WO1999005976A1

WO1999005976A1 - Surgical instrument with multiple spreadable end effectors mounted for arcuate movement

Info

Publication number: WO1999005976A1
Application number: PCT/US1998/015319
Authority: WO
Inventors: Inbae Yoon
Original assignee: Inbae Yoon
Priority date: 1997-08-01
Filing date: 1998-07-31
Publication date: 1999-02-11
Also published as: AU9014198A

Abstract

An instrument (10) for performing a surgical procedure includes a housing (12), an elongate tubular member (16) having a proximal end mounted by the housing (12), a distal end with a peripheral edge, a first end effector assembly (22) protruding from the distal end of the elongate tubular member (16), having an end effector (80, 82) at a distal end, a second end effector assembly (24) protruding from the distal end of the elongate tubular member (16), and having an end effector (128, 130) at a distal end. Distal portions of the first and second end effector assemblies (22, 24) extend laterally outward at an angle from first and second longitudinal axes of the elongate tubular member (16) to positions where at least a portion of the corresponding end effectors (80, 82, 128, 130) are spaced laterally outward of the peripheral edge of the elongate tubular member (16). The end effector assemblies (22, 24) are coupled with the housing (12) for arcuate movement within the periphery of the elongate tubular member (16) to cause the corresponding end effectors (80, 82, 128, 130) to move along first, and second arcuate paths. In use, the end effectors (80, 82, 128, 130) can be moved from undeployed positions to deployed positions disposed laterally outward of the periphery due to the angled configuration of distal portions of the end effector assemblies (22, 24).

Description

Surgical Instrument With Multiple Spreadable End Effectors Mounted For Arcuate Movement

CROSS-REFERENCE TO RELATED APPLICATIONS This application is related to U.S. patent applications Serial No. 08/758,648, filed November 27, 1996, Serial No. 08/847,182, filed May 1 , 1997, and Serial No. 08/877,764, filed June 17, 1997, the disclosures of which are incorporated herein by reference.

BACKGROUND OF THE INVENTION Field of the Invention:

The present invention pertains to surgical instruments and procedures and, more particularly, to an instrument and method for performing various procedures during endoscopic and open surgery. Discussion of the Related Art:

Endoscopic and minimally invasive medical procedures, such as laparoscopy, have become widely accepted for surgery and diagnosis due to the associated advantages relating to reduced trauma and hospital ization time. The performance of an endoscopic procedure typically involves the creation of puncture sites through a wall of an anatomical cavity using penetrating instruments including an obturator, such as a trocar, disposed within a portal sleeve. After the penetrating instrument has penetrated into the anatomical cavity, the obturator is withdrawn leaving the sleeve in place to form a portal in the cavity wall through which endoscopes are introduced to view the surgical site and through which instruments having end effectors, such as forceps, cutters, needle holders, staplers, clip applicators and the like, are introduced at the surgical site. The end effectors are typically disposed at the distal end of the instrument and are manipulated by the surgeon using controls disposed at the proximal end of the instrument.

It is common in endoscopic procedures to use multiple end effectors in combination. However, typical endoscopic instruments include only one end effector, requiring several incisions for placement of multiple portal sleeves to accommodate a suitable number of endoscopic instruments for performing the required functions. Recently, however, in U.S. patent application Serial No. 08/758,648, Serial No. 08/847,182 and Serial No. 08/877,764 it has been proposed to provide a plurality of end effectors on a single endoscopic instrument to minimize the number of puncture sites and thus reduce the risk and healing time associated with endoscopic surgery. The aforementioned patent applications disclose instruments having multiple needle holders movable with respect to one another to suture anatomical tissue; however, it would be desirable to incorporate other types of end effectors into a single endoscopic instrument so that the end effectors can be moved with respect to one another in a similar manner. Also, it would be desirable to move various types of end effectors through predetermined paths, such as an arc, to manipulate tissue without repositioning the entire endoscopic instrument. The needle holders described in the aforementioned patent applications can include distal portions that extend laterally outward at an angle from the instrument to provide a wide range of relative movement for suturing a wide range of tissue sizes. It would also be desirable to provide a wide range of relative movement between various types of end effectors to permit other operative acts or functions to be performed on a wide range of tissue sizes.

SUMMARY OF THE INVENTION Accordingly, it is a primary object of the present invention to overcome the above-mentioned disadvantages of the prior art and to improve surgical instruments and methods of surgery including open and endoscopic surgery. Another object of the present invention is to permit multiple end effectors to be used in combination in surgical procedures without the need of having to utilize multiple instruments.

Still another object of the present invention is to increase the working span or range of movement of multiple end effectors carried by a single instrument while minimizing the insertion diameter of the instrument.

An additional object of the present invention is to minimize the number of puncture sites required for performing operative steps on anatomical tissue in an endoscopic procedure by inserting more than one end effector through a single puncture site or incision with an instrument that is operable to move the end effectors relative to one another in a cooperative manner to operate on anatomical tissue.

The present invention is generally characterized in a surgical instrument including a housing, an elongate tubular member having a proximal end mounted by the housing and a distal end with a peripheral edge, and first and second end effector assemblies protruding from the distal end of the elongate tubular member. Each end effector assembly includes an end effector at a distal end. A distal portion of the first end effector assembly extends laterally outward at an angle from a first longitudinal axis of the elongate tubular member to a position where at least a portion of the corresponding end effector is spaced laterally outward of the peripheral edge of the elongate tubular member. In addition, the first end effector assembly is coupled with the housing for arcuate movement within the peripheral edge of the elongate tubular member to cause the corresponding end effector to move along a first arcuate path. In a preferred embodiment, the second end effector assembly is also coupled with the housing for arcuate movement within the peripheral edge of the tubular member to cause the corresponding end effector to move along a second arcuate path. The first and second end effector assemblies are also preferably movable from undeployed positions where the end effectors are spaced laterally inward of the peripheral edge of the tubular member to deployed positions spaced laterally outward of the tubular member, for example by rotation or axial movement relative to the tubular member. The end effector assemblies are also preferably movable relative to one another in the axial or longitudinal direction.

Another aspect of the present invention is generally characterized in a surgical instrument for use in open and endoscopic procedures including a housing, an elongate tubular member having a proximal end mounted by the housing and a distal end with a peripheral edge, and first and second end effector assemblies mounted by the tubular member. The first end effector assembly includes a proximal portion extending at least part way through the elongate tubular member along a first longitudinal axis, a distal portion extending laterally outward from the proximal portion at an angle, and an end effector mounted on the distal portion. The proximal portion of the first end effector assembly is arcuately movable within the elongate tubular member to move the end effector of the first end effector assembly along a first arcuate path. The second end effector assembly also includes a proximal portion extending at least part way through the elongate tubular member along a second longitudinal axis laterally spaced from the first longitudinal axis, a distal portion extending laterally outward from the proximal portion at an angle, and an end effector mounted on the distal portion. The proximal portion of the second end effector assembly is arcuately movable within the elongate tubular member to move the end effector of the second end effector assembly along a second arcuate path. The first and second arcuate paths each preferably have a radius of curvature causing at least a portion of the end effector to extend outwardly of the peripheral edge of the elongate tubular member.

