WO1996010953A1

WO1996010953A1 - Specification of amendment a percutaneous multicannula guide for biopsies and other percutaneous interventions

Info

Publication number: WO1996010953A1
Application number: PCT/US1995/013346
Authority: WO
Inventors: Gary H. Baker
Original assignee: Baker Gary H
Priority date: 1994-10-05
Filing date: 1995-10-04
Publication date: 1996-04-18

Abstract

A percutaneous multicannula guide (20) is presented having at least one channel cannula (22) for transmittal of interventional devices, and at least one guide channel cannula (24) designed to follow over a guide mandrel (12) or heavy j-wire guide mandrel (30). The multicannula guide (20) can be used for repeated tissue sampling by rotating the channel cannula (22) about an axle formed by anchor mandrel (30).

Description

SPECIFICATION OF AMENDMENT A PERCUTANEOUS MULTICANNULA GUIDE FOR BIOPSIES AND OTHER PERCUTANEOUS INTERVENTIONS BACKGROUND OF THE INVENTION

Background — Field of Invention The invention herein is an independent percutaneous guide instrument comprised of a plurality of cannulas or lumens joined permanently side-to-side and a method defining a positioning means for said multicannula guide requiring medical imaging and an anchor means between guide and target to maintain guidance during target movement, to immobilize target during interventions, and to be an axle around which the interventional channel of the guide can be repositioned to face a new locus on the target, in order to facilitate a variety of percutaneous surgical interventions that biopsy, view, treat or otherwise analyze subcutaneous tissue targets.

Background — Description of Prior Art It has become common to take samples of or to view or treat inner tissue of man and animal with devices which pass through the skin. These tissue samples are used to diagnose various diseases such as cancer without resorting to open surgery. Guidance by medical imaging becomes necessary when targets are not adequately located by external palpation. Currently there is great importance placed on early diagnosis of breast cancer through the use of mammography. Early intervention appears to substantially alter the outcome of the disease. Mammographic screening results in frequent detection of small abnormalities within the breast, often not palpable by the doctor or the patient. Mammography is unable to differentiate between malignant and benign abnormalities most of the time. Thus the patient is confronted with the worry, cost, discomfort and disfigurement of open surgical biopsy as a result of these frequently detected but indeterminate mammographic abnormalities. Most commonly, the abnormality is found to be benign upon biopsy. The only current method of making a definitive diagnosis of breast cancer is by microscopic examination of the suspect tissue. Techniques, other than open surgical biopsy, are desired to obtain a sample of the suspicious tissue for the necessary microscopic examination. Stereotactic mammography-guided core needle biopsy devices which pass through the skin to sample the suspicious target have become a popular alternative to open surgical biopsy. Recent studies suggest these tissue cores, obtained using stereotactic mammographically guided biopsy with large 14 gauge needles, are equal in microscopic diagnostic accuracy to open surgical biopsy (Lindfors, K K et al, Radiology 1994; 190:217-222. Schmidt, RA, CA-A Cancer Journal for Clinicians 1994; 44:172-191). Since the odds favor a benign microscopic diagnosis, open surgical excisional biopsy is purposely confined to the margins of the abnormality to reduce the amount of tissue removed and lessen breast disfigurement. These small disease- free margins around the open surgical biopsy specimen frequently are not adequate when the abnormality turns out to later be diagnosed a cancer. In practice, a second open surgery is required for re-excision of additional tissue for malignant biopsies. If the malignant nature is known or highly suspected prior to open biopsy, larger adequate margins or whole breast removal will be chosen by the surgeon. Pre-surgical knowledge can be obtained by means of percutaneous breast biopsy. Percutaneous biopsy has thus become attractive also to surgeons. Ideally only patients with malignancy need open surgery and then only once. Stereotactic, mammography-guided, large-core needle biopsy has become the most popular method for percutaneous incisional breast biopsy. Most stereotactic, mammography-guided methods clamp the breast in a stationary compression device between a top and a bottom paddle above a film holder. Two x-ray views are taken by moving the x-ray source through an arc of 12°-20°, without moving the breast or the device holding it. These different views are analyzed to determine the X, Y, and Z (depth) coordinates of the abnormality and a biopsy needle is guided to that locus for tissue biopsy. Usually the stereo biopsy needle is guided by an external needle holder, but some percutaneous coaxial needle holder cannulas pass through the skin and tissue. The biopsy needle is then passed through the holder. Same-day stereotactic mammography-guided 3 large needle core biopsy with histology has become preferred to small needle cell- aspiration biopsy and cytology and is being commercialized with vigor as a replacement for open surgical biopsy, touting reductions in cost, waiting period and breast disfigurement. When a suspicious breast lesion can be visualized by medical sonography , sonography can be used instead of stereotactic mammography to guide large needle core biopsy. This set of conditions exists for less than 25% of suspicious breast abnormalities. Stereotactic mammographic guided biopsy requires costly equipment and costly floor space which are new expenses. These expenses are in addition to the widely available dedicated mammography equipment used to initially image the breasts. Stereotactic mammographic guided biopsy suffers from several drawbacks including: cost; needle track seeding with malignant cells; limitation of depth of thrust of needle biopsy apparatuses; patient movement during X, Y, Z calculations of the abnormality and the mobility of the suspicious" breast tissue resulting in target misses during needle thrust, and other problems (Kopans DB, Radiology 1993; 189:665-666. Harter LP et al, Radiology 1992; 713-714. Jackson VP et al, Radiology 1991; 181:633-634, Parker SH et al, Radiology 1990; 176:741-747.). Prior art related to the invention includes: 1. Percutaneous cannula guides have been used to guide biopsy devices to their target tissue for repeated sampling. These are coaxial in design. The cannula goes to or toward the abnormality, but not through it. The biopsy needle passes through the guide cannula. Also, some current needle biopsy devices incorporate outer cutting cannulas which can be left in situ while the specimen is removed by withdrawing the stylet only (Radiplast AB, Uppsala, Sweden; Biopty Needle, Bard Inc., Covington. GA: Lindgren, 4,699,1545 1987 Oct 13 or Taylor, Alan N. 5,249,582 1993 Oct 5.) The outer cutting cannula, left in situ, can be used to guide return to the general location of the prior biopsy. Unfortunately the outer cannula has been thrust forward of its initial preferred pre-biopsy position and must be withdrawn partially to return to the preferred site. Such coaxial guide cannulas present only one trajectory through the tissue target, allowing only different depths of target biopsy unless the whole system is withdrawn and redirected by new imaging guidance. Coaxial devices for biopsy do not completely transfix the target. They maintain only tenuous relationships to the target, so patient, cannula or target motion may result in a miss. These disadvantages are also true for the multi-lumen biopsy cannula designed by Zatloukal et al (US Patent 4,850,373, 1989 Jul 25). It remains essentially a coaxial device, which greatly limits the amount of new target tissue available on repeated biopsies unless the whole cannula is repositioned. Its quarter-moon-shaped extra lumen(s) was not designed for the purpose of transmission of guide pins, fixation wires or other tissue sampling devices. 2. Stylets, wires, pins and mandrels have been used as guide devices for biopsy . Previously, they have all been coaxial. (See 3. below.) The stylet is removed after the biopsy device has been positioned over it. The specimen is difficult to capture and remove when the guide pin is left in situ. The guide pins must be removed because there is only a single channel for biopsy, not two, as in the invention herein. Therefore, these coaxial guide pins are good for only one tissue sample. They must be repositioned by using medical imaging if additional samples are desired. The ingenious large stylet and guide mandrel of the breast biopsy device of Kornberg et al (Patent 5,111,828, 1992 May 12) is coaxial, too, and can only obtain one biopsy with each guide placement, but it is excisional, so this point is not important. The large size of his device required for excision of common abnormalities makes it approach the difficulty of open biopsy, especially in patients with tough fibrous breasts. 3. Multiple cannulas joined side-to-side with target immobilization for the purpose of image-guided interventions have not appeared in the medical or patent literature during search for initial application filing date of 1994 Oct 5. Since that search, the PTO has issued Kambin (US Patent 5, 395, 317, 1995 May 7). Kambin, employs a jig as a means to join and to guide a second tandem cannula alongside the first image-guided cannula. The joining means jig (a)is entirely external. The joining means jig in Kambin (b)does not provide a solid permanent joining, and (c)the joining means cannot penetrate into subcutaneous tissues, and (d)insertion or withdrawal or rotation forces applied to one cannula will not predict the behavior of the movement of the other cannula nor (e) will external forces on the proximal ends of both cannulas predict the behavior of the internal distal ends of both cannulas. The invention of record teaches each of these features, distinguished entirely from Kambin. Kambin and other prior art does not teach to transfix the target with one offset longer cannula or with a guide mandrel, thereby providing a method to rotate the biopsy guide cannula around this axle to seek new target regions for new biopsies. Kambin does not anchor the cannulas with any sort of hook. The other multilumen biopsy device (see 1. above-Zatloukal et al -US Patent 4,850,373, 1989 Jul 25) is a circular cross-section outer cannula containing a O 96/10953 PCI7US95/133 6

