface 4503 collides against the collagen bundle 4515 Thereby continuing to send the discrimination ablation device 4530 along the common boundary 4504. Again, the tissue-engaging surface 4533 can not break the collagen bundle 4515, and the operator again senses that further progress of the differential ablation mechanism 4530 into the common interface 4504 is blocked. The operator then actuates the discrimination ablation mechanism to one side or the other side of the collagen bundle 4515 for this example, as shown in FIG. 45E, and then the tissue-engaging surface 4533 is now in engagement with the penetrating portion 4510, Continue ablation along the common boundary 4504 until it collides against the common boundary 4504. Again, the operator senses the failure and moves the discrimination ablation device 4530 to one side or other side that is behind this penetration 4510 in this example, as shown in Figure 45f.

45g shows the resulting ablation section after the differential ablation mechanism 4530 has been removed. The common boundary 4504 is now resected so that the sacs 4506 and 4507 of the tissues 4501 and 4502 are separated from each other to provide the physician with an important field of view. Importantly, the blood vessel 4520 was not injured; The collagen bundle 4515 is stretched in the gap between the first sac 4506 and the second sac 4507 and the penetrating portion 4510 extends the gap between the first sac 4506 and the second sac 4507 Lt; / RTI &gt; The collagen bundle 4515 and penetration 4520 are thus "skeletonized &quot; and they are now in the open space where they can be cauterized and cut without contacting the sacs 4506 or 4507 or the tissue 4501 or 4502 Seems to be. This is because if bleeding from the penetration 4510 is to be controlled when the tissues 4501 and 4502 are separated and also contact with or heat diffusion from the electrocautery surface causes thermal damage to the tissue 4501 or 4502 If possible, it is especially important.

45A to 45F can be used to remove the gallbladder from the bed of liver, separate adjacent muscles, separate blood vessels from the bladder or other blood vessels, (In in vitro animal tissues, living animal tissues (pigs), and human bodies), such as by isolating and isolating pulmonary arteries and gallbladder ducts and gallbladder arteries, and the like . Surprisingly, each of these ablation was remarkably hemorrhagic due to the ability of differentiating ablations to ablate without destroying blood vessels, even outer diameter vessels as small as 0.5 mm, or tissue sacs. Also, ablation was remarkably safe. During these surgeries, the surgeon carefully tried out operations that were fatal by other organizations. For example, the physician repeatedly stabbed the liver repeatedly with a differential ablation device set at high speed, waved the discrimination ablation device on the pulmonary artery, stabbed into the large intestine, bladder, and lungs, and was without any organ damage. As described above, the absence of sharp edges in the DDM allows safe blast ablation to be performed, unlike any other surgical instrument.

45A to 45F can be used to excise the fascia plane during, for example, abdominal wall molding procedures. In fact, it is possible to excise such a tissue plane without cauterizing or cutting the penetration. Rather, by working to skeletonize it about the perforations during ablation using the differential ablation mechanism shown herein, sufficient separation of the tissue planes can be avoided by avoiding accidental rupture or allowing ablation to be observed when advancing To allow the ablation to proceed without the need to sever the perforations, which is usually done to allow for the separation of sufficient tissue. Conserving rather than cutting the perforations maintains normal blood flow to the upper layer, which is compromised by breakage of the perforations. These results are very prominent and clinically important. Maintenance of normal blood flow reduces the chance of tissue necrosis (due to insufficient blood flow) and increases the chance for rapid and complete recovery (due to sufficient blood flow). This is of extreme importance when the skin is lifted from the underlying tissue (e.g., for shaping or reconstructive procedures) or when the flaps of the tissue are to be isolated but preserved.

Differential ablation devices, such as one of those disclosed herein, can be used to ablate through adipose tissue; In such resection through the fat, there is no organ or other hard tissue to guide the discrimination ablation device, and ablation proceeds only under the guidance of the operator, rather than being guided by the boundary hard tissue. Such ablation was used to separate the skin from the underlying tissue for facial removal in human carcass. Significantly, as explained above, sufficient gaps were generated, without accidentally or unintentionally destroying the penetrating blood vessels, to advance the ablation until completion. In living patients, such procedures maintain and restore normal blood flow to the tissue throughout the surgical procedure. This is in sharp contrast to the prior art, which cauterizes the penetrating blood vessels, blocks this circulation and severely impairs normal blood flow. As described above, preserving the perforations rather than cutting them maintains normal blood flow to the skin that would have been damaged by breakage of the perforations. The maintenance of normal blood flow reduces the chance of tissue necrosis (due to insufficient blood flow) and increases the chance of rapid and complete recovery (due to sufficient blood flow). All of which are strongly desired in all surgical procedures, particularly plastic surgery.