Still another aspect of the present invention is generally characterized in a method of performing a surgical procedure in an anatomical cavity including the steps of introducing a surgical instrument having an elongate tubular member into the anatomical cavity, the surgical instrument including first and second end effector assemblies protruding distally from the distal end of the elongate tubular member, the first end effector assembly including a distal portion extending laterally outward at an angle from a first longitudinal axis of the elongate tubular member to an end effector disposed at least partly outside a peripheral edge of the elongate tubular member and the second end effector assembly including a distal portion extending laterally outward at an angle from a second longitudinal axis of the elongate tubular member to an end effector disposed at least partly outside a peripheral edge of the elongate tubular member, and operating on tissue within the anatomical cavity by moving the first end effector assembly arcuately within the periphery of the tubular member to cause the end effector to move along a first arcuate path extending outwardly of the periphery of the tubular member. Other operative steps or functions can be performed by moving the end effector assemblies axially relative to one another and by moving the second end effector assembly arcuately within the periphery of the tubular member.

Other objects and advantages of the present invention will become apparent from the following description of the preferred embodiments taken in conjunction with the accompanying drawings, wherein like parts in each of the several figures are identified by the same reference numerals or by reference numerals having the same last three digits.

BRIEF DESCRIPTION OF THE DRAWINGS

Fig. 1 is a perspective view, broken longitudinally, of a surgical instrument according to the present invention.

Fig. 2 is an exploded perspective view of the surgical instrument of Fig. 1.

Figs. 3 and 4 are a top view, partly in section, and a front view, respectively, of the surgical instrument of Fig. 1 with the end effectors in undeployed positions.

Figs. 5 and 6 are a top view, partly in section, and a front view, respectively, of the surgical instrument of Fig. 1 with the end effectors in deployed positions.

Fig. 7 is a top view, partly in section, illustrating operation of the end effectors.

Figs. 8 and 9 are fragmentary side views of the distal end of the surgical instrument illustrating use of the surgical instrument according to the present invention.

Fig. 10 is a fragmentary perspective view of the distal end of the surgical instrument shown in Fig. 7.

Fig. 11 is a fragmentary side view of a modified end effector for use with the surgical instrument according to the present invention.

Fig. 12 is a cross-sectional view of the modified end effector of Fig. 11 taken through line 12-12.

Fig. 13 is a fragmentary side view of another modification of an end effector for use with the surgical instrument according to the present invention.

Figs. 14 and 15 are a fragmentary side view and a front view, respectively, of yet another modified end effector for use with the surgical instrument according to the present invention.

Fig. 16 is a fragmentary perspective view of still another modification of an end effector for use with a surgical instrument according to the present invention.

Fig. 17 is a fragmentary side view, partly in section, of yet another modification of an end effector for use with a surgical instrument according to the present invention.

Fig. 18 is a cross-sectional view of the modified end effector of Fig. 17 taken through line 18-18.

DESCRIPTION OF THE PREFERRED EMBODIMENTS The surgical instrument of the present invention can be utilized to manipulate or otherwise operate on any type of anatomical tissue in any type of anatomical cavity; and, accordingly, while the instrument is described hereinafter for use with a portal sleeve in endoscopic procedures, such as laparoscopy, the instrument can be used in open surgery and with catheters and other small and large diameter tubular or hollow, cylindrical members providing access to small cavities, such as veins and arteries, as well as large cavities, such as the abdomen.

A surgical instrument 10 in accordance with the present invention, as illustrated in Figs. 1 - 7, includes a hub or housing 12, a handle 14 coupled with a proximal end of the housing, an outer tubular member 16 extending distally from the housing, an inner tubular member 18 disposed in the outer tubular member with a small radial clearance to define an annular space 20 therebetween, and end effector assemblies 22 and 24 movably disposed in the annular space between the inner tubular member and the outer tubular member. Handle 14 includes a hollow cylindrical portion or housing 26 with longitudinally spaced front and rear walls 28 and 30 oriented perpendicular to a longitudinal axis of the inner tubular member and a pistol grip 32 pivotally mounted on a bolt or pin 34 secured between spaced, parallel flanges 36 extending outwardly from the handle housing. As best seen in Fig. 2, opposite sides of the pistol grip adjacent bolt hole 38 are each provided with one or more radial ribs or ridges 40 which extend outwardly from the pistol grip to fit within cooperatively formed grooves 42 on the inside of flanges 36 to form a detent structure allowing the pistol grip to be locked in a desired position with a ratcheting-like movement when the bolt or pin is tightened. For example, in Fig. 1 , the pistol grip is shown extending transversely from the housing at an acute angle relative to the proximal direction. It will be appreciated, however, that the pistol grip can be pivoted in a counterclockwise direction (shown by broken lines in Fig. 1 ) or in a clockwise direction (not shown) dependent upon the procedure to be performed and the preference of the user. It is also possible to use the instrument housing as a handle, in which case a separate handle need not be attached.

Referring to Figs. 2 and 3, housing 12 includes a hollow, cylindrical portion or side wall 44 with an open proximal end and a front wall 46 at a distal end extending perpendicular to the longitudinal axis of the outer tubular member. A groove 48 is formed about the circumference of the housing side wall adjacent the open proximal end. A cylindrical skirt or rim 50 protrudes from handle 14 in a distal direction to fit telescopically around the proximal end of housing 12 and terminates at a flange 52 which extends radially inward from the skirt or rim to be received within groove 48 to permit rotation of the handle relative to the housing. Flange 52 fits frictionally within groove 48 so that the handle can be locked in any position relative to the housing. The instrument handle and housing can be made of any substantially rigid medical grade material but are preferably formed of a plastic material of relatively high durometer to reduce weight while offering structural support for the distally extending members of the instrument.

Outer tubular member 16 is open at both ends and extends distally from housing 12 through an opening in front wall 46 of the housing. Distal end 54 of the outer tubular member can be blunt as shown, tapered, beveled, slotted or chamfered as desired or have any other distal configuration suitable for a particular procedure. Preferably, outer tubular member 16 is made of a substantially cylindrical length of a substantially rigid material, such as stainless steel or some other medically acceptable plastic or metal material. The outer tubular member terminates proximally at an outwardly extending flange 56 fixedly mounted within a recess 58 formed in the front wall of the housing such that the outer tubular member rotates with the housing. A generally frustoconical collar 60 of decreasing diameter in the distal direction extends outwardly from the outer tubular member adjacent the front wall of the housing and is configured with longitudinal fluting to facilitate manual rotation of the handle relative to the housing.

