WO2001019263A1

WO2001019263A1 - Instrument set for laparoscopic hysterectomy

Info

Publication number: WO2001019263A1
Application number: PCT/SK2000/000018
Authority: WO
Inventors: Jozsef HLUCHÁŇ
Original assignee: Hluchan Jozsef
Priority date: 1999-09-13
Filing date: 2000-09-04
Publication date: 2001-03-22
Also published as: SK125599A3; SK285226B6; AU7327900A

Abstract

Method and instruments of the laparoscopic hysterectomy enable to carry out the gynaecological operation of uterus extirpation laparoscopically, without necessity to open the abdominal cavity by discissing. The method is based on exact levelling of stitches, tightening and knotting, using the laparoscopic needle-holder with which also the 'Z' suture and circular immovable-fixing suture (63) are done. Amputation of the uterus (51) - horizontal incissions (65) and vertical suture (64) are carried out using the laparoscopic horizontal lancet and the laparoscopic vertical lancet. The method also solves the way of removing the redundant tissue from the abdominal cavity.

Description

INSTRUMENT SET FOR LAPAROSCOPIC HYSTERECTOMY

The scope of technique.

The invention concerns the method of gynaecological operation of uterus extirpation and the instruments necessary for performing of it. The method is based on exact levelling of stitches, tightening and knotting, as well as on the way of removing the redundant tissue from the abdominal cavity.

Techniques used hitherto.

Contemporary gynaecological surgery uses standard abdominohysterectomy, colpohysterectomy and very rarely laparoscopic uterus extirpation, all of which have several disadvantages.

Standard operation requires several days hospitalization after the surgery, postoperative pains, defaecation blocking, long convalescence period, necessity of postoperative suture, necessity of stitches' removal and consequent irremovable scar. There are also blood losses that under the ideal conditions in standard surgery make from 300 to 500 ml of blood.

In the yet performed laparoscopic hysterectomies the operator ligates blood vessels using just graspers and loops that do not enable standard removal of adnexa uteri or a Fallopian tube. Majority of laparoscopic hysterectomies make use of bipolar electroagulation that ensures haemostasis of smaller vessels. The major uterine vessels are blocked with staplers, or tantalum clips. These staplers and clips, however, are mostly nonabsorbable.

Substance of the invention.

The above disadvantages of the contemporary surgeries can be surpassed by the method of laparoscopic hysterectomy according to this invention, the substance of which lies in the operation being carried out laparoscopically, without the necessity to open the abdominal cavity by discissing, while apart from the known surgical instruments the ones according to this invention are used - the laparoscopic needle- holder, the laparoscopic vertical lancet and the laparoscopic horizontal lancet.

With the help of the laparoscopic needle-holder sutures are standardly placed, uterine vessels are exposed and at least two sutures are placed on them. Using the laparoscopic needle-holder, the tight sutures for section of round and broad uterine ligaments are lead, later the tight sutures for section of the vascular bundle that nourishes the ovary together with section of excala io vesicouterina, including the possibility of tying up the ovarian ligament or tying up and removing of Fallopian tubes. After removal of primary redundant tissue by Semm's carver, at least two circularly fixed sutures are layed with the laparoscopic needle-holder on the cervical stump bellow the inner entrance level.

Using the vertical laparoscopic lancet at least four vertical incisions are lead on the supposed amputated part of the uterine wall.

Using the horizontal laparoscopic lancet the horizontal amputation of uterus above the inner entrance level is carried out. All parts of redundant tissue are placed into the transportation cavity of the Semm's carver.

First tightening and knotting of the upper circular suture is done using the laparoscopic needle-holder while at the same time Semm's carver is sliding out of the abdominal cavity with consequent tightening and knotting of the lower circular suture. Afterwards the serous envelopes of pelvic base are sutured with at least three continuing stitches using the laparoscopic needle-holder and broad uterine ligament is fixed upon the cervical stump.

The laparoscopic needle-holder consists of a thorn, palm manipulator, case unit and pressing spring. In the front part of the thorn there is a rounded head with outer cylindrical setting, in the rear it is tightly connected to the palm manipulator. It is movable within the case unit, at the end of which is a holder for two fingers with outer cylindrical setting. This setting fits close to inner cylindrical setting of the palm manipulator, in the cavity of which the pressing spring is put between the manipulator's connection with the thorn and outer cylindrical setting of case unit's two fingers' holder.

