CN1083693A - 带叶片的内窥式牵开器 - Google Patents
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Abstract
本发明提供一种在内窥式外科手术中使用的牵
开器。在牵开器的插入端的位于病人体内的带叶片
装置利用体外的位于控制端的控制装置进行手动操
纵。在三个实施例中,牵开器包括一个具有插入端和
控制端的管状体。两个叶片以可移动方式连接在管
体的插入端。各叶片可以以各种组合方式运动,远离
牵开器管体的纵轴延伸和/或相互分开。叶片可以
利用从管体控制端延伸的控制装置进行操纵。
Description
本发明涉及外科手术用的牵开器。更具体地涉及一种带叶片可展开的内窥式牵开器,在内窥检查的手术操作过程中,利用该牵开器可以牵开组织、内部器官或体内其它部分,以便提供目测观察和手术入口。
近年来,内窥式外科手术的领域一直迅速发展前进。在这种形式的外科手术中,利用通过人体上的小的内窥检查的开口插入的器具在病人的体内进行手术操作。这种手术操作借助于一个内窥式装置。该内窥式装置是一个细的管状器具,其特征是有一光源、取景镜和/或其它附件,例如冲洗器、剪刀、套结、刷子或镊子等。内窥式装置可以是柔性的或是刚性的,一般利用光纤向内腔传输光。镜头靠近内窥镜装置的端部设置,在镜头上形成的图象经过光纤或其它透镜系统传送到目镜或观察器上。其它类型的内窥式装置利用光纤从远端透镜将反映内部图象的电信号传输到一个电视监示器,由外科医生对监示器进行观察。
这种类型的外科手术允许从内部目测观察人体构造而无需对组织进行过多的解剖,典型的内窥装置的直径范围通常为5至12毫米,因此仅需要一个很小的切口即可将其插入体内。
由于产生了许多有利于患者的益处,这种类型的外科手术得到迅速发展。因为仅有一个使内窥镜装置穿入的小的切口,内窥式外科手术使人体受到较少的损害并且病人很快康复。虽然内窥式外科手术带来很多益处。然而,外科手术的所有各个方面,例如初始检查,牵开或外科手术操作本身都必须经过小的手术切口或开口才能实现。
内窥式外科手术的明显难题在于不能充分目测观察内部构造,而这对圆满完成手术操作步骤是需要的。因此,一般情况下在难于触到的区域(例如胆囊)进行内窥式外科手术是困难的。在胆囊外科手术(或“胆囊切除手术”)中,胆囊周围的组织和器官用内窥镜检查并被牵开,以便充分露出待切除的器官。
现在,在腹腔中的内窥式外科手术或称腹腔镜检查通常都需要牵开操作。特别是内窥镜胆囊切除手术需要对直接位于胆囊上的肝脏进行牵开。在开放的外科手术操作中,牵开比较容易,因为外科手术就包括暴露整个器官区域。为了获得内窥式外科手术的益处,需要通过若干切口才能实现某种形式的牵开操作。
在包括胆囊或其它腹部器官的内窥式手术中,目前的牵开操作是利用二氧化碳吹胀腹膜内腔来实现的。这种牵开方法包括开一个用以输入气源的小的手术切口。气体经过一个套管输入到体内,产生气腹状态。气体吹胀腹腔以便皮肤和肌肉分离开并使各种器官和组织浮起,因此形成为完成内窥式外科手术所必须的暴露状态。
然而,存在与气腹牵开操作有关的几个问题。首先,只有当所需的气腹状态维持时,暴露状态才能充分维持。因为内窥式外科手术一般需要至少引入内窥镜而通常还要引入几个其它器具,很可能在人体上要开有几个手术切口。这些切口中的每一个一般都利用一个套管使其保持开通以用作出入口,事实上是开一个排气口。充气压力失去的危险会增加使内窥式手术操作产生差错的危险,因为对内窥镜来说充分暴露的条件被消除。
还有,在内窥式手术的过程中维持持续的气腹状态会带来很多复杂问题。腹部过分膨胀继发的急剧的心血管破裂、血管迷走神经的反射活动、心律不齐、气胸、皮下气肿、大的静脉血管返回通道的改变、视网膜出血、失明、二氧化碳栓塞以及普遍的病人不适都与持续的气腹有关。
最后一点,气腹牵开技术仅在将肌肉和组织与上述各器官牵开方面才是有效的。各器官本身在很大程度上并没有彼此牵开。
因此,需要一种装置和方法以提供内窥式手术所需要的牵开操作,其有效地提供充分的目测观察和入口并且安全,比现行方法具有较小的副作用。
根据本发明的一个目的,提供了一种用于内窥式外科手术用的带叶片的牵开器装置。本发明使得在内窥式外科手术的过程中能够使内部的器官和组织进行安全有效的内窥式牵开。
利用本发明实现的牵开操作是通过使用可手动操纵的支承牵开器叶片。各叶片的一端以可动方式连接到用作内窥镜的管体的内侧并从其中延伸到可以用来牵开各种器官和组织的自由端。
在一个实施例中,两个叶片以可移动方式连接到管体的插入端或远端。管体是一细长元件,具有较小外径适于内窥镜之用。管体在其远端有一开口以使得各叶片远离管体的移动范围达到最大。叶片基本上是平的薄支承元件,用位于管体的控制端的控制装置进行手动操纵,该控制端在管体的插入端的相对的一端。当处在非使用位置时,各叶片基本上直接叠放在一起,放置方向沿一条实际平行于管体的纵轴的直线,因此,使牵开器易于固定在病人体内。
叶片的一端连接到安装在管体内侧的第一控制元件中的竖直销柱上。第一控制元件以可旋转方式附着连接在管体的内侧。叶片从第一控制元件经过第二控制元件延伸。第二控制元件是一个中空的箱形元件并放置在一个导轨上,该导轨从管体的远端朝向管体的近端延伸,一个轴位于第二控制元件的内部。该轴安装方向垂直于各叶片并在其间延伸。各叶片在其上的邻近贯穿第二控制元件的通道处有一个凹口以容纳该轴。
一个传动元件连接到第二控制元件上并延伸到位于管体控制端的一个把手上。牵开器各叶片的运动是通过操纵把手来实现的。
在非使用位置,本牵开器实施例的叶片基本上彼此叠放在一起,每一个叶片上的凹口容纳第二控制元件的轴。各叶片沿牵开器管体的纵轴方向放置。在该位置,牵开器可以容易地插入体内。
当希望实现牵开操作时,上推把手,沿管体导轨拉动第二控制元件。当发生这种情况时,在第二控制元件中的轴迫使各叶片分离。同时,第二控制元件迫使各叶片向下,远离管体的纵轴。
