US20030153902A1 - Hand-actuated articulating surgical tool - Google Patents
Hand-actuated articulating surgical tool Download PDFInfo
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- US20030153902A1 US20030153902A1 US10/388,795 US38879503A US2003153902A1 US 20030153902 A1 US20030153902 A1 US 20030153902A1 US 38879503 A US38879503 A US 38879503A US 2003153902 A1 US2003153902 A1 US 2003153902A1
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B34/00—Computer-aided surgery; Manipulators or robots specially adapted for use in surgery
- A61B34/70—Manipulators specially adapted for use in surgery
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B34/00—Computer-aided surgery; Manipulators or robots specially adapted for use in surgery
- A61B34/30—Surgical robots
- A61B34/35—Surgical robots for telesurgery
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B34/00—Computer-aided surgery; Manipulators or robots specially adapted for use in surgery
- A61B34/30—Surgical robots
- A61B34/37—Master-slave robots
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B2017/00367—Details of actuation of instruments, e.g. relations between pushing buttons, or the like, and activation of the tool, working tip, or the like
- A61B2017/00398—Details of actuation of instruments, e.g. relations between pushing buttons, or the like, and activation of the tool, working tip, or the like using powered actuators, e.g. stepper motors, solenoids
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B2017/00535—Surgical instruments, devices or methods, e.g. tourniquets pneumatically or hydraulically operated
- A61B2017/00539—Surgical instruments, devices or methods, e.g. tourniquets pneumatically or hydraulically operated hydraulically
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/28—Surgical forceps
- A61B17/2812—Surgical forceps with a single pivotal connection
- A61B17/282—Jaws
- A61B2017/2829—Jaws with a removable cover
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/28—Surgical forceps
- A61B17/29—Forceps for use in minimally invasive surgery
- A61B2017/2901—Details of shaft
- A61B2017/2908—Multiple segments connected by articulations
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/28—Surgical forceps
- A61B17/29—Forceps for use in minimally invasive surgery
- A61B2017/2926—Details of heads or jaws
- A61B2017/2927—Details of heads or jaws the angular position of the head being adjustable with respect to the shaft
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/28—Surgical forceps
- A61B17/29—Forceps for use in minimally invasive surgery
- A61B2017/2926—Details of heads or jaws
- A61B2017/2931—Details of heads or jaws with releasable head
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/28—Surgical forceps
- A61B17/29—Forceps for use in minimally invasive surgery
- A61B2017/2926—Details of heads or jaws
- A61B2017/2932—Transmission of forces to jaw members
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/28—Surgical forceps
- A61B17/29—Forceps for use in minimally invasive surgery
- A61B2017/2926—Details of heads or jaws
- A61B2017/2932—Transmission of forces to jaw members
- A61B2017/2944—Translation of jaw members
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/28—Surgical forceps
- A61B17/29—Forceps for use in minimally invasive surgery
- A61B2017/2948—Sealing means, e.g. for sealing the interior from fluid entry
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B90/00—Instruments, implements or accessories specially adapted for surgery or diagnosis and not covered by any of the groups A61B1/00 - A61B50/00, e.g. for luxation treatment or for protecting wound edges
- A61B90/03—Automatic limiting or abutting means, e.g. for safety
- A61B2090/033—Abutting means, stops, e.g. abutting on tissue or skin
- A61B2090/036—Abutting means, stops, e.g. abutting on tissue or skin abutting on tissue or skin
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- Health & Medical Sciences (AREA)
- Engineering & Computer Science (AREA)
- Life Sciences & Earth Sciences (AREA)
- Surgery (AREA)
- Robotics (AREA)
- Medical Informatics (AREA)
- Public Health (AREA)
- Heart & Thoracic Surgery (AREA)
- Nuclear Medicine, Radiotherapy & Molecular Imaging (AREA)
- Molecular Biology (AREA)
- Animal Behavior & Ethology (AREA)
- General Health & Medical Sciences (AREA)
- Biomedical Technology (AREA)
- Veterinary Medicine (AREA)
- Surgical Instruments (AREA)
- Manipulator (AREA)
- Fluid-Pressure Circuits (AREA)
- External Artificial Organs (AREA)
- Prostheses (AREA)
Abstract
Description
- This application claims priority to the U.S. Provisional Application Serial No. 60/219,593, filed Jul. 20, 2000, by Doyle et al., and entitled “HAND-ACTUATED ARTICULATING SURGICAL TOOL,” which is incorporated by reference herein in its entirety, including any drawings.
- The invention relates generally to surgical instruments. More particularly, the invention relates to a hand-actuated articulating surgical tool for use in minimally invasive surgical procedures.
- Current laparoscopic surgical tools are limited in accessibility of certain regions of the human body. Existing tools can perform invasive surgery without making a substantial incision, but these tools are incapable of bending within the body to reach, for example, the backside of the human heart.
- Additionally, existing tools rely on use of cables to manipulate the surgical tip of the tool. These tools have the disadvantage of requiring extensive sterilization of the internal components. The cleaning of internal metal cables can be a lengthy and expensive process. This process must be repeated prior to each procedure. Alternatively, disposable components may be used with a substantial increase in recurring costs.
- In order for a surgeon to perform a surgical procedure on an active organ, such as the heart, current tools require the organ to be arrested. For example, in order to operate on a small portion of the heart, the patient must be placed on an artificial support system while the heart is temporarily stopped for the surgery. This requires additional equipment such as the artificial support system, substantially increasing the cost of the procedure. Also, the recovery period for the patient is substantially increased.
- The present invention provides an apparatus for performing minimally invasive surgery while allowing articulation of the tool within the patient's body. Further, the present invention provides a surgical tool that is simple and inexpensive to sterilize and reuse. Another embodiment of the invention allows a surgeon to operate on a portion of an organ, for example, the heart, without the need for arresting the entire organ.