Inner tubular member 18 includes an elongate cylindrical portion 62 of hollow configuration disposed coaxially within outer tubular member 16 and having an outer diameter somewhat smaller than the inner diameter of the outer tubular member to define an annular space 20 therebetween having a radius of curvature less than the radius of curvature of the suture needle to be used. The hollow cylindrical portion 62 of the inner tubular member extends proximally from a distal end 64 aligned with distal end 54 of the outer tubular member through rear wall 30 of the handle housing to define a longitudinal operating channel or passage 66 through the instrument. The inner tubular member terminates at a coupling 68, for example a Luer lock, for connection with sources of fluid or suction, operating units, medical instruments and accessories, with a valve 70 being disposed between the hollow cylindrical portion of the inner tubular member and the coupling, the valve including a hollow spherical valve housing 72 preferably formed integrally with the inner tubular member from a substantially rigid medically acceptable plastic or metal material, and a spherical valve member 74 with a cylindrical aperture opening 76 formed therethrough rotatably disposed within the valve housing and connected with a knob 78.

End effector assemblies 22 and 24 each include an end effector in the form of a forceps having a pair of cooperating jaws or jaw members mounted by the handle or housing for rotation along arcuate paths about a longitudinal axis of the instrument, the jaws further being movable relative to one another to selectively grasp and release suture needles and other objects during surgical procedures. Jaws 80 and 82 of end effector assembly 22 are shown as a pair of pivotably opposed jaws but can have other configurations for grasping and releasing a suture needle and other objects as well as for performing other functions during a surgical procedure. Jaws 80 and 82 are shown formed at the distal end of an elongate rod 84 of solid cross-section as an integral one-piece unit; however, it will be appreciated that the jaws can be formed separately for attachment to the rod and that the rod can be of hollow, tubular configuration to define an additional operating channel as shown, for example, by broken lines at 84' in Fig. 3 with a valve 70' and a coupling 68'. The jaws of the end effector assembly are biased apart toward an open position, shown at the top of Fig. 7, where inner grasping surfaces 86 and 88 of the jaws are angularly spaced from one another. Opposed inner surfaces 86 and 88 of the jaws are shown with a plurality of longitudinally spaced teeth or ribs 90 oriented perpendicular to the longitudinal axis of the rod to securely hold a suture needle, tissue or other objects therebetween during a surgical procedure. In addition, inner surfaces 86 and 88 are oriented to permit a suture needle having a radius of curvature to be held between the jaws of the end effector assembly such that the needle extends from the jaws along an arcuate path coaxial with the central longitudinal axis of the inner tubular member. Rod 84 includes a proximal portion 92 of generally straight configuration disposed within the annular space 20 between inner and outer tubular members, and a distal portion 94 with a predetermined deployed shape or condition where the distal portion bends outwardly at an angle relative to the longitudinal axis of the proximal portion of the rod, the distal portion assuming the deployed shape or condition when the end effector assembly is in an axially extended position with the distal portion protruding distally beyond the distal end 54 of the outer tubular member as shown in Fig. 5. The length and angular deflection of the distal portion of the rod are such that at least portions of jaws 80 and 82 are spaced laterally outward of a peripheral edge or diameter of the outer tubular member when the distal portion is in the deployed condition. The rod is preferably formed of an elastic material, such as a spring steel, having elastic properties allowing the distal portion to bend inwardly, in a lateral direction relative to the longitudinal axis of the rod, when the rod is moved proximally relative to the outer tubular member from the extended position shown in Figs. 5 and 6 to the retracted position shown in Figs. 3 and 4. In the retracted position, a sufficient amount of the distal portion of the rod is disposed within the outer tubular member to cause the distal portion to assume an undeployed shape or condition where the jaws do not protrude beyond the periphery or diameter of the outer tubular member. If desired, however, the instrument can be modified to permit complete retraction of the end effector assembly (and/or the end effector assembly) to positions where the jaws are proximally spaced from the distal end of the outer tubular member as shown by broken lines in Fig. 3.

A flexible outer member or sleeve 96 of tubular configuration fits telescopically around rod 84 and is axially movable along the length of the rod between a retracted position where a distal end 98 of the flexible sleeve is proximally spaced from the jaws and an extended position where the distal end of the flexible outer member slides over the jaws. The flexibility of sleeve 96 is such that the sleeve will preferably conform to the shape of the rod even when in the outwardly bent, deployed position. A relatively rigid flange or tongue 100 extends laterally outward from flexible sleeve 96 within the instrument housing, and a similar flange or tongue 102 extends outwardly from rod 84 through a slot 104 formed in the sleeve to be disposed distally of the sleeve tongue 100. Flexible sleeve 96 terminates proximally at a second flange 106, and a bias member 108, for example a leaf spring of generally U-shaped configuration, is held in compression between sleeve proximal flange 106 and a flange 110 mounted on the rod proximally of the sleeve proximal flange to bias tongues 100 and 102 together so that the distal end 98 of the flexible sleeve is biased to move distally relative to the rod to an extended position where the distal end of the sleeve slides over jaws 80 and 82, causing the jaws to close.

A push button 112 is disposed externally of the instrument housing and is mounted on a plunger or post 114 which extends from the button through a slot 116 in the housing to a wedge 118 disposed within the housing. The wedge defines a slot or groove 120 for receiving tongue 100 and has a width of decreasing dimension in a laterally inward direction to define an angled distal face or cam surface 122 which acts on tongue 102 to spread tongues 100 and 102 apart when the button is in a depressed position or condition, as shown at the top of Fig. 7, and to maintain contact with tongue 100 when in an elevated or non- depressed position or condition, as shown in Figs. 3 and 5, such that movement of the push button along the slot will cause the wedge to impart movement to the end effector assembly as a whole. Push button 112 is preferably of a known type which will alternatingly extend the plunger inwardly and retract the plunger outwardly in response to repeated depression. In addition, it is preferred that a portion of the push button mechanism slide frictionally within the slot 116 so that, once the push button has been moved to a desired position along the slot, the push button will not move until forced deliberately by the user. As best seen in Figs. 1 and 2, slot 116 includes a longitudinal portion 124 oriented parallel to a longitudinal axis of the housing and a transverse portion 126 extending perpendicularly from a distal end of the longitudinal slot portion in a clockwise direction looking proximally, the transverse portion extending about a third of the way around the circumference of the housing.