本发明的第二实施例基本上与第一实施例相似。然而,在该实施例中,第一和第二控制元件是可独立手动操纵的,以使使用者能分别分开和/或展开各叶片。在该实施例中,除去传动元件从第一控制元件延伸到管体的控制端的一个可锁定的把手以外,第一控制元件与在第一实施例中的第一控制元件相同。
第二控制元件包含一个轴,该轴放置在管体的远端的间隔180°的两导轨中。第二控制元件被弹簧偏置朝向管体的远端。传动元件从第二控制元件延伸到在管体控制端处的把手。
叶片在其非使用位置彼此叠放在一起,如在第一实施例中一样,沿着壳体的纵轴方向。当希望实现牵开操作时,各叶片可以通过在管体远端的开口而向外展开和/或彼此分离。延伸到第一控制元件的传动元件使得使用者能上下移动各叶片,或者换句话说,在竖直平面内从管体的纵轴径向向外移动。
第二控制元件可以利用牵开器管体控制端处的相应把手控制动作。再次拉动把手,向近端移动第二控制元件以使得各叶片分离。
在本发明的第三实施例中,带叶片的内窥式牵开器包括一个管体、控制装置和三个叶片。牵开器的管体也是管状和细长的,外径小适于内窥镜之用。管体在其远端或插入端也具有开口以使叶片能向外延伸。
叶片是薄的平支承元件,每一个叶片以可旋转方式连接到管体上并且彼此间隔120°。每一个叶片连接到一个可旋转元件上,该元件使得叶片能够从非使用位置展开到牵开位置,在非使用位置叶片基本上沿一条平行于管体纵轴的直线就位,在牵开位置各叶片从管体中向外延伸。每一个元件都具有一个连接到其上的传动元件,该传动元件延伸到位于管体控制端或远端的把手上。还有提供一个锁定机构以使每一个传动元件和每一个叶片牢固地固定在任何位置上。当该牵开器置入体内时,使用者能够独立地沿下行、横行和中间方向选择并调节牵开程度。
在本发明第四个实施例中,带叶片的内窥式牵开器包括两个叶片。该牵开器的管体是管状和细长的,在其插入端的壁上具有一个开口以使叶片能通过它延伸。
叶片同样基本上是薄的平支承元件,两个叶片从管体内部的近端延伸到伸出牵开器管体的远端。叶片的近端位于第二控制元件的内部,第二控制元件的位置邻近第一控制元件。各叶片从第二控制元件远侧延伸以便与第一控制元件相连接。第一控制元件以可旋转方式连接到管体远端的内部。
在第一控制元件的内部,各叶片通过一个销柱而互相连接,在各叶片的邻近端部处,在各叶片之间设一弹簧偏置件,使得当处于非使用位置时,各叶片的远端彼此贴在一起。
第二控制元件以可移动方式放置在管体内部,因此使得该控制元件能够沿管体的纵轴移动。第二控制元件具有一个内部切口,各叶片的邻近端安装在该切口内。
若干传动元件连接到第一和第二控制元件两者之上并从其延伸到管体的近端或控制端。可锁定的把手在其近端连接到传动元件上。
第四个实施例中的各叶片同第二个实施例一样可以独立移动使彼此分开和/或远离管体的纵轴而延伸。有利点在于,本实施例使人体内的组织受到损伤的危险较少。这是因为第一和第二控制元件两者都位于远离在牵开器管体远端处端部开口的某一距离处。这就使组织被压入牵开器端部并且塞住各种控制装置的机会得以减少。
在本发明的所有实施例中,当各叶片展开时,通过将周围的器官和组织横向推开和远离手术区域,各叶片有效支承周围各种器官和组织。此外,各叶片可以提升和分开各个器官和组织。因此,本发明的牵开器为内窥式外科手术操作提供辅助牵引作用。即,由于缺少对精确深度的感觉,很多形式的内窥式外科手术操作的严重危险在于开口或切口太深而可能伤害健全的组织和器官。因此,为了在这类外科手术操作中实现精确操作,需要从切口的区域移开邻近的组织,使其免受伤害,利用反向牵引作用可以圆满实现这一点,在反向牵开过程中邻近的组织和器官利用牵开器沿某一方向移动,而另一个装置进行切口或开口操作。这种沿相反方向的移动称作反向牵引。采用这种方式,牵开器叶片还可以用来撕开或剥离各种组织和器官而无需使用第二种器具,因此可以用作剥离器。
还有,在各叶片延伸和分离时,在各叶片之间不存在可能干扰外科手术操作的障碍物或机械构件。因此,外科医生可以在叶片之间的范围内进行剪、切或缝合操作。关于这一点应当指出,各叶片安装到管体上须使得当叶片向下旋转或换句话说延伸时,管体与牵开的范围呈相切关系进而避免了任何手术干扰。
而且,叶片具有足够的刚性,以便当管体被推动前进并且各叶片用于将器官和组织推远时,叶片不会过分弯曲,这就使得叶片能更强地推动各种组织和器官。这一点特别重要,因为在使用过程中,叶片基本上处在从管体悬出的悬臂状态。
另外一方面,叶片具有轻微弯曲也是所希望的,为的是避免损伤各种组织和器官。在所述各实施例中实现这一点是叶片形状带有轻微的弯曲部分。该弯曲部分不仅提供轻微的挠度,而且还能够用于缩小或扩大牵开表面的面积。例如,假若叶片沿牵开的方向是凹入的,牵开的有效表面面积会增加。假如叶片沿牵开的方向是凸出的,在叶片与各种组织和器官之间接触的表面面积会降低,借此,限制对所述组织和器官的损伤。
因此,本发明的一个重要优点是本牵开器的叶片能够可靠地为范围广泛的各种内窥式外科手术操作提供反向牵引作用。此外,牵开器的叶片没有棱角或其它机械连接件,因此能避免损伤被牵开的组织。叶片形状还稍有弯曲以提供一定限度的挠性,缩小或扩大牵开表面的面积。
带叶片的本内窥式牵开器保证提供可靠的牵开效能,而没有持续的腹膜吹气操作所带来的各种危险,本发明能够仅要求轻微的起始吹气操作以使器具易于插入。在插入之后,利用叶片能够简单而可靠地保持牵开状态。
有利点在于,本牵开器相当小,且仅通过一个小的开口就可以容易地插入体内。还有,本牵开方法在牵开大的器官方面远比吹气法更有效。本发明使得外科医生或助手仅仅利用控制装置操纵叶片的位置就能手动牵开一个器官到任何所需范围。这与吹气法相反,在吹气法中气体普遍地充满体腔。
还有,这类牵开器适于在各种尺寸的器官上使用。通过调整叶片的尺寸和位置,该牵开器几乎能够牵开任何器官。