Differentiation ablation mechanisms, such as one of those disclosed herein, can be used to tunnel into and through a portion of the body while allowing the tissue sac, vessel wall, nerve bundle, and other hard tissue to guide the tissue- Can be used in a similar manner. However, for tunneling, the operator does not move the differential ablation mechanism laterally to separate the broad sections of the tissue planes; Rather, the operator pushes the differential excision mechanism into the tissue plane, with only limited lateral movement to create a narrow tunnel. Such tunnels are used in many surgical procedures, such as tunneling to position a pacemaker for pacemakers and other cardiac pacemakers, and are used in many surgical procedures, such as robotic surgery, thoracoscopic surgery , And minimally invasive surgical procedures such as laparoscopic surgery. One problem that arises in tunneling is the lack of visibility at the end of the tunnel and doctors do not like to do it without seeing.

Figs. 46A-1, 46A-2, 46B-1, 46B-2, 46C-1 and 46C-2 show mechanisms for tunneling by means of a differential excision mechanism combined with an endoscope. Figures 46a-46c illustrate ablation system 4600 for visible tunneling provided by a differential ablation instrument and a television camera or other viewing device. As shown in Figs. 46A-1 and 46A-2, ablation system 4600 is comprised of an instrument tube 4610 having two lumens, an endoscopic lumen 4620 and an instrument lumen 4630. Additional lumens may be used to introduce multiple instruments simultaneously.

As shown in Figures 46b-1 and 46b-2, the endoscopic lumen 4620 accommodates an endoscope 4640 equipped with a television camera or other viewing device at an opposite end (not shown) to provide. The endoscope 4640 may also include an optical fiber, separate from the one for the camera, to transmit light into the ablation zone. The instrument lumen 4630 is used to insert one of several different instruments into the camera's watch where the instruments are used to ablate or otherwise manipulate tissue under the view of the endoscope 4640. Figures 46b-1 and 46b-2 illustrate instrument tubes 4610 with differential discrimination mechanisms 4650 having an endoscope 4640 within the endoscopic lumen 4620 and a DDM 4655 within the instrument lumen 4630 do. Endoscope 4640 has a clock 4645 that allows observation of the DDM 4655 of the differential ablation device 4650 and its interaction with the tissue. Differentiating ablation mechanism 4650 may be rotated within instrumental lumen 4630 to allow the oscillating plane of DDM 4655 to rotate and align with different tissue planes. (The oscillation plane should be parallel to the tissue plane.)

If multiple instruments are needed, they can be inserted into the instrument lumen 4630 one at a time. 46C-1 and 46C-2 illustrate an electrosurgical instrument 4660 (e.g., a hook) inserted into the instrument lumen 4630. As shown in FIG. The electrosurgical hook 4660 can also be inserted into the instrument lumen 4630 and allowed to rotate internally to allow the hook to point in any direction. In use, the instrument tube 4610 is charged into an endoscope 4640 within the endoscope lumen 4620 and a differential ablation mechanism 4650 loaded into the instrument lumen 4630. The instrument tube is positioned at the correct point on the patient by the operator activating differential discrimination mechanism 4650 to initiate blunt resection, as determined by observing the display of endoscope 4640. [ The discrimination ablation mechanism 4650 can be rotated within the instrument lumen 4630, as indicated by the curved bi-directional arrow 4657, to align the oscillation plane with the tissue plane; Differential ablation device 4650 may also be configured such that as indicated by a straight bi-directional arrow 4656 such that DDM 4655 projects further or less away from surface 4605 of instrument tube 4610, And can be advanced into and out of the lumen 4630. Once the tunnel is open, the ablation system 4600 is advanced into the tunnel while the endoscope 4640 provides visibility to the operator as the tunnel is opened. If a sharp ablation or electrocautery is required, the differential ablation device 4650 can be removed and the electrosurgical hook 4660 can be introduced into the instrument lumen 4630 for cutting or cauterization.