The vertical laparoscopic lancet consists of a thorn, palm manipulator, case unit, pressing spring and vertical cutting instrument. The thorn in its front ends with forked score in which the vertical cutting instrument is placed rotationally. In the front part of the thorn there is the front outer cylindrical setting and in the rear part the rear outer cylindrical setting and it ends with palm manipulator. It is placed movably and rotationally inside the case unit that in the middle of its case contains the middle inner cylindrical setting and at the end the rear inner cylindrical setting. On the outside end of the case unit there is two-fingers holder. Inside the case unit the pressing spring is placed between the middle inner cylindrical setting of the case unit and rear outer cylindrical setting of the thorn.

The horizontal laparoscopic lancet consists of a thorn, palm manipulator, case unit, pressing spring and horizontal cutting instrument. The thorn in its front ends with forked score in which the horizontal cutting instrument is placed rotationally. In the front part of the thorn there is the front outer cylindrical setting and in the rear part the rear outer cylindrical setting and it ends with palm manipulator. It is placed movably and rotationally inside the case unit that in the middle of its case contains the middle inner cylindrical setting and at the end the rear inner cylindrical setting. On the outside end of the case unit there is two-fingers holder. Inside the case unit a pressing spring is placed between the middle inner cylindrical setting of the case unit and rear outer cylindrical setting of the thorn. The outline of the figures on the drafts.

The invention shall be further described in the following, with reference to the added drafts that depict the course of the operation according to this invention's method as well as the instruments required by this method. The individual figures show: fig.1 location of placing the individual trocars upon the patient's abdomen fig.2 the "Z" suture fig.3 immovable-fixing suture fig.4 circular immovable-fixing suture fig.5 standard placing of immovable-fixing sutures using the laparoscopic needle-holder on individual uterine ligaments fig.6 immovable-fixing suture placed on uterine vessels fig.7 primary removal of redundant uterine tissue using Semm's carver fig.8 circular immovable-fixing on cervical stump fig.9 vertical incisions on supposed amputated part of uterus fig.10 horizontal incisions on supposed amputated parts of uterus fig.11 placing of the redundant amputated uterine tissue into the transportation cavity of Semm's carver fig.12 tightening of the upper circular immovable-fixing suture on the cervical stump fig.13 tightening of the lower circular immovable-fixing suture on the cervical stump fig.14 suturing of the serous envelopes of uterus fig.15 fixation of the broad uterine ligament upon the cervical stump fig.16 finishing fixation of the broad uterine ligaments and serous envelopes upon the cervical stump fig.17 partial longitudinal incision of the laparoscopic needle-holder with the head pulled in and pulled out fig.18 longitudinal incision with the laparoscopic vertical lancet with the cutting instrument pulled in fig.19 longitudinal incision with the laparoscopic vertical lancet with the cutting instrument pulled out fig.20 tilting of the laparoscopic vertical lancet's cutting instrument into the working position fig.21 longitudinal incision of the laparoscopic horizontal lancet with the cutting instrument pulled in fig.22 longitudinal incision of the laparoscopic horizontal lancet with the cutting instrument pulled out before its tilting fig.23 tilting of the laparoscopic horizontal lancet's cutting instrument into the working position Example of the invention's realization.

The method of the laparoscopic hysterectomy.

The placement of the necessary trocars for the laparoscopic hysterectomy according to the depiction on fig.l is as follows: In the upper part of the abdomen 50 in the middle a trocar of 10 mm diameter for a camera 41_. is placed, further down 2 trocars of 10 mm diameter 42 in each side and in the middle one trocar of 5 mm 43.

During the operation the absorbable material, "Z" sutures, immovable-fixing suture and circular immovable-fixing suture are used. The "Z" suture 61 is depicted on fig.2. It begins with the first insertion 611. followed by the first drawing out of the needle 612. the second insertion 613 and finishes with the second drawing out of the needle 614.