5 close fitting inner biopsy cannula with its circular cross section flattened less than 1/3 its maximal diameter, producing a 1/3 moon-shaped extra lumen between inner and outer cannulas. Its extra lumen(s) was designed for purposes other than those of the current invention and ill-designed to provide for these purposes without substantial modification. Coaxial, these cannulas are not joined. One is free to rotate inside the other, thereby failing to provide a predictable orbit for the application channel to rotate around the axle in the target in order for the application channel to appose a new locus on the target. 4. External needle guides, some employing cannulas, have been used to hold and guide percutaneous biopsy needles (Siczek et al Patent 5,078,142 , 1992 Jan 7, Aarnio et al Patent 5 107 843, 1992 Apr and others). Most of these guides are external and require stereotactic positioning. One such device includes a combination of external and percutaneous guides (Teubner et al Patent 5,219,351, 1993 Jun 15). Part of Teubner's stereotactic guided device is called a needle in his patent, but it is a percutaneous guide cannula. It is coaxial and stereotactic, so suffers from most of the drawbacks of these methods. It solves one of the stereotactic biopsy problems (difficulties with targets lying near the posterior skin surface) by allowing the biopsy needle the freedom to angle away from perpendicular to the image receptor and one problem not pertinent to the invention herein (improved choice of puncture site). Teubner's stereotactic guided device is expensive and access to it is limited. External guide devices are distant from the target and subject to needle trajectory deflection and to patient or target motion. Hook mandrels, removable hubs, cannulas and stylets are parts of this present invention. They are all prior art and are not claimed independently.

