CA2195408A1 - Retractors, tool, and method for direct access endoscopic surgery - Google Patents
Retractors, tool, and method for direct access endoscopic surgeryInfo
- Publication number
- CA2195408A1 CA2195408A1 CA002195408A CA2195408A CA2195408A1 CA 2195408 A1 CA2195408 A1 CA 2195408A1 CA 002195408 A CA002195408 A CA 002195408A CA 2195408 A CA2195408 A CA 2195408A CA 2195408 A1 CA2195408 A1 CA 2195408A1
- Authority
- CA
- Canada
- Prior art keywords
- handle
- rigid frame
- tool
- mount
- blade mount
- Prior art date
- Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
- Abandoned
Links
Classifications
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/02—Surgical instruments, devices or methods, e.g. tourniquets for holding wounds open; Tractors
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/02—Surgical instruments, devices or methods, e.g. tourniquets for holding wounds open; Tractors
- A61B17/0206—Surgical instruments, devices or methods, e.g. tourniquets for holding wounds open; Tractors with antagonistic arms as supports for retractor elements
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/02—Surgical instruments, devices or methods, e.g. tourniquets for holding wounds open; Tractors
- A61B17/0293—Surgical instruments, devices or methods, e.g. tourniquets for holding wounds open; Tractors with ring member to support retractor elements
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/28—Surgical forceps
- A61B17/2812—Surgical forceps with a single pivotal connection
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/02—Surgical instruments, devices or methods, e.g. tourniquets for holding wounds open; Tractors
- A61B17/0218—Surgical instruments, devices or methods, e.g. tourniquets for holding wounds open; Tractors for minimally invasive surgery
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B90/00—Instruments, implements or accessories specially adapted for surgery or diagnosis and not covered by any of the groups A61B1/00 - A61B50/00, e.g. for luxation treatment or for protecting wound edges
- A61B90/06—Measuring instruments not otherwise provided for
- A61B2090/061—Measuring instruments not otherwise provided for for measuring dimensions, e.g. length
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B90/00—Instruments, implements or accessories specially adapted for surgery or diagnosis and not covered by any of the groups A61B1/00 - A61B50/00, e.g. for luxation treatment or for protecting wound edges
- A61B90/30—Devices for illuminating a surgical field, the devices having an interrelation with other surgical devices or with a surgical procedure
- A61B2090/306—Devices for illuminating a surgical field, the devices having an interrelation with other surgical devices or with a surgical procedure using optical fibres
Abstract
A retractor endoscope for less invasive, direct access endoscopic surgery includes a rigid frame (32) capable of supporting applied loads required to perform retraction of an incision site (Figure 2). The rigid frame includes a handle (28) at one end and a lower blade mount (33) rotatably connected to the opposite end. A translation frame (38) is slidably connected to the rigid frame and includes an upper blade mount (39) rotatably connected thereto.
Lower and upper blades (20, 22) are removably mounted to the lower and upper blade mounts, respectively, with at least one of the blades including pivot mounts (70) for high intensity fiberoptics. The angle of the lower blade along the lower blade mount rotatable connection and the angle of the upper blade along the upper blade mount rotatable connection are independently adjustable.
The size of an operating window is determined by the distance between the lower and upper blade mounts and the angle of the lower and upper blades. A
method of less invasive, direct access open surgery includes using the retractor with a tool (Figure 3) having an angled handle.
Lower and upper blades (20, 22) are removably mounted to the lower and upper blade mounts, respectively, with at least one of the blades including pivot mounts (70) for high intensity fiberoptics. The angle of the lower blade along the lower blade mount rotatable connection and the angle of the upper blade along the upper blade mount rotatable connection are independently adjustable.
The size of an operating window is determined by the distance between the lower and upper blade mounts and the angle of the lower and upper blades. A
method of less invasive, direct access open surgery includes using the retractor with a tool (Figure 3) having an angled handle.
Description
."'u~ 151 ~ WO9~02195 2 1 ~ 5 4 o ~
n~.,a~lor~,Tool,and MethodforDirectAccess~ndosco~icSur~ery The present invention relates in general to ~ log~u~r~ and retractors for use in surgery.
It is the aim o~ such devices to provide access to and/or lighted viewing of a body cavity for the purpose of investigating and treating disorders.
It is an important object of this invention to provide an apparatus and techniriues for a new concept in ~urgery, i.e. less invasive, direct access endoscopic surgery.
It is another object of the invention to create an operating window at the a~Lu~riate surgical site.
It is another object of the invention to provide new and ; uved in~LLI ~S and techniques for performing precision ~LuceduLes at a surgical site while using a retractor ~n~oscope according to the invention.
Retractor ~n~scop~- o~ the current invention utilize c~ncide~ably shorter (e.g., 3-6 times shorter) incisions than conventional surgery and enable three-~r~~-i~n~l direct viewlng of and direct access to the surgical site.
According to the invention, an apparatus for less invasive, direct access ~n~CulJir surgery through an operating window oomprises a rigid ~rame capable of supporting applied loads required to perform retraction of an ;n~ici~n site. The rigid frame ;n~ Pc a handle at one end having a handle slot therein, a lower blade mount rotatably connected to the opposite end, and rigid frame slots on either side of the rigid frame. A translation frame is slidably connected to the rigid frame through the handle slot and the rigid frame slots and includes an upper blade mount rotatably connected thereto.
The sl;~Ah]P connection is cu~ u~Led and arranged to allow the handle to translate the translation frame with respect to the rigid frame to adjust the distance between the lower blade mount and the upper blade mount. The handle ir ~o..~L-u~Led and arranged to prevent sliding of the translation frame along the ~ Ahl~ connection in at least one direction.
The apparatus further includes lower and upper blades each with free and supported ends mounted to the lower and upper blade mounts respectively. At least one of the lower and upper blades include a pivot mount for high intensity ~iberoptics. ~ first adjusting screw and bar assembly is functionally connected between the lower blade mount and the rigid frame for jn~PpPn~pntly adjusting the angle of the lower blade along the lower blade mount rotatable c~nn~C1 i~n~ and a second adjusting screw and bar assembly is functionally connected between the upper blade mount and the rigid frame for ;n~pPn~ntly adjusting the angle of the upper blade along the upper blade mount rotatable connection. The first and second adjusting screw and bar A~CPmh~ are constructed and arranged to prevent rotation along the rotatable connections in at least one direction.
The size of the operating window between the lower and upper blades i8 de~rm;n~d by the distance between the lower blade mount and the upper blade mount set by the handle and the angles of the lower and upper blades set by the first and second adjusting screw and bar assemblies respectively.
~ccording to one aspect of the invention, the lower and upper blades are removably mounted to the lower and upper blade mounts respectively.
~ WO96102195 .~ J~151 ~ v~ 1 9 5 4 ~ 8 According to another aspect of the invention, a scale is fixedly attached to the rigid frame for measuring the distance between the lower blade mount and the upper blade mount. In an exemplary embodiment of the invention, the scale is laser etched to the rigid frame.
According to another aspect of the invention, the lower blade and the upper blade differ in shape.
According to another aspect of the invention, the r-~hAn;sm for translating the handle comprises a rack and pinion ~h~ni-m, a lead screw r--h~nicm, or a ratchet r~~h~ni~m. In an exemplary embodiment of the invention, a torque wrench is removably connected to the lead screw r-~hlni~m for increasing the applied torque.
According to another aspect of the invention, the apparatus further includes an adjustable microcamera mount slidably and rotatably connected to the rigid frame in one of the rigid frame slots and includes a cam lock for locking the mount in the rigid frame slot. The microcamera mount further includes a microcamera holder, the magnification of the microcamera being adjustable by sliding the miulu1 ~
within the microcamera holder when seated in the microcamera holder.
According to another aspect of the invention, the apparatus further includes a retention device, e.g., a sleeve or one or two slide blades, for keeping body parts clear of the operating window.
According to another aspect of the invention, the apparatus is formed from nonmagnetic material, e.g., titanium.
According to another aspect of the invention, a tool for performing medical procedures comprises a distal working portion including two working members, a proximal handle angled at a predet~rmi n~d angle with respect to the distal SUSSTITUTE S~IEET (RULE 26) WO96/02195 .~I/rJ~ S
WO96/02195 ~ ,.SI
~ (rP ~ 1 9 5 4 0 g working portion and including two finger rings, and a region between the distal working portion and the proximal handle including a single pivot joint. ~ ~
The single pivot joint is constructed and arranged so that the actuation of the proximal handle by moving the finger rings apart or together in substantially a horizontal plane results in the working members moving apart or together in a working plane tilted at the predet~rm;n angle from the horizontal plane.
According to another aspect of the invention, the region between the distal working portion and the proximal handle further includes a gripping zone, e.g., knurled finger grips or a knurled finger pad, and a spike finger support integral with one of the finger rings. According to an exemplary embodiment of the invention, the tool is formed from nonmagnetic material, e.g., titanium.
According to another aspect of the invention, the predet~rmin~ angle is located proximal of the pivot joint and the distance between the proximal end of the handle and the angle location is less than the distance between the distal end of the working portion and the angle location.
According to another aspect of the invention, a hand retractor for retracting an incision comprises a blade, and a handle removably mounted to the blade. The blade includes pivot mounts for high intensity fiberoptics. The hand retractor is formed from a nonmagnetic material, e.g., titanium.