- One embodiment of the present invention is a surgical device, comprising at least one controller located at the proximal end of the device adapted to transmit hydraulic control signals. At least one manipulator, configured to be controlled by a human finger actuates the controller. At least one slave, located at the distal end of the device, is in fluid communication with the controller and is configured to respond to the hydraulic control signals transmitted by the controller. A control line provides hydraulic communication between the controller and the slave.
- In a preferred embodiment, the controller comprises a control cavity and a piston within the control cavity. The piston divides the control cavity into a first control cavity portion and a second control cavity portion and prevents communication between the two portions. The slave comprises a slave cavity and a piston within the slave cavity that divides the slave cavity into first and second portions and prevents communication between the two portions. The control line provides hydraulic communication between the first control cavity portion and the first slave cavity portion. A second control line provides hydraulic communication between the second control cavity portion and the second slave cavity portion.
- In another embodiment, the surgical device comprises a control portion located at the proximal end having a plurality of controllers, each controller being adapted to transmit hydraulic control signals. A plurality of manipulators, configured to be controlled by a human finger, actuate a corresponding controller. A slave portion located at the distal end of the device comprises a plurality of slaves. Each slave is in communication with a corresponding controller, and responds to the hydraulic control signals transmitted by the controller. A surgical tip is manipulated by the slaves in response to the hydraulic control signals. Control lines provide communication between the controllers and the slaves. In a preferred embodiment, an outer sleeve envelops the control lines.
- The device can also include an articulating portion. The articulating portion comprises a spring bar on one side and a plurality of pockets on an opposing side. The pockets are configured to receive a hydraulic fluid and expand, causing the device to bend as desired. In a preferred embodiment, the device includes a stabilizer having a rigid shaft and a stabilizing plate. The stabilizing plate has an access cutout, and is configured to pivot about the end of the shaft. The shaft can include an articulating portion, if desired.
- The features, objects and advantages of the present invention will become more apparent from the detailed description set forth below when taken in conjunction with the drawings in which like references identify correspondingly throughout, and wherein:
- FIG. 1 is an overview of one embodiment of the invention.
- FIG. 2 is a detailed drawing of one embodiment of the control portion of the invention. FIG. 2A is top view, FIG. 2B is side view, and FIG. 2C is front view. FIG. 2D shows a top view of a grasp cam. FIG. 2E shows a top view of a bend cam.
- FIG. 3 is a detailed drawing of an embodiment of a control cylinder. FIG. 3A shows the cylinder's retracted position, while FIG. 3B shows the cylinder's extended position. FIG. 3D shows the components of the control cylinder individually.
- FIG. 4 is a detailed drawing of an embodiment of a hydraulic extend module. FIG. 4A shows the module's retracted position, while FIG. 4B shows the module's extended position. FIG. 4C shows the front view of the module. FIGS.4D-E show two embodiments of an electrical extend module.
- FIG. 5A is a detailed drawing of an embodiment of a hydraulic rotate module. FIG. 5B is a detailed drawing of an embodiment of an electrical rotate module.
- FIG. 6A is a detailed drawing of an embodiment of a hydraulic bend module. FIG. 6B is a drawing of a gear component in the module. FIG. 6C is a drawing of a rack component in the module. FIG. 6D is a detailed drawing of an embodiment of an electrical bend module.
- FIG. 7A-B is a detailed drawing of an embodiment of a hydraulic grasp module. FIG. 7A is top view and FIG. 7B is side view. FIG. 7C is a detailed drawing of an embodiment of an electrical grasp module.
- FIG. 8 depicts a tool adapted to fit over the tynes of a grasp module.
- FIG. 9 depicts various arrangements of the modules. FIG. 9A shows the modules in bend-extend-rotate-grasp configuration, with the bend module in the straight conformation. FIG. 9B shows the same arrangement with the bend module in the bent conformation. FIG. 9C shows the modules in extend-rotate-bend-grasp configuration, with the bend module in the straight conformation. FIG. 9D shows the same arrangement with the bend module in the bent conformation.
- FIG. 10 shows an embodiment of the tubing management. FIG. 10A shows the guide tubes as they are attached to the cannula using an elastic strap. FIG. 10B shows the position of the guide tubes with respect to the bend module, while FIG. 10C shows the position of the guide tubes with respect to the extend module.
- FIGS.11A-B show an embodiment of the patient restraint.
- FIG. 12 shows an embodiment of the tissue restraint module. FIG. 12A is top view while FIG. 12B is side view. FIGS.12C-E show various embodiments of the separable tynes of the tissue restraint modules.
- FIG. 13 shows the different cylinder diameters for changing the ratio of movement between the control cylinder and slave cylinder.
- FIG. 14 shows an embodiment of the multiple stroke cylinder.
- FIGS.15A-B are side views showing the articulation mechanism of the present invention.
- FIGS.16A-C are side views showing the articulation mechanism of FIGS. 15A-B in greater detail.
- Certain embodiments of the invention will now be described in detail with reference to the figures.
