WO2005000127A1

WO2005000127A1 - Apparatus for performing an anastomosis

Info

Publication number: WO2005000127A1
Application number: PCT/CH2004/000395
Authority: WO
Inventors: Petr Medricky; Roger Von Mentlen; Charles Brom
Original assignee: Zürcher Hochschule Winterthur
Priority date: 2003-06-27
Filing date: 2004-06-25
Publication date: 2005-01-06

Abstract

Disclosed is a device for performing an anastomosis by means of a sutured connection between a terminal stump (14) of a first hollow organ (12) and a sidewall of a second hollow organ (16). Said device comprises: - a holder (20) that is provided with a guiding slot (26) which penetrates said holder from an inlet end (22) to an outlet end (24) and is used for leading the terminal stump (14) of the first hollow organ (12) through; - an anvil (32, 34) that is disposed at the outlet end (24) of the holder (20) and is used for folding the terminal stump (14) of the first hollow organ (12) outward against an exterior wall (36, 38) of the anvil (32, 34) and inserting said terminal stump (14) into an aperture (18) located in the sidewall of the second hollow organ (16); - two clamping jaws (44, 46) that are pivotally hinged to the holder (20) and are respectively provided with a clamping surface (52, 54) which faces the exterior wall (36, 38) of the anvil (32, 34) and contacts the sidewall of the second hollow organ (36) resting on the folded terminal stump (14) of the first hollow organ (12) in the area of the aperture (18) in a closed position; - two guiding channels (56, 58) that are formed in the closed position in the area of the anvil (32, 34) by the holder (20) and the clamping jaws (44, 46); and - two helical needles (98) that can be inserted into the guiding channels (56,58) in order to pierce the parts of the hollow organs (12, 16), which lie on top of each other on the exterior wall (36, 38) of the anvil (32, 34), and insert a suture connecting the hollow organs (12, 16).

Description

Apparatus for performing an anastomosis

The invention relates to a device for performing an anastomosis with a sewn connection between a terminal stump of a first hollow organ and a side wall of a second hollow organ.

When performing an anastomosis according to the classic surgical procedure, the chest must be opened by dividing the breastbone so that the surgeon has direct access to the heart.

Today, microsurgical techniques for microscopic cardiac surgery are also in use. For example, a telemanipulation system is known in which the operator controls the intervention from a master console using two instrument handles. Motion sensors perceive the surgeon's movements on the instrument handles and transfer them process-controlled to three manipulators, which operate a videoscope and two interchangeable endoscopic instruments. The instruments have a miniaturized mechanical wrist at the tip, which enables even the finest movements, such as are required to sew an anastomosis.

A major disadvantage of today's telemanipulation systems is that complex movements, such as those on which a sewing process is based, are difficult and require a lot of practice from the operator to precisely control a desired movement sequence via the videoscope. The surgeon has to perform the sewing process visually without any tactile feedback.

The invention has for its object to provide a device of the initially to create named type with which the production of the sewn connection can be simplified and thus the work by hand, with telemanipulators or with robots can be made easier.

To achieve the object according to the invention, a device comprises - a holder with a guide slot passing through it from an inlet side to an outlet side for carrying out the terminal stump of the first hollow organ, - an anvil arranged on the outlet side of the holder for flipping over the terminal stump of the first hollow organ outside against an outer wall of the anvil and inserting it into an opening in the side wall of the second hollow organ, - two clamping jaws pivotably articulated on the holder, each with one opposite the outer wall of the anvil in a closed position and the end stump of the first hollow organ lying around in the region of the opening Side wall of the second hollow organ adjacent clamping surface, - two guide channels formed in the area of the anvil in the closed position by the holder and the clamping jaws and - two helical needles which can be inserted into the guide channels for piercing the a Parts of the hollow organs lying on top of one another in the outer wall of the anvil and introduction of a thread connecting the hollow organs.

In a preferred embodiment of the device according to the invention, the anvil comprises two webs arranged on the outlet side of the holder on both sides of the guide slot.

For easier insertion of the terminal stump of the first hollow organ, the guide slot is expediently widened on the entry side of the holder, the opening of the guide slot generally having a ratio of length to width of approximately 1: 3 to 1:20, ie the guide slot has a flat cross section. Since the smallest possible entry angle of the first hollow organ into the side wall of the second hollow organ is desired for fluidic reasons, the preferred ratio of length to width is in many cases between about 1:10 and 1:20.

Positioning hooks projecting from the outer wall of the anvil and from the clamping surfaces can be provided for positioning and securing the hollow organs.

In a particularly preferred embodiment of the device according to the invention, a helical guide groove is arranged in the wall of each guide channel and the side walls of the guide groove are formed by a guide web serving as a support surface for the hollow organs. The helical needles and the guide channels can have a straight or a curved shape.

Appropriately, a hollow cylindrical receptacle for each helical needle projects laterally from each clamping jaw and is arranged coaxially to the guide channel. On the opposite side of the clamping jaw, each receiving part is assigned a hollow cylindrical shell part which projects from it and is arranged coaxially to the guide channel.

In a further preferred device, a holding wing protrudes from one side of the holder.

On the outlet side of the holder, two positioning aids for the holder, which are provided for insertion into the second hollow organ, can be fixed in the region of the guide slot, each using a preferably flexible fastening wire.