According to another aspect of the invention, a method of less invasive, direct access endoscopic surgery through an operating window is performed with an apparatus having a rigid frame capable of supporting applied loads required to perform retraction of an incision site. The rigid frame includes a handle at one end having a handle ~ WO96/02195 . P~ "C3151 . ~,",.i~;~ i.'~ 21~5408 , , .
slot therein, a lower blade mount rotatably connected to the opposite end, and rigid frame slots cn either side of the rigid fram~. A translation frame is slidably conn~rted to the riyid fra_e through the handle slot and the rigid frame slots and includes an upper blade mount rotatably connected thereto.
Th~ slidable connection is cO~laL~ ~Led and arranged to allow the handle to translate the translation fra_e with respect to the rigid frame to adjust the tistance between the lower blade mount and the upper blade _ount. The handle is c~n~L,~Led and arranged to prevent sliding of the translation frame along the slidable connection in at least one direction.
The apparatus further in~ es lower and upper blades each with free and supported ends mounted to the lower and upper blade mounts respectively. At least one Or the lower and upper blades include a pivot nount for high intensity fiberoptics. A first adjusting screw and bar assembly is functionally connected between the lower blade mount and the rigid ~rame for in~op~n~p~ntly adjusting the angle of the lower blade along the lower blade mount rotatable connection, and a second adjusting screw and bar assembly is functionally connected between the upper blade mount and the rigid frame for ;n~-lPn~ Lly adjusting the angle of the upper blade along the upper blade mount rotatable connection. The first and second adjusting screw and bar ~s~mhlipc are constructed and arranged to prevent rotation along the rotatable connections in at least one direction.
The size of the operating window between the lower and upper blades is detP-~;ned by the distance between the lower blade mount and the upper blade mount set by the handle and the angles of the lower and upper blades set by WO96102195 ~J~ a315 the first and second adjusting screw and bar assemblies respectively.
The method includes creating a small incision in the skin c~L.~ ;nq to a surgical site, retracting the 5 inricinn by placing the a~a~atus with the lower and upper blades angled such that the free ends of the lower and upper blades are close together into the inn;cinn and adjustinq the handle and the first and second adjusting screw and bar ~r ~lies to create the desired sized operating window, 111nr;n~ting the operating window with high intensity fiberoptic lighting, and performing surgery. According to an exemplary D~ho~i- of the invention, the method further ;nnl--~r~ tilting the apparatus to adjust the operating window.
According to another aspect of the invention, the method further includes a ~~nir~llAting tool having an angled handle so that the handle is clear of the operating window to enable visualization of the operating window during use of the tool.
The r-nir11l~ting inc'udes causing a working portion of the tool to enter the surgical site through the operating window while the angled handle remains removed from the surgical site, and performing surgery including r-nirnl~ting the working portion of the tool through actuation of the angled handle while observing the surgical site through the operating window. The tool is selected from the group consisting of clamps, forceps, and needle holders.
In another aspect of the invention, the method further inrlu~es ~L~eLLacting the ;nricinn with a hand retractor comprising a handle removable mounted to a first blade ;rcln~;ng pivot mounts for high intensity fiberoptics, removing the handle while inserting the apparatus, the apparatus ;nrl~;nq only one of the lower and upper blades W096/0~195 i '~ ' 2 ~ 9S408 P~ SC.3I5I
leaving one of the lower and upper blade mounts empty, attArhlng the Sirst blade to the apparatus in the empty blade mount during the insertion, and retracting the 1 nr~l cioln .
According to another aspect o~ the invention, a method o~ lesc invasive, direct access elldo3_v~ic surgery is perfcrmed with a retractor c~n~scope and a tool. The retractor Pn~oscope in~ln~o~c adjustable blades that can be positioned to create an operating window. The tool in~ln~oc a distal working portion cc_prising two working members, a proximal handle angled at a predetermined angle with respect to the distal working portion and including two finger rings, and a regicn between the distal working portion and the proximal handle in~ln~;ng a single pivot joint. The single pivot joint is cu-.s~L~ed and arranged so that actuation o~ the proximal handle by moving the finger rings apart or together in substcantially a horizontal plane results in the working _embers moving apart or together in a working plane tilted at the predetermined angle ~rom the horizontal plane. The angled handle enables vicnAl;7ation o~ an operating window during use of the tool.
The method ;nrltl~o~c creating a short incision in the skin cvLLa~vl,ding to a surgical site, retracting the incision with the retractor on~Ccv~e~ nminAting the operating window with high intensity fiberoptic lighting, causing a working portion of the tool to enter the surgical site through the operating window while the angled handle remains removed ~rom the surgical site, and performing surgery ;nrl~;ng t~-rir~ ting the working portion o~ the tool through actuation of the angled handle while observing the surgical site through the operating window.
Nl v~s other ~eatures, objects and advantages of the invention will become ~ale.,L fro~ the following W096/02195 , ,i, 2 1 9 5 4 0 8 specification when read in connection with the accompanying drawings in which:
FIG. l is a diagrammatic representation of a surgical procedure utilizing the retractor endoscope of the invention;
FIG. 2 is a perspective view of the retractor endoscope;
FIG. 2a is an exploded top view of the apparatus;
FIG. 2b is a side view of a handle of the apparatus;
FIG. 2c is an exploded side view of the handle section of the apparatus;
FIG. 3 is a perspective view of an angled handled tool for use in combination with the apparatus;
FIG. 3a is a perspective view of an alternative embodiment of an angled handles tool having a knurled finger pad shown positioned for right handed use;
FIGS. 4-4b show the retractor endoscopic in operation;
FIG. 5 is a perspective view of a hand retractor which may be used in combination with the retractor ~n~scope;
FIG. 6 is a side view of an alternative ~mho~;r?nt of the handle;
PIG. 7 is a top view of another alternative ~mh~ L
of the handle;
FIG. 8 is a side view showing a transparent plastic sleeve slid over the blades of the apparatus;
FIG. 9 is a perspective view of microcamera mount and a slide blade attached to the apparatus; FIG. 9a is a side view of the microcamera mount.
With reference now to the drawings and more particularly FIG. l thereof, there is shown the retractor endoscope of the current invention in a patient during SUnSI,~ t ~ tt ~ 6) ~ WO96/0219S ~ 5/~9lSI
j 'j 2 ~ 9~4~
surgery. After incision, an opening i5 seen made by retractor endoccupe 10 creating an operating window 14.
Tool 16 for performing a surgical ~oue1u ~ is positioned at a surgical slte throuqh operating window 14. Illumination 5 i5 provided by high intensity fiberoptic 1i qht i ng 12.
Utilizing r~L-~_Lur ~nd~cope 10, a large operating window 14 can be created from an incision that is considerably shorter (e.g., 3-6 times shorter~ than an inr~ n which would be used in conventional open surgery to perform the same p-ocedu~~.
Referring to FIGS. 2 and 2A, retractor ~n~n~cope 10 for m;nir-lly invasive, direct access Pn~scopic surgery ~nc~ P~ a very sturdy, rigid U-frame 32 capable of supporting applied loads required to perform retraction cr incision sites. Rigid U-frame 32 ;nrlU~PS a handle 28 at one end and a lower blade mount 33 rotatably connected to the opposite end. A translation frame 38 i~ slidably connected to rigid frame 32 through a handle slot 31 and rigid frame slots 34, 36. Translation frame 38 inrlu~p~ a rack 84 at one end and an upper blade mount 39 rotatably connected at the other end.
The sl;d~hlP connection between translation frame 38 and rigid frame 32 enables handle 28 to translate frame 38 with respect to rigid frame 32, as described below. This translation adjusts the distance between lower blade mount 33 and upper blade mount 39. The ~ hle cnnnpction is constructed to prevent sliding in at least one direction to hold the position set by the user.
Retractor Pn~nscope 10 includes lower and upper blades 20, 22 that are removably mounted to lower and upper blade mounts 33, 39 respectfully. Blades 20, 22 are slipped into angulated dovetail locks 24, 25 in blade mounts 33, 39.
Angulated dovetail locks 24, 26 are angled, e.g., at 5 _ g _ WO96102195 ~ u~lSl ~
~Q~ J'~ 2 1 954~8 degrees, to set the position of the blades within the blade mounts preventing the blades from sliding through the blade mounts, and locking screws 60, 62 lock the blades in place.
At least one of blades 20, 22 includes pivot mounts 70 threadably attached to the blade for receiving high intensity fiberoptic lighting 12. Fiberoptic lighting 12 is a bifurcated bundle terminating in curved ends 18, 19, e.g., 90~ bend, to insure that fiberoptic lighting 12 does not block the view of operating window 14 and does not interfere with the performance of the surgical procedure. For additional illumination, fiberoptic lighting 12 may be mounted to both blades.
A first adjusting screw and bar assembly 55 is functionally connected between lower blade mount 33 and rigid frame 32 for independently adjusting the angle of lower blade 20 along arrow 48 and a second adjusting screw and bar assembly 51 is functionally connected between upper blade mount 39 and rigid frame 32 for independently adjusting the angle of upper blade 22 along arrow 50. Pirst and second assemblies 55, 51 are capable of preventing rotation along the rotatable connections in at least one direction in order to hold a set angle. Specifically, adjustment of angle 50 is accomplished by turning fine-threaded, e.g., 1/4-28, high torque angle-adjusting screw 52 which adjusts lever arm 54 moving upper blade 22 along angle 50.