Objects and Advantages The present invention is a multicannula guide comprised of at least two joined cannulas and a method to employ said multicannula guide for various surgical interventions through one of its channels. One cannula channel is slidably passed over an image-guided percutaneous mandrel, thus providing at least one extra open passageway to the tissue target for surgical interventions through the second cannula. The multicannula guide is made up of 2 or more cannulas permanently joined side-to-side so they are not coaxial. The multicannula guide invention proposes to replace stereotactic breast biopsy with a percutaneous biopsy technique which is guided by less costly, standard, widely- available non-stereo imaging equipment. The aciculate guide mandrel is aimed using common, public-domain, non- stereo mammographic or sonographic guidance techniques. The guide mandrel transfixes deeply through the target. One channel of the multicannula guide is placed over the guide mandrel. This guide channel cannula follows the guide mandrel through intervening tissue to the target transfixed previously by the guide mandrel. One or more unused application channel(s) of the multicannula guide is used to slidably transmit any of several compatible existing biopsy needles or other interventional devices through the skin and inner tissues, guiding them to the tissue target. The application passageway(s) of the multicannula guide can also be used for passage of other devices, used for applications other than tissue sampling, which share the need for precise positioning in a tissue target area and one or more open passageways to the target area. The embodiment of the device presented herein is tailored to function with guidance from a standard diagnostic mammograph but is also suited to guidance by medical sonographic imaging equipment. Both of these imaging methods are ubiquitous throughout the medical community. The present invention does not require the use or purchase of a stereotactic mammograph nor the space to install or use it. The multicannula guide device should be helpful when obtaining multiple tissue samples using medical sonographic guidance. The invention method is substantially independent of the medical imaging method used for guidance and of the body part being biopsied. The proposed device differs from prior art because it is multi-axial, rather than coaxial. The multi-lumen cannula follows the guide mandrel to the abnormality, pierces and holds the abnormality with the guide channel cannula while it biopsies the transfixed abnormality through the application channel cannula(s). The eccentric central axes of the multilumen channels and the target immobilization provided by the guide channel cannula and mandrel permits rotation of the application channel cannula around the transfixing guide channel cannula. This action exposes the application channel cannula to different portions of the target for sampling without the need to withdraw and re-direct the guide system. a. The primary object sought by this multicannula guide device invention is to provide a guide and passageway channel(s) to use existing percutaneous biopsy instruments assisted by commonly owned medical imaging equipment to reliably obtain subcutaneous tissue samples from specified sites using commonly performed techniques. Invention Advantage: Innumerable facilities exist where radiologists have learned to perform pre-biopsy needle localizations of non-palpable lesions for subsequent open surgical biopsy by their surgeons. The imaging equipment and technical know-how are the same as those required for employment of this technique for biopsy using the multicannula guide. Invention Disadvantage: This device has not yet been used in a large number of cases, nor subjected to randomized research trials. Stereotactic breast biopsy, on the other hand, has been through these tests. b. A further object is to reduce medical costs by eliminating purchase of expensive stereotactic imaging equipment currently considered essential for percutaneous breast biopsy. Invention Advantage: The components of the multicannula guide set appear inexpensive to produce. There are no special imaging add-ons or stereotactic devices to purchase and amortize within the patient fee. Mammography centers unable to afford stereo can biopsy their own few patients. Stereotactic percutaneous biopsy is at least one third the expense of an open surgical biopsy, often more. This invention expects to reduce this expense, because of low equipment cost and a shorter procedure time. c. A further object is to make the multicannula guide and mandrel and their position visible on medical images in order to remain confident throughout the procedure of their three-dimensional (x,y,z coordinates) relationship to the tissue biopsy target. Invention Advantage: By choosing appropriate fabrication materials and cannula sizes, this device can be modified for easy visibility with Mammography, Medical Sonography, Standard X-ray and Fluoroscopy, Computed Tomography or Magnetic Resonance Imaging (MRI). Nitinol and Stainless Steel materials should work for all but MRI. d. A further object is to enable multiple tissue samples to be obtained from several adjacent sites within or very near the tissue biopsy target avoiding repeated repenetration of skin and intervening normal tissues. As many as 5 to 15 large core biopsy specimens are currently considered usual and necessary for large core needle biopsy of breast. Invention Advantage: Transfixion of the target by an off-set bayonet and Anchor guide mandrel prevent a change in relationship between the target and the mandrel. The off-set axis of the application channel cannula of the multicannula guide device allows new portions of the abnormality to be sampled as the application channel cannula is rotated around the long axis of the guide channel cannula transfixing the target. Biopsy depth may also be varied. All guide device maneuvers can be performed without withdrawing the guide. The various biopsy devices freely pass slidably in and out of the application channel cannula many times without repeated penetration of skin or intervening normal tissue. Prior Art Disadvantage: Stereotactic and Coaxial devices require withdrawal and redirection to reach new areas of the target. Multiple passes through tissue often leave the breast temporarily bruised and pin-cushioned in appearance. e. A further object is to eliminate reimaging for each tissue sample. Stereotactic biopsy requires periodic re-imaging, because slight patient movements and biopsy tissue displacements require re-confirmation and re-calculation of target location. Invention advantage: Transfixion of the target by the off-set bayonet guide channel cannula and mandrel provide a stable known relationship to the target. Therefore, re- imaging is usually unnecessary. Since the mandrel and the bayonet guide channel cannula hold the lesion confidently, the off-set application channel cannula can be rotated around the mandrel and guide channel cannula in a measured, reliable fashion, exposing the slidably transmitted biopsy device to new portions of the target or adjacent tissue at a known measurable distance from the prior sample. Prior Art Disadvantage: Coaxial guides allow repeated passage of biopsy devices, but suffer because they offer only one pathway through the target. To obtain tissue from a new part of the target, they must be re- directed and their position reconfirmed by imaging means. f . A further object is to enable fixation between the multilumen guide and mandrel and the tissue biopsy target such that their relationships remain stable during moderate patient movements. Some stereotactic large core biopsies resulting in false-negative diagnoses have been blamed on patient movement between the time of imaging and the time of actual needle biopsy. The stereo guided biopsy needle was sent to the prior location of the target, but in the meantime, the patient and the target had moved. Invention Advantage: Very great patient motion would be required to substantially change the transfixed relationship between the bayonet guide channel cannula of the multicannula guide plus its Anchor guide mandrel and the transfixed target. If the patient and target move, the guide goes with them. After major patient movement another image could be obtained to prove the sustained, transfixed relationship. Prior Art Disadvantage: Unstable, unreliable relationship between target and biopsy needle is a serious drawback to both stereo and coaxial techniques. Prior to thrust, the biopsy needle is usually poised in tissues just out side the target or barely entering it in a tenuous relationship. Patient or biopsy movements can change said tenuous relationship significantly, resulting in target misses or requiring re-imaging. g. A further object is to enable fixation between the multilumen guide and mandrel and the tissue biopsy target such that the tissue biopsy target cannot slip out of the path of the biopsy device during the forward needle thrust of tissue sampling action. Some large core biopsies with false-negative results have been blamed on tangential needle biopsy thrusts at firm targets located in soft pliable breast tissue. The target was able to slip to the side and avoid penetration. Invention Advantage: The mandrel and the bayonet portion of the needle transfix the target before the biopsy device is employed. The transfixed target is unable to move off to the side during biopsy thrusts. h. A further object is to enable retrieval of multiple biopsy specimens inside the guide device channel with less potential to seed malignant cells or bacteria in the needle track that passes through normal intervening tissue. In the medical literature, needle track seeding with malignant cells has been documented histologically in a breast which was surgically removed for cancer after undergoing large core stereotactic needle biopsies (This case had only 5 core biopsies. Currently stereotactic biopsy averages 5-15 cores. Harter L P et al, Radiology 1992; 185:713-714). Invention Advantage: Only the multilumen guide passes through intervening tissues after biopsies, during its withdrawal at the end of the procedure. i. A further object is to reliably permit safe, long-throw biopsy thrusts. Invention Advantage: The method associated with the positioning means using multicannula guide (Fig B) operates with the biopsy needle parallel to the compression paddle and film holder, rather than perpendicular. Biopsy thrusts are in the direction of the long dimension of the compressed breast. Skin penetration problems can be totally averted. Only long-throw needles are needed. Prior Art Disadvantage: Most stereotactic biopsy units operate preferentially with the needle perpendicular to and directed toward a compression paddle or film holder. Fig A. This is the shortest dimension of a breast flattened by these compression paddles. Small breasts or targets near the far skin surface run the risk of biopsy needle penetration of the skin on the far side of the breast and damage to the biopsy instrument or the compression paddle or film holder plus potential impairment in the quality of the biopsy.