- FIG. 1 shows a surgical tool according to the present invention. The tool has a
control portion slave portion 120 at the distal end of the device. As used herein, “proximal” refers to the part of the device that remains outside the patient's body, closest to the user. “Distal” refers to the end inserted into the patient, farthest away from the user. As with a specific component of the device, “proximal” refers to the part of the component closest to the proximal end of the device, whereas “distal” refers to the part of the component closest to the distal end of the device. Anintermediate portion 190 lies between thecontrol portion 110 and theslave portion 120. The “slave portion,” or the “distal end of the device,” 120 is the portion of the device comprising the slave modules, i.e., the extend module, the bend module, the rotate module, and the grasp module, as each is described in greater detail below. Each portion will now be described in greater detail. The term “cannula” is used to refer to the portion of the device comprising both theintermediate portion 190 and theslave portion 120. - The
control portion slave portion 120 of the device. For example, two such devices are shown in FIG. 1. - In certain embodiments, the
control portion - In one embodiment, the
control portion 112 clamps onto the arm of the user by way of aclamp 115. Thecontrol portion 112 featuresfinger loops 117, into which the user inserts the user's fingers. By squeezing eachfinger loop 117, the user creates hydraulic pressure or an electrical signal that results in a corresponding motion at thedistal end 120 of the device. The user may then “open” the squeezed finger to create the opposite motion. - Each
finger loop 117 is connected with a control cylinder 310 (shown in FIG. 3). Thefinger loop 117 should be large enough to allow comfortable insertion of a human finger. Thefinger loop 117 is connected to a longitudinal shaft. The shaft may be made of, for example, metal, ground glass, or ceramic. The shaft may be of any cross-sectional shape, but a circular cross-section is preferred. The cross-sectional size of the shaft, along with the material, are designed to provide sufficient stiffness for predictable control when thefinger loop 117 is moved. The shaft slides through an opening in the end of the cylinder body. The interface between the shaft and the opening in the end of the cylinder body is formed to allow for smooth forward and backward movement of the shaft and preferably, at the same time, to provide a waterproof seal. - Another embodiment of the invention includes a
control portion 110 that is clamped to the side of a surgicalbed using clamps 130. In this embodiment, the user grasps thecontrol portion 110 much in the same way that a motorcycle driver grasps the handles of a motorcycle. The user may turn the handles, push them in, pull them out, pivot them about their axes, or, with the aid of a thumb loop, squeeze them. As detailed below, each of these motions creates a corresponding motion at thedistal end 120 of the device. - In another embodiment, the
control portion 110 is clamped to an object other than the surgical bed, such as a table or a cart. In yet another embodiment, thecontrol portion 110 is clamped to the user's arms or hand. In still another embodiment, thecontrol portion 110 is held by the user, without it being clamped to anything. - FIG. 2A shows the top view of the
control portion 110. Ahandle 210 is provided for the user's fingers to pass through, while the user's thumb is inserted through athumb loop 212. Thehandle 210 may exhibit ridges on the inside of the open loop in order to more comfortably accommodate a user's fingers. - The movements of the
control portion 110 are translated into hydraulic motion through the use ofcontrol cylinders thumb loop 212 towards thehandle 210, abend cam 222 is turned about a vertical axis. Thebend cam 222 is shown in FIG. 2D. As thebend cam 222 turns, aroller 224 is pushed towards the back of the handle. Theroller 224 is connected to anouter cylinder 312 of acontrol cylinder 214 via ashaft 318. The backward movement of theshaft 318 extends apiston 320 backwards, thereby creating the hydraulic pressure needed to actuate a slave cylinder in thedistal end 120 of the device. The function of a control cylinder and its connection to a slave cylinder are discussed in greater detail below. In one embodiment of the invention, the squeezing of the thumb loop actuates a grasp function at thedistal end 120. - The
control portion 110 may be attached to the side of a surgical bed using aclamp 130. However, the control portion is free to rotate about avertical axis 226, shown in FIG. 2B. The rotation of thecontrol portion 110 about theaxis 226 causes aroller 230 to move within abend cam 228. Thebend cam 228 is shown in FIG. 2E. Theroller 230 is connected to anouter cylinder 312 of acontrol cylinder 220 via ashaft 318. The forward movement of theshaft 318 extends thepiston 320 forward, thereby creating the hydraulic pressure needed to actuate a slave cylinder in thedistal end 120 of the device. In one embodiment of the invention, the turning of the handle results in a rotation of thedistal end 120 of the device through a rotate module, described in detail below. - A user may also push the
handle 210 forward, in which case, the top portion of thecontrol portion 110 moves forward over aslide 232. Theslide 232 is connected to anouter cylinder 312 of acontrol cylinder 218 via anattachment point 330. Theouter cylinder 312 is in turn attached to thepiston 320 via ashaft 318. The forward movement of theshaft 318 extends thepiston 320 forward, thereby creating the hydraulic pressure needed to actuate a slave cylinder in thedistal end 120 of the device. In one embodiment of the invention, the forward movement of the handle results in an extension of thedistal end 120 of the device through an extension module, described in detail below. - The handle part of the
control portion 110 may also rotate along a longitudinal axis coinciding with theshaft 234, as shown in FIG. 2B. In certain embodiments of the invention, the turning of the handle part causes ascrew 236 to rotate within anut 238. In some embodiments of the invention, thescrew 236 is stationary and thenut 238 is mobile, whereas in other embodiments of the invention, thescrew 236 is mobile and thenut 238 is stationary. The movement of thescrew 236 within thenut 238 causes the mobile unit to move linearly with respect to the stationary unit. The mobile unit, whether the screw or the nut, is connected to anouter cylinder 312 of acontrol cylinder 216 via anattachment point 330. Theouter cylinder 312 is in turn attached to thepiston 320 via ashaft 318. The forward movement of theshaft 318 extends thepiston 320 forward, while the backward movement of theshaft 318 pulls thepiston 320 backward. The forward and backward motion of thepiston 320 creates the hydraulic pressure needed to actuate a slave cylinder in thedistal end 120 of the device. In some embodiments of the invention, rotation of the handle part results in the rotation of thedistal end 120 of the device through a rotation module, described in detail below. - In certain embodiments of the invention, the movements of the different parts of the
