WO1997024990A1

WO1997024990A1 - Surgical instrument

Info

Publication number: WO1997024990A1
Application number: PCT/EP1997/000069
Authority: WO
Inventors: Arnold Pier; Jörg HUMMEN
Original assignee: Arnold Pier; Hummen Joerg
Priority date: 1996-01-09
Filing date: 1997-01-09
Publication date: 1997-07-17
Also published as: DE19600519A1

Abstract

A surgical instrument (1) has a handle with actuating means (4), a tubular shaft (6) secured to the handle (2) and containing a slide (8) which can be moved in the longitudinal direction by the actuating means (4), and a clip device (12) arranged in the tubular shaft (6) and containing several clips (10) which may be moved by the slide (8) in the axial direction of the tubular shaft (6). The tubular shaft (6) has receiving means (16) for holding a blood vessel prosthesis (18). The clip device (12) is arranged at the distal end (14) of the tubular shaft (6) with several clips (10) uniformly distributed around its circumference for fastening one end of the blood vessel prosthesis (18).

Description

Surgical instrument

The invention relates to a surgical instrument according to the preamble of claim 1 and a method for jamming anastomoses according to the preamble of claim 21.

Such instruments are used, for example, for laparoscopic surgery, but can also be used for open surgery.

In laparoscopic or endoscopic surgery, the surgical instrument is inserted through a trocar sleeve, e.g. in the abdominal area.

In the case of a known applicator, several clips are fed from a clip magazine to a plier-like application head which is located at the end of a hollow tube. The application head is actuated by an actuating device and a thrust element which is longitudinally displaceable in the tube. One such surgical instrument is

ORIGINAL DOCUMENTS however only able to apply isolated brackets.

Vascular prostheses, e.g. are sutured manually at the aorta. Such an operation is therefore only possible when the chest is open.

The invention has for its object to provide a surgical instrument and a method with which vascular prostheses can be connected to a vessel wall without suturing.

The features of claim 1 and 21 serve to solve this problem.

The invention advantageously provides that the shaft tube has a receiving device for a vascular prosthesis, and that a clamp device is arranged on the distal end of the shaft tube with a plurality of clamps uniformly distributed over the circumference for fastening one end of the vascular prosthesis. The clamp device makes it possible to clamp one end of the vascular prosthesis to a vessel wall. Several clamps evenly distributed around the circumference are advanced by a slide in the axial direction of the shaft tube, first penetrating the end of the vascular prosthesis and then the vascular wall.

A counter-pressure device for the clamping device, which is movable relative to the shaft tube, is likewise mounted in the shaft tube and can clamp the vessel prosthesis with a vessel wall and / or cut the vessel wall with a scalpel, extending the vessel wall through a slot beyond the distal end of the shaft tube in reach behind the vessel wall. Before using the surgical instrument, a small slot must first be cut into the vessel wall through which the counterpressure device can be inserted.

A second actuating device of the surgical instrument allows the position of the counterpressure device to be adjusted relative to the shaft tube. In particular, the position of the part of the counterpressure device located behind the vessel wall can be changed with the aid of the second actuating device in such a way that a counterpressure means is created for the shaft tube and for the scalpel.

The scalpel is arranged in a linearly movable manner in the shaft tube and has an outer diameter which corresponds essentially to the inner diameter of the vascular prosthesis. The scalpel can protrude from the distal end of the shaft tube and punch out the vessel wall accordingly using the counterpressure device.

It is preferably provided that the receiving device for the vascular prosthesis is surrounded radially on the outside by the clamp device, the vascular prosthesis having a radially outwardly projecting edge on the end face of the shaft tube.

The clamps preferably project in the open state with the free ends relative to the end face of the shaft tube and penetrate the outwardly projecting edge of the vascular prosthesis. The free ends run axially parallel to the shaft tube.

It is preferably provided that the counter pressure device consists of a linearly movable and additionally pivotable stored disc exists. Such a pivotable disc can be inserted into the slot of the vessel wall in the state inclined relative to the longitudinal axis of the shaft tube and can then be pivoted into a position orthogonal to the longitudinal axis of the shaft tube, in which the disc is a counterpressure medium for the end of the shaft tube or Scalpel forms.

The second actuating device can clamp the vessel wall between the counterpressure device and the end face of the shaft tube with the edge of the vascular prosthesis clamped in between with a predetermined limited contact pressure.