In these situations, using stereotactic techniques, sometimes a short- throw biopsy needle must be employed, a needle which has proved to provide inferior tissue specimens compared to long-throw needles. Also the periodic use of a short-throw needle requires the inventory expense of owning and stocking separate short-throw equipment. j . A further object is to improve mechanical function of the biopsy device by placing it freely slidable within a rigid empty cannula lumen, unaffected by friction or pressure from outside intervening tissues. . Invention Advantage: Inserted through compressed breast tissue, rather than inside the multicannula invention device lumen, the action of the biopsy device in many stereotactic units is retarded by pressure from the compressed breast on the walls of the outer cutting cannula. k. A further object is to shorten procedure time. Invention Advantage: Less imaging time for guidance and less time to obtain multiple samples. 1. A further object is to permit an adequate number of biopsy cores to be confidently obtained even if the target becomes obscured to medical imaging by biopsy-induced bleeding. Invention Advantage: Guided by the readily visible multicannula guide and mandrel and by the confidence that the target remains transfixed as documented on earlier clear images, biopsy cores can continue to be obtained, even after the target image is obscured by bleeding. Prior Art Disadvantage: Procedures such as stereotactic biopsy, which rely on clear images to localize the target periodically, are abandoned whenever the target becomes obscured. m . A further object is to permit a low trauma patient experience. Invention advantage: The 5 to 15 needle passages through the intervening breast tissue, required with most stereotactic biopsy units, are replaced by a single positioning of the multicannula guide. Subsequent biopsies are performed by passing the biopsy device through the guide's application channel cannula. Invention Disadvantage: The Multicannula guide is larger, with two lumens, one of which is larger than the 14G biopsy needle which must pass inside it. n. A further object is to prevent the target from slipping off the transfixing bayonet guide channel cannula and the mandrel itself. Also, it is very important to provide a strong mandrel and guide channel lumen to prevent accidental transsection by the biopsy device. Invention advantage: In the current preferred embodiment, an Anchor guide mandrel of heavy gauge protrudes out of the distal guide channel cannula. Its hook prevents target escape. Its hook prevents excess guide penetration also. Guide length is designed to match biopsy needle length to prevent biopsy depths beyond the bayonet guide channel cannula. Together the guide channel cannula and the mandrel present formidable strength preventing transsection by cutting biopsy devices. N.B. It must be noted that the curved J-hook on the distal end of the mandrel is not a necessary component of this invention. It can and has been substituted with a solid, straight mandrel (guide pin), preferably with a removable hub and an acicular tip (Surgical Dynamics, Concord CA). However, the Anchor Guide serves the several benefits described herein, though it requires the acicular tip mandrel and an exchange cannula for delivery through the target. o. A further object is to provide a joining means between the two cannulas that forms a completely solid one piece multicannula guide. . Invention advantage: The joining means travels with the multicannula guide into the subcutaneous tissues and ensures that the application channel cannula ends directly beside the guide channel cannula and its contained guide mandrel. This joining means offers the advantage that rotational or push/pull movements applied externally to the proximal end of one or both cannulas thereby predicts the movement of both cannulas' internal distal ends, especially since they are further aligned along a guide mandrel axle. The external movement that is visible to the naked eye predicts the internal non- visible movement without need to resort to medical imaging. Prior Art Disadvantage: Wherever prior art multichannel devices for percutaneous interventions have been fabricated, it has been with independent separately movable cannulas, either not joined at all or joined temporarily and joined external to the skin. Thus the movements and relationships between the multiple tandem cannulas could not be reliable predicted if they were orbited about one another. A further object is to minimize unnecessary utilization. Invention advantage: The current invention requires only imaging equipment already present and in use in all facilities performing mammography, so does not require purchase or amortization of new devices other than the simple multicannula guide set itself, which will probably cost less than the disposable assessories reqviired for stereotactic biopsy. Prior Art

Disadvantage: It is known in many fields of medical study that availability of expensive equipment often induces increased utilization of the associated procedure. First, there is the matter of convenience and availability often accompanied by zealous promotion of perceived value. Importantly, there is the need to amortize the cost of the expensive (stereotactic breast biopsy) equipment by using it on large numbers of patients.

Still further objects and advantages will become apparent from a consideration of the ensuing description and drawings.

Reference Numerals In Drawing Figures

12 Stylet for Application Channel 14 Hub-for Stylet Cannula

16 Bevel distal tip for Stylet 18 Aciculate Guide Mandrel

20 Multicannula Guide 22 Application Channel Cannula

24 Guide Channel Cannula 26 Sharp cutting edge, distal cannulas

28 Permanent Joining Means 30 Anchor Guide Mandrel

32 J-hook distal mandrel 34 Tissue Dilator Cannula configuration

40 Depth-penetration Stop 42 Set screw

44 Hole Side Lobe-fits over Anchor 46 Hole-for Application Channel Guide Mandrel & Guide Cannula Channel Cannula

50 Removable Hub 54 Large cylindrical partial bore-fits over cannulas

56 Small cylindrical complete bore-fits 60 Single Lumen Cannula over mandrels

70 Star-shaped target abnormality in 71 Top mammograph film holder breast 72 Compression paddle extension 73 Bottom mammograph compression arm paddle and film holder