In a similar manner, angle 48 of lower blade 20 is adjusted by turning angle-adjusting screw 56, which adjusts lever arm 58 moving lower blade 20 along angle 48 (angle-adjusting screw 56 may have courser threading e.g., 1/4-20, than angle-adjusting screw 52 due to a greater mechanical advantage gained by lever arm 58 being longer than lever arm 54). Angle-adjusting screws 52, 56 may include pins 44 to SUBSTITUTE SHEET (RULE 26) ~ WO 96102195 I ~ Sl 2 1 q 5 4 0 8 aid in applying large torque. The ~p~hility of in~epen~Pntly adjusting thc distances between the proximal and distal ends of blades 20, 22 enable the user to expose a surgical site that i5 larger than operating window 14 thus reguiring a shorter ;n~icion and less retraction of the i n~ n than would conventionally be required to gain access to the same sized surgical site.
The 8iZ- of operatlng window 14 between lower and upper blades 20, 22 i8 determined by the distance between lower blade mount 33 and upper blade mount 39 set by handle 29 and the angles of lower and upper blades 20, 22 set by first and second ~sDmhliP~ 55, 51 respectfully. To enable a quick determination of the distance between lower and upper blade mounts 33, 39, main frame 32 includes a scale 64. Scale 64 is mounted to or formed on main frame 32 by any suitable method, e.g., laser etching.
Retractor endoscope 10 may be hand held by the surgeon during retraction of an incision site. Once operating window 14 has been created, retractor Pndoscope 10 need not be held by the surgeon during performance of a surgical ~LU~ed~' e. If desired, retractor Dnd~soope 10 may be attached to the operating table via mounting to a securing arm (not shown) at fixation sites 120, 122.
Referring to FIG. 2a, lower blade mount 33 is rotatably connected to rigid frame 32 via pins 72, 74.
Spring loaded set screws 73, 75 hold pins 72, 74 in place and allow lower blade mount 33 to be quickly ~icconnpcted from rigid frame 32 to facilitate clP~ning. Arm 58 is fixedly attached to lower blade mount 33 by screw 77.
Angle-adjusting screw 56 is rotatably connected to rigid frame 32 by screw 76. Upper blade mount 39 is rotatably connected to translation frame 38 via screws 80, 82; side rods 40, 42 o~ translation frame 38 threadably receive "~,~,, c ~,151 ~
21 9 5 4 ~ 8 screws 80, 82 respectively and upper blade mount 39 is clearance fit to screws 80, 82 to allow rotation. Arm 54 is fixedly attached to upper blade mount 39.
Referring to PIG. 2b, one example of a - ~ni c~ for 5 ad~usting the distance between lower blade mount 33 and upper blade mount 39 is a type of rack and pinion system in which rotation of a rod 30 turns a pinion 86 which translates rack 84 along arrow 29 resulting in translation of frame 38.
Referring to FIG. 2c, h~ndle 28 is formed from two sections 28a, 28b. To ~cc~hle the handle portion of retractor - ~scul,e 10, translation frame 38 with rack 84 is sandwiched between sections 28a, 28b with the top and bottom edges 87, 89 of rack 84 slid into slots 91, 93 of sections 28a, 28b. Before placing section 28b over rack 84, pinion 86 is placed in opening 85 of section 28b. The assembly is held together with dismantling screw 83. Referring also to FIGS. 2 and 2A, U-frame 32 with lower blade mount 33 is then attached to the handle portion by sliding it over side rods 40, 42 and bolting it to handle 28 by screws 81, 81' (screw 81' not shown). Upper blade mount 39 is then positioned within U-frame 32 and the assembly is held together with screws 80, 82. Lower and upper blades 20, 22 are then slid into position in dovetails 24, 26 and locked via locking screws 60, 62.
Referring to FIG. 3, tool 16, used in combination with retractor en~oscope 10, ;n~ C a proximal angled handle 90 (e.g., angled at 30, 45, or 60 degrees at bends 105, 105') which permits v;Cll~1;7ation of the surgical site during a pluceduLe by L ~ ; n; nq clear of operating window 14 during use of tool 16. Proximal angled handle 90 also facilitates keeping the user's hand which is ~rirul~ting tool 16 from hlo~; n5 operating window 14.
~ WC96/02195 2 1 9 5 4 0 8 r~ c ~
~ 3 J
Proximal angled handle 90 inc]n~s two finger rings 101, 101'. Tool 16 has a distal worlcing portion 94 for performing a surgical pL~ceduL~ which ;nrln~os two worklng members 103, 103' and a single pivot joint 99 located between distal working portion 94 and proximal handle 90.
Pivot joint 99 permits actuation of handle 90 by moving finger rings 101, 101' apart or together in a horizontal plane which results in working members 103, 103' moving apart or together in the same plane tilted at the angle of bends 105, 105'. Bends 105, 105' are located proximally of pivot joint 99; the distance between the proximal end of proximal handle 90 and bends 105, 105' is less than the distance between the distal end of working portion 94 and bend 105, 105'.
Tool 16 further ;ncln~- knurled finger grips 92 located proximally of pivot point 99 and a spike finger support 95 located on finger ring 101 or 101', ~p~n~;n~ on left or right handed use. Finger grips 92 and spike finger support 95 facilitate precision h~n~l i ng of tool 16.
Working portion 94 of tool 16 may be any suitable device for performing the desired ~LvceduL~, e.g., forceps, clamps, needle holders. Referring to FIG. 3a, in another ~hoS;--nt of tool 16, knurled finger grips 92 are replaced with knurled finger pad 97. Knurled finger pad 97 can be positioned for either left or right handed use.
Referring to FlGS. 4-4b, in operation a short incision 95 (e.g., 3-6 times shorter than the incision made for the same ~L oceduL e in conventional surgery) is made in the skin c~LLes~lrl~;ng to the site of a surgical procedure.
The use of a short incision results in more rapid healing, ; less wound surface, less bleeding and less pain than the standard sized inr;cinn used in conventional surgery. The ;rrieion is retracted by placing lower and upper blades 20, WO96/02195 ~J~t~i6 ~ Sl ~
2 1 9 ~ 4 0 8 22, angled with their ~ree ends close together, into the ;nr~cirn. The desired sized operating window 14 is created by adjusting handle 2a and first and second Acsemhl;~q 55, 51. The surgical site is ;llnm7n~ted with high intensity fiberoptic lighting 12.
Working portion 94 of tool 16 then enters the surgical site through operating window 14 while angled handle 90 remains removed from the surgical site. Surgery is then performed ;nrln~ing manipulating working portion 94 o of tool 16 through actuation of angled handle 9o while observing the surgical site through the operating window.
This method facilitates performing surgical ~LUCedULe while allowing illl~m;nAtion and hinorlllAr visualization of the operating site.
Referring to FIG. 5, in operation, a hand retractor may be employed to perform initial retraction and lighting of incision 95. Hand retractor 124 includes a handle 126 with a retractor blade (either lower blade 20 or upper blade 22, lower blade 20 shown) removably mounted thereto by screws 128, 130 through slots 132, 134. Slots 132, 134 have two circular sections, one section 136 having a smaller diameter than the diameter of the heads of screws 128, 130 so that the screw can be tightened for mounting, and another section 138 having a larger diameter than the screw head diameter so that the handle can be removed. Fiberoptic mounts 70 may replace one or both of screws 128, 130.
After initial retraction with hand retractor 124, screws 128, 130 are looson~d, handle 126 is pushed in the direction of arrow 140 and removed leaving the retractor blade in place while retractor endoscope 10 is inserted.
Retractor ~ndosrope 10 i nr~ c only one of lower and upper blades 20, 22 leaving the other respective blade mount empty to accept the retractor blade which was le K in place in ~ W096/02195 21 954~8 ~ . ,151 incision 95 for attachment to retractor endoscope 10 during the insertion of retractor endoscope lo into incision 95.
Various nfph~n;~m~ may be employed to adjust the distance between lower and upper blade mounts 33, 39.
Referring to FIG. 6, rack and pinion 84, 86 can be replaced with lead screw 100. Rotating knob 102 turns lead screw 100 translating frame 38. Torque wrench 104 can be used to a apply additional torque to lead screw 100.
Referring to FIG. 7, rack and pinion 84, 86 can be replaced with a ratchet r~ch~n; Sm. Handle 28 includes finger pivot 110 with end 111 which locks into grooves 114 of ratchet 112, ratchet 112 being connected to translation frame 38. Frame 38 can be freely translated within handle 28 in the direction which moves lower and upper blade mounts 33, 39 further apart, but end 111 of finger pivot 110 falls into grooves 114 as the grooves pass by preventing free translation of frame 38 within handle 28 in the direction which moves lower and upper blade mounts 33, 39 closer together. This allows the position of lower and upper blade mounts 33, 39 to be maintained without having to apply continual load to retractor endoscope 10. In order to move lower and upper blade mounts 33, 39 closer together, end 111 must be moved out of groove 114 by pushing on pad 113 of finger pivot llo.