End effector assembly 24 is shown as being identical to end effector assembly 22, with an end effector in the form of a forceps having jaws 128 and 130 mounted at the distal end of a rod 132 having straight and angled portions 134 and 136 slidably disposed within a sleeve 138. It will be appreciated, however, that the end effector assembly 24 can have any configuration for performing operative steps or functions during a surgical procedure. Push-button 140, which controls operation of end effector assembly 24, is similar to pushbutton 112 with a plunger or post 142 extending therefrom through a slot 144 formed in the housing in circumferentially spaced relation to slot 116. As best seen in Figs. 1 and 2, slot 144 is similar to slot 116, with a longitudinal portion 146 parallel to the longitudinal portion of slot 116 and spaced about 180° therefrom, and a transverse portion 148 extending circumferentially from a distal end of longitudinal slot portion 146 in a clockwise direction, looking proximally, to a position adjacent slot 116. Slots 116 and 144 may also include proximal transverse portions as shown, for example, by broken lines in Fig. 1 at 150 and 152, to permit arcuate rotation of one or both graspers in axially retracted positions as shown and described in patent application Serial No. 08/758,648, filed November 27, 1996, the disclosure of which was incorporated hereinabove by reference. Also, while end effector assembly 22 and end effector assembly 24 are both shown as bending outwardly of the periphery of outer tubular member 16 in their respective deployed positions, it will be appreciated that one or both of the end effector assembly and the end effector assembly can remain straight, as shown in Fig. 8, or bend slightly to be disposed within the periphery of the outer tubular member when extended distally dependent upon procedural use.

An electrical connector can optionally be mounted on the handle 14, as shown by broken lines at 154 in Fig. 1, or at any other suitable location on the instrument including, but not limited to, the side of instrument housing 12 or the proximal end of inner tubular member 18 adjacent valve 70, to connect electrically conductive elements of the instrument with a source of electricity for performing unipolar or bipolar procedures such as electric coagulation, for example using one or both of the jaws of an end effector as conductive elements. In addition, an interior surface of the operating channel 66 can be coated with an electrical and/or thermal insulating layer to permit safe insertion of electrical, thermal and/or other types of energy transmitting devices through the operating channel.

In use, instrument 10 is grasped using pistol grip 32 and, in the case of an endoscopic procedure, the instrument is guided to the operative site by a portal sleeve positioned in the wall of an anatomical cavity. The portal sleeve can be positioned in the anatomical cavity wall using any suitable penetrating technique, including those creating puncture sites by means of removable obturators, such as trocars, and can include a valve housing, if desired, to prevent loss of pneumoperitoneum during insertion and withdrawal of the instrument. Visualization of the endoscopic procedure can be accomplished using a conventional endoscope incorporated into the instrument, for example within the longitudinal operating channel 66 defined by tubular shaft 62, or separately positioned within the anatomical cavity through a second portal sleeve located at another puncture site.

Prior to insertion, instrument 10 is preferably in the position shown in Figs. 1 and 3. More specifically, end effector assembly 22 and end effector assembly 24 are preferably initially positioned at diametrically opposed locations within annular space 20, for example by sliding push buttons 112 and 140 counterclockwise, looking proximally, within transverse slot portions 126 and 148 until posts 114 and 142 are disposed within longitudinal slot portions 124 and 146 and then sliding the push buttons proximally along the longitudinal slot portions until the posts abut respective proximal ends of slots 116 and 144. End effector assembly 22 and end effector assembly 24 should then be in retracted positions with their end effectors spaced laterally inward of the peripheral edge of the outer tubular member in an undeployed condition so as not to snag or catch on structure within the portal sleeve or valve housing during insertion. To this end, push buttons 112 and 140 are preferably initially disposed in the elevated positions shown in Fig. 3 so that each of the end effectors will be in the closed or grasping position with inner grasping surfaces of the jaws close together or abutting one another. Alternatively, or in addition to the above, a sheath (not shown) can be telescopically fitted around the elongate tubular member or shaft in a manner to be movable axially or longitudinally between a retracted position spaced proximally of the end effectors and an extended position protruding distally from the shaft to cover and protect the end effectors.

After insertion, end effector assembly 22 and end effector assembly 24 can be moved distally relative to outer tubular member 16 from the retracted, undeployed positions shown in Figs. 3 and 4 to the extended, deployed positions shown in Figs. 5 and 6 by sliding buttons 112 and 140 distally along longitudinal slot portions 124 and 146, respectively. As the end effector assemblies are advanced longitudinally, distal portions of the end effector assemblies are no longer laterally restrained within the outer tubular member and thus tend to bend outwardly, away from the longitudinal axis of the outer tubular member, toward deployed positions where the jaws of each of the end effectors are spaced laterally outward of the peripheral edge of the outer tubular member to maximize the relative range of movement or working span of the end effectors. Under certain circumstances, however, It may be desirable for a first end effector assembly 22 to bend or spread outwardly in the extended position while a second end effector assembly 24 remains within the periphery of the outer tubular member as shown, for example, in Fig. 8.

End effector assemblies 22 and 24 can be moved individually relative to one another or in combination relative to the elongate tubular member or shaft 16. The types of possible end effector movements include, but are not limited to, axial movement relative to one another and/or the shaft 16, and arcuate movement within annular space 20. Furthermore, shaft 16 can be moved in an axial or lateral direction or rotated about a longitudinal axis to cause the end effector assemblies to move.

As mentioned above, the end effector assemblies 22 and 24 are movable axially or longitudinally by moving push buttons 112 and 140 along longitudinal slot portions 116 and 114 formed in housing 12. As push buttons 112 and 140 are moved, wedgesl 18 and 160 engage flanges 100 and 162 and move the end effector assemblies axially within annular space 20. the end effector assemblies can be moved axially individually or in combination. When end effector assemblies 22 and 24 are longitudinally aligned with transverse slot portions 126 and 148, respectively, push buttons 112 and 140 can be moved along the transverse slot portions to cause the end effector assemblies to rotate or move arcuately within annular space 20 between the inner and outer tubular members. Arcuate movement of end effector assemblies 22 and 24 within annular space 20 causes the end effectors at the distal end of the assemblies to move along arcuate paths extending outwardly of the periphery of the outer tubular member. During rotation of end effector assemblies 22 and 24, it will be appreciated that wedges 118 and 160 maintain the radial or outward orientation of tongues 100 and 162 while maintaining grasping pressure on any objects disposed between jaws of the end effector.

Jaws 80 and 82 can be moved from the closed position to the open position at any time by depressing the push button 112 to cause the wedge 118 to spread tongues 100 and 102 apart against the influence of bias member 108, as shown in Fig. 7, such that distal end 98 of the sleeve 96 is moved proximally relative to the jaws. Proximal movement of sleeve 96 permits the jaws to move apart elastically under the force of their own resilience. To close the jaws, push button 112 on the side of the instrument corresponding to the end effector assembly is depressed to cause the wedged-shaped terminal end 118 to elevate or move away from tongues 100 and 102 so that the tongues can move together under the influence of bias member 108. Movement of tongue 100 towards tongue 102 causes distal end 98 of sleeve 96 to move distally relative to rod 84 and into camming contact with jaws 80 and 82, causing the jaws to move toward one another and into gripping contact with any object disposed between the jaws. Jaws 128 and 130 of end effector assembly 24 are operated in a similar manner by use of push button 140.