The immovable-fixing suture 62 is depicted on fig.3. It begins with the first insertion 621. followed by the first drawing out of needle 622. the second insertion 623. the second drawing out of needle 624 and finishes with drawing under the area between the first drawing out of needle 623 and the second insertion 633.

The first acts of the laparoscopic hysterectomy are depicted on fig.5. The immovable-fixing sutures 62 are placed and knotted as first ones using the laparoscopic needle-holder X, simultaneously on broad ligament 52 and round ligament 53 of the uterus 5JL then individually on broad ligament 52, round ligament 53 and on the vascular bundle that nourishes the ovary 54. Knotted broad 52 and round 53 ligaments are cut, then the vascular bundle 54_^ too, including cutting of plica vesicouterina and the Fallopian tubes.

Afterwards the uterine vessels are exposed and immovable-fixing sutures 62 are situated on them 55 according to fig.6.

Primary redundant uterine tissue 5_1 is removed using Semm's carver 44 according to fig.7, while the carved cylinder of the primary redundant tissue 5J_1 reaches from cervix to fundus uteri.

Using the laparoscopic needle-holder X two circular immovable-fixing sutures 63 are placed on cervical stump 513 bellow the inner entrance level 514 of the uterus 51 according to fig.8. Semm's carver 44 stays in the position of carving the primary redundant tissue. Using the laparoscopic vertical lancet 2 two vertical incisions 64 are done on the supposed amputated part of the uterus 51. as it is depicted on fig.9.

Using the laparoscopic horizontal lancet 3, amputation of uterus is realized, using horizontal incision 65 bellow the inner entrance level 514. according to fig.10. It is followed by partial withdrawing of Semm's carver 44 from the arxiominal cavity and placing of the redundant amputated uterine tissue 5J2 using the laparoscopic needle-holder into the transportation cavity of Semm's carver 44 as shown on fig.11.

After further withdrawing of Semm's carver 44 to the level under the upper circular immovable-fixing suture 63, tightening and knotting of the upper circular immovable-fixing suture 63 is done according to fig.12, and during gradual withdrawal of Semm's carver 44 also tightening and knotting of the lower circular immovable-fixing suture 63 of the cervical stump 513, of the uterus 5J. is done - fig.13.

Using continuing stitches 66 the serous envelopes 56 of the pelvic base are sutured according to fig.14 and the broad ligament of uterus 52 are fixed with continuing stitches upon the cervical stump 5_13 of uterus 5_1 according to fig.15, while cervical stump 5J3 is closed using continuing suture, as shown on fig.16.

The instruments necessary for performing of the method of the laparoscopic hysterectomy.

The laparoscopic needle-holder 1 according to fig. 17 consists of the thorn ϋ, ended by the palm manipulator X2, while the thorn ϋ is lengthwise movable, it rotates in the case unit 13 and the pressing spring 14 ensures drawn-in position of the thorn XX in the case unit 13.

The thorn U_. in its front part ends with the set outer rounded head Hi which with its set part fits close to the head of the case unit 13. The palm manipulator 12 consists of a case and a cavity 122 which is ended by the inner cylindrical setting 121. This setting fits close to the outer cylindrical setting 132 of the case unit 13, in front of which there is the two fingers' holder X3X of the laparoscopic needle-holder 1.

The laparoscopic needle-holder 1 is manipulated by pressing the palm manipulator 12 with a palm, two fingers' holder 131 is pulled, by which the pressing spring's pressure 14 is overpowered and the set outer rounded head HI of the thorn X X is pushed out of the case unit's head 13. Thus a gap 15 is formed between the back of the set outer rounded head HI and the head of the case unit 13, into which the necessary instruments of sewing material are caught during gradual releasing of the palm manipulator 12. Fig.17 depicts resting laparoscopic needle-holder 1 above the axis, in the position under the axis there is the laparoscopic needle-holder 1 after pressing of the palm manipulator 12.

The laparoscopic vertical lancet 2 depicted on fig. 18-20 consists of the thorn 21 that in its front has vertical cutting instrument 25 and in the back of it fits close to palm manipulator 22, while thorn 21 is placed movably and rotatingly in the case unit 23 and the lengthwise movement of the thorn 2 in the case unit 23 is limited by the pressing spring 24. The thorn 2_1 has in its front part the front outer cylindrical setting 213. before which there is the forked score 211. and in its rear part the rear outer cylindrical setting 214. In the forked score 2U_. there is vertical cutting instrument 25 placed rotatingly on the pin 212.