control portion 110 creates electrical signals that are sent through wires in theintermediate portion 190 to the slave cylinders in thedistal end 120 of the device, The electrical signal is sufficient to actuate a motor in the corresponding slave cylinder, which in turn results in the slave module being actuated. Thus, for example, a forward movement of thehandle 210 creates an electrical signal that actuates a motor in an extend module, which results in the extension of that module. Similarly, the rotation of thehandle 210, the bending of thehandle 210, and the squeezing of thethumb loop 212, result in the rotate module, the bend module, and the grasp module, respectively, being actuated. The slave modules having a motor are described in greater detail below. -
Cylinders typical control cylinder 310 is shown in its retracted position in FIG. 3A and in its extended position in FIG. 3B. Thecontrol cylinder 310 comprises anouter cylinder 312 and aninner cylinder 314. Theinner cylinder 314 has a diameter that allows it to move within theouter cylinder 312. Theouter cylinder 312 is connected to ashaft 318, which in turn is connected to thecontrol portion 110 through theattachment point 330. The movements of thecontrol portion 110, described above, causes theouter cylinder 312 to move longitudinally with respect to the stationaryinner cylinder 314. - A
piston 320, attached to ashaft 318, moves within theinner cylinder 314, within a distance defined by the twoinlet points shaft 318 is configured to be capable of attachment to thepiston 320, while the proximal end of theshaft 318 is configured to be capable of attachment to the outer cylinder at a site close to theattachment point 330. The outer cylinder or the handle assembly may be provided with ratchet teeth. The ratchet teeth are adapted to engage with a locking mechanism to secure thepiston 320 at a desired position relative to the cylinder body. Alternatively, a locking mechanism may employ a friction lock to secure thepiston 320 at a desired position. - The
piston 320 has a solid front face and is movable along the longitudinal axis of theinner cylinder 314. The front face of thepiston 320 is identical in shape to the cross section of the cylindrical cavity. The outer surface of thepiston 320 forms an airtight seal with the inner surface of theinner cylinder 314. Thus, the portion of the cavity on one side of thepiston 320 does not communicate with the portion of the cavity on the other side of thepiston 320. At the same time, thepiston 320 must be allowed to move smoothly back and forth along the longitudinal axis of theinner cylinder 314. - The proximal end of the
inner cylinder 314 is sealed with aseal 316, comprising an opening therethrough, through which theshaft 318 can slide. The distalend of theinner cylinder 314 is sealed with anotherseal 328, optionally comprising an 0-ring 326. - Thus, in the extended position of the
control cylinder 310, FIG. 3B, thepiston 320 is at rest against theproximal seal 316. The hydraulic fluid is located in theinner cylinder 314 in front of thepiston 320. When thecontrol portion 110 is moved in a way described above, i.e., when thehandle 210 is moved forward, theouter cylinder 312 moves forward, thereby moving theshaft 318 and thepiston 320. Hydraulic fluid exits theinner cylinder 314 through aninlet 324, creating a hydraulic pressure at a point in thedistal end 120 of the device. Additional hydraulic fluid, displaced from a slave cylinder, enters to the back of thepiston 320 through anotherinlet 322, thereby keeping the volume of the hydraulic fluid in the system constant. When thecontrol portion 110 is moved completely, thecontrol cylinder 310 is in its retracted position, FIG. 3A. In this position, thepiston 320 is at the distal end of theinner cylinder 314, resting against thedistal seal 328. The hydraulic fluid is in the back of thepiston 320. Those of skill in the art understand that although in the above discussion thepiston 320 is described to move from the fully retracted position to the fully extended position, thepiston 320 may move from any point along the two extremes to any other point along the two extremes, and thereby cause a corresponding movement in a slave cylinder. - The
cannula 190 comprises hydraulic tubings, connecting the control cylinders of thecontrol portion 110 with the slave cylinders at thedistal end 120, and housings for the hydraulic tubings. - The
distal end 120 comprises modular components. The components can be selected from, for example, an extend module, a rotate module, a bend module, and a grasp module. Other functions can be included as well and activated in the manner described in detail below. Each module is individually describe in greater detail below. The invention is adapted such that the user can pick the combination of modules and the quantity of each individual module that is best suitable for the user's needs and assemble them conveniently. - The extend
module 410 is depicted in both its retracted position, FIG. 4A, and extended position, FIG. 4B. The extendmodule 410 is identical in its construction to thecontrol module 310; however, the function of the two are reversed. By applying hydraulic pressure using thecontrol portion 110, hydraulic fluid enters the inner cylinder 414 pushing the piston 420 towards the distal end of the module and the distal seal 416. The shaft 418 moves through the distal seal 416, but it is attached to the outer cylinder 412 at the distal end of the outer cylinder 430. The movement of the piston 420 moves the outer cylinder 412 towards the distal end of the module, thereby extending the cannula. The hydraulic fluid present inside the inner cylinder 414 exits the inner cylinder 414 through the distal outlet 422. The proximal seal 428 prevents the leakage of hydraulic fluid from proximal end of the inner cylinder 414. - Additional modules can be attached to the extend module either at its distal end, through the distal attachment point430, or at its proximal end, through the proximal attachment point 431.