The first actuation device drives the clips of the clip device through the vascular prosthesis and through the vessel wall and clamps the clips with the aid of the counterpressure device.

After completion of the stapling process, the first actuation device drives the scalpel into the vessel wall to punch out a hole with the inside diameter of the vascular prosthesis. The disk of the counterpressure device in turn serves as a counterpressure medium for the scalpel. When the surgical instrument is removed, the counterpressure device is preferably pivoted again. The punched-out part of the vessel wall remains on the scalpel and is pulled out by the scalpel with the surgical instrument, while the vascular prosthesis remains on the vessel wall and is pulled out of the surgical instrument.

In a preferred embodiment of the shaft tube, an inner tube is provided, the inner wall of which is the ring Chamber for the vascular prosthesis is limited radially outwards and the outside diameter of the clamp device accommodates it.

The shaft tube, the slide and the inner tube can preferably have openings distributed uniformly on the circumference, which are connected to the annular chamber for the vascular prosthesis. Through these openings the vascular prosthesis can be filled with liquids e.g. Blood are impregnated to seal the vascular prosthesis.

The end face of the shaft tube, and thus also the scalpel, can also run at an angle to the longitudinal axis of the shaft tube, so that the surgical instrument can be placed at an angle against the vessel wall. In this case, an elliptical hole is punched out in the vessel wall and clamped onto the vascular prosthesis at an angle to the vessel wall.

At the distal end of the inner tube, open receiving pockets for the clips are arranged uniformly distributed over the circumference to the inside of the shaft tube.

The clamps, which are uniformly distributed over the circumference, can be arranged in two circular rows concentric with one another.

Alternatively, the clips can be arranged spirally around the circumference.

The clamps can be connected to one another with bridge elements with which the contact pressure between the vascular prosthesis and the vascular wall is distributed more uniformly over the circumference becomes .

Exemplary embodiments of the invention are explained in more detail below.

Show it:

1 shows a side view of the surgical instrument,

2 shows the distal end of the shaft tube with a counterpressure device inserted into a vessel,

2A the clamping of the vascular prosthesis with the vascular to 2D wall and the punching out of a hole from the vascular wall,

2E is a plan view of the line IIE-IIE in Fig. 2A,

3 shows the first actuating device,

4 shows a section along the line IV-IV in FIG. 2,

Fig. 5 is a partially sectioned plan view of the distal end of the shaft tube, and

6 sections along the line VI-VI or VII-VII in and 7 Fig. 5th

The surgical instrument 1 for fastening vascular prostheses 18 has a handle 2 with an actuating device 4 in the form of a two-armed lever, which can move a slide 8 guided in an elongated shaft tube 6. The shaft tube 6 is attached to the handle 2. The shaft tube 6 can alternatively be mounted rotatably in the handle 2. At the proximal end of the handle, a second actuating device 38 is arranged, by means of which a counterpressure device 26 projecting outward from the distal end 14 of the shaft tube 6 can be actuated.

2 shows the distal end 14 of the shaft tube in cross section and after insertion of the counterpressure device 26 through a slot 32 in a vessel wall 30 of a vessel to which the vascular prosthesis 18 is to be attached. Such vascular prostheses 18 consist of anastomoses, by means of which bypasses can be placed. The anastomoses are preferably impregnated with blood, as a result of which they have sufficient pressure tightness when exposed to a blood flow and the formation of vascular cells can be accelerated.

The distal end of the shaft tube 6 is constructed as follows from the outside in:

There follows first a tubular slide 8, which is used to actuate a clamp device 12 arranged on the distal end 14 of the shaft tube 6 and a scalpel 34, the slide 8 being mounted between the outer shaft tube 6 and an inner tube 54 which is fixed relative to the shaft tube 6 is. The inner wall of the inner tube 54 delimits an annular chamber 58 for receiving the vascular prosthesis 18. The annular chamber 58 is connected to the openings 66 of the shaft tube 6 for impregnating the vascular prosthesis 18 via corresponding cutouts. The clip device is on the distal outer end of the inner tube 54 12 arranged, which is surrounded by an end sleeve 52 of the shaft tube 6. The annular chamber 58 is delimited radially inward by the scalpel 34, which can likewise be advanced by a predetermined amount by means of the actuating device 4 and the slide 8 coaxially to the shaft tube 6 for punching a hole in the vessel wall 30. In the interior of the scalpel 34 there are elements of the second actuating device 38 which allow pivoting and a linear movement of the counterpressure device 26 which is axially parallel to the shaft tube 6.