因此,本发明的牵开器在内窥式手术过程中对由于充气牵开操作所带来的各种问题,提供了非常有利的解决方案。
图1是表示本发明的牵开器通过一个用于内窥式外科手术的小的手术切口的插入方式的示意图。
图2是本发明的带叶片的内窥式牵开器的第一实施例的侧向透视图,表示牵开器的叶片处于非分离,非延伸(非旋转)的位置,适于(例如)内窥式插入操作。
图3是第一实施例的远端的局部放大的侧视图。
图4是本发明的远端的局部放大的顶视图,表示各叶片处在稍微分开位置。
图5是本发明的远端的局部放大的透视图,表示各叶片处在稍微分离的非伸出位置。
图6是本发明的远端的放大的侧视图,表示各叶片处在分离的伸出牵开位置。
图7是本发明的远端的放大的透视图,表示各叶片处在分离的伸出牵开位置。
图8是本发明的第二实施例的局部侧视图。
图9是本牵开器的第二实施例的侧视图,表示向下朝向远离牵开器管体的纵轴倾斜的叶片。
图10是第二实施例的牵开器的端部视图,表示处于非伸出位置下的各叶片。
图11是本牵开器的第二实施例的局部顶视图,表示处于非伸出位置下的各叶片。
图12是本牵开器的第二实施例的局部顶视图,表示处在分离的伸出牵开位置下的各叶片。
图13是本发明的第三实施例的局部放大的端部透视图。
图14是图3所示带有伸出的叶片的牵开器的端部放大视图。
图15是本发明的第四实施例的局部侧视图。
图16是图15所示带有处于伸出牵开位置的各叶片的牵开器的局部侧视图。
图17是图15所示牵开器的远端处沿线17-17所取的局部顶视图。
图18是图15所示的带处于分离的伸出牵开位置叶片的牵开器的远端的局部顶视图。
首先参阅图1,表示了经管内窥式外科手术的病人的示意图。该图示有一个小的手术切口A,内窥镜21经过该切口插入。这就使得外科医生能观察在手术范围内的内部组织和器官。其它外科手术器具(未示出)可以经过类似的手术切口B和C插入,以便进行所希望的手术操作。
该图表示本发明的牵开器20经过另外一个切口插入以便进入手术区。因此,该牵开器在手术过程中用来可靠地操纵各种组织和器官。然而应当指出,本发明的原理并不是局限于任何特定的外科手术操作,而是可以应用到范围广泛的各种手术操作中。
参阅图2,表示本发明的带叶片的内窥式牵开器20的一个实施例。图2公开的管体22具有各种的牵开器叶片24,叶片从管体中的延伸是可利用各种控制装置26进行操纵的。如图所示,带叶片的内窥式牵开器20的管体22是一个管。管体22可以具有其它形状,然而,圆形截面是优选的,因为它最易于插入到一个套管中。管体22的外径最好较小,使得将内窥式牵开器插入所需的切口尺寸以及对病人身体的操作降至最小。管体22的长度基本上取决于使用带叶片的内窥式牵开器20的手术操作的类型。
管体22具有一个近端或控制端23以及一个远端或插入端25。管体22的远端25具有一个细长开口27(图3所示),该开口沿管体22的下侧朝接近的方向上从端部延伸出来。近端23是操作牵开器的各种控制装置的安装位置。管体22最好由不锈钢之类的材料制成,这类材料保持不受剥蚀,易于无菌处理并且是生物相容的。
叶片24在邻近远端25处安装在管体22的内部以便从其中延伸。如图4所示,叶片24基本上是平的细长元件。当然,叶片24可以取各种不同的形状,这取决于特定的外科手术操作,只要在插入或使用过程中它们不会对内部组织和器官引起伤害。各叶片24在它们地近端32(图3所示)逐渐变细带有锥度,在其近端各叶片以可移动方式连接到管体22上。每一个叶片24在其从管体22的出口的相近点处具有一个凹口21。各凹口21稍微呈细长形并且末端朝某一处逐渐变化带有锥度,在该处每一凹口的宽度足以容纳轴48,下面参照图5予以介绍。
在图2-5上所示的叶片24当处在非使用位置时彼此叠放在一起。如图5所示,销柱34竖直通过叶片24近端中的孔36。销柱34依次又安装到第一控制元件38上。第一元件38包括一个相对较厚基本上呈圆柱形的圆盘。该圆盘在靠近管体远端25处容纳在管体22的内部。第一控制元件38的直径小于管体22的内径,使得它可以在管体22中旋转。第一控制元件38从其中间部分切去一个矩形部分,支承叶片24的销柱34安装在其内部,第一控制元件30从其底部表面开有一个小的弧形缺口39,因此使下文将详细介绍的传动元件54能够通过。
二销柱40(图5所示)彼此相对安装在第一控制元件38的每一侧并垂直于销柱34的安装方向。销柱40从第一控制元件38延伸进入管体22上的小孔42中。这种安装方式使得第一控制元件38能围绕销柱40旋转。
第二控制元件44离开第一控制元件38安装。该第二控制元件44是一个中空的方形壳体,轴48安装在其内。轴48的方向垂直于叶片24。如图5所示,二叶片24分别在轴48的每一侧贯穿通过第二控制元件44。参阅图3可以看出,第二控制元件44的高度小于二叶片24在它们的邻近端32处连接到第一控制元件38上时所处的高度。所形成的这种差值用于实现围绕连接销柱40的运动,下文将要详细介绍。
如图5所示,第二控制元件44放置在管体24内部的一个导轨50中。第二控制元件44在导轨50上的这种安装方式使得第二控制元件44能在平行于管体22的纵轴的方向上沿着管体22的内侧移动。传动元件54在第二控制元件44的近侧的下端连接到该第二控制元件44之上并通过第一控制元件38中的弧形开口39延伸再继续通过管体22达到其近端,在该处传动元件54连接到把手56之上。
参阅图2,把手43、56两者都位于管体22的近端23的外部。把手43、56如图所示是细长形的,其尺寸足以适于用手操纵。每一个把手43、56最好由不锈钢制作。把手43固定地连接到管体22上。把手56利用销柱66以可旋转方式连接到把手43上。把手56还利用销柱41连接到传动元件54上。当然,把手43、56可以用塑料或其它耐用材料来制造并且可以采用粘接、螺钉或其它方式连接到传动元件54上。