74 Small top mammograph 75 Biopsy apparatus—Spring-loaded compression paddle Gun and Biopsy Needle

Brief Description of Drawings Fig 1 shows several examples of the aciculate guide mandrels 18 , in various diameters. Tiny diameter mandrels require passage of small stiffening cannulas over them before they are strong enough to serve as guides for larger cannulas. Fig 2 shows the single lumen cannula. Fig 3 shows anchor guide mandrel 30 and J-hook distal configuration. It is approximately 2 1/2 times the length of the multicannula guide. Fig 4 shows the multicannula guide 20 and an enlargement of its distal end. Fig 5 shows tissue dilator cannula 34 . Fig 6 shows the stylet 12 that fits the large application channel cannula member of the multicannula guide. Stylet keeps application channel cannula clean during tissue penetration with multicannula guide. Fig 7 shows the front and rear of a removable hub. This hub is designed to fit on the aciculate mandrel, anchor guide mandrel, the single lumen exchange cannula, and the multicannula guide application channel cannula. Fig 8 shows the depth-penetration stop, slidable on the outside of the multicannula guide. Fig 9 shows the introduction set, with an assembly of removable hub, single lumen cannula, and anchor guide mandrel with the distal J-hook configuration retracted into the cannula thereby straightening the J-hook. Fig 10 shows an assembly diagram for the stylet, the depth penetration stop, the multicannula guide and the anchor guide mandrel. Fig 11 shows the same components as Fig 10 after assembly. Fig 12-a shows a side view of a patient with her breast compressed by a fenestrated, grid coordinate compression paddle 71 in the lateral projection. Portions of the mammograph (the Tube Head) are not pictured, since they would obscure visibility of the compression paddle from this perspective. A suspicious target 70 is shown in the breast. Fig 12-b to 12-e show the same projection of the breast Fig 12-b is the same as 12-a, simplified and magnified.. Fig 12-c shows the fenestrated paddle and the breast punctured by three aciculate guide mandrels, one of which transfixes the target perfectly. Fig 12-d shows selection of the best "hit" mandrel and removal of the other two. The single lumen cannula or, alternatively, the tissue dilator cannula has been passed deeply over the aciculate guide mandrel to serve next as an exchange cannula. Fig 12-e shows that the aciculate guide mandrel has been removed and exchanged for the anchor guide mandrel, reforming its J as it is pushed out the distal end of the exchange cannula. Fig 12-f repeats, for viewer convenience, images of the aciculate guide mandrel, the single lumen cannula for exchanging guides, the tissue dilator cannula which can be used in place of the single lumen cannula and the anchor guide mandrel. They have been labeled the "Introduction Set". Fig 12-g again shows the patient with the mammograph turned 90° for a craniocaudad (top) view. The suspicious target is somewhere on the anchor guide mandrel, but now the mandrel is parallel to the film. Fig 12-h views the patient's breast in new position as from above, over the patient's shoulder, just as it will be seen on the film images. The anchor guide mandrel, now parallel to the compression paddles, is seen passing through the star-shaped target. The fenestrated compression paddle is no longer needed and has been replaced by a smaller paddle, which allows easier operator access and instrument manipulation around the edges of the breast, near the skin puncture site. N.B. Except for use of aciculate-tips, hubless needles, dilators, stiffer hook-wires and the multicannula, drawings 12a-12h portray maneuvers performed daily now for pre-biopsy needle localization of non-palpable breast lesions done prior to open surgical biopsy. Differences exist in compression paddles used, needle hubs and tips and styles of hook wires, but the procedural method and intent is the same. World-wide, thousands are expert in this procedure. Fig 12-i shows the same image as Fig 12-h, but after the multicannula guide has been inserted a pre-measured depth, following over the anchor guide mandrel to the target. Now the anchor guide mandrel and the guide channel cannula transfix the target and the application channel cannula is poised ready to transmit a biopsy apparatus to the front surface of the target. Fig 12-j shows the same view. A biopsy apparatus (in this instance, a spring loaded biopsy gun 75) has been loaded through the larger application channel cannula member of the multicannula guide and fired into the target, cutting and capturing a tissue core sample. Fig 12-k show two blown up images of 12-j. One image shows the biopsy needle capturing a specimen at 6 o'clock on one side of the target. The second image is identical except that the multicannula has been slidingly rotated 180° around the anchor guide mandrel axle and guide channel cannula sleeve to capture a specimen at 12 o'clock. In between there are lots of other specimens to be taken. Backing out slightly and bending the multicannula sideways allows specimens to be obtained at a distance away from the transfixed site in the target. Fig 13-a through Fig 13-d are samples of variations and ramifications on the basic invention concept of a transfixing guide mandrel slidably fitting inside a guide channel cannula joined to an eccentric, substantially-parallel application channel cannula. Fig 13-a: conceptualizes changes in the lengths and overlap of cannulas, including off-parallel configurations (not shown). Fig 13-b: shows configurations for the multicannula guide device which call for spacer joining or additional lumens in various relationships. Fig 11-c: Considered a variation on the tandem multicannula, this drawing shows a single application channel cannula joined permanently in tandem with a solid pointed guide mandrel. Fig 11-d: Considered a variation on the multicannula invention, this drawing shows a single application channel cannula following over a separate pointed guide mandrel using designs other than a guide channel cannula to follow the guide mandrel essentially in tandem and parallel. The drawing depicts a loop snare joining means and a pointed guide mandrel, but variations familiar to those skilled in the art should be considered ramifications. Fig 11-e: Shows alternative guide mandrel designs.