Dependent upon the procedure to be performed, closing of the jaws may be used to grasp or hold an object positioned between the jaws. If the jaws are provided with a cutting member, objects positioned between the jaws can be cut when the jaws are closed. Similarly, if a biopsy box is mounted on the jaws, tissue samples may be taken from tissue positioned between the jaws when the jaws are closed. One or both of the jaws may also function as a cautery electrode, if desired. Conversely, opening of the jaws can be used to spread objects apart or to permit a suture needle, tissue or some other object to be placed between the jaws. The foregoing functions are merely exemplary of the types of functions that may be performed using an end effector assembly with an end effector in the form of jaws

At any point during the surgical procedure, operating channel 66 of the surgical instrument can be used for irrigation or aspiration of the surgical site and can serve as a space for holding suture material or as a portal for the introduction of other medical instruments and devices such as, for example, forceps, cutting members, needles and endoscopes. Knotting elements can also be introduced at the operative site via the operating channel for use in lieu of or in addition to traditional knotting techniques during suturing procedures. Some examples of suitable knotting elements for this purpose are described in U.S. patent application Serial No. 08/366,285, filed December 29, 1994, Serial No. 08/377,723, filed January 25, 1995, Serial No. 08/401 ,002, filed March 9, 1995, and Serial No. 08/585,875, filed January 16, 1996, the disclosures of which are incorporated herein by reference. Fig. 10 illustrates a further use of operating channel 66 wherein a clip applier 174 is advanced distally through the channel to apply a clip as part of a surgical procedure. End effector assemblies 22 and 24 are shown by solid lines in their axially extended, outwardly spread positions with jaws closed and by broken lines with their jaws open. The end effector assemblies can be used in any suitable manner to manipulate or position tissue so that it can be clipped or to move tissue so that the clip applier can access other areas of the body.

In addition to the main operating channel 66, auxiliary operating channels can be defined through one or both of the end effector assembly 80 and the end effector assembly 82 as shown by broken lines at 66' in Fig. 6 to provide access to the operative site from outside the anatomical cavity. The auxiliary operating channels can terminate distally at openings adjacent the jaws of the end effector assembly and the end effector assembly or at openings defined at the bend connecting straight and angled portions of the end effector assembly and the end effector assembly.

Figs. 11 and 12 show a modification of an end effector assembly 1022 for use with the surgical instrument according to the present invention wherein the modified assembly 1022 includes an end effector in the form of a pair of jaws 1080 and 1082 pivotably mounted on a pair of pins 1184 secured to diametrically opposed sides of a hollow tubular rod or sleeve 1084 telescopically fitted within an outer tubular sleeve 1096, the tubular rod defining an auxiliary operating channel 1066' providing access to the operative site from outside the anatomical cavity. Jaws 1080 and 1082 are biased apart toward the open position shown in Fig. 11, for example using a torsion spring (not shown) coiled around one of the pins and connected between the jaws or a pair of spring members (not shown) held in compression between each jaw and the hollow tubular rod, and the jaws are movable inwardly toward one another against the spring bias in response to distal movement of outer tubular sleeve 1096 against the rear or back edges of the jaws.

Any of the jaws described herein can carry a biopsy box or a cutting member such as the blade shown by broken lines at 1186 in Fig. 11. Blade 1186 is oriented perpendicular to inner surface 1086 of the upper jaw 1080 and extends inwardly from the inner surface to fit within a cooperatively configured pocket or recess 1188 formed along an edge of lower jaw 1082 when the jaws are closed together. An elongate groove or recess with an open proximal end can be formed along an inner surface of one or both of the jaws, for example as shown by broken lines at 1189 in Fig. 12, to permit a cutting member, such as a blade, to slide between the jaws when closed. Examples of other cutting members which can be used are shown and described in U.S. patent applications Serial No. 08/612,634, filed March 4, 1996, and Serial No. 08/376,186, filed January 20, 1995, the disclosures of which are incorporated herein by reference.

The modified end effector assembly 2022 shown in Fig. 13 is similar to the end effector assemblies shown above but with a hollow, tubular rod or sleeve 2084 of generally cylindrical configuration defining an operating channel 2066' along the length of the end effector assembly and a pair of jaws 2080 and 2082 formed integrally with the hollow tubular rod as a one-piece unit. The lower jaw 2082 in Fig. 13 is of fixed configuration and extends in parallel with a longitudinal axis of the hollow tubular rod while the upper jaw 2080 is pivotably movable between an open position extending outwardly from the tubular rod longitudinal axis at an angle and a closed position abutting the lower jaw. If desired, the fixed jaw can be formed integrally with the tubular rod and the movable jaw can be pivotably mounted on one or more pins as shown, for example, in Figs. 11 and 12.

Yet another modified end effector assembly is shown in Figs. 14 and 15 at 3022 and includes a first jaw member in the form of an outer tubular sleeve 3096 with a lateral cut-out or window 3190 having a grasping surface 3086 formed along a proximal-facing peripheral edge of the window and a second jaw member in the form of an inner tubular sleeve 3192 fitted telescopically within the outer tubular sleeve and having a grasping surface 3088 formed along a distal peripheral edge of the inner sleeve to operate cooperatively with the grasping surface of the window to hold a suture needle or other objects within the window while permitting access to the operative site via the channel defined by the inner tubular sleeve.

The window 3190 in the outer tubular sleeve 3096 of the modified end effector assembly 3022 can be oriented to face in any suitable direction relative to the central longitudinal axis of the outer tubular member of the surgical instrument dependent upon procedural use. For example, the end effector window can be orientated to face inwardly, toward the central longitudinal axis, or outwardly, away from the central longitudinal axis, both of which orientations are shown in U.S. patent application Serial No. 08/847,182, filed May 1 , 1997, the disclosure of which is incorporated herein by reference.