The vascular prosthesis 18 is bent radially outward on the end face 20 of the end sleeve 52 and forms a radially projecting edge 22. The clips 10 from the clip device 12 are already through this edge 22 of the vascular prosthesis 18 before the surgical instrument 1 is used pushed through so that the free ends of the clamps project axially slightly beyond the edge 22 of the vascular prosthesis 18.

The distal end of the counterpressure device 26 consists of a disk 42 which can be pivoted relative to the longitudinal axis of the shaft tube 6 and which, in the inclined state, is inserted into the vessel through the slot 32 in the vessel wall 30. On the disk 42, two tension bands 40, 41 are articulated at a distance from one another and can be displaced relative to one another parallel to the longitudinal axis of the shaft tube 6. If the tension band 40 is moved in the proximal direction relative to the tension band 41, the disk 42 straightens up to a position orthogonal to the longitudinal axis of the shaft tube 6. A stop 50, as can best be seen from FIG. 2E, limits the further proximal movement of the tension band 40 by resting against the guide element 45. direction 38, both drawstrings 40, 41 are moved uniformly in the proximal direction, as a result of which disc 42, as best seen in FIG. 2A, is pressed against the back of vessel wall 30 with a predetermined and limited contact pressure. In its orthogonal position to the longitudinal axis of the shaft tube, the disk 42 first forms a counterpressure medium for the clips 10 of the clip device 12. The clips 10 are moved with the aid of the first actuating device 4 via the slide 8, a sleeve 9 consisting of two halves, and via a thrust element 11 for each clip 10 that presses on the proximal end of the clips 10. Compared to the clamps 10, the disc 42 has cutouts 43 which facilitate the bending over of the free ends of the clamps 10 and steer them in the correct direction. The stapling device 12 can simultaneously place several, for example six or even more staples evenly distributed on the circumference of the rim 22, which staples the rim 22 circumferentially onto the vessel wall 30. Bridge elements 60 can be provided between the clamps 10, which press the edge 22 of the vascular prosthesis 18 more uniformly against the vessel wall 30 over the entire circumferential area.

As can best be seen from FIG. 3, the scalpel 34 is advanced by the slide 8 only after a certain actuation path of the slide 8. It is thereby achieved that the scalpel 34 is only advanced when the stapling process is complete. For this purpose, the slide 8 has cam elements 80 which engage in a cutout 82 in the scalpel 34 and thereby advance the scalpel 34 only after a time delay.

2C shows the scalpel 34 in the advanced state, in which a preferably circular hole in the vascular wall 30 is cut, the diameter of the hole corresponding to the inside diameter of the vascular prosthesis 18. The disc 42 is provided with a recess 44 adapted to the scalpel cross-section, so that the scalpel 34 can penetrate the entire vessel wall 30 and thus can carry out a clean cut, a plastic ring 68, for example made of elastomer material, in the recess 44 of the disc 42 serves as a counterpressure to the scalpel. The circular piece 28 of the vessel wall 30 having the slot 32 remains on the scalpel 34.

At the proximal end, the shaft tube 6 has an elongated hole 62, through which a pin 64 attached to the tubular scalpel 34 indicates the position of the scalpel 34. The surgeon can assess the exact position of the scalpel from the relative position of the pin 64 to the elongated hole 62. For example, markings on the elongated hole 62 can indicate whether the scalpel 34 has penetrated up to the vessel wall 30 or up to the plastic ring 68.

As can be seen from FIG. 2D, the disk 42 can then be pivoted again with the aid of the second actuating device 38, so that it can be removed more easily from the vessel. For this purpose, the disk 42 is moved back to its original starting position. When the surgical instrument 1 is withdrawn, the vascular prosthesis 18 is completely pulled out of the annular chamber 58 and the counterpressure device 26 with the disk is removed through the vascular prosthesis 18. What is essential here is the safe removal of the punched-out circular piece 28 of the vessel wall 30. This vessel wall piece 28 remains in the scalpel 34. Even if the punched vessel wall piece 28 would detach from the scalpel 34, it is carried along by the following disk 42 of the counter pressure device 26.

The second actuating device 38 shown in section in FIG. 3 essentially consists of a rotary knob 35 which transmits a predetermined maximum torque to a spindle drive 37 with the aid of a slip clutch 36. With the aid of the spindle drive 37, a second push rod 39 can be moved linearly back and forth coaxially to the shaft tube 6, to the slide 8 and to the scalpel 34.