A biasing means, e.g., spring or spring steel, (not shown) may be incorporated to bias finger pivot llo in the position in which end 111 is engaged with groove 114. Screw 116 which is threadably mounted to ratchet 112 may be employed to aid in increasing the distance between lower and upper blade mounts 33, 39. With end 117 of screw 116 against handle 28, turning screw 116 causes ratchet 112 and thus translation frame 38 to move in the direction of arrow SUBSTITUTE Sl iEET (RULE 26,~
WO96/02l95 ~ r~ c 3lsl ~
2 1 9 ~ 4 ~ 8 119. Screw 116 must be backed off to allow lower and upper blade mounts 33, 39 to be moved closer together.
Removable blades 20, 22 may be sterili7~hle or ~iepo~Ahl~. !31ade 20 may be dir~erent in length from blade 22. This is particularly userul in surgical ~Lvced~ ~s such as bladder neck surgery in which one of the blades would hit the pelvic bone if the blade were too long. In operation, the blades generally ~i~pl~A~ce organs to create operating window 14. Referring to FIG. 8, in order to keep the organs out Or the operating window, particularly ln procedures such as bowel surgery, a retention device, e.g., a sleeve 149, can be placed around blades 20, 22. Sleeve 14g is surriciently elastic to allow it to stretch and retract as blades 20,22 are adjusted and may include a slit 151 facing away from an area containing organs to be retained, thus allowing access to a surgical area beyond slit 151.
Alternatively, referring to FTG. 9, one or two side blades 142 may be utilized for this purpose.
Blades 20, 22 may include windows to enable viewing of the anatomy beyond the blades. The shape of blades 20, 22 may vary, e.g., non-rectangular, wider, narrower, shorter, longer. Blades 20, 22 are replArp~hle. This is particularly advantageous if, after initial insertion of retractor ~n~oscope 10, it is found that one or both of the blades are of the wrong size.
An advantage of the current invention is that the surgeon can use his or her own two eyes to view the surgical site. Thus the surgeon has a three-dimensional direct image through a relatively short incision. Additionally, fine needle suturing is relatively easy and precise.
An additional advantage of the current system is that if operating window 14 is incorrectly positioned, the angle of viewing can be adjusted by tilting retractOr ~ WO96/02l95 ~ 2 1 9 5 4 8 r ~ sl i, q .'~ ~ O
scope 10 as a unit or by independently moving the blades, thus viewing a new area without making an additional - inricinn~
Additionally, the current invention utilizes shorter 5 inrjc;n~c (e.g. 3-6 timeg ghorter) than conventional surgery and provides three-dlmensional direct vie~ing and direct access to the surgical site, facilitating shorter operating times. For example, in aorto-bifemoral bypass surgery, the ;~rjc;~n made is a sixth o~ the size of the incision made in conventional surgery. In r._~.L__Lomy, laparoscopically the oceduLe takes 5~ to 6 hours, conventionally the ~-v.eduLe takes one hour with a 30 to 32 cm ;nricion site, with the current invention the ~L ~ takes one hour with an incision site of approximately 6 cm. Additionally, the surgeon can place his or her flngers into the surgical site ~nd perform manual palpation.
Retractor ~ninscop~ 10 can be used in a wide variety of urgical ~LuceduL~s ;nrlnAi~g vascular, cardiac, spinal, pnl -ry, urology, trauma and ~'' ;"Al surgery. During spinal fusion, access to the surgical site can be obtained through a mini-incision from the front of the body instead of from the back. For heart or lung surgery a rib does not have to be removed; rigid U-frame 32 must be able to support the load seen by retractor ~ins~e 10 while retracting and holding the ribs apart to allow access to the heart or lung.
Retractor ~n~n~cope 10 can be used in cvl.jul.~ion with operating room ~i~Luscv~e~ vi~eo~ ras, h;noclllAr magnifying loops and surgical lasers. Additionally, retractor endoscope 10, tool 16 and hand retractor 124 may be used in conjunction with a magnetic r~cn~A~re imaging system provided they are constructed ~rom ~-~ ?tiC
material, e.g., titanium.
WOg6/02l95 ~ r~ , ,o~.s P ~ 5 ~ 0 8 Referring to FIGS 9-9a, U-frame 32 includes an ad~ustable mount 150 for a video microcamera (not shown) Mount 150 is attached to U-frame 32 along either rigid frame slot 34 or 36 (shown in slot 36~ such that mount 150 can slide along arrow 152 and rotate along arrow 154 Arm 156 of mount 150 can translate along arrow 158 and rotate along arrow 160 A mi~-- a holder 162 slidably holds the mi~. a allowing the magnification of the mi~L ~ a to be ad~usted by sliding the mi~.. a along arrow 164 within mi~.- a holder 162 Mi~Lu~ a holder 162 may be fluted with slots 172 If necD~ry~ mi~ a holder 162 may contain a lens for use with the mi~L~ a. Mount 150 can be locked in place against U-frame 32 by rotating a cam lock 168 using rod 170, thus preventing motion along arrows 152, 154, 158 and 160 Other amho~ s are within the following claims What is claimed is
n~.,a~lor~,Tool,and MethodforDirectAccess~ndosco~icSur~ery The present invention relates in general to ~ log~u~r~ and retractors for use in surgery.
It is the aim o~ such devices to provide access to and/or lighted viewing of a body cavity for the purpose of investigating and treating disorders.
It is an important object of this invention to provide an apparatus and techniriues for a new concept in ~urgery, i.e. less invasive, direct access endoscopic surgery.
It is another object of the invention to create an operating window at the a~Lu~riate surgical site.
It is another object of the invention to provide new and ; uved in~LLI ~S and techniques for performing precision ~LuceduLes at a surgical site while using a retractor ~n~oscope according to the invention.
Retractor ~n~scop~- o~ the current invention utilize c~ncide~ably shorter (e.g., 3-6 times shorter) incisions than conventional surgery and enable three-~r~~-i~n~l direct viewlng of and direct access to the surgical site.
According to the invention, an apparatus for less invasive, direct access ~n~CulJir surgery through an operating window oomprises a rigid ~rame capable of supporting applied loads required to perform retraction of an ;n~ici~n site. The rigid frame ;n~ Pc a handle at one end having a handle slot therein, a lower blade mount rotatably connected to the opposite end, and rigid frame slots on either side of the rigid frame. A translation frame is slidably connected to the rigid frame through the handle slot and the rigid frame slots and includes an upper blade mount rotatably connected thereto.
The sl;~Ah]P connection is cu~ u~Led and arranged to allow the handle to translate the translation frame with respect to the rigid frame to adjust the distance between the lower blade mount and the upper blade mount. The handle ir ~o..~L-u~Led and arranged to prevent sliding of the translation frame along the ~ Ahl~ connection in at least one direction.
The apparatus further includes lower and upper blades each with free and supported ends mounted to the lower and upper blade mounts respectively. At least one of the lower and upper blades include a pivot mount for high intensity ~iberoptics. ~ first adjusting screw and bar assembly is functionally connected between the lower blade mount and the rigid frame for jn~PpPn~pntly adjusting the angle of the lower blade along the lower blade mount rotatable c~nn~C1 i~n~ and a second adjusting screw and bar assembly is functionally connected between the upper blade mount and the rigid frame for ;n~pPn~ntly adjusting the angle of the upper blade along the upper blade mount rotatable connection. The first and second adjusting screw and bar A~CPmh~ are constructed and arranged to prevent rotation along the rotatable connections in at least one direction.
The size of the operating window between the lower and upper blades i8 de~rm;n~d by the distance between the lower blade mount and the upper blade mount set by the handle and the angles of the lower and upper blades set by the first and second adjusting screw and bar assemblies respectively.
~ccording to one aspect of the invention, the lower and upper blades are removably mounted to the lower and upper blade mounts respectively.
~ WO96102195 .~ J~151 ~ v~ 1 9 5 4 ~ 8 According to another aspect of the invention, a scale is fixedly attached to the rigid frame for measuring the distance between the lower blade mount and the upper blade mount. In an exemplary embodiment of the invention, the scale is laser etched to the rigid frame.
According to another aspect of the invention, the lower blade and the upper blade differ in shape.
According to another aspect of the invention, the r-~hAn;sm for translating the handle comprises a rack and pinion ~h~ni-m, a lead screw r--h~nicm, or a ratchet r~~h~ni~m. In an exemplary embodiment of the invention, a torque wrench is removably connected to the lead screw r-~hlni~m for increasing the applied torque.
According to another aspect of the invention, the apparatus further includes an adjustable microcamera mount slidably and rotatably connected to the rigid frame in one of the rigid frame slots and includes a cam lock for locking the mount in the rigid frame slot. The microcamera mount further includes a microcamera holder, the magnification of the microcamera being adjustable by sliding the miulu1 ~
within the microcamera holder when seated in the microcamera holder.
According to another aspect of the invention, the apparatus further includes a retention device, e.g., a sleeve or one or two slide blades, for keeping body parts clear of the operating window.
According to another aspect of the invention, the apparatus is formed from nonmagnetic material, e.g., titanium.
According to another aspect of the invention, a tool for performing medical procedures comprises a distal working portion including two working members, a proximal handle angled at a predet~rmi n~d angle with respect to the distal SUSSTITUTE S~IEET (RULE 26) WO96/02195 .~I/rJ~ S
WO96/02195 ~ ,.SI
~ (rP ~ 1 9 5 4 0 g working portion and including two finger rings, and a region between the distal working portion and the proximal handle including a single pivot joint. ~ ~
The single pivot joint is constructed and arranged so that the actuation of the proximal handle by moving the finger rings apart or together in substantially a horizontal plane results in the working members moving apart or together in a working plane tilted at the predet~rm;n angle from the horizontal plane.