Fig. 16 shows still another modification of an end effector assembly for use with the surgical instrument according to the present invention wherein the modified end effector assembly 4022 includes a first jaw member 4080 in the form of a hook and a second jaw member 4082 in the form of a keeper movable relative to the hook to capture and release a suture needle placed within the hook. The jaws are preferably formed of flat strips of a medically acceptable material, such as stainless steel, configured to lay flat against one another to permit relative sliding movement of the jaws. The first jaw member 4080 includes an elongate portion or leg 4194 extending distally from within the instrument housing to a bend 4196 where the first jaw member folds inwardly upon itself to form a short leg 4198 parallel to the elongate portion or leg of the jaw member thereby defining a hook with a proximal-facing mouth having a gap width suitable for receiving the shaft or body of a suture needle. The second jaw member 4082 is slidingly disposed along the first jaw member 4080 and includes a distal end 4200 configured to fit within the mouth of the hook as a keeper, the distal end of the second jaw member being shown with an optional scalloped edge having one or more curved recesses. The first or second jaw member may also be formed with a cutting member such as a blade or a notch of generally V-shaped configuration defined along an edge of the jaw member and having one or more sharp edges to cut lengths of suture material received therein under pressure. The first jaw member is also shown with optional slots or openings 4202 and 4204 formed on opposite sides of the hook to permit straight or slightly curved suture needles to be placed perpendicularly through short and long legs of the hook so as to be oriented radially relative to the longitudinal axis of the inner tubular member. The slotted openings extend transversely, relative to a longitudinal axis of the end effector assembly, from respective open ends disposed along a lateral or longitudinal edge of the first jaw member to generally centrally located terminal ends of rounded or semicircular configuration with a size to receive the body or shank of a suture needle extending transversely through legs of the hook. As mentioned above, the scalloped edge at the distal end of the second jaw member or keeper 4082 is configured with laterally spaced recesses, one of which is preferably aligned with the terminal portion or end of the slotted openings to cradle a needle positioned within the openings in a manner to secure the needle during laterally inward and outward suturing procedures performed as described in patent application Serial No. 08/758,648, filed November 27, 1996, the disclosure of which is incorporated herein by reference.

The hook-like jaw member shown in Fig. 16 can be positioned within the annular space between the inner and outer tubular members of the surgical instrument such that the mouth of the hook formed at the distal end of the jaw member opens inwardly or outwardly as shown in U.S. patent application Serial No. 08/847,182, filed May 1 , 1997, the disclosure of which is incorporated herein by reference. In addition, the jaw members of the end effector shown in Fig. 16 can be of increased width and have a curvature corresponding to the radius of curvature of the annular space to fit conformally therein as shown in application Serial No. 08/847,182.

Still another modification of an end effector assembly for use with the surgical instrument according to the present invention, as shown in Figs. 17 and 18, includes a pair of jaws 5080 and 5082 extending distally from a pair of crossed arms 5240a and 5240b connected by a pivot 5242 located medially along the lengths of the arms. A pair of elongate linkages 5244a and 5244b extend inwardly from pivots 5246a and 5246b at respective proximal ends of the arms to a pivot 5248 connecting the linkages with an elongate rod 5084. Linkages 5244a and 5244b are disposed on opposite sides of the rod, with pivot 5248 extending through the linkages and the rod and with tabs or ears 5252 extending laterally outward from the rod in opposite directions to overhang the linkages as stops preventing the linkages from spreading outwardly beyond a predetermined position. Jaws 5080 and 5082 are moved relative to one another by moving the outer tubular member and rod relative to one another. The jaws are normally biased apart, for example by a torsion spring coiled around a pivot and connected between the jaws, and are closed by moving the outer tubular member distally relative to the jaws, for example by advancing the outer tubular member distally and/or pulling the rod in the proximal direction. In a preferred embodiment, the outer tubular member is biased distally relative to the jaws so that the jaws are normally in a closed position.

From the above, it will be appreciated that the surgical instrument according to the present invention permits manipulation of anatomical tissue during endoscopic procedures without the need of having to use multiple instruments inserted through multiple puncture sites by inserting an elongate tubular member or shaft carrying at least two end effector assemblies through a single puncture site. Preferably, the end effector assemblies each include a distal portion movable between an undeployed, contracted or parked position spaced laterally inward of a peripheral edge of the elongate tubular member to facilitate insertion through a portal sleeve and a deployed, expanded or working position where at least part of the distal portion is spaced laterally outward of the peripheral edge of the elongate tubular member to provide maximum working span. The elongate tubular member is mounted by a handle with controls for moving one or both of the end effector assemblies axially and in an arcuate manner. The end effector assemblies each include an end effector at a distal end. While the end effectors are described above as being forceps jaws, it will be appreciated that the end effectors can have any suitable configuration for individually or cooperatively manipulating or otherwise affecting tissue and other objects during a surgical procedure including, but not limited to, forceps, cutters, needle holders, cauteries, clip appliers, staplers, ligators and the like.

The end effector assemblies of the surgical instrument can be of the same or different design. For example, one end effector assembly can include an end effector in the form of a forceps while another end effector assembly includes an end effector in the form of a cutter. While the end effector assemblies are shown disposed within an annular space defined between concentric tubular members, it will be appreciated that the end effector assemblies can be disposed within separate arcuate channels defined through the elongate tubular member. Distal portions of the end effector assemblies preferably extend laterally outward at an angle from respective longitudinal axes of the elongate tubular member so that, when the end effector assemblies are moved within the annular space, the end effectors at the distal ends of the assemblies are made to move along arcuate paths which may or may not be concentric. Any type of end effector assembly can be modified for use with the surgical instrument according to the present invention by configuring a distal portion of the end effector assembly to be normally bent outwardly at an angle relative to the proximal portion, including, but not limited to, any of the end effector assemblies or drivers described in U.S. patent application Serial No. 08/758,648, filed November 27, 1996, and Serial Nos. 08/847,182, 08/847,254, 08/847,253, 08/847,189, and 08/847,252, filed May 1 , 1997, the disclosures of which are incorporated herein by reference. For example, the end effector assemblies can include a transverse connecting member extending outwardly from a proximal portion of the end effector assembly at an angle to connect with longitudinally oriented end effectors laterally offset from the proximal portion.

The end effectors can be straight, curved or angled in configuration and, when an end effector is a pair of jaws, the jaws can be provided with ribs, a diamond tread pattern or any other type of grasping surface to assure a positive grip as well as grooves, slots or holes to permit access through the jaws when the jaws are closed. The jaws can also carry cutting members, such as slots with sharp edges or protruding blades, and can have opposed arcuate or concave portions for clamping tubular objects, such as organs, without compressing the objects, as well as portions configured to take a tissue sample for biopsy.

When the end effectors are carried at the distal end of one or more elongate components, for example a rod telescopically fitted within a tube, either component can include a distal portion of predetermined shape which, in an unrestrained condition, bends laterally outward at an angle relative to the longitudinal axis of the proximal portion of the end effector component. Furthermore, components of an end effector assembly can be keyed or coupled to move together so that, for example, if one of the components is rotated the other component will be rotated as well. The end effectors can be used alone or in combination to perform lysis of adhesion, dissection, pickup and cutting, pickup and clipping, pickup and suturing with a suture needle, unipolar and bipolar electrosurgery, and numerous other procedures. For example, the end effectors can be used in combination to perform dual electrode cauterization, to clamp tissue between adjacent end effectors, or to separate tissue by placing adjacent end effectors between tissue sections and moving the end effectors away from one another. Adjacent end effectors, acting as electrodes, can also be pressed against opposite sides of tissue to cauterize the tissue. Also, a button or switch can be provided to selectively switch the electric power between end effectors for unipolar cauterization.