When the surgical instrument 1 is inserted, as shown in FIG. 2, the second push rod 39 is moved forward in the distal direction with the aid of the second actuating device 38. As a result, a displaceable guide element 45 of the counterpressure device 26 is also moved forward in the distal direction. The drawstring 41 of the disk 42 is fixedly attached to the displaceable guide element 34, while the drawstring 40 is fixed to the push rod 39. The counterpressure device 26 also has a distal guide element 26 at the distal end of the scalpel, which receives and guides the two tension bands 40, 41, and a proximal guide element 47, which receives and guides the second push rod 39. The displaceable guide element 45 slides in the inner cross section of the scalpel 34 between the distal and the proximal guide element 46, 47, the displaceable guide element 45 being supported on the distal and proximal guide element 46, 47 with a spring 48, 49, respectively. When the second push rod 39 moves forward, the disk 42 is first pivoted, since initially only the tension band 40 moves in the proximal direction. When the maximum swivel position of the disk 42 is reached, the tension band also becomes 41 entrained by the movement of the second push rod 39 and thus also the movable guide element 45, so that the disc 42 can be moved away from the distal end 14 of the shaft tube 6 in its pivoted position.

When the second push rod is moved in the proximal direction, the disk 42 is also initially moved in the proximal direction and then pivoted into a position orthogonal to the longitudinal axis of the shaft tube 6. As a result of the slip clutch 36, the pulling force of the second push rod 39 is limited, so that the disk 42 cannot be pressed against the vessel wall 30 with an excessively high contact pressure.

The shaft tube 6, the tubular slide 8 and the inner tube 54 can be provided with recesses, not shown in part, in order to impregnate the vascular prosthesis 18 with liquid, e.g. Blood.

FIG. 4 shows a cross section through the distal end 14 of the shaft tube 6 in the region of the closure sleeve 52 and the fixed distal guide element 46, which receives and guides the tension bands 40, 41 in a recess 48. The annular chamber 58 is formed between the scalpel 34 and the inner tube 54 and, as already mentioned, serves to hold the vascular prosthesis 18. On the outer circumference of the inner tube 54 there are receiving pockets 56 for the clamps 10, which are evenly distributed over the circumference and are open to the free end face of the inner tube 54.

FIG. 5 shows a top view of the illustration according to FIG. 4. The brackets 10 protrude and penetrate opposite the end face 20 of the shaft tube 6 or the end sleeve 52 of the shaft tube 6, as already in connection explained with Fig. 2, the edge 22 of the vascular prosthesis 18. In the proximal direction behind the brackets 10 are in the receiving pockets 56, the push elements 11 for the brackets 10, which in turn can be moved forward by a split sleeve 9 in the distal direction. The divided sleeve 9 is in turn pushed forward in the distal direction by the end of the slide 8.

6 shows a section of a cross section through the receiving pocket 56 in the region of the push element 11.

7 is a cross section through the shaft tube 6 in the area of the split sleeve 9.

Claims

claims

1. surgical instrument (l) with a handle with an actuating device (4),

a shaft tube (6) fastened to the handle (2), in which a slide (8) which is longitudinally displaceable by the actuating device (4) is arranged,

- One in the shaft tube (6), a plurality of clips (10) containing clip device (12), the clips (10) of the slide (8) in

Axial direction of the shaft tube (6) are displaceable, characterized in that the shaft tube (6) has a receiving device (16) for a vascular prosthesis (18), and that the clamp device (12) at the distal end (14) of the shaft tube (6) a plurality of circumferentially evenly distributed clamps (10) for fastening one end of the vascular prosthesis (18) is arranged.

2. Instrument according to one of claim 1, characterized gekenn¬ characterized in that a relative to the shaft tube (6) moveable counter pressure device (26) for the Klammerein¬ device (12) is mounted in the shaft tube (6) and for clamping the vascular prosthesis (18) with a vessel wall (30) and / or for cutting the vessel wall

(30) with a scalpel (34) beyond the distal end (14) of the shaft tube (6) beyond the vessel wall (30) through a slot in the vessel wall (30).

3. Instrument according to one of claims 1 or 2, characterized in that a second actuating device device (38) adjusts the position of the counterpressure device (26) relative to the shaft tube (6).