一个带切口的元件68从把手43朝把手56延伸。带切口的元件68稍微弯曲并且直接位于把手56旁边。在带切口元件68上的切口与从把手56向外延伸的销柱(图上未表示)相啮合。采用这种方式,使用销柱和切口锁定机构可以使把手56和其相应的传动元件54锁定在任何位置上。
参阅图3-7,现在将介绍在胆囊切除手术操作中用于保证提供牵开功能的牵开器20的使用,该牵开器20被插入到体内。实现这一点一般是通过产生轻微的气腹状态,然后将牵开器20通过一个套管滑入体内。当牵开器20初始插入时,叶片24应当处在非使用位置,即,借助二个叶片彼此叠放在一起,使叶片准直平行于管体22的轴线(图3所示)。很明显,调节在第二控制元件44中的轴48以便使得叶片24在非使用位置上几乎彼此直接叠放在一起。这一点是特别有利的,因为叶片24可以因此而彼此靠在一起,因此降低了为容纳牵开器20所需要的套筒的尺寸大小。
一旦牵开器20插入体内,它可充分地进行调整和操作。牵开器20的放置可以借助于一个内窥镜。一旦就位,把手56沿着带切口元件68推动远离把手43。采用这种方式,传动元件54朝着管体22的控制端23沿着导轨50拉动第二控制元件44。当发生这种情况时,在第二控制元件44中的轴48(图5所示)迫使二叶片24分开。同时,由于第二控制元件44的高度低于叶片24与第一控制元件38的连接点,叶片24由于上述的运动力被迫向下并远离管体22的纵轴。正如由图5-7所能看到的,通过采用第一控制元件38的在销柱40上的可旋转的安装方式使叶片24远离管体22的纵轴的旋转是很方便的。因此,在第一实施例中传动元件54的操纵动作同时使二叶片展开并向下推动它们使之远离管体22的纵轴。二叶片展开进入牵开位置的实现是借助二叶片24的同时展开(图7所示)以及它们向下旋转(图6所示)远离管体22的纵轴。
因此,本牵开器的叶片能够置于各种位置,其展开角度与叶片的旋转成比例。当实现叶片的适当展开时,它们能够被锁定就位以便可靠牵开。如图7所示,为了避免操作被牵开的组织,本牵开器的叶片24是较钝的并且没有锐利的边缘。此外,还如图7所示,在二叶片之间没有会夹住或撕裂组织的各种连接件或机械连接件。因此,本牵开器在很多类型的内窥式外科手术操作中在腹部区域可靠地提供反向牵引功能。
一旦外科手术操作完成并希望取出牵出器20时,沿把手56的方向拉动把手43。沿该方向拉动把手43迫使第二控制元件44朝向管体22的远端25移动。这就使得二叶片一起靠拢到这样一点,在该点轴48再次置于凹口21中并且叶片24几乎彼此叠在一起。与此同时,当二叶片24彼此靠近时,由于第二控制元件44已经运动远离第一控制元件38,使得叶片24反向旋转朝着管体22的纵轴。这时,牵开器20可以从人体内取出。
图8-12表示牵开器220的第二个实施例。该实施例与第一个实施例相似,然而,在该实施例中第一和第二控制元件238、244是可独立地用手来操纵的。因此,二叶片的分开程度或展开程度为了牵开之用能够独立进行调整或者调整叶片向下旋转的程度或者调整叶片远离管体222纵轴的伸出程度。此外,这些分离程度的调整和向下旋转的调整根据需要可以一次完成一项或者同时完成。
如图8所示,牵开器220包括管体222,可用各种控制装置226手动操纵使牵开器叶片224从管体中伸出。
管体222在结构方面与上述管体22相似,具有相似的尺寸和使用相似的材料,管体222具有一个近端或控制端223和一个远端或插入端225。再者,管体222具有一个从远离225向近端223延伸的较低的细长开口227。还有各种控制装置226位于管体222的近端223。
叶片224从管体222的远端延伸并且其形状和材料都与上述那些相应部分相似。凹口221(图口所示)设置在每一个叶片224上以便利于轴248的引入,下文将更完整地予以介绍。
图8、10和11所示的叶片224在非使用位置下时彼此叠放在一起。销柱234竖直贯穿通过叶片224的近端中的孔236。销柱234依次安装到第一控制元件238之中。弹簧235(图11所示)附着连接到每个叶片224和管体222的内部,以便使叶片224偏向管体222的中心并靠紧轴248。
叶片224的近端连接到第一控制元件238上,该第一控制元件基本上类似于上述相应元件,因此这里不再重复介绍。
传动元件241(图8和图9所示)在接近控制元件238的顶部中央处安装到第一控制元件238的近侧。传动元件241最好是一个细长杆,它从管体222近端处的把手243延伸到在第一控制元件238上的安装元件245上。安装元件245(如图8所示)基本上呈U形。传动元件241利用销柱246连接到安装元件245上,销柱246贯穿通过传动元件241和安装元件245。
第二控制元件244(图8和图9所示)安装到第一控制元件238的远端侧。第二控制元件244包括一个其两端装入导轨250中的轴248。轴248的两端沿导轨250滑动,导轨为形成在管体222内部的T形槽。二导轨250彼此相隔180°。轴248在两导思250之间延伸,并在两叶片254之间穿过。如图11可以看到,当轴248在导轨250中处于其最远点时,轴贯穿通过叶片中的凹口221。
轴248在导轨250中的安装方式使得轴248能沿管体222的内侧在平行于管体轴线的方向上移动。安装在第二控制元件244的远侧上的弹簧252使轴248偏向其在导轨250上的最远点。如图8所示,弹簧252在远离导轨250的一点处连接到管体222的内侧。
传动元件254(图9所示)在轴的下端近侧连接到轴248上并通过第一控制元件238上的弧形开口239(图10所示)延伸,再继续通过管体222直到管体的近端,在该处传动元件连接到把手256上。
参阅图8和图9,传动元件241、254每一个都通过导向元件258延伸。如图所示的导向元件258是一个U形元件,它靠近管体222的近端连接到管体222的内部。每一个导向元件258都环绕其相应的传动元件241、254,因此构成一个管,传动元件241、254贯穿通过该管。