According to another aspect of the invention, the region between the distal working portion and the proximal handle further includes a gripping zone, e.g., knurled finger grips or a knurled finger pad, and a spike finger support integral with one of the finger rings. According to an exemplary embodiment of the invention, the tool is formed from nonmagnetic material, e.g., titanium.
According to another aspect of the invention, the predet~rmin~ angle is located proximal of the pivot joint and the distance between the proximal end of the handle and the angle location is less than the distance between the distal end of the working portion and the angle location.
According to another aspect of the invention, a hand retractor for retracting an incision comprises a blade, and a handle removably mounted to the blade. The blade includes pivot mounts for high intensity fiberoptics. The hand retractor is formed from a nonmagnetic material, e.g., titanium.
According to another aspect of the invention, a method of less invasive, direct access endoscopic surgery through an operating window is performed with an apparatus having a rigid frame capable of supporting applied loads required to perform retraction of an incision site. The rigid frame includes a handle at one end having a handle ~ WO96/02195 . P~ "C3151 . ~,",.i~;~ i.'~ 21~5408 , , .
slot therein, a lower blade mount rotatably connected to the opposite end, and rigid frame slots cn either side of the rigid fram~. A translation frame is slidably conn~rted to the riyid fra_e through the handle slot and the rigid frame slots and includes an upper blade mount rotatably connected thereto.
Th~ slidable connection is cO~laL~ ~Led and arranged to allow the handle to translate the translation fra_e with respect to the rigid frame to adjust the tistance between the lower blade mount and the upper blade _ount. The handle is c~n~L,~Led and arranged to prevent sliding of the translation frame along the slidable connection in at least one direction.
The apparatus further in~ es lower and upper blades each with free and supported ends mounted to the lower and upper blade mounts respectively. At least one Or the lower and upper blades include a pivot nount for high intensity fiberoptics. A first adjusting screw and bar assembly is functionally connected between the lower blade mount and the rigid ~rame for in~op~n~p~ntly adjusting the angle of the lower blade along the lower blade mount rotatable connection, and a second adjusting screw and bar assembly is functionally connected between the upper blade mount and the rigid frame for ;n~-lPn~ Lly adjusting the angle of the upper blade along the upper blade mount rotatable connection. The first and second adjusting screw and bar ~s~mhlipc are constructed and arranged to prevent rotation along the rotatable connections in at least one direction.
The size of the operating window between the lower and upper blades is detP-~;ned by the distance between the lower blade mount and the upper blade mount set by the handle and the angles of the lower and upper blades set by WO96102195 ~J~ a315 the first and second adjusting screw and bar assemblies respectively.
The method includes creating a small incision in the skin c~L.~ ;nq to a surgical site, retracting the 5 inricinn by placing the a~a~atus with the lower and upper blades angled such that the free ends of the lower and upper blades are close together into the inn;cinn and adjustinq the handle and the first and second adjusting screw and bar ~r ~lies to create the desired sized operating window, 111nr;n~ting the operating window with high intensity fiberoptic lighting, and performing surgery. According to an exemplary D~ho~i- of the invention, the method further ;nnl--~r~ tilting the apparatus to adjust the operating window.
According to another aspect of the invention, the method further includes a ~~nir~llAting tool having an angled handle so that the handle is clear of the operating window to enable visualization of the operating window during use of the tool.
The r-nir11l~ting inc'udes causing a working portion of the tool to enter the surgical site through the operating window while the angled handle remains removed from the surgical site, and performing surgery including r-nirnl~ting the working portion of the tool through actuation of the angled handle while observing the surgical site through the operating window. The tool is selected from the group consisting of clamps, forceps, and needle holders.
In another aspect of the invention, the method further inrlu~es ~L~eLLacting the ;nricinn with a hand retractor comprising a handle removable mounted to a first blade ;rcln~;ng pivot mounts for high intensity fiberoptics, removing the handle while inserting the apparatus, the apparatus ;nrl~;nq only one of the lower and upper blades W096/0~195 i '~ ' 2 ~ 9S408 P~ SC.3I5I
leaving one of the lower and upper blade mounts empty, attArhlng the Sirst blade to the apparatus in the empty blade mount during the insertion, and retracting the 1 nr~l cioln .
According to another aspect o~ the invention, a method o~ lesc invasive, direct access elldo3_v~ic surgery is perfcrmed with a retractor c~n~scope and a tool. The retractor Pn~oscope in~ln~o~c adjustable blades that can be positioned to create an operating window. The tool in~ln~oc a distal working portion cc_prising two working members, a proximal handle angled at a predetermined angle with respect to the distal working portion and including two finger rings, and a regicn between the distal working portion and the proximal handle in~ln~;ng a single pivot joint. The single pivot joint is cu-.s~L~ed and arranged so that actuation o~ the proximal handle by moving the finger rings apart or together in substcantially a horizontal plane results in the working _embers moving apart or together in a working plane tilted at the predetermined angle ~rom the horizontal plane. The angled handle enables vicnAl;7ation o~ an operating window during use of the tool.
The method ;nrltl~o~c creating a short incision in the skin cvLLa~vl,ding to a surgical site, retracting the incision with the retractor on~Ccv~e~ nminAting the operating window with high intensity fiberoptic lighting, causing a working portion of the tool to enter the surgical site through the operating window while the angled handle remains removed ~rom the surgical site, and performing surgery ;nrl~;ng t~-rir~ ting the working portion o~ the tool through actuation of the angled handle while observing the surgical site through the operating window.
Nl v~s other ~eatures, objects and advantages of the invention will become ~ale.,L fro~ the following W096/02195 , ,i, 2 1 9 5 4 0 8 specification when read in connection with the accompanying drawings in which:
FIG. l is a diagrammatic representation of a surgical procedure utilizing the retractor endoscope of the invention;
FIG. 2 is a perspective view of the retractor endoscope;
FIG. 2a is an exploded top view of the apparatus;
FIG. 2b is a side view of a handle of the apparatus;
FIG. 2c is an exploded side view of the handle section of the apparatus;
FIG. 3 is a perspective view of an angled handled tool for use in combination with the apparatus;
FIG. 3a is a perspective view of an alternative embodiment of an angled handles tool having a knurled finger pad shown positioned for right handed use;
FIGS. 4-4b show the retractor endoscopic in operation;
FIG. 5 is a perspective view of a hand retractor which may be used in combination with the retractor ~n~scope;
FIG. 6 is a side view of an alternative ~mho~;r?nt of the handle;
PIG. 7 is a top view of another alternative ~mh~ L
of the handle;
FIG. 8 is a side view showing a transparent plastic sleeve slid over the blades of the apparatus;
FIG. 9 is a perspective view of microcamera mount and a slide blade attached to the apparatus; FIG. 9a is a side view of the microcamera mount.
With reference now to the drawings and more particularly FIG. l thereof, there is shown the retractor endoscope of the current invention in a patient during SUnSI,~ t ~ tt ~ 6) ~ WO96/0219S ~ 5/~9lSI
j 'j 2 ~ 9~4~
surgery. After incision, an opening i5 seen made by retractor endoccupe 10 creating an operating window 14.
Tool 16 for performing a surgical ~oue1u ~ is positioned at a surgical slte throuqh operating window 14. Illumination 5 i5 provided by high intensity fiberoptic 1i qht i ng 12.
Utilizing r~L-~_Lur ~nd~cope 10, a large operating window 14 can be created from an incision that is considerably shorter (e.g., 3-6 times shorter~ than an inr~ n which would be used in conventional open surgery to perform the same p-ocedu~~.
Referring to FIGS. 2 and 2A, retractor ~n~n~cope 10 for m;nir-lly invasive, direct access Pn~scopic surgery ~nc~ P~ a very sturdy, rigid U-frame 32 capable of supporting applied loads required to perform retraction cr incision sites. Rigid U-frame 32 ;nrlU~PS a handle 28 at one end and a lower blade mount 33 rotatably connected to the opposite end. A translation frame 38 i~ slidably connected to rigid frame 32 through a handle slot 31 and rigid frame slots 34, 36. Translation frame 38 inrlu~p~ a rack 84 at one end and an upper blade mount 39 rotatably connected at the other end.
The sl;d~hlP connection between translation frame 38 and rigid frame 32 enables handle 28 to translate frame 38 with respect to rigid frame 32, as described below. This translation adjusts the distance between lower blade mount 33 and upper blade mount 39. The ~ hle cnnnpction is constructed to prevent sliding in at least one direction to hold the position set by the user.
Retractor Pn~nscope 10 includes lower and upper blades 20, 22 that are removably mounted to lower and upper blade mounts 33, 39 respectfully. Blades 20, 22 are slipped into angulated dovetail locks 24, 25 in blade mounts 33, 39.
Angulated dovetail locks 24, 26 are angled, e.g., at 5 _ g _ WO96102195 ~ u~lSl ~
~Q~ J'~ 2 1 954~8 degrees, to set the position of the blades within the blade mounts preventing the blades from sliding through the blade mounts, and locking screws 60, 62 lock the blades in place.
At least one of blades 20, 22 includes pivot mounts 70 threadably attached to the blade for receiving high intensity fiberoptic lighting 12. Fiberoptic lighting 12 is a bifurcated bundle terminating in curved ends 18, 19, e.g., 90~ bend, to insure that fiberoptic lighting 12 does not block the view of operating window 14 and does not interfere with the performance of the surgical procedure. For additional illumination, fiberoptic lighting 12 may be mounted to both blades.