Conversely, as in the differential excision mechanism shown in Fig. 41, a differential excision mechanism having an extendable electrosurgical hook may be used to avoid the need to switch between the differential excision mechanism 4650 and the electrosurgical hook 4660 . Other instruments such as scissors, forceps, bipolar forceps, or ultrasonic cutters may also be introduced via instrument lumen 4630 if necessary for ablation, or they may be part of a multifunctional differential ablation mechanism, as described above.

A resection system, such as resection system 4600, may be used for endoscopic harvesting of the vein, endoscopic tunneling for anterior approach to the spinal column, tunneling into the neck, tunneling into the lung for lobectomy, or minimally invasive valve replacement , &Lt; / RTI &gt; the tunneling of many types of endoscopic tunneling. A major advantage of the ablation system 4600 for conventional endoscopic vein harvesting systems is that the addition of differential ablation reduces the chance of damage to the branch tract or vessel wall. Such trauma to the blood vessels usually requires surgical restoration, such as suturing of the extraction site, and significantly impairs the quality of the graft during coronary artery bypass surgery, thereby deteriorating the long term durability of the graft.

In one demonstration of the effectiveness of the differential ablation device as disclosed herein, in order to safely ablate the main blood vessel with the graft, the physician will insert a differential ablation device (not shown) into the incision above the blood vessel in a live pig (approximately 120 pounds) Was then inserted and then advanced along the path of minimal resistance without looking at the differential ablation device, assuming it was a tissue plane overlying the blood vessel. At the end of the ablation along the 20 cm pathway, the surgeon found that the ablation ablation apparatus had ablated to the shaft, the differential resection mechanism followed the blood vessels, and the blood vessels were removed from the surrounding tissues without exudation of the branches or contusions of the main vessel wall.

47A-47D illustrate another mechanism for tunneling by a differential ablation device associated with an endoscope, including sub-components for improving ablation and improving the watch for an endoscope. 47A-47D illustrate a ablation system 4700 similar to ablation system 4600 for tunneling into tissue, such as along a blood vessel. However, ablation system 4700 may include:

An inflatable (not shown) inflator located at the distal end of the instrument tube 4610, which, at inflation, extends the diameter of the tunnel into the tissue 4701 and forms a hermetic seal between the instrument tube 4610 and the surrounding tissue 4701; An annular balloon 4710, and

Allowing inflation / contraction of the balloon 4710 and injection of pressurized air into the end of the tunnel to extend the end of the tunnel and into the tissue 4701 to assist in blunt ablation, A venting system 4720 that provides a source cavity 4702 with respect to a surface 4605 that allows the user to observe the action of the instrument inserted into the second instrument lumen 4630 and the second instrument lumen 4630 A system for injecting air into the air)

.

Figs. 47A-1 and 47A-2 show a front view and a side view, respectively, of the distal end of the ablation system 4700. Fig. (Or other instrument) inserted into the second instrument lumen 4630 and the endoscope 4640 inserted into the first instrument lumen 4620, as in the ablation system 4600, There is a mechanism tube 4610. The balloon 4710 surrounds the end of the instrument tube 4610 and can be inflated by the air flow 4714 through the inflation tube 4712. The balloon 4710 is shown retracted in FIG. 47A, which is juxtaposed to the instrument tube 4610 to facilitate insertion of the instrument tube 4610 into the tissue 4701.

Figures 47b-1 and 47b-2 show the inflation of balloon 4710 by air flow 4714 provided by balloon inflation tube 4712 and driven by air pumping device 4718 (shown in Figure 47d) Are respectively shown in a front view and a side view. The air pumping device 4718 may be any of a number of devices for providing controlled air flow, including syringes, air pumps, and the like. It should be noted that air flow 4714 can be in the opposite direction of suction, allowing for contraction of balloon 4710 when needed.

As shown in Figure 47c, the inflation of the balloon 4710 pushes the tissue 4701 away radially from the distal end of the instrument tube 4610, as indicated by arrow 4716. [ Thus, the instrument tube 4610 can be inserted into the tissue 4701 while the balloon 4710 is retracted. After insertion, balloon 4710 may be inflated to help create cavity 4702 to improve the view for camera 4740 attached to endoscope 4640.