Invention Description — Figures 1 to 11 The invention is defined by two components, a new multicannula guide device and a new method to deploy said guide and use it to assist repeated percutaneous surgical interventions. The method is described in the next section. Aciculate Guide Mandrel(s) 18 is used to pierce the skin at the site determined on medical images to overlie the target. Aciculate Guide Mandrel(s) 18 is aligned to the xray beam and passed deeply, since the depth of the target is not yet known. (Fig 1) After images show successful transfixion of the target by Mandrel 18, Single Lumen Cannula 60 (Fig 2) is passed deeply over Aciculate Guide Mandrel 18 to match their tip depths. Anchor Guide Mandrel 30 is after loaded into Single Lumen Cannula 60 after removing Aciculate Guide Mandrel 18 . Anchor Guide Mandrel 30 is advanced out the distal aperture of Cannula 60 to reform anchor J-hook 32. In the current preferred embodiment, Mandrel 30 (Fig 3) is made of Nitinol. Only with great force and sharp instruments can it be cut. Deployed beyond cannula 60, J-hook 32 reforms, anchoring itself deep to the target. When pliable tissue (i.e. breast) is removed from the imaging device, the tissue re-expands to its normal shape and thickness. J-hook 32 prevents the distal end of mandrel 30 from withdrawing as the tissue re-expands and as the it is mobilized for a new view. J- hook 32 will also prevent multicannula guide 20 (Fig 6) from over-penetrating beyond the shaft of mandrel 30. J-hook 32 eliminates the possibility that the biopsy thrusts will push the target lesion off the distal end of mandrel 30. Stiff cannulas (20, 34 or 60) can slidably follow over mandrel 30, but cannot be advanced beyond a deployed J-hook 32. On the other hand, it is easy to withdraw mandrel 30 into cannula 60 or 20, straightening J-hook 32 and allowing repositioning of cannulas. Multicannula guide 20 (Fig 4) is the essential device component of the invention. Two or more cannulas are joined side to side in a substantially parallel fashion. Joining may be by any secure method such as welding, soldering or adhesives. One of the multicannula guide 20 passageways, the guide channel cannula 24 follows over the shaft of Anchor guide mandrel 30 . One or more substantially parallel passageway(s), the application channel cannula(s) 22 in the multicannula guide is (are ) available to transmit compatible tissue sampling or testing apparatuses. Both types of Channel Cannula members 22 and 24 have sharpened distal tips. Member 22 and member 24 are substantially parallel and joined at 28 where Guide channel cannula 24 overlaps distal to Application channel cannula 22 by about 30mm, forming a bayonet shape. Application channel cannula 22 of Multicannula Guide 20 is of sufficient internal diameter and length to provide access for transmittal of common core biopsy instruments which perform their functions just beyond the distal aperture of this cannula. Multicannula Guide 20 can be modified to be useful for a variety of biopsy tools and other interventional devices. Different breasts offer different resistance to penetration. In firm breasts Tissue Dilator Cannula 34 (Fig 5) may need to be employed. Tissue Dilator Cannula 34 has thick walls, an aciculate distal end and a central bore. Dilator 34 follows mandrel 30 and spreads firm tissues which are otherwise difficult to negotiate with multicannula guide 20 alone. Tissue Dilator Cannula 34 can be used in place of Single Lumen Cannula 60 as the exchange cannula for deployment of Anchor Guide Mandrel 30. Stylet 12 (Fig 6) fits inside and runs the length of application channel cannula member 22. Stylet 12 prevents clogging of application channel cannula member 22 during penetration of multicannula guide 20. Essentially all the equipment except accessory stylet 12 have no hubs, in order that one component can pass over the other. Removable hub 50 (Fig 7) is supplied because it is useful in very difficult penetrations or torque movements, but is often unused. Large hub 50 assists in "shadow guidance" of the trajectory of Aciculate Guide Mandrel 18., by centering the hub shadow produced by the localizer light source emanating from the xray tube housing of the mammograph over the puncture site. Hub 50 is removed during imaging because some tissue targets are so small that they are obscured by superimposed hubs. After multicannula guide 20 has been positioned at the desired depth, unrecognized further penetration or withdrawal is undesirable . After multicannula guide 20 has reached the desired relationship to the tissue target, Depth-penetration stop 40 (Fig 8) is slidably passed down multicannula guide 20 against the skin entrance site and set screw 42 is firmly tightened. Biopsy needle in gun 75 is passed down Application Channel Cannula 22 to obtain a tissue sample as many times as desired. After the first biopsy sample, Fig 12h shows the positioning means to obtain samples from other locations within the target without withdrawing Multicannula Guide 20 . Using Anchor guide mandrel 30 as a target transfixer, clock-wise or counter clock-wise rotation of Multicannula Guide 20 around guide channel cannula 24 sleeve and Anchor guide mandrel 30 axle allows application channel cannula 22 to point toward a new clock face location on the target, ready for repeat biopsy. This is novel. Between each sample, multicannula guide 20 is rotated slightly to sample a new area. Multicannula 20 can be advanced for deeper target samples. From the above invention description, a number of advantages of the preferred embodiment of the multicannula guide and guide method become apparent. The acicular tip of guide mandrel 18 is not deflected to the side during passage through tissue as a bevel tip would be. The J-hook 32 of amchor guide mandrel 30 can be retracted into cannula 60 or multicannula 20, so it can be removed or repositioned, but when deployed distal to cannula, it provides a tissue anchor to prevent easy dislodgment or withdrawal of mandrel 30. Removable hub 50 provides for through passage of mandrel 30 and attachment to cannula 60, guide mandrel 18 or multicannula guide 20. Hub 50 provides cannula trajectory guidance using the "shadow guidance" technique. Hub 50 can be removed to provide unimpeded viewing of mammogram images of the target. Mandrel 30 is tough nitinol and of sufficient diameter and stiffness to resist buckling or cutting when exchange Single Lumen Cannula 60, guide channel cannula 24 or dilator 34 are advanced over it. When deployed, J-hook 32 prevents excess penetration by various cannulas and tissue sampling apparatuses. The bayonet relationship between large application channel cannula member 22 and mandrel cannula member 24 provide two benefits. First, a softer, smaller Guide Channel Cannula 24 better fits and follows mandrel 30 to the target, dragging larger application channel cannula 22 behind it. Second, Guide Channel Cannula 24 covers and strengthens mandrel 30 in the tissue biopsy cutting area, further eliminating the possibility of transsection. Tissue sampling is performed just outside the distal end of application channel cannula member 22, alongside Guide Channel Cannula 24. Depth-penetration Stop 40 prevents inadvertent advancement of pre-positioned Multicannula Guide 20 and allows return to exact pre-positioning if the Multicannula Guide 20 is inadvertently or intentionally withdrawn. Further advantages of the invention will become apparent during the description of Operation.

Operation— Figures 12-a to 12-k The method for use of the invention for mammograph-guided breast biopsy is illustrated in Fig 12-a through 12-k and described herein. The patient is sitting up or lying on her side. A breast containing a tissue target abnormality (star- shaped lesion 70) is placed in between the compression paddles 71, 73 (Fig 12-g) of the mammograph. The top paddle 71 is fenestrated to allow passage of a needle or guide mandrel into the breast while it is held in compression. The top compression paddle 71 also has a grid for guidance purposes. This grid is visible on the paddle and also on the image of the breast along with target lesion 70. (Fig 12-b) This is prior art. Fenestrated mammography compression paddles like these are commonly available. Similar mammographic guidance methods are performed regularly at most mammography centers. Their purpose heretofore has been to assist in localizing non-palpable breast abnormalities discovered by mammography so the surgeon can find them during open surgical breast biopsy. The method begins with the placement of a diamond-tip or aciculate guide mandrel, designed to pass in a straight-line through skin, through tissues, and O 96/10953 PCIYUS95/13346

21 through target lesion 70. The mandrel itself is aimed at a target 70 by using medical imaging, such as standard mammography films: first to visualize the target; then to assist in pin guidance; and finally to confirm successful penetration of the target by the pin. In the case of Core Needle Biopsy of the Breast, at first the breast is immobilized continuously between a bottom film holder 73 and a top fenestrated paddle 72 for producing images, first image to find target 70 and therefore the appropriate skin puncture site. The second image confirms accurate placement of aciculate guide mandrel 18 through target 70, approximately perpendicular to film holder 73. Aciculate guide mandrel 18 is the first instrument used to puncture the skin, entering at a site predetermined by test (scout) image #1 and aligned to a trajectory determined by slidably attaching Hub 50 and employing the "shadow method". The Xray Positioning Light that emanates from the xray tube housing casts a hub shadow onto the breast. Aciculate guide mandrel 18 is passed a few mm into the skin puncture site. If the hub shadow is then centered over the puncture site, the puncturing guide mandrel is aligned to the same trajectory traveled by the xray beams when they produced the image of the target. One successful puncture through target 70 with stiff guide mandrel 18 is enough to follow over with single lumen cannula 60 or with the tissue dilator cannula 34. (N.B. In practice it is often better to deploy several tiny caliber long hubless guide mandrels, instead of one (Fig 12-c). Choose the best aimed one from among them based on their location on the subsequent test image #2. Remove the others. Over the chosen tiny guide mandrel, a close-fitting hubless stiffening cannula is passed, to make the sum of the two, coaxial mandrel and cannula, as stiff as one large guide mandrel 18 . Employing multiple tiny guide mandrels reduces excess imaging for targeting failures. In this document, a small guide mandrel plus its stiffening cannula sleeve are considered the same as one stiff aciculate cannula 18.) Single lumen cannula 60 is used to follow the aciculate guide mandrel 18 to and through the target (Fig 12-d). Once deeply placed, the guide mandrel 18 is removed and replaced by Anchor guide mandrel 30 (Fig 12-e), pushing it out the distal end of cannula 60, reforming its distal J-hook configuration 32. The target is now firmly transfixed and known to be located somewhere on Anchor guide mandrel 30, no matter if the target or patient moves. Tissue dilator cannula 34 may be used in place of the single lumen cannula 60 or may be used later to pass slidably over Anchor guide mandrel 30 to produce a tunneled out space in tough fibrous breasts for passage of multicannula guide 20 or may not be needed at all. Cannula 60 may be removed or left in place a little longer. O 96/10953 PCIYUS95/13346