各操纵柄260连接到带螺纹的轴262上,该轴贯穿通过管体222中的圆孔264。轴262与在每一个导向元件258中的螺纹孔相啮合。每一个操纵柄260可以紧固到导向元件258中,以便迫使其中的传动元件241、254紧靠导向元件258的另外一侧,因此防止传动元件241、254移动。因此,在外科手术过程中可以用来使叶片224的位置锁定。
参阅图8-12,现在将介绍一般的外科手术操作中,用来实现牵开功能的牵开器220的操作。将牵开器220插入人体内。实现这一点一般是通过产生一种轻微的气腹状态,然后将牵开器220通过一个套管滑入人体内。当牵开器220插入就位时,各叶片224应当处于图8所示的非使用位置。即垂直平行于管体222的轴线,彼此叠放在一起。很明显,凹口221容纳轴248,以便使得各叶片224在非使用位置下几乎直接彼此靠在一起。这一点是特别有利的,因为各叶片224可以因此而彼此靠在一起,以此降低了容纳牵开器220所需的套管的尺寸大小。
一旦牵开器220被插入人体,可以适当地进行调整和操作。牵开器220的设置可以借助于内窥镜。通过手动操纵第二控制装置244可以展开叶片224。将连接到第二控制元件244上的传动元件254固紧的操纵柄260松开。拉动把手256以将传动元件254向近端移动,因此,轴248被朝向管体222的近端移动。如图12所示,这将迫使轴248接近在叶片224之间,使得叶片分离。一旦各叶片已被分开合适的距离,操纵柄260被固紧以便锁定传动元件254并使叶片224就位。
叶片224既可以在被分离之后从管体222的纵轴方向旋转,也可以省略上述分离步骤。如图9所示,为了展开叶片224,固定传动元件241的操纵柄260被松开。作用在传动元件241上的把手243被推向远端,迫使第一控制元件238旋转。第一控制元件238依次又使叶片224通过开口227旋转而离开管体222的纵轴方向。然后操纵柄260可以被固紧,以便将传动元件241锁定以及使叶片224置于伸出位置。
在管体222的远端225中的开口227的重要性现在变得很明显了。开口227要具有这样的宽度和长度,以便使得在使用时相互间隔的叶片224沿径向向外移动的距离大小没有开口227所能达到的距离。当然,开口能够开在管体222的顶部;然而,仅仅利用翻转牵开器220,就能容易地实现任何“向上的”牵开操作。应当指出,假如叶片被分开以前,叶片224被向下移动,那么运动的范围是有限的,因为叶片224将接触朝管体222的远端225延伸的导轨250(图9所示)。仅仅通过调节第一控制元件238与管体222远端225的距离,在接触导轨250之前叶片224从管体222的伸出角度可能被改变。
当希望取出牵开器220时,叶片224要合在一起。通过松开连接传动元件254的操纵柄260来实现这一点。弹簧252使轴248向远端运动,一直到轴落入在叶片224中的凹口内,这时叶片224将靠在一起。应当指出,弹簧235使二叶片224彼此靠拢,以便当轴248移入凹口221的同时,叶片靠在一起。然后连接到传动元件241上的操纵柄260被松开,以便叶片224移回平行于管体222的纵轴的一条直线上。实现这一点是通过拉动把手243,使传动元件241沿接近的方向移动,使第一控制元件238更接近竖直位置,借此导致叶片224近于水平位置与牵开器220的管体222相对准。这时,牵开器220可以通过套管从人体内取出。
在图13、14所示的第三个实施例中。管体70容有三个叶片72、74、76。第一叶片72被设计用于实施中间方向的牵开操作,第二叶片74设计用于实施向下的牵开操作,第三叶片被设计用于实施横向的牵开操作。所有三个叶片72、74、76最好是平薄的元件。当然,每一个叶片72、74、76的精确长度、宽度和形状对于各种特定的手术操作而言可以是互不相同的。还有,打算仅采用一个或两个或者四个或多个叶片也是可以实现的。
三个叶片72、74、76全都采用相同的方式进行安装和控制,三个叶片在管体70内在接近其远端或插入端102处彼此间隔120°。因此下文将仅介绍一个叶片的安装和控制方式。
第一叶片72一端连接到包含一个小的刚性元件的部件80上。如图13所示,一个U形安装销柱82贯穿通过在部件80中的一个孔(未表示)。销柱82的每一端连接到管体70的内部。这种安装方式使部件80以及叶片72能绕销柱82旋转。可以考虑使部件80构成为叶片72的一部分,以使叶片72实际上有一个安装端(参阅图13)。
传动元件86连接到部件80的朝向管体70中心的一侧(图13所示)。一个销柱(图上未表示)贯穿通过传动元件86和在部件80上的一个安装元件90上,这种构成方式是为使传动元件86能够相对部件80运动。传动元件86与上述第二个实施例中的方式相似延伸通过管体70的长度而到达位于管体近端或控制端的一个把手(图上未表示)。如在第二实施例中所述,传动元件86贯穿通过一个管状导向元件(图上未表示)。以在上述实施例中所述的相同方式连接到操纵柄上的带螺纹的轴也可用于锁定传动机构86并以此防止叶片72移动。
弹簧100(图13所示)安装在部件80与传动元件86同侧的一端。弹簧100的另一端安装到管体70上并使叶片72偏向这样一种位置,即,在该位置叶片72沿着一条与管体70的纵轴相平行的直线放置。
管体70的形状基本上相似于上述管体22。然而在本实施例中,在管体70的远端102处有三个开口104。开口104从远端102沿着管体70朝向近端延伸刚好通过组件80。各开口104为叶片72、74、76提供使其从管体70径向向外延伸的区域。
参照图13和14下面将介绍本牵开器20的第三个实施例的操作。