Aeration system 4720 may also be attached to the proximal end of instrument tube 4610 (see Figure 47d). The ventilation system 4720 includes a vent tube 4726 that connects the second device lumen 4630 to an air pump 4728 that provides a regulated air flow. The conditioned air flow is controllable by the operator so that air can be pumped into or out of the second instrument lumen 4630 via the aeration tube 4726. [ Air pump 4728 may be any of a number of devices for providing controlled air flow, including syringes, air pumps, and the like. Pressurized air flows into and through the second instrument lumen 4630 into and out of the aeration tube 4726 (as shown by arrow 4724), and as shown by arrow 4724 in Figure 47c, And escapes into the cavity 4702 at the distal end of the tube 4610. The air exits the second instrument lumen 4630 by a seal 4722 between the differential ablation mechanism 4650 (or any other mechanism inserted into the second instrument lumen 4630) and the second instrument lumen 4630 It is blocked from going out. The air inside the cavity 4702 can be pressurized and the cavity 4702 can be pressurized so that the cavity 4702 can be moved further to improve visibility for the camera 4740 attached to the endoscope 4640 and maneuverability to the discrimination ablation mechanism 4650 Expand. The pressurized air within cavity 4702 also stretches the tissue along the periphery of cavity 4702, including cut-off region 4704 for DDM 4655. (As described earlier, tissue tension facilitates differential resection; it also places the differential ablation member within the balloon, acts on the tissue through the balloon membrane to excise it, The seal 3022 may be applied to the second instrument lumen 4630 when a mechanism such as differential ablation mechanism 4650 or electrosurgical hook 4660 is inserted into the second instrument lumen 4630. [ Lt; / RTI &gt; The second seal 4723 may optionally be positioned between the endoscope 4640 and the first instrument lumen 4620 to stop air flow from any gaps.

The embodiments described herein are illustrative and not intended to encompass the entirety of the present invention. Many modifications and embodiments of the invention described herein will be apparent to those skilled in the art to which the invention pertains utilizing the teachings presented in the foregoing description and the associated drawings. It is therefore to be understood that the invention is not to be limited to the specific embodiments disclosed, and that modifications and other embodiments are intended to be included within the scope of the appended claims. Although specific terms are used herein, they are used in a generic and descriptive sense only and not for purposes of limitation.

Claims (34)