22 Compression is released, the patient is removed for a brief rest and placed again in compression after the mammograph tube has been repositioned to aim approximately 90° from its initial xray trajectory. The fenestrated compression paddle is replaced with a small compression paddle to facilitate access to the puncture site. The long shaft of Anchor guide mandrel 30 is now approximately parallel to the imaging plane where its whole length is visible on medical image #3 (Fig 12-h). The penetration distance required to slidably insert guide channel cannula 24 of multicannula 20 over mandrel 30 can be obtained from image #3. Up to this point, very common techniques used for "needle localization of non-palpable breast lesions" have been described. Assembly of Multicannula guide is performed. Depth-penetration Stop 40 (Fig 9) is placed loosely over of multicannula guide 20. Stylet 12 (Fig 6) is placed inside application channel cannula member 22 of multicannula guide 20 (Fig 4) to prevent clogging of the lumen during transmission through intervening tissue. A small scalpel incision at the skin entrance of mandrel 30 is made large enough to transmit multicannula guide 20. Guide channel cannula 24 of multicannula guide 20 is slidably passed over the proximal end of mandrel 30 along with depth-penetration stop 40 . Depth-penetration stop 40 has been slidably positioned over multicannula guide 20 and tightened at the predetermined target depth. Guide Channel Cannula 24 of multicannula guide 20 follows mandrel 30 to the measured depth. If resistance to tissue passage of multicannula guide 20 is high, due to unusually firm breast tissue, tissue dilator cannula 34 (Fig 5 ) temporarily slidably replaces multicannula guide 20 over mandrel 30. Dilator 34 more effectively separates the breast tissues down to the level of target lesion 70 and provides the space through dense but normal breast tissue to advance multicannula guide 20 over mandrel 30 into target lesion 70. A mammogram is obtained to confirm or adjust the proper relationship between the multicannula guide 20 and target lesion 70 (Image #4 Fig 12-i). The relationship is considered good when Guide Channel Cannula 24 transfixes the target lesion 70 and application channel cannula member 22 is positioned apposed to the surface of target lesion 70 or alternatively at a specifically chosen depth within or next to target lesion 70. Stylet 12 is withdrawn. The desired appropriate tissue sampling apparatus 75 is selected, armed and passed slidably inside application channel cannula 22 of the multicannula guide 20 until tissue resistance is felt or until the pre-measured cannula length is reached. The tissue sampling apparatus 75 is usually positioned just short of target lesion 70, but it may be placed more deeply. The instructed manufacturer's procedure for the given biopsy apparatus 75 is followed to obtain a core tissue sample. In Fig 12-j, a spring-loaded gun 75 is fired, passing its biopsy stylet and cutting cannula through the target lesion 70 and cutting off and capturing a sample thereof. The tissue sampling apparatus 75 is withdrawn and the sample removed and deposited in an appropriate container. Multicannula guide 20 is twisted 20° to 180° about the long axle of mandrel 30 and guide channel cannula 24 , presenting a new portion of target lesion 70 to the distal end of application channel cannula 22. Tissue sampling apparatus 75 is reinserted and the tissue sampling and retrieval procedures are repeated (Fig 12- k). These procedural steps can be repeated many times, varying the rotational angle and the multicannula guide depth, until the desired number of target lesion samples have been obtained.

Ramifications and Variations — [Fig 11-a to Fig 11-d] — Fig 11-a to 11-e Ramifications and variations on the multicannula guide and means for positioning percutaneous tissue biopsy guide described herein fall into one or more anticipated design areas. Ramifications are described below by anticipated category. "Ramifications on this invention" are distinguished from issues of "prior art versus this invention". Category 1: Follow-over Guides:-Changes in design configuration of guide pin: A simple, straight, pointed, guide mandrel with a removable hub is the basic guide pin concept. It may eventually prove superior to the complex aciculate cannula and J-hook mandrel shown as the preferred embodiment herein. Variations in materials, length, flexibility, diameter and shape of guide pins are anticipated and indeed will be incorporated by the inventor for special conditions or when new imaging techniques are employed. Actual attachment of the transfixing guide pin to an application channel cannula of a guide or to the biopsy needle itself is an anticipated variation which infringes on the base concept of an immobilizing transfixing guide pin eccentric to the biopsy process. Changes in anchor means from J-hook, such as corkscrew, split diverging tip, and retractable barbed needles. Category 2: Changes in configuration and /or joining methods of the several cannulas into one multicannula guide: More than two cannulas; single cannula divided into multi-channels by septa or external shaping; changes in materials; changes in length of one or another component cannula; changes in joining means (permanent or detachable) or use of spacers between cannulas; lumen diameter, long-axis relationships (non-parallel, curved); lumen cross-section changes; new end shapes; different visualization methods or materials, new target immobilization techniques (corkscrew). Category 3: Changes in means for application channel cannula to follow guide mandrel; Noose, gutters, clamps, permanent attachment, etc. Category 4: Alternate methods of delivering or guiding both guide mandrel and multicannula guide to the target (large tube, cut-down, other imaging or non-imaging guidance such as endoscopic visualization, radio transmission control, magnetism detection) are all anticipated variations which yet finally require the employment of a transfixing guide mandrel and guide channel and an eccentric application channel cannula approach. Category 5: New uses for the device: Specific anticipated uses are listed. a. Visual inspection of hidden target tissue through multilumen Guide channel cannula(s); b. In vivo testing of target tissue performed through Guide channel cannula(s): c. In vivo treatments or manipulations on hidden target tissue through Application channel cannula(s); d. Placement of anchor guide mandrel(s), for later (deferred or long term) interventions.