Although the surgical instrument is shown and described herein as having two end effectors, it will be appreciated that the instrument can have one end effector or more than two end effectors (e.g., three or four) dependent upon the procedure to be performed and the preference of the user. Also, the end effectors can be positioned at diametrically opposed locations relative to the central longitudinal axis of the elongate shaft as shown or at any other laterally spaced positions.

The end effector assemblies of the present invention are preferably movably disposed about a tubular member defining one or more operating channels or passages through the instrument to permit various medical devices and instruments such as, for example, needles, blades, forceps, cauteries, endoscopes, illuminating devices and lengths of suture material to be introduced at the operative site without the need of having to remove the surgical instrument from the body. The tubular member defining the operating channel can have any configuration in transverse cross-section including, but not limited to, elliptical, polygonal and irregular or asymmetrical cross-sectional configurations. Also, all or part of the inner surface of the tubular member can be electrically insulated to permit passage of electrosurgical instruments therethrough. The valve and coupling shown at the proximal end of the tubular member are merely exemplary of the types of conventional valves and conventional couplings that can be used. Operating channels may also be defined along the length of the end effector assembly and the end effector assembly of the instrument, if desired. The elongate tubular member or shaft can also have any configuration in exterior cross-section including, but not limited to, elliptical and rectangular cross- sections. The elongate tubular member can also include optical fibers disposed therein, or the elongate tubular member can be formed by the optical fibers themselves, for example by embedding or molding the optical fibers within a medically acceptable polymer matrix or by adhesively connecting the fibers together. When the elongate tubular member includes optical fibers, the operating channels can be formed by thin wall, tubular sleeves (as shown herein) or by voids or spaces defined between the optical fibers.

While a particular handle assembly is shown and described herein for holding the instrument and controlling operation of the end effectors, it will be appreciated that other handle configurations can be used including, but not limited to, configurations wherein the handle includes pivoted legs with finger loops, one fixed and one pivoted leg with finger loops, a pistol grip with one or more movable triggers, and/or resilient U-shaped handle members. It is also possible to mount handle members on both sides of the handle housing so that operation of the end effector assemblies is controlled by separate pairs of handle members as described, for example, in application Serial No. 08/847,254, the disclosure of which is incorporated herein by reference. Moreover, the handle can have adjustable handle members of variable orientation as shown or handle members which are fixed in a specific orientation relative to the housing. If desired, the housing and at least a portion of the handle can be formed as an integral one-piece unit.

While the end effector assemblies have been described above as being independently controlled by operating mechanisms such as push buttons and collars which, for the most part, must be operated with both hands, it will be appreciated that a single operating mechanism can be used to synchronize movement of the end effector assemblies relative to one another as well as operation of their respective end effectors when appropriate to further simplify the surgical process by allowing one-hand operation of the instrument.

Moving the end effectors of the present invention relative to one another can be accomplished in any suitable manner, for example by connecting a knob at the proximal end of each end effector assembly and sliding the knobs along slots formed in the handle housing or by mounting the end effector assemblies on geared components and moving the gears with a trigger or some other handle member or device.

While the end effector assemblies have been described herein as having a normally bent configuration which can be straightened by retracting the end effector assemblies in a proximal direction relative to a tubular member so as to elastically deform the end effector assemblies, it will be appreciated that the end effector assemblies of the present invention can be moved between contracted and expanded positions using any suitable method including, but not limited to, methods utilizing linkages, gears, cables, movable stiffeners or inserts, shape memory materials, actuators or motors. Dependent upon the angular deflection and length of the bent or angled distal portions of the end effector assemblies, the distal portions may be movable between deployed and parked positions merely by rotation about their respective axes. Also, distal portions of the end effector assemblies need not be straight as shown but can be curved or multiply angled, if desired.

While the end effector assemblies have been described as being mounted for arcuate movement within an annular space of generally circular configuration, it will be appreciated that the end effector assemblies can be mounted for movement along arcuate paths having any type of circular or non-circular curvature.

The components of the surgical instrument of the present invention can be made of any suitable, medical grade materials to permit sterilization for reuse or disposal for single patient use. The components can be made of multiple parts of various configurations and materials to reduce cost. The handle and/or housing can have various valves, stop cocks and seals therein to control the flow of fluid and medical devices through the surgical instrument.

The features of the various embodiments described above can be combined in any manner desired dependent upon the operational requirements of the procedure to be performed and the complexity of the surgical instrument. Inasmuch as the present invention is subject to many variations, modifications and changes in detail, it is intended that all subject matter discussed above or shown in the accompanying drawings be interpreted as illustrative only and not be taken in a limiting sense.

Claims

WHAT IS CLAIMED IS:

1. A surgical instrument for use in open and endoscopic surgery comprising a housing; an elongate tubular member having a proximal end mounted by said housing and a distal end with a peripheral edge; a first end effector assembly protruding from said distal end of said elongate tubular member and having an end effector at a distal end; and a second end effector assembly protruding from said distal end of said elongate tubular member and having an end effector at a distal end; said first end effector assembly including a distal portion extending laterally outward at an angle from a first longitudinal axis of said elongate tubular member to a position where at least a portion of said corresponding end effector is spaced laterally outward of said peripheral edge of said elongate tubular member; said first end effector assembly further being coupled with said housing for arcuate movement within said peripheral edge of said elongate tubular member to cause said corresponding end effector to move along an arcuate path extending outwardly of said peripheral edge of said elongate tubular member.

2. A surgical instrument as recited in claim 1 wherein said end effector of said first end effector assembly is movable between an undeployed position where said end effector is spaced laterally inward of said peripheral edge of said elongate tubular member and a deployed position where at least a portion of said end effector is disposed laterally outward of said peripheral edge.

3. A surgical instrument as recited in claim 2 wherein said first end effector assembly includes an elongate proximal portion extending at least partly through said tubular member.

4. A surgical instrument as recited in claim 3 wherein said first end effector assembly is longitudinally movable relative to said elongate tubular member between an axially extended position where said distal portion of said first end effector assembly bends outwardly in a lateral direction relative to said first longitudinal axis and an axially retracted position where said distal portion of said first end effector assembly is drawn laterally inward toward said first longitudinal axis.

5. A surgical instrument as recited in claim 4 wherein said end effector of said first end effector assembly is proximally spaced from said distal end of said tubular member in said retracted position.