- In another embodiment, the extend module may be extended using electrical power instead of hydraulic power. In this embodiment, by pushing forward on the
handle 210 of thecontrol portion 110, the user causes an electrical connection to be formed, whereby electrical signal is sent from thecontrol portion 110 through wires in theintermediate portion 190 to the extendmodule 432, FIGS. 4D, 4E. The electrical signal causes anelectrical motor 434 to turn. In one embodiment, FIG. 4D, ascrew 436 is mounted within themotor 434. The turning of themotor 434 causes the screw to move outward, thereby causing theouter cylinder 440 to move away from theinner cylinder 442. In this embodiment, the motor is stationary, i.e., it is attached to theinner cylinder 442, whereas the screw is mobile, i.e., it moves with respect to the motor and theinner cylinder 442. Thescrew 436 is attached at its distal end to theouter cylinder 440. - In another embodiment, FIG. 4E, the
motor 434 causes thescrew 436 to turn within anut 438. Thenut 438 is attached to theouter cylinder 440. The turning of thescrew 436 causes thenut 438 to move with respect to thescrew 436, thereby moving theouter cylinder 440 longitudinally with respect to theinner cylinder 442, causing the module to extend. In this embodiment, themotor 434 and thescrew 436 are stationary with respect to theinner cylinder 442, whereas thenut 438 and theouter cylinder 440 are mobile. - The rotate
module 510, FIG. 5A, comprises similar hydraulic components as those of the extendmodule 410. As in the extendmodule 410, hydraulic pressure, applied by rotating thecontrol portion 110 along a longitudinal axis, causespiston 520 to move toward the distal end of the module, causing theshaft 518 to move in that direction as well. Theshaft 518 is attached to alead screw 522 at anattachment point 524. Extension of theshaft 518 causes thelead screw 522 to move towards the distal end of the module. The lead screw is incapable of rotating, since astabilizer 526 prevents its rotation. Thelead screw 522 instead is extended through anut assembly 528 which is immovably attached to anouter cylinder 530. The movement of thelead screw 522 through thenut assembly 528 causes thenut assembly 528 to rotate, thereby rotating theouter cylinder 530. - Additional modules can be attached to the rotate module either at its distal end, through the
distal attachment point 532, or at its proximal end, through theproximal attachment point 534. - In another embodiment, the rotate module may be rotated using electrical power instead of hydraulic power. In this embodiment, by turning the
handle 210 of thecontrol portion 110, the user causes an electrical connection to be formed, whereby an electrical signal is sent from thecontrol portion 110 through wires in theintermediate portion 190 to the rotatemodule 540, FIGS. 5B. The electrical signal causes anelectrical motor 542 to turn. Theelectrical motor 542 is attached to ashaft 544 which in turn is attached to theouter cylinder 546. The turning of the shaft rotates the outer cylinder. In some embodiments, agear reducer assembly 548 may also be present to reduce the rotation speed. In certain embodiments, the connection between theouter cylinder 546 and the cylinder housing themotor assembly 542 may feature a bearingassembly 550. - The
bend module 610 is depicted in FIG. 6A. This module also features the same hydraulic assembly present in the extend and the rotate modules, above. Applying hydraulic pressure by rotating thecontrol portion 110 along thevertical axis 226 in a clockwise direction causes thepiston 620 and theshaft 618 to move towards the distal end of the module. Theshaft 618 is attached to arack 624 either directly or through anattachment assembly 622. The movement of theshaft 618 moves therack 624. Therack 624 has teeth that correspond to the teeth on agear 626. The movement of therack 624 causes thegear 626 to rotate clockwise. Thegear 626 is connected to thedistal end 628 of the module. The rotation of thegear 626 causes thedistal end 628 of the module to bend clockwise. By rotating thecontrol portion 110 in a counter-clockwise direction, thepiston 620 is moved towards the proximal end of the module, causing therack 624 to move backwards as well, which in turn causes thegear 626 to turn counter-clockwise, which in turn causes thedistal end 628 of the module to bend counter-clockwise. - In some embodiments, the bending of the
distal end 628 of the module is through an angle of at least 110°, i.e., when thepiston 620 moves from the proximal end of the hydraulic portion completely to the distal end of the hydraulic portion, thedistal end 628 of the module bends at least 110°. In other embodiments, the rotation is an angle of at least 110°, at least 150°, at least 200°; at least 250°, at least 300°, or an angle of at least 350°. - Additional modules can be attached to the bend module either at its distal end, through the
distal attachment point 630, or at its proximal end, through theproximal attachment point 632. - In another embodiment, the bend module may be bent using electrical power instead of hydraulic power. In this embodiment, by turning the
handle 210 of thecontrol portion 110, the user causes an electrical connection to be formed, whereby electrical signal is sent from thecontrol portion 110 through wires in theintermediate portion 190 to the bend module. The electrical signal causes an electrical motor to turn. The electrical motor is attached to a shaft which in turn is attached to therack 624. The movement of theshaft 618 moves therack 624, which in turn causes thegear 626 to rotate, which in turn causes thedistal end 628 of the module to bend. - In another embodiment, FIG. 6D, the turning of the
motor 640 causes alead screw 642 to rotate within anut 644. Thelead screw 642 is stationary with respect to themotor 640 and the outer body of the module, whereas thenut 644 is mobile. Thenut 644 is connected to alink 646 at the proximal end of thelink 646. The distal end of thelink 646 is connected to the distal end of the module. When thenut 644 is moved backwards, it causes thelink 646 to move backwards, thereby causing the distal end of the module to rotate. Reversing the electrical current, by rotating thecontrol portion 110 in the opposite direction, will cause the motor to turn in the opposite direction, thereby causing the nut to move forward and the distal end of the module to bend in a clockwise direction. - FIG. 7A depicts the top view of the
grasp module 710, whereas FIG. 7B depicts its side view. Thegrasp module 710 also features a hydraulic portion similar to those of other modules. When thethumb loop 212 is squeezed towards thehandle 210, hydraulic pressure is applied and theshaft 718 moves towards the distal end of the module. This movement causes thepin 720 to move towards the distal end of the module as well, thereby causing the twopins 722 to move away from the center. As the twopins 722 move away from the center, the angle defined by pin 722-pin 720-pin 722 tends away from 90° and towards 180°. The movement of thepins 722 causes the twotynes 724 to move towards each other and, eventually, touch. Moving thethumb loop 212 away from thehandle 210 will have the opposite effect of causing thetynes 724 to move away from each other and open up. - In another embodiment, the squeezing of the
thumb loop 212 causes an electrical current to turn amotor 740, FIG. 7C, in thegrasp module 730. Themotor 740 turns astationary lead screw 742, which in turn causes anut 744 to move longitudinally. The movement of thenut 744 causes the tynes to move closer to each other and, eventually, touch. Moving thethumb loop 212 away from thehandle 210 will have the opposite effect of causing thetynes 724 to move away from each other and open up. - The