如上所述,牵开器20插入到病人的体内。牵开器20的各叶片72、74、76应在这时沿牵开器管体70的轴线对齐。一旦牵开器20被插入到病人的体内,各叶片72、74、76可以独立地延伸,以便牵开各种组织和器官。给定的叶片72、74、76利用其各自的传动元件86可以容易地手动操纵。松开锁定操纵柄,使得传动元件86利用在其端部的把手可以向内推动。这就使得部件80绕销柱82旋转,使各叶片72、74、76通过其相对应的开口104移动而远离管体70的纵轴,锁定操纵柄然后被固紧以固定各叶片72、74、76的位置,如图所示,所有三个叶片72、74、76便利地彼此独立地移动。这就使得使用者能在横向、下向和中间方向进行定向牵开操作。
通过松开该锁定操纵柄并使弹簧100反向偏置叶片72、74、76朝向管体的轴线,可以简便地取出牵开器20。当所有叶片72、74、76已经返回到该位置时,可以取出牵开器20。
下面参阅图15-18介绍本发明的另一个实施例。在本实施例中的带叶片的内窥式牵开器120类似于上述第一个实施例,该牵开器包括管体122和各种牵开器叶片124,各叶片从管体伸出并且可用各种控制装置126手动操纵。
如图15所示,牵开器120的管体122是一个管。管体122的形状和尺寸类似于在上述实施例中所述的管体并可以用同样的材料制成。管体122也有一个近端或控制端123及一个远端或插入端121。管体122的远端121最好具有一个从近处沿管体122延伸的大的开口127。在管体122的近端123安装各种操作牵开器的控制装置126。
如图15和18所示,叶片124安装在管体122的远端内并从管体伸出。叶片124具有与上述实施例中的叶片几乎相同的形状和尺寸,除去在本实例中叶片的近端向外弯曲朝向管体122的侧面,如图15和16所示。一个S形弹簧125在叶片的近端处安装在各叶片124之间。如图17和18所示,弹簧125由平板弹簧钢制成并牢固地固定到各叶片124的端部,弹簧向远处延伸直接接触另一个叶片。弹簧125具有迫使各叶片124的近端分开,而各叶片124的远端靠在一起的趋势。
如图15和17所示,叶片124的远端在非使用位置彼此靠近放置。叶片124从其位于管体外侧的远端延伸进入管体122的远端,然后贯穿通过第一控制元件138并且叶片近端终止在第二控制元件144的近端内部。销柱164在介于第一和第二控制元件138、144之间的某一点处贯穿通过叶片124中的孔。销柱164的设计需使得叶片124可靠地保持在销柱164上并且还使叶片124在销柱164上有间隙以便使叶片能轻微活动。实现这一点是使在叶片124中的孔的直径稍大于销柱164的直径,同时并使销柱164的端部大到足以防止叶片124移出。
第一控制元件138是一个较厚的基本上呈圆柱形的圆盘。第一控制元件138在靠近管体122的远端121和刚好接近管体122中的开口127近端处容纳在管体122内。第一控制元件138的形状和尺寸基本上与在第一实施例中所述的第一控制元件38相同。第一控制元件138在其中部有一计时砂漏状的开口139(图18所示),叶片124通过该开口伸出。开口139的高度几乎与叶片124的高度相同。开口139的宽度需使得叶片能够彼此移开。
叶片124彼此相连并连接到第一控制元件138上。一个叶片124具有一个朝向另外一个叶片124的U形元件160。另外一个叶片124具有一个伸入到U形元件160的开口中的凸缘162。销柱164位于在第一控制元件138中的开口139内并且销柱方向垂直于叶片124的轴线。该销柱164贯穿通过在U形件160和凸缘162中的孔。
还有,二销柱140彼此相对地安装在第一控制元件138的每一侧并且销柱140垂直于叶片124的轴线。销柱140从第一控制元件138中伸入管体122中的小孔142中。这种安装方式使得第一控制元件138能绕管体122内的销柱140旋转。
如图15和16所示,传动元件141在靠近元件138的顶部中央某一点处安装在第一控制元件138的近侧。传动元件141最好是一个细长杆,其从在管体122的近端处的把手143延伸到一个锁定元件145上,该锁定元件与在上述详细介绍的第二个实施例中的锁定元件相同。
如上所述,第二控制元件144靠近第一控制元件138安装。该第二控制元件144包括一个安装在导轨150上的传动部件148。
传动部件148其外表面基本上是圆的。如图17和18所示,在部件148中带有一个开口149以便能够容纳叶片124的近端。开口149从远方朝向传动部件148的那一侧延伸,当它延伸通过部件靠近朝向部件一侧的近端处时逐渐变宽,该开口具有固定的尺寸。开口149具有的高度需使得它允许叶片124在其中上下移动而不与开口的顶部或底部相接触。
如图15和17所示,叶片124的近端伸入到传动部件148中的开口149中。叶片124近端的形状使得叶片124与在部件148内的开口的侧壁相符合。
如上所述,传动部件138安装在导轨150上。导轨150平行于叶片124走向。传动元件148安装在传动部件148近端的表面的下部并延伸到位于管体122近端的把手156(图15所示)。
把手143、156以及它们的可锁定安装方式基本上与在上述第二个实施例所介绍的相似,因此这里不再表述。
下面介绍牵开器120的操作。牵开器120在要用叶片124牵开的区域插入人体内,其时叶片124处于非使用位置即对应这样一种状况:叶片124的远端彼此并排靠拢并沿管体122的纵轴就位(图15和17所示)。
当为了实现牵开操作而希望移动叶片124时要使用各种把手143、156。为了使叶片124彼此移开,拉动第二把手156,迫使第二控制元件144沿着导轨150朝向管体122的近端移动。这就使得叶片124的近端受压彼此相向移动,这是因为在第二控制元件144的传动部件148中的开口149的宽度大小逐渐降低,如图18所示。这种对叶片124的压力使弹簧125压缩。如该图所示,使得各叶片124通过它们在第一控制元件138中的销柱164处的可旋转的连接而彼此分离。
当希望上下移动叶片124远离管体122的纵轴时,使用第一把手143。使用者推动第一把手143以迫使第一控制元件138绕销柱140旋转。这就使得贯穿通过在第一控制元件138中的开口139的叶片124朝下旋转。叶片124的远端移开管体122的纵轴并通过在管体122中的开口127伸出,如图16所示。