6. A surgical instrument as recited in claim 1 wherein said second end effector assembly extends laterally outward at an angle from a second longitudinal axis of said elongate tubular member to a position where at least a portion of said corresponding end effector is spaced laterally outward of said peripheral edge of said elongate tubular member.

7. A surgical instrument as recited in claim 6 wherein said second end effector assembly is coupled with said housing for arcuate movement within said peripheral edge of said elongate tubular member to cause said corresponding end effector to move along a second arcuate path extending outwardly of said peripheral edge.

8. A surgical instrument as recited in claim 6 wherein said end effector of said second end effector assembly is movable between an undeployed position where said end effector is spaced laterally inward of said peripheral edge of said elongate tubular member and a deployed position where at least a portion of said end effector is disposed laterally outward of said peripheral edge.

9. A surgical instrument as recited in claim 8 wherein said second end effector assembly includes an elongate proximal portion extending at least partly through said tubular member.

10. A surgical instrument as recited in claim 9 wherein said second end effector assembly is longitudinally movable relative to said elongate tubular member between an axially extended position where said distal portion of said second end effector assembly bends outwardly in a lateral direction relative to said second axis of rotation and an axially retracted position where said distal portion of said second end effector assembly is drawn inwardly toward said second axis of rotation.

11. A surgical instrument as recited in claim 10 wherein said end effector of said second end effector assembly is proximally spaced from said distal end of said tubular member in said retracted position.

12. A surgical instrument as recited in claim 1 and further comprising an operating channel defined through said elongate tubular member to provide access to the operative site from outside the body.

13. A surgical instrument as recited in claim 1 and further comprising a plurality of operating channels defined through said elongate tubular member in laterally spaced relation to provide access to the operative site from outside the body.

14. A surgical instrument as recited in claim 12 wherein said operating channel extends through said housing to define a longitudinal channel along the length of said instrument, and further comprising a coupling at a proximal end of said channel.

15. A surgical instrument as recited in claim 12 wherein said operating channel extends through said housing to define a longitudinal channel along the length of said instrument, and further comprising a valve disposed along said longitudinal channel to control passage of fluids and instruments therethrough.

16. A surgical instrument as recited in claim 1 wherein an operating channel is defined through one of said end effector assemblies to provide access to the operative site from outside the body.

17. A surgical instrument as recited in claim 16 wherein said end effector assembly having an operating channel defined therethrough includes an elongate proximal portion extending through said elongate tubular member and wherein said operating channel terminates distally at an opening adjacent the junction between said proximal and distal portions of said end effector assembly.

18. A surgical instrument for use in open and endoscopic procedures comprising a housing; an elongate tubular member having a proximal end mounted by said housing and a distal end with a peripheral edge; a first end effector assembly having a proximal portion extending at least part way through said elongate tubular member along a first longitudinal axis, a distal portion extending laterally outward from said proximal portion at an angle, and a end effector mounted on said distal portion, said proximal portion of said first end effector assembly being coupled with said housing for arcuate movement within said elongate tubular member to move said end effector of said first end effector assembly along a first arcuate path; and a second end effector assembly having a proximal portion extending at least part way through said elongate tubular member along a second longitudinal axis laterally spaced from said first longitudinal axis, a distal portion extending laterally outward from said proximal portion at an angle, and an end effector mounted on said distal portion, said proximal portion of said second end effector assembly being coupled with said housing for arcuate movement within said elongate tubular member to move said end effector of said second end effector assembly along a second arcuate path; wherein said first arcuate path has a radius of curvature causing at least a portion of said end effector of said first end effector assembly to extend outwardly of said peripheral edge of said elongate tubular member.

19. A surgical instrument as recited in claim 18 wherein said second arcuate path has a radius of curvature causing at least a portion of said end effector of said second end effector assembly to extend outwardly of said peripheral edge of said elongate tubular member.

20. A surgical instrument as recited in claim 18 wherein said respective end effectors of said first and second end effector assemblies are movable between undeployed positions where said end effectors are spaced laterally inward of said peripheral edge of said elongate tubular member and deployed positions where at least a portion of each of said end effectors is disposed laterally outward of said peripheral edge.

21. A surgical instrument as recited in claim 18 wherein said first and second end effector assemblies are longitudinally movable relative to said elongate tubular member between respective axially extended positions where respective distal portions of said first and second end effector assemblies bend outwardly in a lateral direction relative to said first and second longitudinal axes, respectively, and respective axially retracted positions where said distal portions are drawn inwardly toward said first and second longitudinal axes, respectively.

22. A surgical instrument as recited in claim 21 wherein said end effectors of said first and second end effector assemblies are proximally spaced from said distal end of said elongate tubular member in said respective retracted positions.

23. A method of performing a surgical procedure in an anatomical cavity comprising the steps of introducing a surgical instrument having an elongate tubular member into the anatomical cavity, the surgical instrument including first and second end effector assemblies protruding distally from the distal end of the elongate tubular member, the first end effector assembly including a distal portion extending laterally outward at an angle from a first longitudinal axis of the elongate tubular member to an end effector disposed at least partly outside a peripheral edge of the elongate tubular member; and operating on tissue within the anatomical cavity by moving the first end effector assembly arcuately within the peripheral edge of the tubular member to cause the end effector to move along a first arcuate path extending outwardly of the peripheral edge.

24. A method of performing a surgical procedure as recited in claim 23 and further comprising, prior to said operating step, the step of moving the first end effector assembly laterally outward from an undeployed position spaced laterally inward of the peripheral edge of the elongate tubular member to a deployed position spaced laterally outward of the peripheral edge of the elongate tubular member.

25. A method of performing a surgical procedure as recited in claim 23 and further comprising, prior to said operating step, the step of moving the first end effector assembly distally relative to the elongate tubular member from an axially retracted position within the elongate tubular member to an axially extended position protruding from the distal end of the elongate tubular member.

26. A method of performing a surgical procedure as recited in claim 23 wherein the second end effector assembly includes a distal portion extending laterally outward at an angle from a second longitudinal axis of the elongate tubular member to an end effector disposed at least partly outside a peripheral edge of the elongate tubular member and further comprising the step of operating on the tissue by moving the second end effector assembly arcuately within the peripheral edge of the tubular member to cause the end effector to move along a second arcuate path extending outwardly of the peripheral edge.

27. A method of performing a surgical procedure as recited in claim 23 and further comprising the step of operating on the tissue by moving the second end effector assembly axially relative to the first end effector assembly.

28. A method of performing a surgical procedure as recited in claim 23 and further comprising the step of operating on the tissue by moving the first end effector assembly axially relative to the second end effector assembly.

29. A method of performing a surgical procedure as recited in claim 23 and further comprising the step of operating on the tissue by rotating the tubular member.