The case unit 23 has inside of the middle part the middle inner cylindrical setting 231 and inside the rear part the rear inner cylindrical setting 232. while at the end of case unit 23 there is two fingers' holder 232. The pressing spring 24 is placed inside the case unit 23 and with its heads it fits close to middle inner cylindrical setting 231 of the case unit 23 and rear outer cylindrical setting 214 of the thorn 21; thus keeping the vertical cutting instrument 25 in the resting position, drawn inside the case unit 23 as shown on fig.18.

When bringing the laparoscopic vertical lancet 2 from the resting position to the working one, the lancet is held so that palm supports the palm manipulator 22 and two fingers' holder 233 is held with fingers. By pressing the palm manipulator 22 the thorn 21 moves forward, overpowering the pressure of the spring 24 and from the case unit 23 the cutting instrument 25 is pushed out as depicted on fig.19. The cutting instrument 25 is bent by 90° (either by its own weight or using some other instrument, e.g. the laparoscopic needle-holder X) into working position as on fig.20, where it is depicted by dashed line. After slight releasing of the palm manipulator 22 in this position the cutting instrument 25 bends and fits to the head of the case unit 23, which is on fig.20 depicted by full line and in this position the cutting instrument 25 is secured by the pressing spring 24. The operator manipulates it using two fingers' holder 233 and the palm manipulator 22.

When putting the laparoscopic vertical lancet 2 from the working position to resting one the palm manipulator 22 is pressed, releasing the cutting instrument 25 and drawing it in front of the case unit's 23 head, which enables its bending by 90° by its own weight or using some other instrument. After further releasing of the palm manipulator 22 it slides inside the case unit 23 as shown on fig.18.

Fig. 21-23 show the laparoscopic horizontal lancet 3 that consists of the thorn 3_1 which in its front has the horizontal cutting instrument 35 and in the back it fits close to the palm manipulator 32, while the thorn 3_1 is movably and rotatingly placed in the case unit 33 and the thorn's 3_1 lengthwise movement within the case unit 33 is restricted by the pressing spring 34- The thorn 31 in its front part has the front outer cylindrical setting 313. in front of which there is the forked score 311 and in its rear part it has the rear outer cylindrical setting 314.

In the forked score 3H there is the horizontal cutting instrument 35, placed rotatingly on the pin 312. The case unit 33 has inside of its middle part the middle inner cylindrical setting 33J_. and inside the rear part the rear inner cylindrical setting 332. while at the end of the unit 332 there is two fingers' holder 333. The pressing spring 34 is placed inside the case unit 33 and with its heads it fits close to the middle inner cylindrical setting 331 of the case unit 33 and the rear outer cylindrical setting 314 of the thorn 31; thus keeping the horizontal cutting instrument 35 in the resting position, drawn inside the case unit 33 as shown on fig.21.

When bringing the laparoscopic horizontal lancet 3 from the resting position to the working one, the lancet is held so that palm supports the palm manipulator 32 and two fingers' holder 333 is held with fingers. By pressing the palm manipulator 32 the thorn 3J_. moves forward, overpowering the pressure of the spring 34 and from the case unit 33 the cutting instrument 35 is pushed out as depicted on fig.22. The cutting instrument 35 is bent by 90° (either by its own weight or using some other instrument, e.g. the laparoscopic needle-holder X) into working position as on fig.23, where it is depicted by dashed line. After slight releasing of the palm manipulator 32 in this position, the cutting instrument 35 bends and fits to the head of the case unit 33, which is on fig.23 depicted by full line and in this position the cutting instrument 35 is secured by pressing spring 34- The operator manipulates it using two fingers' holder 333 and the palm manipulator 32, while the palm manipulator 32 enables or restricts rotation.

When putting the laparoscopic horizontal lancet 3 from the working position to resting one, the palm manipulator 32 is pressed, releasing the cutting instrument 35 and drawing it in front of the case unit's head 33, which enables its bending by 90° by its own weight or using some other instrument. After further releasing of the palm manipulator 32 it slides inside the case unit 33 as shown on fig.21.