A first adjusting screw and bar assembly 55 is functionally connected between lower blade mount 33 and rigid frame 32 for independently adjusting the angle of lower blade 20 along arrow 48 and a second adjusting screw and bar assembly 51 is functionally connected between upper blade mount 39 and rigid frame 32 for independently adjusting the angle of upper blade 22 along arrow 50. Pirst and second assemblies 55, 51 are capable of preventing rotation along the rotatable connections in at least one direction in order to hold a set angle. Specifically, adjustment of angle 50 is accomplished by turning fine-threaded, e.g., 1/4-28, high torque angle-adjusting screw 52 which adjusts lever arm 54 moving upper blade 22 along angle 50.
In a similar manner, angle 48 of lower blade 20 is adjusted by turning angle-adjusting screw 56, which adjusts lever arm 58 moving lower blade 20 along angle 48 (angle-adjusting screw 56 may have courser threading e.g., 1/4-20, than angle-adjusting screw 52 due to a greater mechanical advantage gained by lever arm 58 being longer than lever arm 54). Angle-adjusting screws 52, 56 may include pins 44 to SUBSTITUTE SHEET (RULE 26) ~ WO 96102195 I ~ Sl 2 1 q 5 4 0 8 aid in applying large torque. The ~p~hility of in~epen~Pntly adjusting thc distances between the proximal and distal ends of blades 20, 22 enable the user to expose a surgical site that i5 larger than operating window 14 thus reguiring a shorter ;n~icion and less retraction of the i n~ n than would conventionally be required to gain access to the same sized surgical site.
The 8iZ- of operatlng window 14 between lower and upper blades 20, 22 i8 determined by the distance between lower blade mount 33 and upper blade mount 39 set by handle 29 and the angles of lower and upper blades 20, 22 set by first and second ~sDmhliP~ 55, 51 respectfully. To enable a quick determination of the distance between lower and upper blade mounts 33, 39, main frame 32 includes a scale 64. Scale 64 is mounted to or formed on main frame 32 by any suitable method, e.g., laser etching.
Retractor endoscope 10 may be hand held by the surgeon during retraction of an incision site. Once operating window 14 has been created, retractor Pndoscope 10 need not be held by the surgeon during performance of a surgical ~LU~ed~' e. If desired, retractor Dnd~soope 10 may be attached to the operating table via mounting to a securing arm (not shown) at fixation sites 120, 122.
Referring to FIG. 2a, lower blade mount 33 is rotatably connected to rigid frame 32 via pins 72, 74.
Spring loaded set screws 73, 75 hold pins 72, 74 in place and allow lower blade mount 33 to be quickly ~icconnpcted from rigid frame 32 to facilitate clP~ning. Arm 58 is fixedly attached to lower blade mount 33 by screw 77.
Angle-adjusting screw 56 is rotatably connected to rigid frame 32 by screw 76. Upper blade mount 39 is rotatably connected to translation frame 38 via screws 80, 82; side rods 40, 42 o~ translation frame 38 threadably receive "~,~,, c ~,151 ~
21 9 5 4 ~ 8 screws 80, 82 respectively and upper blade mount 39 is clearance fit to screws 80, 82 to allow rotation. Arm 54 is fixedly attached to upper blade mount 39.
Referring to PIG. 2b, one example of a - ~ni c~ for 5 ad~usting the distance between lower blade mount 33 and upper blade mount 39 is a type of rack and pinion system in which rotation of a rod 30 turns a pinion 86 which translates rack 84 along arrow 29 resulting in translation of frame 38.
Referring to FIG. 2c, h~ndle 28 is formed from two sections 28a, 28b. To ~cc~hle the handle portion of retractor - ~scul,e 10, translation frame 38 with rack 84 is sandwiched between sections 28a, 28b with the top and bottom edges 87, 89 of rack 84 slid into slots 91, 93 of sections 28a, 28b. Before placing section 28b over rack 84, pinion 86 is placed in opening 85 of section 28b. The assembly is held together with dismantling screw 83. Referring also to FIGS. 2 and 2A, U-frame 32 with lower blade mount 33 is then attached to the handle portion by sliding it over side rods 40, 42 and bolting it to handle 28 by screws 81, 81' (screw 81' not shown). Upper blade mount 39 is then positioned within U-frame 32 and the assembly is held together with screws 80, 82. Lower and upper blades 20, 22 are then slid into position in dovetails 24, 26 and locked via locking screws 60, 62.
Referring to FIG. 3, tool 16, used in combination with retractor en~oscope 10, ;n~ C a proximal angled handle 90 (e.g., angled at 30, 45, or 60 degrees at bends 105, 105') which permits v;Cll~1;7ation of the surgical site during a pluceduLe by L ~ ; n; nq clear of operating window 14 during use of tool 16. Proximal angled handle 90 also facilitates keeping the user's hand which is ~rirul~ting tool 16 from hlo~; n5 operating window 14.
~ WC96/02195 2 1 9 5 4 0 8 r~ c ~
~ 3 J
Proximal angled handle 90 inc]n~s two finger rings 101, 101'. Tool 16 has a distal worlcing portion 94 for performing a surgical pL~ceduL~ which ;nrln~os two worklng members 103, 103' and a single pivot joint 99 located between distal working portion 94 and proximal handle 90.
Pivot joint 99 permits actuation of handle 90 by moving finger rings 101, 101' apart or together in a horizontal plane which results in working members 103, 103' moving apart or together in the same plane tilted at the angle of bends 105, 105'. Bends 105, 105' are located proximally of pivot joint 99; the distance between the proximal end of proximal handle 90 and bends 105, 105' is less than the distance between the distal end of working portion 94 and bend 105, 105'.
Tool 16 further ;ncln~- knurled finger grips 92 located proximally of pivot point 99 and a spike finger support 95 located on finger ring 101 or 101', ~p~n~;n~ on left or right handed use. Finger grips 92 and spike finger support 95 facilitate precision h~n~l i ng of tool 16.
Working portion 94 of tool 16 may be any suitable device for performing the desired ~LvceduL~, e.g., forceps, clamps, needle holders. Referring to FIG. 3a, in another ~hoS;--nt of tool 16, knurled finger grips 92 are replaced with knurled finger pad 97. Knurled finger pad 97 can be positioned for either left or right handed use.
Referring to FlGS. 4-4b, in operation a short incision 95 (e.g., 3-6 times shorter than the incision made for the same ~L oceduL e in conventional surgery) is made in the skin c~LLes~lrl~;ng to the site of a surgical procedure.
The use of a short incision results in more rapid healing, ; less wound surface, less bleeding and less pain than the standard sized inr;cinn used in conventional surgery. The ;rrieion is retracted by placing lower and upper blades 20, WO96/02195 ~J~t~i6 ~ Sl ~
2 1 9 ~ 4 0 8 22, angled with their ~ree ends close together, into the ;nr~cirn. The desired sized operating window 14 is created by adjusting handle 2a and first and second Acsemhl;~q 55, 51. The surgical site is ;llnm7n~ted with high intensity fiberoptic lighting 12.
Working portion 94 of tool 16 then enters the surgical site through operating window 14 while angled handle 90 remains removed from the surgical site. Surgery is then performed ;nrln~ing manipulating working portion 94 o of tool 16 through actuation of angled handle 9o while observing the surgical site through the operating window.
This method facilitates performing surgical ~LUCedULe while allowing illl~m;nAtion and hinorlllAr visualization of the operating site.
Referring to FIG. 5, in operation, a hand retractor may be employed to perform initial retraction and lighting of incision 95. Hand retractor 124 includes a handle 126 with a retractor blade (either lower blade 20 or upper blade 22, lower blade 20 shown) removably mounted thereto by screws 128, 130 through slots 132, 134. Slots 132, 134 have two circular sections, one section 136 having a smaller diameter than the diameter of the heads of screws 128, 130 so that the screw can be tightened for mounting, and another section 138 having a larger diameter than the screw head diameter so that the handle can be removed. Fiberoptic mounts 70 may replace one or both of screws 128, 130.
After initial retraction with hand retractor 124, screws 128, 130 are looson~d, handle 126 is pushed in the direction of arrow 140 and removed leaving the retractor blade in place while retractor endoscope 10 is inserted.
Retractor ~ndosrope 10 i nr~ c only one of lower and upper blades 20, 22 leaving the other respective blade mount empty to accept the retractor blade which was le K in place in ~ W096/02195 21 954~8 ~ . ,151 incision 95 for attachment to retractor endoscope 10 during the insertion of retractor endoscope lo into incision 95.
Various nfph~n;~m~ may be employed to adjust the distance between lower and upper blade mounts 33, 39.
Referring to FIG. 6, rack and pinion 84, 86 can be replaced with lead screw 100. Rotating knob 102 turns lead screw 100 translating frame 38. Torque wrench 104 can be used to a apply additional torque to lead screw 100.