tynes 724 of thegrasp module 710 are configured to accommodate a number of different tools. For example, in FIG. 8, agrasp tool 810 is shown that can fit over thetynes 724. When thetynes 724 move towards each other, the end portion of thegrasp tool 810 also move toward each other and, eventually, touch. If an object or tissue is located between the end portions of thegrasp tool 810, the object is then grasped by the tool. There may be a number of tools that can be attached over thetynes 724. In addition to the grasp tool, these include a scissors, a knife for cutting the tissue, drill bits for drilling into bones, heating elements for cauterizing tissue, or any other tool necessary during a surgical procedure. - All the above tools and other tools can fit individually and interchangeably on the
grasp module 710. Therefore, during a surgical procedure, the user may attach one tool to thegrasp module 710, use it, remove it, and then attach another tool to thesame grasp module 710. This process can be repeated any number of times with any number of tools. - As mentioned above, the modules of the present invention are designed to be placed in order that the user deems most useful. For example, FIG. 9 depicts four of the modules attached in the order of (from proximal end to distal end) bend, extend, rotate, and grasp. FIG. 9A shows the bend module in its retracted position, where the cannula is straight. FIG. 9B shows the bend module in its extended position where the module is bent. Alternatively, the four modules could be arranged in the extend-rotate-bend-grasp configuration, as shown in FIGS. 9C, 9D. Other combinations are also possible. In addition, the user may attach more than a single module of a particular type, for example, two or three or more extend modules or two or three or more bend modules, could be put together, along with other modules to form the
distal end 120 of the device. Preferably, thegrasp module 710 is always the most distally located module. - As shown in FIG. 4C, the front view of the extend module, the hydraulic tubing connecting the various modules to the control cylinders are located at one side of the slave cylinders. The hydraulic tubing runs alongside the cannula and connects to the inlet openings of the hydraulic portion of each module. In some embodiments of the invention, to keep the hydraulic tubing in place, a series of low
friction guide tubes 1010 are attached to the cannula by an elastic strap 1012 (FIG. 10A). Eachhydraulic tubing 1014 fits through one guide tubing and is free to move longitudinally, i.e., in the direction of thearrow 1016, within theguide tubing 1010. Thus, when the bend module bends, FIG. 10B, or when the extend module extends, FIG. 10C, the hydraulic tubing can move along the cannula and maintain theconnection 1018 with the hydraulic inlets of each of the modules. - In certain embodiments, the present invention features a
restraint 1110 that can be attached to thecannula 190 using a thumb screw 1112 (FIG. 11). Therestraint 1110 sits adjacent to the patient's skin on the outside of the patient's body at the point of entry of thecannula 190. Therestraint 1110 keeps the depth of thecannula 190 with respect to the body of the patient's body. If the patient makes any moves during the surgery, for example if the anesthesia begins to wear off and the patient jolts, the cannula moves with the patient. More importantly, the depth of the cannula inside the patient's body remains unchanged. Therefore, if the patient moves, the patient will not be damaged by the cannula. - As part of their normal physiological function, certain organs in the body have continuous motion. For example, the heart beats, the lungs expand and contract as the patient breathes, and the gastrointestinal tract also undergoes contractile motion. When performing surgery, it is often necessary stabilize the part of the organ undergoing surgery so that additional injury to the organ does not occur and the organ can be worked on. Aspects of the invention also feature a tissue restraint module1210 (FIG. 12) that can be inserted into the patient's body at or near the site where any other cannula has been inserted. The
tissue restraint module 1210 features a bend module, as described above. Once inserted into the patient's body, the separable tynes 1214 can be brought close to the tissue that is to be restrained. The bend module allows the tyne assembly to be bent with respect to the cannula, so that thetynes 1214 may be placed over the tissue. Thetynes 1214 are separable so that they can provide a relatively stable tissue area for the performance of the surgery. - A number of different mechanisms for separating the
tynes 1214 are shown in FIGS. 12C-E. In the embodiments shown, the tissue restraint module comprises two tynes 1214. Thetynes 1214 are adapted to be separable. When inserting the module into the patient's body, thetynes 1214 are held together to reduce the width of the device. Inside the patient's body, thetynes 1214 can be separated. In the embodiment shown in FIG. 12C, onetyne 1214 is stationary, while thesecond tyne 1214 slides away from thefirst tyne 1214. In the embodiment shown in FIG. 12D, bothtynes 1214 move away from the center. Since the twotynes 1214 are bent inward, in their fully extended position the distal end of the twotynes 1214 would be parallel to each other. The embodiment shown in FIG. 12E functions similarly, except that the two tynes are not bent. In the fully extended position the twotynes 1214 form a “V” shaped opening. Other embodiments are also contemplated. For example, the tissue restraint module may comprise only one tyne. In certain embodiments, the single-tyne module may have a shape such as “∩”, “┌”, or “”. - In certain embodiments, the tissue restraint module is held against a tissue or an organ during the surgical procedure. By doing so, in the space between the two
tynes 1214, or a particular space created within a single tyne, a surface area of the tissue or organ becomes restrained, i.e., the local motion of the tissue or the organ is considerably reduced as compared with an unrestrained region of the tissue or the organ. The restraining of the tissue or the organ provides a relatively stable area on which the user can perform the surgical procedure. - In certain embodiments, the
immediate portion 190 of the cannula can be adapted to hold a number of different tools to be used during the operation. The cannula may be the cannula leading to the tissue restraint module or the cannula leading to thegrasp module 710 at thedistal end 120 of the device. Preferably, the cannula is the one leading the tissue restraint module. During the operation, the user can retrieve a first tool from the cannula while within the patient's body and attach it to thegrasp module 710. After using the first tool, the user can then return the first tool to the cannula, retrieve a second tool and attach it to thegrasp module 710. Other tools may subsequently be used in a similar fashion. - The
cannula 190 is held in place using a positioning arm 140 (see FIG. 1). Thepositioning arm 140 comprises at least one joint capable of being tightened or loosened using a release mechanism. The user can release the joint, move thepositioning arm 140 to a desired location, and thereby re-position thecannula 190. In one embodiment, the invention provides for a one-hand-release mechanism. In this embodiment, the user can grasp thepositioning arm 140 with one hand, and while holding thepositioning arm 140, loosen the joint using the same hand, move thepositioning arm 140 to a new location using the same hand, and then tighten the joint, again using the same hand. The one-hand-release mechanism allows the user to reposition the cannula using one hand, while manipulating thedistal end 120 of the device using thecontrol portion 110 with the other hand. - In using the devices of the present invention, it is often the case that the tools at the distal portion of the device are to move a short distance. This distance is small enough that it would become difficult for the user to move his hands or fingers for that short a distance. Therefore, a system is needed to convert a longer movement of the user's hands and fingers at the proximal end of the device to a short movement of the tools at the distal end of the device. This is accomplished by having the control cylinder and the slave cylinder be of different diameters. Of importance, is the relationship between the piston area and the shaft area when using cylinders of different diameters, as generally described below.