由图可以看出,开口127的存在使得叶片124的移动范围大于没有该开口可能达到的范围。假如移动第一控制元件138使得它向上推动叶片,叶片的移动受到管体122的限制。而当在管体122的顶部和底部两侧都可能带有开口时,这将破坏管体122的远端121的结构完整性。这一相同的功能的实现是仅仅通过提供一个开口和使该器件翻转以提供向上的牵开功能。
上述配置使各叶片124能独立地展开或上下移动到任何程度。对使牵开器120处于特定的使用的情况,这种配置可便利地使牵开操作在一个或两个方向上实现互不相同。最后一点,这种牵开器有许多益处。例如,在非常靠近端部即管体122的开口端没有控制元件。这就防止可能轻微推入管体122的端部的组织或其它体内物质由于操作牵开器120而受到伤害。还有本牵开器120的机械操作不太复杂使得装置的成本能够降低。
应当理解,上述装置的配置及其方法仅仅是本发明的原理应用的介绍。可以有许多其它实施例及改进而不脱离本发明的构思和保护范围。
Claims (26)
1、一种内窥式牵开器,包括:
一个管体,其具有一个远端和一个近端,所述的远端插入到病人体内而所述的近端保留在人体外,所述的远端对所述的管体限定一个端面;
一个牵开元件,其具有远端和近端,所述的牵开元件的所述近端铰接安装在所述管体的所述远端上,所述牵开元件的所述远端适于牵开各种组织、器官和类似物;以及
一个传动元件,其在所述管体的所述远端处连接到所述的牵开元件上并沿着所述管体延伸到所述管体的近端,所述传动元件连接到所述牵开元件的所述近端并且可在外部手动操纵使得所述牵开元件相对于所述管体的纵轴处于范围宽广的各种角度的位置下并且在范围宽广的各个方向上实现牵开操作。
2、如权利要求1所述的内窥式牵开器,其特征在于还包括一个控制元件,该该控制元件以可旋转方式安装在所述管体的所述远端并且与所述牵开元件的所述近端相连接。
3、如权利要求要求2所述的内窥式牵开器,其特征在于其中的所述控制元件的安装还用以在平行于所述管体的纵轴的方向上使其移动,所述的纵向移动的产生对应于外部手动操纵所述传动元件,借此,可以调节所述牵开元件到各种横向位置。
4、如权利要求1至3中任何一种所述的牵开器,其特征在于其中所述的牵开元件至少包括一个具有远端和近端的叶片,所述叶片的所述近端铰接安装在所述管体的所述远端,在牵开过程中,所述叶片的所述远端大约伸到所述管体的所述端面以外,使之能够在远离所述管体的方向上以对所述管体干扰最小的条件下实现牵开。
5、如权利要求1至4中任何一个所述的牵开器,其特征在于,其中的所述管体的远端下部被切去使得所述叶片能处于所述的各种角度位置下。
6、如权利要求1至5中任何一个所述的牵开器,其特征在于,该牵开器包括至少两个叶片,其中所述的每一个叶片在其近端铰接安装在所述管体的所述远端上,使得通过手动操纵所述的传动元件使所述的叶片彼此分开。
7、如权利要求6所述的牵开器,其特征在于,其中处于分开位置的各叶片在叶片之间无障碍地限定一个开放区间,以此在其中可以进行其它手术操作。
8、如权利要求6或7所述的牵开器,其特征在于,其中所述叶片的安装使得所述叶片同时置于所述的角度和分开的位置下并与所述传动元件的单向运动成正比。
9、如权利要求6至8中任何一个所述的牵开器,其特征在于,其中所述叶片的安装使得各叶片的角度和分开的位置由所述传动元件的独立移动所产生。
10、如权利要求6至9中任何一个所述的牵开器,其特征在于,其中所述的传动元件包括两个机构,第一机构用于使所述叶片延伸,第二机构用于使所述叶片分开。
11、如权利要求6至10中任何一个所述的牵开器,其特征在于还包括若干控制元件,每一个所述控制元件连接到每一个所述叶片的近端,并且在其中,牵开器包括若干传动元件,每一个所述传动元件连接到一个所述的控制元件上,借此所述的叶片都是可独立地手动操纵的。
12、如权利要求11所述的牵开器,其特征在于,其中控制元件、叶片和传动元件的数量是相同的。
13、如权利要求6至12中任何一个所述的牵开器,其特征在于,其中所述叶片的所述近端包括一个杠杆并且所述控制元件与所述杠杆连接以便手动操纵所述叶片。
14、如权利要求6至13中任何一个所述的牵开器,其特征在于,其中所述叶片每一个都具有一个远端和一个近端,所述的近端旋转安装在所述管体的所述远端上,所述远端大约伸到所述管体的所述端面之外,所述叶片贴近地对准并彼此一致以便置于纵向插入位置,借此移动所述传动元件使所述控制元件与所述叶片的近端配合,借此,所述叶片旋转到一个伸出位置以便相对于所述管体的纵轴在范围广泛的各种角度位置实现牵开。
15、如权利要求2至14中任何一个所述的牵开器,其特征在于,其中所述控制元件的移动是在近端的方向上。
16、如权利要求6至15中任何一个所述的牵开器,其特征在于,其中所述控制元件在远离方向上被偏置以便使得所述叶片返回到插入位置。
17、如权利要求6至16中任何一个所述的牵开器,其特征在于,其中所述控制元件与一个所述叶片相连接,使得两个所述叶片旋转到伸出位置。
18、如权利要求6至17中任何一个所述的牵开器,其特征在于,其中所述的控制元件进一步包括一个插入到所述叶片之间的轴,借此,所述控制元件的所述移动同时使得所述叶片的所述远端相分离。
19、如权利要求6至18中任何一个所述的牵开器,其特征在于所述的叶片被偏置朝向其准直的插入位置。
20、如权利要求6至19中任何一个所述的牵开器,其特征在于,所述控制元件在某一点而不是沿贯穿通过所述叶片与所述管体的连接处并平行于所述管体纵轴的一条直线连接所述叶片,借此,所述传动元件的移动产生围绕所述控制元件的转矩,从而使所述叶片旋转。