Differential ablation (DDI) for differentiating complex tissues,
A handle having a central longitudinal axis;
A distal end of the device substantially facing the complex tissue, and a proximal end of the device substantially facing the user;
A elongate member having a distal end and a proximal end connected to the handle;
A discriminating member rotatably attached to a distal end of the elongate member, the discriminating member having a rotational axis, at least one tissue engaging surface; And a first torque point disposed on a first side of a rotational axis of the discriminating ablation member; And
Mechanism mechanism configured to mechanically rotate the differential ablation member about the axis of rotation such that the at least one tissue-engaging surface moves in at least one direction relative to the composite tissue includes at least one force having a distal end and a proximal end, Wherein the distal end is attached to the first torque point of the discriminating ablation member and the proximal end of the at least one force transmitting member is attached to the motion source,
/ RTI &gt;
The at least one tissue-engaging surface is configured such that when the discriminating ablation member is pressed into the composite tissue, at least one tissue-engaging surface moves across the composite tissue, and at least one tissue-engaging surface destroys at least one soft tissue within the composite tissue A device, comprising: at least one flexible tissue configured to selectively couple with a complex tissue,
Discrimination abstinence mechanism. The differential ablation instrument of claim 1, wherein the at least one force transmitting member is a connecting rod. The differential discriminating mechanism according to claim 1, wherein the rotation of the discriminating member imparted by the at least one force transmitting member is canceled by a reverse torque with respect to the rotational axis. 4. The differentiation ablation apparatus according to claim 3, wherein the reverse torque with respect to the rotational axis of the discriminating ablation member is supplied by a torsion spring configured to resist rotation imparted to the discrimination member by at least one force transmitting member. 5. The differential ablation instrument of claim 4, wherein the at least one force transmitting member is a tension member. 6. The differential ablation instrument of claim 5, wherein the proximal end of the tension member terminates on a cam follower. The differential discrimination mechanism according to claim 6, wherein the motion source is a camshaft driven by a motor. 2. The differential ablation device of claim 1, wherein the discriminating ablation member further comprises a second torque point disposed on a second side of the axis of rotation of the discrimination ablation member to provide a reverse torque on the discrimination ablation member. 9. The differential ablation instrument of claim 8 wherein the spring is attached to a second torque point of the differential ablation member and the spring is configured to resist rotation imparted to the differential ablation member by the at least one force transmission member. 9. A device according to claim 8, wherein the back torque is provided by a second force transmission member comprising a distal end and a proximal end, the distal end being attached to a second torque point of the differential ablation member, Forming, discrimination ablation apparatus. 11. The differential ablation instrument of claim 10, wherein the first force transmitting member and the second force transmitting member each terminate on their respective proximal ends in respective cam followers on the camshaft. 12. The differential discrimination mechanism according to claim 11, wherein the cam follower of the first force transmitting member and the cam follower of the second force transmitting member both engage with a single camshaft. 13. The apparatus of claim 12, wherein the single camshaft includes a first eccentric cam for the cam follower of the first force transmission member and a second eccentric cam for the cam follower of the second force transmission member; The camshaft has a central rotation axis, and the first eccentric cam and the second eccentric cam are arranged at 180 degrees from each other with respect to the central rotation axis so that when the camshaft rotates, the cam follower of the first force transmission member is most proximal And the cam follower of the second force transmitting member is at its greatest circle. The differential excision mechanism according to claim 5, wherein the tension member is a cable. 11. The differential ablation instrument of claim 10, wherein the first and second force transmission members are flexible tension members. 6. The differential ablation instrument of claim 5, wherein the tension member is formed of a flexible tension member such as a wire, string, rope, tape, belt, or chain. 16. The differential ablation instrument of claim 15, wherein the flexible tension member is comprised of a single continuous tension member, such as a loop. 18. The apparatus of claim 17, wherein the single continuous tension member has a first end and a second end, the first end of the single continuous tension member defining a proximal end of the first force transmission member, Forming a proximal end of the second force transmitting member. The differential discrimination mechanism according to claim 1, wherein the motion source is a linear actuator. 13. The apparatus of claim 12, wherein the differential ablation member and a portion of the mechanism configured to mechanically rotate the differential ablation member about the axis of rotation, which is remote from the camshaft, form an output shaft and tip assembly, Further comprising a compressed compression spring for moving the output shaft and tip assembly toward the distal end of the instrument and the movement of the output shaft and tip assembly toward the distal end of the instrument is resisted and limited by tension within the cable. 21. The method of claim 20, wherein the proximal force further compresses the spring to drive the differential ablation member assembly proximal, thereby reducing the spring force and thus relaxing the tension member, The force exerted by the compressed compression spring can be adjusted to a level below the level at which the tissue is damaged by constituting the force overload safety element so that the differential ablation member still stops spinning even if it is still rotated by the motion source, Discrimination abstinence mechanism. 2. The apparatus of claim 1, wherein at least a first overload mechanism is configured to respond to a force applied in a proximal direction on the discriminating ablation member to stop rotation of the discriminating member when the force exceeds at least a first threshold force Further comprising a first overload mechanism. 