Summary and Scope The reader will see the broad scope of possible uses for a device made up of a simple guide mandrel positioned using imaging guidance, said guide mandrel substantially parallel to and eccentric to an application channel cannula. Said application channel cannula provides access and guidance for surgical instruments while at the same time incorporating a design means to follow alongside the guide mandrel to a percutaneous tissue target (i.e. the Multicannula Guide Invention , whereby at least one guide channel cannula is solidly joined, inside and outside the body, in tandem with at least one application channel cannula) . Under medical imaging-guidance a percutaneous guide mandrel is placed. The guide mandrel transfixes an internal target of tissue. The target is generally an area of suspicious internal tissue that is seen on medical imaging. The guide mandrel holds the target in place and also provides a rigid guide path through intervening normal non-target tissues to reach the target. The mandrel retains its relationship transfixing the target even in the face of patient movement or multicannula rotation. Again using medical imaging guidance, but a new perpendicular view, the distance along the guide mandrel to the target is measured. The Multicannula Guide is then employed. One cannula follows the guide mandrel path to the target by fitting over the guide mandrel. The other empty cannula(s) provide(s) a passageway to the target for transmission of interventional devices, directly adjacent to (eccentric to; non-coaxial to;) the guide mandrel. The multicannula guide is designed: a. to be left in place, with interventions through the application channel cannula performed as many times as desired, for as long as desired, and for whatever intervention is possible through the cannula; b. to rotate the application channel cannula(s) about the transfixing guide mandrel and the mandrel cannula to reach new target sites. The eccentric relationship between the application channel cannula and the guide channel cannula /mandrel provide access to new clock face regions of the target by this rotational action and also by changes in depth of penetration; and c. to provide the confident relationship of the application channel cannula to the target by transfixing the target with the guide channel cannula and guide mandrel thereby permitting cannula rotations, patient movements and additional interventions without need for repeated imaging. The preferred embodiment is specified clearly herein. Its advantages include: (1) Invention is inexpensive to manufacture. Invention replaces expense for in-vogue stereotactic imaging equipment for core breast biopsy. Invention uses widely distributed existing imaging equipment. One type of biopsy device (long throw type) will work in all situations and with most types of medical imaging means, not just mammography. Inventory costs and capital expenditures are reduced. These are all problems not yet solved using stereotactic breast biopsy. (2) The invention is easy to use. Easy for operator: The invention follows widely applied techniques already in existence for another purpose. Easy for (biopsy) device: Positioned through a rigid cannula, the side pressure from breast compression does not impede the action of the biopsy device. (3) Single tissue penetration with guide allows multiple biopsies as a result of instrument access through an empty indwelling application channel cannula. (4) The probability of needle track seeding of intervening normal tissue with malignant cells or abscess bacteria is greatly reduced. (5) The target won't be missed because of untimely patient movement. (6) The target can't slip off to the side during biopsy thrusts. (7) The target can still be hit, even after bleeding obscures the target to further imaging. (8) Simple rotation of eccentric biopsy channel around transfixing guide pin allows biopsy of a new portion of target. No need to withdraw or re- use medical imaging to reposition the biopsy device for the next specimen. The embodiment specified herein depicts a mammographically-guided device to allow repeated tissue biopsies of mammographically detected, but externally hidden, tissue targets. It is intended however that this is a more widely applicable guide device invention. The positioning means using the multicannula guide is: a. independent of the type of interventional device transmitted through invention's application channel cannula (i.e. tissue sampling devices using needles, forceps, corkscrews, endoscopes); b. independent of the task performed through the application channel cannula (simple visual inspecting, tissue sampling, in vivo testing or treating, placing guides or test or treatment devices or as a positioning guide for deferred use); c. independent of the guiding method for initial target transfixion (endoscopy, x-ray, computed tomography, medical sonography, magnetic resonance imaging-guidance, or non-imaging r-f or thermal or magnetic or calculated guidance means); d. independent of the body part being entered; and e. independent of the various design changes to the percutaneous guide pin and the inside-the-body joining means to a percutaneous eccentric application access channel(s). Although the description above contains many specifications, these should not be construed as limiting the scope of the invention but as merely providing illustrations of the present preferred commercially pursuable embodiment of this invention. Thus the scope of the invention should be determined by the appended claims and their legal equivalents, rather than by the examples given.

Claims

CLAIMS What is claimed is:

12. An elongate percutaneous multicannula guide to aid surgical interventions comprised of a plurality of cannulas or lumens joined solidly together approximately parallel and side-by-side, joined outside the skin proximally and beneath the skin distally, said multicannula guide employed to facilitate a variety of percutaneous surgical interventions performed through one or more multicannula guide channels(s) that intervene to biopsy, view, treat or otherwise analyze a subcutaneous target in man or animal, and a method combining a.) positioning means that place at least one application channel cannula of said multicannula guide in apposition to said subcutaneous target and b.) anchoring means for retaining said multicannula guide relationship in apposition to said subcutaneous target, said anchoring means needed to permit target, anatomical part and even patient movement and to allow forceful interventions directed at the target with confidence of maintaining the guide path, and c) conduit means in the form of one or more application channel cannula(s) to slidably transmit to the target a variety of interventional surgical instruments, and d) repositioning means whereby said application channel cannula of said multicannula guide orbits around the axle formed by anchor guide mandrel and guide channel cannula to appose a new locus on or in the target for further interventions, without requirement to withdraw said multicannula guide or re puncture the skin or repeat image guidance, where what art is known is, 1. guidance using two dimensional x-ray images and a movable target to locate said sucutaneous target, and 2. guidance using xray images and a stationary target whereby the x and y position coordinates of said subcutaneous target are determined by two dimensional images but depth is determined by stereotactic imaging or by medical ultrasound images, and 3. subcutaneous target fixation by percutaneous hook-wires, and 4. pre-positioned hubless guide mandrels, followed over by percutaneous cannulas to reach said subcutaneous targets, and 5. essentially parallel tandem guidance positioning means , wherein tandem guidance is provided external to skin, with and without external joining means, and 6. coaxial percutaneous or external needle guides and cannulas as positioning means for subsequent subcutaneous interventions, and

where what is new is, 7. a surgical instrument guide where at least two of the plurality of cannulas are permanently joined approximately parallel and side-by- side, said application channel cannula(s) and said guide channel cannula(s), such that where one goes, the other(s) must follow exactly , e.g. cannulas are not independent, and 8. penetration of the skin is accomplished by all the following, a.) the means for joining the cannulas and b) by at least two cannulas of the multicannula guide, such that the joining means and cannulas are themselves at least partially within subcutaneous tissues e.g. joining means not entirely external, and 9. a stiff removable and repositionable target-anchoring guide (a)to allow target and patient movement, while retaining the guide path and (b) to prevent the target from slipping off to the side of the path of oncoming interventional devices, and 10. a simple repositioning means, for repeated changes in alignment of the application guide channel of said multicannula guide device to appose a new locus on or in said subcutaneous target reliably and accurately, allowing repeated interventions on each new locus via access through said application channel cannula without withdrawal of said multicannula guide or loss of internal target guidance and anchoring.