Referring to FIG. 7, rack and pinion 84, 86 can be replaced with a ratchet r~ch~n; Sm. Handle 28 includes finger pivot 110 with end 111 which locks into grooves 114 of ratchet 112, ratchet 112 being connected to translation frame 38. Frame 38 can be freely translated within handle 28 in the direction which moves lower and upper blade mounts 33, 39 further apart, but end 111 of finger pivot 110 falls into grooves 114 as the grooves pass by preventing free translation of frame 38 within handle 28 in the direction which moves lower and upper blade mounts 33, 39 closer together. This allows the position of lower and upper blade mounts 33, 39 to be maintained without having to apply continual load to retractor endoscope 10. In order to move lower and upper blade mounts 33, 39 closer together, end 111 must be moved out of groove 114 by pushing on pad 113 of finger pivot llo.
A biasing means, e.g., spring or spring steel, (not shown) may be incorporated to bias finger pivot llo in the position in which end 111 is engaged with groove 114. Screw 116 which is threadably mounted to ratchet 112 may be employed to aid in increasing the distance between lower and upper blade mounts 33, 39. With end 117 of screw 116 against handle 28, turning screw 116 causes ratchet 112 and thus translation frame 38 to move in the direction of arrow SUBSTITUTE Sl iEET (RULE 26,~
WO96/02l95 ~ r~ c 3lsl ~
2 1 9 ~ 4 ~ 8 119. Screw 116 must be backed off to allow lower and upper blade mounts 33, 39 to be moved closer together.
Removable blades 20, 22 may be sterili7~hle or ~iepo~Ahl~. !31ade 20 may be dir~erent in length from blade 22. This is particularly userul in surgical ~Lvced~ ~s such as bladder neck surgery in which one of the blades would hit the pelvic bone if the blade were too long. In operation, the blades generally ~i~pl~A~ce organs to create operating window 14. Referring to FIG. 8, in order to keep the organs out Or the operating window, particularly ln procedures such as bowel surgery, a retention device, e.g., a sleeve 149, can be placed around blades 20, 22. Sleeve 14g is surriciently elastic to allow it to stretch and retract as blades 20,22 are adjusted and may include a slit 151 facing away from an area containing organs to be retained, thus allowing access to a surgical area beyond slit 151.
Alternatively, referring to FTG. 9, one or two side blades 142 may be utilized for this purpose.
Blades 20, 22 may include windows to enable viewing of the anatomy beyond the blades. The shape of blades 20, 22 may vary, e.g., non-rectangular, wider, narrower, shorter, longer. Blades 20, 22 are replArp~hle. This is particularly advantageous if, after initial insertion of retractor ~n~oscope 10, it is found that one or both of the blades are of the wrong size.
An advantage of the current invention is that the surgeon can use his or her own two eyes to view the surgical site. Thus the surgeon has a three-dimensional direct image through a relatively short incision. Additionally, fine needle suturing is relatively easy and precise.
An additional advantage of the current system is that if operating window 14 is incorrectly positioned, the angle of viewing can be adjusted by tilting retractOr ~ WO96/02l95 ~ 2 1 9 5 4 8 r ~ sl i, q .'~ ~ O
scope 10 as a unit or by independently moving the blades, thus viewing a new area without making an additional - inricinn~
Additionally, the current invention utilizes shorter 5 inrjc;n~c (e.g. 3-6 timeg ghorter) than conventional surgery and provides three-dlmensional direct vie~ing and direct access to the surgical site, facilitating shorter operating times. For example, in aorto-bifemoral bypass surgery, the ;~rjc;~n made is a sixth o~ the size of the incision made in conventional surgery. In r._~.L__Lomy, laparoscopically the oceduLe takes 5~ to 6 hours, conventionally the ~-v.eduLe takes one hour with a 30 to 32 cm ;nricion site, with the current invention the ~L ~ takes one hour with an incision site of approximately 6 cm. Additionally, the surgeon can place his or her flngers into the surgical site ~nd perform manual palpation.
Retractor ~ninscop~ 10 can be used in a wide variety of urgical ~LuceduL~s ;nrlnAi~g vascular, cardiac, spinal, pnl -ry, urology, trauma and ~'' ;"Al surgery. During spinal fusion, access to the surgical site can be obtained through a mini-incision from the front of the body instead of from the back. For heart or lung surgery a rib does not have to be removed; rigid U-frame 32 must be able to support the load seen by retractor ~ins~e 10 while retracting and holding the ribs apart to allow access to the heart or lung.
Retractor ~n~n~cope 10 can be used in cvl.jul.~ion with operating room ~i~Luscv~e~ vi~eo~ ras, h;noclllAr magnifying loops and surgical lasers. Additionally, retractor endoscope 10, tool 16 and hand retractor 124 may be used in conjunction with a magnetic r~cn~A~re imaging system provided they are constructed ~rom ~-~ ?tiC
material, e.g., titanium.
WOg6/02l95 ~ r~ , ,o~.s P ~ 5 ~ 0 8 Referring to FIGS 9-9a, U-frame 32 includes an ad~ustable mount 150 for a video microcamera (not shown) Mount 150 is attached to U-frame 32 along either rigid frame slot 34 or 36 (shown in slot 36~ such that mount 150 can slide along arrow 152 and rotate along arrow 154 Arm 156 of mount 150 can translate along arrow 158 and rotate along arrow 160 A mi~-- a holder 162 slidably holds the mi~. a allowing the magnification of the mi~L ~ a to be ad~usted by sliding the mi~.. a along arrow 164 within mi~.- a holder 162 Mi~Lu~ a holder 162 may be fluted with slots 172 If necD~ry~ mi~ a holder 162 may contain a lens for use with the mi~L~ a. Mount 150 can be locked in place against U-frame 32 by rotating a cam lock 168 using rod 170, thus preventing motion along arrows 152, 154, 158 and 160 Other amho~ s are within the following claims What is claimed is
Claims (34)
1. Apparatus for less invasive, direct access endoscopic surgery through an operating window, comprising:
a rigid frame capable of supporting applied loads required to perform retraction of an incision site, said rigid frame including a handle at one end, said handle having a handle slot therein, a lower blade mount rotatably connected to the opposite end of said rigid frame, rigid frame slots on either side of said rigid frame, and a translation frame slidably connected to said rigid frame through said handle slot and said rigid frame slots and including an upper blade mount rotatably connected thereto, said slidable connection constructed and arranged to allow said handle to translate said translation frame with respect to said rigid frame to adjust the distance between said lower blade mount and said upper blade mount, said handle construction and arranged to prevent sliding of said translation frame along said slidable connection in at least one direction, said apparatus further including lower and upper blades each with free and supported ends mounted to said lower and upper blade mounts respectively, at least one of said lower and upper blades including a pivot mount for high intensity fiberoptics, a first adjusting screw and bar assembly functionally connected between said lower blade mount and said rigid frame for independently adjusting the angle of said lower blade along said lower blade mount rotatable connection and a second adjusting screw and bar assembly functionally connected between said upper blade mount and said rigid frame for independently adjusting the angle of said upper blade along said upper blade mount rotatable connection, said first and second adjusting screw and bar assemblies constructed and arranged to prevent rotation along said rotatable connections in at least one direction, wherein the size of said operating window between said lower and upper blades is determined by the distance between said lower blade mount and said upper blade mount set by said handle and the angles of said lower and upper blades set by said first and second adjusting screw and bar assemblies respectively.
a rigid frame capable of supporting applied loads required to perform retraction of an incision site, said rigid frame including a handle at one end, said handle having a handle slot therein, a lower blade mount rotatably connected to the opposite end of said rigid frame, rigid frame slots on either side of said rigid frame, and a translation frame slidably connected to said rigid frame through said handle slot and said rigid frame slots and including an upper blade mount rotatably connected thereto, said slidable connection constructed and arranged to allow said handle to translate said translation frame with respect to said rigid frame to adjust the distance between said lower blade mount and said upper blade mount, said handle construction and arranged to prevent sliding of said translation frame along said slidable connection in at least one direction, said apparatus further including lower and upper blades each with free and supported ends mounted to said lower and upper blade mounts respectively, at least one of said lower and upper blades including a pivot mount for high intensity fiberoptics, a first adjusting screw and bar assembly functionally connected between said lower blade mount and said rigid frame for independently adjusting the angle of said lower blade along said lower blade mount rotatable connection and a second adjusting screw and bar assembly functionally connected between said upper blade mount and said rigid frame for independently adjusting the angle of said upper blade along said upper blade mount rotatable connection, said first and second adjusting screw and bar assemblies constructed and arranged to prevent rotation along said rotatable connections in at least one direction, wherein the size of said operating window between said lower and upper blades is determined by the distance between said lower blade mount and said upper blade mount set by said handle and the angles of said lower and upper blades set by said first and second adjusting screw and bar assemblies respectively.
2. The apparatus of claim 1 wherein said lower and upper blades are removably mounted to said lower and upper blade mounts respectively.
3. The apparatus of claim 1 and further comprising a scale fixedly attached to said rigid frame for measuring the distance between said lower blade mount and said upper blade mount.
4. The apparatus of claim 3 wherein said scale is laser etched to said rigid frame.
5. The apparatus of claim 1 wherein said lower blade and said upper blade differ in shape.
6. The apparatus of claim 1 and further comprising a rack and pinion mechanism for translating said handle.
7. The apparatus of claim 1 and further comprising a lead screw mechanism for translating said handle.
8. The apparatus of claim 7 and further comprising a torque wrench removably connected to said lead screw mechanism for increasing the torque applied to said lead screw mechanism.