24. The differentiating ablation device of claim 23, wherein the at least one switch is an omni-directional control switch accessible from substantially any direction with respect to the longitudinal axis of the differential ablation mechanism. The apparatus of claim 1, further comprising at least one overload mechanism configured to stop rotation of the discriminating ablation member in response to at least a first threshold force when a force exceeding at least a first threshold force is applied to the discriminating ablation member Including differential discrimination mechanisms. 25. The differential ablation instrument of claim 24, wherein the at least one first overload mechanism stops the motion source in response to a force exceeding at least a first threshold force. 25. The apparatus of claim 24, wherein the at least second overload mechanism is configured to cause the second overload mechanism to withdraw the discriminating ablation member proximally away from the tissue to be excised when the force exceeds at least a second threshold force, In response to a force applied to the patient. 27. The method of claim 26, wherein at least the second overload mechanism comprises:
An inner sleeve arranged substantially parallel to the central longitudinal axis of the handle, and
The inner sleeve being configured to be slidable within the outer sleeve in a direction substantially parallel to the longitudinal axis of the handle, the outer sleeve being substantially parallel to the central longitudinal axis,
Lt; / RTI &gt;
The inner sleeve is configured to slide proximal to the outer sleeve to load the spring against the sliding of the inner sleeve relative to the outer sleeve.
Discrimination abstinence mechanism. 28. The method of claim 27,
A first spring stop fixed to the inner sleeve;
A second spring stop fixed to the outer sleeve;
So that the slide of the inner sleeve against the outer sleeve applies a load to the spring between the first spring stop and the second spring stop to resist sliding between the inner sleeve and the outer sleeve, A spring positioned between the spring stop and the second spring stop
Further comprising a differential ablation device. 29. The differential ablation instrument of claim 28 wherein the spring is a compression spring and the proximal slide of the inner sleeve against the outer sleeve compresses the spring. 32. The device of claim 29, wherein the inner sleeve and the outer sleeve are held in predetermined relative positions when a force is not applied to the discriminating ablation member such that the compression spring is partially compressed by the at least one force transmitting member, Wherein the force associated with the initial compression establishes at least a first critical force or at least a second critical force. 29. The differentiating ablation instrument of claim 28, further comprising a mechanism for adjusting the initial compression and at least one critical force or at least a second critical force. A tissue-force limiting device for a surgical instrument,
A elongated body having a central longitudinal axis and having a proximal end and a distal end;
A vibratable tissue engaging element disposed at a distal end of the elongated body and having a tissue-oriented rotational position, wherein the tissue engaging element vibrates;
A spring associated with the tissue binding element and providing a tension to maintain a tissue-oriented rotational position of the tissue binding element; And
Means for adjusting the upper limit of the tension supplied to the tissue by the tissue engaging element so that exceeding the upper limit of the tension releases the tissue engaging element from holding its tissue-
/ RTI &gt; It is a differential resection device for differentiating complex tissues,
handle;
A elongate member having a distal end and a proximal end connected to the handle;
Discriminating member configured to be rotatably attached to the distal end, the discriminating member having a rotational axis, at least one tissue-engaging surface; And a first torque point and a second torque point disposed on each side of the discriminating ablation member;
Mechanism-mechanism configured to mechanically rotate the differential ablation member about the axis of rotation such that the at least one tissue-engaging surface moves in at least one direction relative to the composite tissue comprises a mechanism-mechanism attached to the first torque- At least one force transmission member having a distal end and a proximal end attached to a linear oscillator configured to drive rotation of the differential ablation member,
/ RTI &gt;
The at least one tissue-engaging surface is configured such that when the discriminating ablation member is pressed into the composite tissue, at least one tissue-engaging surface moves across the composite tissue, and at least one tissue-engaging surface destroys at least one soft tissue within the composite tissue A device, comprising: at least one flexible tissue configured to selectively couple with a complex tissue,
Discrimination abstinence mechanism. It is a differential resection device for differentiating complex tissues,
handle;
A elongate member having a distal end and a proximal end connected to the handle and having a central longitudinal axis;
Discriminating member configured to be rotatably attached to the distal end, the discriminating member having a rotational axis, at least one tissue-engaging surface; And a first torque point and a second torque point disposed on each side of the discriminating ablation member;
Mechanism-mechanism configured to mechanically rotate the differential ablation member about the axis of rotation such that the at least one tissue-engaging surface moves in at least one direction relative to the composite tissue comprises a mechanism-mechanism attached to the first torque- At least one flexible tension member having a distal end and a proximal end attached to the cam follower; Torque resistance means operatively connected to the discriminating ablation member; A cam shaft associated with the proximal end of the at least one flexible tension member and configured to engage the cam follower; A motor operatively associated with the camshaft such that rotation of the motor rotates the camshaft; And a power source for the motor;
An omni-directional control switch operatively associated with the motor and the power source, the omni-directional control switch being configured to be accessible from substantially any direction; And
A tissue-force limiting spring operatively associated with the at least one tension member and maintaining its non-zero tension,
/ RTI &gt;
The at least one tissue-engaging surface is configured such that when the discriminating ablation member is pressed into the composite tissue, at least one tissue-engaging surface moves across the composite tissue, and at least one tissue-engaging surface destroys at least one soft tissue within the composite tissue A device, comprising: at least one flexible tissue configured to selectively couple with a complex tissue,
Discrimination abstinence mechanism.

Images