- At least a portion of the
intermediate portion 190 of the laparoscopic tool is preferably an articulation portion. FIGS. 15A-B and 16A-C illustrate one embodiment of an articulation mechanism implemented in the articulation portion of theintermediate portion 190. Aspring bar 1510 is embedded within the body of the outer sleeve. The spring bar may be made of any material, such as plastic or metal, that allows it to resiliently bend while exerting a reacting force against the bending. Thespring bar 1510 acts to prevent the articulation portion from bending unless a force is exerted to cause it to bend. An opposite wall of the sleeve is lined withsmall pouches 1520. FIG. 16C illustrates the arrangement of thepouches 1520 and thespring bar 1510 in a cross-sectional view of the articulation portion. Thepouches 1520 are densely placed along the length of the articulation portion. Thepouches 1520 are connected to a reservoir of hydraulic liquid (not shown) by a series of orifices or valves in each pouch. When hydraulic fluid is supplied to thepouches 1520 through the orifices or valves, thepouches 1520 are filled with the hydraulic liquid. The filledpouches 1520 press against one another and force an expansion of the side of the articulation portion with thepouches 1520. This expansion causes thespring bar 1510 to bend, causing the articulation portion to bend, as shown in FIG. 16B. - Double Acting/Double Cylinder System
- Another aspect of the present invention includes a double acting/double cylinder system. This system is depicted in FIG. 13. The system comprises a
control cylinder 1320 and aslave cylinder 1310. The control cylinder comprises apiston 1318 and ashaft 1320 attached thereto. Thepiston 1318 is capable of moving within thecontrol cylinder 1320. The piston divides the control cylinder into two cavities: a distal cavity, a wall of which is A1, and a proximal cavity, a wall of which is A2. Theshaft 1322 passes through the proximal cavity. Thepiston 1318 prevents liquid communication between the distal cavity and the proximal cavity. - The slave cylinder comprises a
piston 1314 and ashaft 1316 attached thereto. Thepiston 1314 is capable of moving within theslave cylinder 1310. The piston divides the slave cylinder into two cavities: a distal cavity, a wall of which is A3, and a proximal cavity, a wall of which is A4. Theshaft 1316 passes through the proximal cavity. Thepiston 1314 prevents liquid communication between the distal cavity and the proximal cavity. - A control line provides hydraulic communication between the proximal cavity of the control cylinder and the proximal cavity of the slave cylinder. Another control line provides hydraulic communication between the distal cavity of the control cylinder and the proximal cavity of the slave cylinder. Thus, in the system, the two distal cavities are in hydraulic communication with each other, the two proximal cavities are in hydraulic communication with each other, but no proximal cavity is in hydraulic communication with any distal cavity.
- If the
control cylinder piston 1318 moves towards the distal end of thecontrol cylinder 1320, hydraulic fluid is moved from the distal cavity of the control cylinder, through a control line, and into the distal cavity of the slave cylinder, thereby pushing theslave cylinder piston 1314 towards the proximal end of theslave cylinder 1310. The reverse may also happen. If thecontrol cylinder piston 1318 moves towards the proximal end of thecontrol cylinder 1320, hydraulic fluid is moved from the proximal cavity of the control cylinder, through a control line, and into the proximal cavity of the slave cylinder, thereby pushing theslave cylinder piston 1314 towards the distal end of theslave cylinder 1310. Further, while thecontrol cylinder piston 1318 remains stationary, thesalve cylinder piston 1314 also remains stationary. - In an embodiment, the double acting/double cylinder system of the invention comprises an overpressure reservoir. If the hydraulic pressure within the cylinders or the control lines exceeds a certain amount, some hydraulic fluid is transferred to the overpressure reservoir. The opening to the overpressure reservoir may comprise a pressure gauge device, which can become activated when the hydraulic pressure within a system surpasses a certain preset value. When the pressure gauge device is activated, the opening to the overpressure reservoir opens and hydraulic fluid can then enter the reservoir.
- In another embodiment, the overpressure reservoir comprises an opening, which is in constant fluid communication with the hydraulic fluid within the system. The reservoir further comprises a spring mechanism at the side opposite to the opening. When the hydraulic pressure within the system surpasses the pressure applied by the spring mechanism, hydraulic fluid enters the reservoir from the system. Conversely, when the pressure within the system falls below the pressure applied by the spring mechanism, for example due to a leak in the system, hydraulic fluid enters the system from the reservoir. Thus, the reservoir may also function as a fluid replacement reservoir.
- In certain embodiments, the flow of the hydraulic fluid inside the system will move very easily so that not enough resistance is afforded. In these situations, it is difficult for a user to control the movement of the cylinders with fine precision. Therefore, certain embodiments of the invention feature a narrowing at a point in the hydraulic tubing, the purpose of which is to create resistance. In some embodiments, the user can change the amount of narrowing, and therefore, the amount of resistance in the hydraulic tubing.