Claims

PATENT'S CLAIMS.

1. Method of the laparoscopic hysterectomy, using exact standard sutures' placement, tight knotting, removal of the redundant tissue from the abdominal cavity, is distinguishing for standard suture situation (62) using the laparoscopic needle-holder (1), exposition of uterine vessels (55) and inserting at least two sutures (62) upon the uterine vessels (55), removing of primary redundant tissue (511) using Semm's carver (44), placing of at least two circular immovable-fixing sutures (63) on the cervical stump (513) bellow the inner entrance level using the laparoscopic needle-holder (1), making at least four vertical incisions (64) on the supposed amputated part of the uterine wall (51) using the laparoscopic vertical lancet (2), uterus (51) amputation bellow the inner entrance level by using horizontal incision (65) which is done with the laparoscopic horizontal lancet (3), placing all parts of the redundant amputated tissue (512) into the transportation cavity of the Semm's carver (44), tightening and knotting of the upper circular immovable-fixing suture (63) by using the laparoscopic needle-holder (1) during simultaneous sliding out of the Semm's carver (44) from the abdominal cavity with consequent tightening and knotting of the lower circular immovable-fixing suture (63), suturing of serous envelopes (56) of the pelvic base with at least three continuing sutures (66) by using the laparoscopic needle-holder (1) and fixation of the broad uterine ligament (52) upon the cervical stump (513).

2. The method according to the claim 1., is distinguishing for the fact that by standard suture placement by using the laparoscopic needle-holder (1) the tight sutures (62) are inserted, consequently cutting the round ligament (53) and broad ligaments (52) of the uterus and cutting of the vascular bundle that nourishes the ovary (54) including cutting of plica vesicouterina, ovarian ligament, or the Fallopian tubes.

3. The instruments for realization of the method of the laparoscopic hysterectomy according to claims 1 and 2 consisting of the trocars, the laparoscopic tower, the laparoscopic needle-holders, the laparoscopic vertical lancet, the laparoscopic horizontal lancet, absorbable materials for suturing are distinguishing for the thorn (11) of the laparoscopic needle-holder (1) having in the front part the set outer rounded head (111) and in the rear part fitting close to the palm manipulator (12) and being placed movably in the case unit (13) which is ended by the two fingers' holder (131) with outer cylindrical setting (132), upon which the inner cylindrical setting (121) of the palm manipulator (12) fits close, while the pressing spring (14) (the heads of which fit close on the case unit (13) and the palm manipulator (12)) is placed in the cavity (122) of the palm manipulator (12) at the end of the thorn (11).

4. The instruments according to claim 3. are custkgμishing for the thorn (21) of the laparoscopic vertical lancet (2) ending in the front part with the forked score (211) inside of which the vertical cutting instrument (25) is placed movably on the pin (212); in the front part having the front outer cylindrical setting (213) and in the rear part the rear outer cylindrical setting (214); ending with the palm manipulator (22) and with its outer cylindrical setting (213) and (214) it is movably and rotatingly placed inside the case unit (23) with the middle inner cylindrical setting (231) at the end of which is the two fingers' manipulator (233) with the rear inner cylindrical setting (232), while inside the case unit (23) in the space between the thorn (21) the pressing spring (24) is placed, the heads of which fit close to middle inner cylindrical setting (231) of the case unit (23) and rear outer cylindrical setting (214) of the thorn (21).

5. The instruments according to claim 3. are distinguishing for the thorn (31) of the laparoscopic horizontal lancet (3) ending in the front part with the forked score (311) inside of which the horizontal cutting instrument (35) is placed movably on the pin (312); in the front part having the front outer cylindrical setting (313) and in the rear part the rear outer cylindrical setting (314); ending with the palm manipulator (32) and with its outer cylindrical setting (313) and (314) it is movably and rotatingly placed inside the case unit (33) with the middle inner cylindrical setting (331) at the end of which is the two fingers' manipulator (333) with the rear inner cylindrical setting (332), while inside the case unit (33) in the space between the thorn (31) the pressing spring (34) is placed, the heads of which fit close to middle inner cylindrical setting (331) of the case unit (33) and rear outer cylindrical setting (314) of the thorn (31).