4. Instrument according to one of claims 1 to 3, characterized in that a scalpel (34) which is linearly movable in the shaft tube (6) and has an outer diameter which essentially corresponds to the inner diameter of the vascular prosthesis (18) at the distal end ( 14) of the shaft tube (6) is arranged.

5. Instrument according to claim 1 to 4, characterized gekenn¬ characterized in that the receiving device (16) for the vascular prosthesis (18) relative to the clamping device

(12) is arranged radially on the inside, and that the vascular prosthesis (18) on the end face (20) of the shaft tube

(6) has a radially outwardly projecting edge (22).

6. Instrument according to claim 5, characterized in that the clamps (10) in the open state with the free ends project relative to the end face (20) of the shaft tube (6) and the edge (22) of the vascular prosthesis (18) penetrate.

7. Instrument according to one of claims 4 to 6, characterized in that the counter-pressure device (26) consists of a linearly movable and additionally pivotably mounted disc (42).

8. Instrument according to claim 7, characterized in that the disc (42) is pivotable from an inclined position relative to the longitudinal axis of the shaft tube (6) into an orthogonal position. 4990 PC17EP97 / 00069

16 -

9. Instrument according to one of claims 3 to 8, characterized in that the second actuating device (38), the vessel wall (30) between the counter pressure device (26) and the end face (20) of the shaft tube (6) with the vascular prosthesis (18) with a predetermined, limited contact pressure.

10. Instrument according to one of claims l to 9, characterized in that the first actuating device (4) advances the clamps (10) of the clamp device (12) through the vessel wall (30) and clamps with the aid of the counterpressure device (26).

11. Instrument according to claim 10, characterized in that the first actuating device (4) after completion of the stapling the scalpel (34) for punching out a hole (46) with the inner diameter of the vascular prosthesis (18) through the vessel wall (30) ¬ drives.

12. Instrument according to one of claims 1 to 12, characterized in that the receiving device (16) for the vascular prosthesis (18) is formed from an annular chamber (58) which is arranged between the shaft tube (6) and the scalpel (34) .

13. Instrument according to one of claims 1 to 12, characterized in that the shaft tube (6) is an inner tube

(54), the inner wall of which delimits the annular chamber (58) radially outward and the outer diameter of which accommodates the clamping device (12).

14. Instrument according to claim 13, characterized in that the shaft tube (6), the push rod (8) and that The inner tube (54) preferably has openings (66) distributed uniformly on the circumference, which are connected to the annular chamber (58) for the vascular prosthesis (18).

15. Instrument according to claim 14, characterized in that at the distal end of the inner tube (54) to the end face (20) of the shaft tube (6) open receiving pockets (56) for the clamps (10) evenly distributed over the circumference are arranged.

16. Instrument according to one of claims l to 15, characterized in that the circumferentially evenly distributed brackets (10) are arranged in two concentric circular rows relative to one another.

17. Instrument according to one of claims 1 to 15, characterized in that the clamps (10) are arranged circumferentially spirally.

18. Instrument according to one of claims 1 to 17, characterized in that the brackets (10) are connected to one another with bridge elements (60).

19. Instrument according to one of claims 1 to 18, characterized in that the end face (20) of the Schaft¬ tube (6) at an angle to the longitudinal axis of the shaft tube (6) and that the counter-pressure device (26) elliptical in shape the end face (20) is adapted.

20. Instrument according to one of claims 2 to 19, characterized in that on the shaft tube (6) a display device (62, 64) the position of the scalpel (34) displays.

21. Method for clamping a vascular prosthesis (18) to a vascular wall (30)

- by having the vascular prosthesis (18) with an edge (22) protruding radially from the distal end of the vascular prosthesis in a receiving device (16) within a shaft tube (6) of a clip applicator, by cutting a slot (32) into it Vessel wall (30), by reaching behind the vessel wall (30) with a counter-pressure device (26) movable along the shaft tube (6) through the slot (32), by clamping the edge (22) of the vascular prosthesis (18 ) with the vessel wall (30) with a plurality of clamps (10) using a clamp device (12) arranged in the shaft tube (6) and the counterpressure device (26), by cutting the vessel wall (30) with one mounted in the shaft tube (6) and for punching out a scalpel (34) that is movable distally to the inside diameter of the vascular prosthesis using the counterpressure device (26), by removing the punched-out part (28) of the vessel wall (30) with the aid e of the scalpel (34), and by pulling the vascular prosthesis (18) out of the receiving device (16) by pulling back the clip applicator.