- FIG. 13 depicts the relationship between the
control cylinder 1310 and the slave cylinder 1312. Thecontrol cylinder 1310 has apiston 1314 and ashaft 1316. The front of thepiston 1314, i.e., the opposite face from where theshaft 1316 attaches to thepiston 1314, has an area of A3 and the back of thepiston 1314, i.e., the face where theshaft 1316 attaches, has an area is A4. Thus, A3 is equal to A4 plus the area of theshaft 1316. When thepiston 1314 moves backwards a distance of l2, the amount of hydraulic fluid displaced in front of thepiston 1314 will have a volume of A3l2. However, the volume of the hydraulic fluid displaced behind thepiston 1314 will be A4l2. - The slave cylinder1312 also has a
piston 1318 and ashaft 1320. The volumes of displaced hydraulic fluid in front of and behind thepiston 1318 must be equal to the volume of displaced hydraulic fluid in front of and behind thepiston 1314. In other words, - A 1 l 1 =A 3 l 2
- and
- A 2 l 1 =A 4 l 2
-
-
- It is readily understood by those of skill in the art that the above relationship will also hold true if the control cylinder and the slave cylinder are configured such that small movements by the user's hands and fingers results in longer movements at the distal end of the device, In other words, in FIG. 13, in one embodiment1312 represents the slave cylinder and 1310 represents the control cylinder, whereas in another embodiment, 1312 represents the control cylinder and 1310 represents the slave cylinder.
- In certain embodiments, when it is desirable to have a long range of movement or very fine movement at the distal end of the device, it is preferable to affect a full range of movement at a slave cylinder at the distal end of the device using multiple strokes of a control cylinder. In these embodiments, the present invention features a multiple stroke cylinder system (FIG. 14). A stroke of the control cylinder1410 causes
check valve 1414 to close andcheck valve 1412 to open. Hydraulic fluid is then transferred from the control cylinder 1410 to theslave cylinder 1418. Returning the piston of the control cylinder 1410 to the original position, i.e., at the proximal end of the control cylinder, causes thecheck valve 1412 to close and thecheck valve 1414 to open. Additional hydraulic fluid is then transferred from thereservoir 1422 to the control cylinder 1410. Another stroke of the control cylinder 1410 will then cause additional movement in theslave cylinder 1418. - The system is also equipped with a “dump”
valve 1416. Thedump valve 1416 may be activated by the user at anytime. When thedump valve 1416 is activated, hydraulic fluid is transferred from theslave cylinder 1418 back to thereservoir 1422. - In some embodiments, to aid the removal of the hydraulic fluid from the slave cylinder1418 a
spring mechanism 1420 is placed behind the piston of the slave cylinder. Those of skill in the art know of other mechanisms that can be used to return the piston of the slave cylinder to its original position. - In other embodiments, the system is so configured that the user can reverse the flow of the hydraulic fluid. Therefore by additional strokes of the control cylinder the user can remove hydraulic fluid from the
slave cylinder 1418 and transfer it back to thereservoir 1422. - Thus, those of skill in the art will appreciate that the devices described herein provide a relatively easy and economical instrument to perform minimally invasive surgery.
- One skilled in the art will appreciate that these devices are and may be adapted to carry out the objects and obtain the ends and advantages mentioned, as well as those inherent therein. The methods, procedures, and devices described herein are presently representative of preferred embodiments and are exemplary and are not intended as limitations on the scope of the invention. Changes therein and other uses will occur to those skilled in the art which are encompassed within the spirit of the invention and are defined by the scope of the disclosure.
- It will be apparent to one skilled in the art that varying substitutions and modifications may be made to the invention disclosed herein without departing from the scope and spirit of the invention.
- Those skilled in the art recognize that the aspects and embodiments of the invention set forth herein may be practiced separate from each other or in conjunction with each other. Therefore, combinations of separate embodiments are within the scope of the invention as disclosed herein.
- All patents and publications mentioned in the specification are indicative of the levels of those skilled in the art to which the invention pertains. All patents and publications are herein incorporated by reference to the same extent as if each individual publication was specifically and individually indicated to be incorporated by reference.
- The invention illustratively described herein suitably may be practiced in the absence of any element or elements, limitation or limitations which is not specifically disclosed herein. Thus, for example, in each instance herein any of the terms “comprising”, “consisting essentially of” and “consisting of” may be replaced with either of the other two terms. The terms and expressions which have been employed are used as terms of description and not of limitation, and there is no intention that in the use of such terms and expressions indicates the exclusion of equivalents of the features shown and described or portions thereof. It is recognized that various modifications are possible within the scope of the invention disclosed. Thus, it should be understood that although the present invention has been specifically disclosed by preferred embodiments and optional features, modification and variation of the concepts herein disclosed may be resorted to by those skilled in the art, and that such modifications and variations are considered to be within the scope of this invention as defined by the disclosure.
Claims (18)
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US11/352,899 US7470268B2 (en) | 2000-07-20 | 2006-02-13 | Hand-actuated articulating surgical tool |
US12/336,950 US8105319B2 (en) | 2000-07-20 | 2008-12-17 | Hand-actuated articulating surgical tool |
US12/792,630 US20100241137A1 (en) | 2000-07-20 | 2010-06-02 | Hand-actuated articulating surgical tool |
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US20060195071A1 (en) | 2006-08-31 |
AU2001280635B2 (en) | 2006-09-21 |
DK1309277T3 (en) | 2008-10-06 |
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US6607475B2 (en) | 2003-08-19 |
AU8063501A (en) | 2002-02-05 |
WO2002007608A2 (en) | 2002-01-31 |
CA2415250A1 (en) | 2002-01-31 |
EP2005914A2 (en) | 2008-12-24 |
DE60134236D1 (en) | 2008-07-10 |
JP2004504095A (en) | 2004-02-12 |
EP1309277A2 (en) | 2003-05-14 |
KR20030040365A (en) | 2003-05-22 |
EP1309277B1 (en) | 2008-05-28 |
ES2310186T3 (en) | 2009-01-01 |
ES2383004T3 (en) | 2012-06-15 |
US7470268B2 (en) | 2008-12-30 |
EP2005914A3 (en) | 2008-12-31 |
US20050090811A1 (en) | 2005-04-28 |
US8105319B2 (en) | 2012-01-31 |
ATE551965T1 (en) | 2012-04-15 |
EP2005914B1 (en) | 2012-04-04 |
US20090105727A1 (en) | 2009-04-23 |
ATE396650T1 (en) | 2008-06-15 |
WO2002007608A3 (en) | 2002-06-20 |
KR100834843B1 (en) | 2008-06-04 |
CA2415250C (en) | 2010-07-06 |
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