9. The apparatus of claim 1 and further comprising a ratchet mechanism for translating said handle.
10. The apparatus of claim 1 and further comprising an adjustable microcamera mount, said mount being slidably and rotatably connected to said rigid frame in one of said rigid frame slots and including a cam lock for locking said mount in said rigid frame slot, said microcamera mount further comprising a microcamera holder, the magnification of the microcamera being adjustable by sliding the microcamera within said microcamera holder when seated in said microcamera holder.
11. The apparatus of claim 1 and further comprising a retention device for keeping body parts clear of said operating window.
12. The apparatus of claim 11 wherein said retention device comprises a sleeve.
13. The apparatus of claim 11 wherein said retention device comprises a side blade.
14. The apparatus of claim 1 formed from nonmagnetic material.
15. The apparatus of claim 14 wherein said nonmagnetic material is titanium.
16. A tool for performing medical procedures, comprising:
a distal working portion comprising two working members, a proximal handle angled at a predetermined angle with respect to said distal working portion and including two finger rings, and a region between said distal working portion and said proximal handle including a single pivot joint, said single pivot joint constructed and arranged so that actuation of said proximal handle by moving said finger rings apart or together in substantially a horizontal plane results in said working members moving apart or together in a working plane tilted at said predetermined angle from said horizontal plane.
a distal working portion comprising two working members, a proximal handle angled at a predetermined angle with respect to said distal working portion and including two finger rings, and a region between said distal working portion and said proximal handle including a single pivot joint, said single pivot joint constructed and arranged so that actuation of said proximal handle by moving said finger rings apart or together in substantially a horizontal plane results in said working members moving apart or together in a working plane tilted at said predetermined angle from said horizontal plane.
17. The tool of claim 16 wherein said region between said distal working portion and said proximal handle further comprises a gripping zone.
18. The tool of claim 17 wherein said gripping zone comprises knurled finger grips.
19. The tool of claim 17 wherein said gripping zone comprises a knurled finger pad.
20. The tool of claim 16 and further comprising a spike finger support integral with one of said finger rings.
21. The tool of claim 16 formed from nonmagnetic material.
22. The tool of claim 21 wherein said nonmagnetic material is titanium.
23. The tool of claim 16 wherein said predetermined angle is located proximal of said pivot joint and the distance between the proximal end of said handle and said angle location is less than the distance between the distal end of said working portion and said angle location.
24. A hand retractor for retracting an incision, comprising, a blade, and a handle removably mounted to said blade.
25. The hand retractor of claim 24 wherein said blade includes pivot mounts for high intensity fiberoptics.
26. The hand retractor of claim 24 formed from a nonmagnetic material.
27. The hand retractor of claim 26 wherein said nonmagnetic material is titanium.
28. A method of less invasive, direct access endoscopic surgery through an operating window performed with an apparatus having a rigid frame capable of supporting applied loads required to perform retraction of an incision site, said rigid frame including a handle at one end, said handle having a handle slot therein, said apparatus including a lower blade mount rotatably connected to the opposite ends of said rigid frame, rigid frame slots on either side of said rigid frame, and a translation frame slidably connected to said rigid frame through said handle slot and said rigid frame slots and including an upper blade mount rotatably connected thereto, said slidable connection constructed and arranged to allow said handle to translate said translation frame with respect to said rigid frame to adjust the distance between said lower blade mount and said upper blade mount, said handle constructed and arranged to prevent sliding of said translation frame along said slidable connection in at least one direction, said apparatus further including lower and upper blades each with free and supported ends mounted to said lower and upper blade mounts respectively, at least one of said lower and upper blades including at least one pivot mount for high intensity fiberoptics, and a first adjusting screw and bar assembly functionally conneted between said lower blade mount and said rigid frame for independently adjusting the angle of said lower blade along said lower blade mount rotatable connection and a second adjusting screw and bar assembly functionally connected between said upper blade mount and said lower blade along said lower blade mount rotatable connection, said first and second adjusting screw and bar assemblies constructed and arranged to prevent rotation along said rotatable connections in at least one direction, wherein the size of said operating window between said lower and upper blades is determined by the distance between said lower blade mount and said upper blade mount set by said handle and the angles of said lower and upper blades set by said first and second adjusting screw and bar assemblies respectfully, said method comprising:
creating a small incision in the skin corresponding to a surgical site, retracting the incision by placing said apparatus with said lower and upper blades angled such that the free ends of said lower and upper blades are close together into the incision and adjusting said handle and said first and second adjusting screw and bar assemblies to create the desired sized operating window, illuminating said operating window with high intensity fiberoptic lighting, and performing surgery.
creating a small incision in the skin corresponding to a surgical site, retracting the incision by placing said apparatus with said lower and upper blades angled such that the free ends of said lower and upper blades are close together into the incision and adjusting said handle and said first and second adjusting screw and bar assemblies to create the desired sized operating window, illuminating said operating window with high intensity fiberoptic lighting, and performing surgery.
29. The method of claim 28 and further including a manipulating tool having an angled handle so that the handle is clear of the operating window to enable visualization of the operating window during use of said tool, said manipulating including:
causing a working portion of said tool to enter said surgical site through said operating window while said angled handle remains removed from said surgical site, and performing surgery including manipulating the working portion of said tool through actuation of said angled handle while observing the surgical site through the operating window.
causing a working portion of said tool to enter said surgical site through said operating window while said angled handle remains removed from said surgical site, and performing surgery including manipulating the working portion of said tool through actuation of said angled handle while observing the surgical site through the operating window.
30. The method of claim 29 wherein said tool is selected from the group consisting of clamps, forceps, and needle holders.
31. The method of claim 28 and further including tilting said apparatus to adjust the operating window.
32. The method of claim 28 and further comprising:
preretracting said incision with a hand retractor comprising a handle removable mounted to a first blade, removing said handle while inserting said apparatus, said apparatus including only one of said lower and upper blades leaving one of said lower and upper blade mounts empty, attaching said first blade to said apparatus in said empty blade mount during said insertion, and retracting said incision.
preretracting said incision with a hand retractor comprising a handle removable mounted to a first blade, removing said handle while inserting said apparatus, said apparatus including only one of said lower and upper blades leaving one of said lower and upper blade mounts empty, attaching said first blade to said apparatus in said empty blade mount during said insertion, and retracting said incision.
33. The method of claim 32 wherein said first blade includes pivot mounts for high intensity fiberoptics.
34. A method of less invasive, direct access endoscopic surgery performed with a retractor endoscope and a tool, said retractor endoscope having adjustable blades that can be positioned to create an operating window, said tool including a distal working portion comprising two working members, a proximal handle angled at a predetermined angle with respect to said distal working portion and including two finger rings, and a region between said distal working portion and said proximal handle including a single pivot joint, said single pivot joint constructed and arranged so that actuation of said proximal handle by moving said finger rings apart or together in substantially a horizontal plane results in said working members moving apart or together in a working plane tilted at said predetermined angle from said horizontal plane, said angled handle enabling visualization of an operating window during use of said tool, said method including:
creating a short incision in the skin corresponding to a surgical site, retracting the incision with said retractor endoscope, illuminating said operating window with high intensity fiberoptic lighting, causing a working portion of said tool to enter said surgical site through said operating window while said angled handle remains removed from said surgical site, and performing surgery including manipulating the working portion of said tool through actuation of said angled handle while observing the surgical site through the operating window.
creating a short incision in the skin corresponding to a surgical site, retracting the incision with said retractor endoscope, illuminating said operating window with high intensity fiberoptic lighting, causing a working portion of said tool to enter said surgical site through said operating window while said angled handle remains removed from said surgical site, and performing surgery including manipulating the working portion of said tool through actuation of said angled handle while observing the surgical site through the operating window.
Applications Claiming Priority (2)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| US08/277,094 | 1994-07-19 | ||
| US08/277,094 US5503617A (en) | 1994-07-19 | 1994-07-19 | Retractor and method for direct access endoscopic surgery |
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|---|---|
| CA2195408A1 true CA2195408A1 (en) | 1996-02-01 |
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|---|---|---|---|
| CA002195408A Abandoned CA2195408A1 (en) | 1994-07-19 | 1995-07-17 | Retractors, tool, and method for direct access endoscopic surgery |
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| US (2) | US5503617A (en) |
| EP (2) | EP0698374A2 (en) |
| JP (1) | JPH10507098A (en) |
| AU (1) | AU698839B2 (en) |
| BR (1) | BR9508313A (en) |
| CA (1) | CA2195408A1 (en) |
| WO (1) | WO1996002195A1 (en) |
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- 1995-07-17 WO PCT/US1995/009151 patent/WO1996002195A1/en not_active Application Discontinuation
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| AU698839B2 (en) | 1998-11-12 |
| US5813978A (en) | 1998-09-29 |
| US5503617A (en) | 1996-04-02 |
| EP0810843A1 (en) | 1997-12-10 |
| MX9700503A (en) | 1998-05-31 |
| WO1996002195A1 (en) | 1996-02-01 |
| EP0698374A2 (en) | 1996-02-28 |
| JPH10507098A (en) | 1998-07-14 |
| EP0698374A3 (en) | 1996-03-13 |
| EP0810843A4 (en) | 2000-04-12 |
| BR9508313A (en) | 1997-12-23 |
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Legal Events
| Date | Code | Title | Description |
|---|---|---|---|
| EEER | Examination request | ||
| FZDE | Discontinued |