21、如权利要求1至20中任何一个所述的牵开器,其特征在于,进一步包括一个装置,借助该装置所述叶片可以在牵开过程中从插入位置即所述叶片基本上平行于所述管体的所述纵轴的位置延伸到一个第二位置即在该位置下所述叶片大约伸到所述管体的所述端面以外,以便在离开所述管体的方向上和相对所述纵轴成某一角度的情况实现牵开操作。
22、如权利要求1至21中任何一个所述的牵开器,其特征在于还包括:
第一控制元件,安装在所述管体的所述远端;
第二控制元件,安装在接近所述第一控制元件处的所述管体上,以及
一个传动元件,连接到第一控制元件和第二控制元件两者之上,因此,所述传动元件的运动使得所述第一控制元件能连接到所述叶片的近端,借此所述叶片被铰接,使得相对于所述管体的纵轴在范围广泛的各种角度位置下实现牵开,并且因此传动元件的运动使所述第二控制元件连接到所述叶片的近端,因此所述叶片彼此之间分开。
23、如权利要求22所述的牵开器,其特征在于,进一步包括:
第一传动元件,连接到所述第一控制元件上,借此,所述第一传动元件的移动使所述第一控制元件连接到所述叶片的近端,因此,所述叶片被铰接以便相对于所述管体的纵轴在范围广泛的各种角度位置下实现牵开;以及
第二传动元件,连接到所述第二控制元件上,借此,所述第二传动元件的移动使所述第二控制元件连接到所述叶片的近端,因此,所述叶片彼此之间分开。
24、一种用于内窥式牵开器的叶片,包括:
用于安装到所述牵开器的近端;以及
用于实现牵开的远端,所述的远端基本上呈桨叶状并且没有锐利的边缘用以避免对被牵开的各种组织和器官产生伤害,所述叶片在牵开的方向上是凹入的以增加所述牵开的表面面积。
25、如权利要求24所述的牵开器叶片,其特征在于,其中所述的叶片沿牵开方向是凸出的,以便使在所述叶片和被牵开的所述各种组织和器官之间的接触表面面积缩小,因此,降低对所述组织和器官的伤害。
26、一种在内窥式外科手术中实现牵开操作的方法,包括:
在病人的身体上切一开口;
通过所述开口插入一个牵开器,该牵开器包括一个具有远端和近端的管体,所述远端对所述管体限定一个端面;至少一个具有远端和近端的叶片,所述远端大约伸到所述管体的所述端面以外;以及一个传动元件;使得所述管体的远端在病人的体内而所述近端保持在病人的体外;
使所述的叶位定位以便在病人的体内约束所选择的内部器官或组织;以及
手动操纵所述传动元件,使得所述叶片相对于所述管体置于任何范围广泛的各种角度位置下,使得可以利用所述叶片将所述的器官或组织在任意方向移动。
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US880,757 | 1992-05-08 | ||
US07/880,757 US5293863A (en) | 1992-05-08 | 1992-05-08 | Bladed endoscopic retractor |
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CN1083693A true CN1083693A (zh) | 1994-03-16 |
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Application Number | Title | Priority Date | Filing Date |
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CN93107021A Pending CN1083693A (zh) | 1992-05-08 | 1993-05-08 | 带叶片的内窥式牵开器 |
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US (2) | US5293863A (zh) |
EP (1) | EP0641177A1 (zh) |
CN (1) | CN1083693A (zh) |
AU (1) | AU4237093A (zh) |
WO (1) | WO1993022973A1 (zh) |
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CN102834045B (zh) * | 2010-07-09 | 2015-03-11 | 奥林巴斯医疗株式会社 | 内窥镜保持装置及内窥镜系统 |
CN103281979A (zh) * | 2010-09-24 | 2013-09-04 | 伊西康内外科公司 | 用于铰接外科装置的控制结构 |
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CN103181793A (zh) * | 2012-12-06 | 2013-07-03 | 池永龙 | 内窥镜下软组织拨开器 |
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CN112274101A (zh) * | 2020-10-30 | 2021-01-29 | 河北省中医院 | 阴道窥器 |
CN112274101B (zh) * | 2020-10-30 | 2022-08-19 | 河北省中医院 | 阴道窥器 |
Also Published As
Publication number | Publication date |
---|---|
AU4237093A (en) | 1993-12-13 |
WO1993022973A1 (en) | 1993-11-25 |
US5423814A (en) | 1995-06-13 |
EP0641177A1 (en) | 1995-03-08 |
US5293863A (en) | 1994-03-15 |
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