Further advantages, features and details of the invention result from the following description of preferred exemplary embodiments and hand drawing; this shows schematically in

- Figure 1 is an oblique view from above of a device for performing an anastomosis with an open and a closed jaw.

FIG. 2 shows an oblique view from below of the device from FIG. 1;

FIG. 3 shows an enlarged detail of area A from FIG. 2;

4 shows an enlarged detail of area B from FIG. 2;

5 shows an oblique view from above of the device from FIG. 1 with both clamping jaws in the closed position;

6 is an oblique view from below of the device of FIG. 5;

7 is a top view of the device of FIG. 5;

8 is a bottom view of the device of FIG. 5;

9 shows a section through the device from FIG. 8 along the line 1-1 thereof with the hollow organs positioned for performing an anastomosis, with the clamping jaws in the open position;

10 shows the device from FIG. 9 with the clamping jaws in the closed position;

11 shows a plan view of a first embodiment of a helical needle; 12 shows a plan view of a second embodiment of a helical needle;

13 shows a plan view of a third embodiment of a helical needle;

14 is an oblique view of a device for holding, opening and closing the device of FIG. 1;

15 is an enlarged detail of area A of FIG. 14; 16 shows the detail of FIG. 15 from a different angle;

17 shows a longitudinal section through a device for holding and rotating a helical needle;

18 is an enlarged detail of area A of FIG. 17;

FIG. 19 shows an enlarged detail of area B of FIG. 17; 20 shows the longitudinal section through the detail of FIG. 19 rotated by 90 °;

21 shows part of the detail of FIG. 18 with a connecting link to the releasably attaching a helix needle; 22 shows the part of FIG. 21 with the connecting member in the fixing position.

1 to 10 an apparatus 10 for performing an anastomosis between a terminal stump 14 of an artery responsible for supplying the left half of the chest with arterial blood (Left Infernal Mammary Artery, LIMA) 12 and a coronary artery (Coronary Artery, CA) 16 via an opening 18 cut into it has a holder 20 with a guide slot 26 passing through it from an inlet side 22 to an outlet side 24 for the passage of the terminal stump 14 of the LIMA 12. The opening of the guide slot 26 in the present example has a ratio of length I to width b of approximately 1: 7 and is generally between approximately 1: 3 and 1:20, i.e. the LIMA 12 has a flat cross section through the guide slot 26. On the entry side 22 of the holder 20, the guide slot 26 has correspondingly curved inner walls 28, 30 for widening and thus for easier insertion of the terminal stump 14 of the LIMA 12. On the outlet side 24 of the holder 20, the inner walls 28, 30 of the guide slot 26 also form inner walls of two webs 32, 34 protruding from the holder 20 with outer walls 36, 38 running parallel to the inner walls 28, 30. Via the free ends 40, 42 of the webs 32, 34 forming an anvil, the terminal stump 14 of the LIMA 12 inserted through the guide slot 26 is folded outwards.

On the entry side 22 of the holder 20, a clamping jaw 44, 46 is pivotally mounted on both sides of the guide slot 26 about axes of rotation 48, 50 lying parallel to the longitudinal side of the guide slot 26. The clamping jaws 44, 46 each have a clamping surface 52, 54 which, when the clamping jaws 44, 46 are in the closed position, lie opposite the outer walls 36, 38 of the webs 32, 34 of the anvil. Recesses 45, 47 are provided on the back of the clamping jaws 44, 46, so that the guide slot 26 is accessible even when the clamping jaws are open. In the closed position of the clamping jaws 44, 46, in the region of the webs 32, 34, together with the holder 20, they delimit guide channels 56, 58 which run parallel to the webs 32, 34. A helical guide groove 60, is located in the cylindrical wall of each guide channel 56, 58. 62 for a helical needle 98 (FIGS. 11 to 13) with values for diameter D and pitch a given according to the dimensions of the guide groove. These parameters are used to set the stitch spacing and stitch height.

A first part of the guide groove 60, 62 lies in the corresponding clamping jaw 44, 46, the second part in the holder 20 including the webs 32, 34. The guide groove 60, 62 results as a whole only in the closed position of the clamping jaws 44, 46. Die Side walls of the guide groove 60, 62 form a guide web 64, 66 which extends helically in accordance with the guide groove, the free end 68, 70 of which offers a support surface for the LIMA 12 or the CA 16 at the tissue entry and exit points of the needle tip. The desired stitch distance from the edge of the LIMA 12 and the CA 16 can be set by a defined change in the distance e from the center of the guide channel to the free ends 40, 42 of the webs 32, 34.

A hollow cylindrical receiving part 76, 78, each coaxial with the guide channel 56, 58, projects from each clamping jaw 44, 46 for one helical needle. On the opposite side of the clamping jaw 44, 46, each receiving part 76, 78 is assigned a hollow cylindrical shell part 80, 82 which projects therefrom and is arranged coaxially to the guide channel 56, 58 for supporting the helical needle emerging from the guide channel 56, 58. The shell part 80, 82 separates the helix needle from the tissue of the CA 16 and prevents the helix needle from getting caught when the needle is unscrewed.

Small positioning hooks 72 and 74 protrude from the outer walls 36, 38 of the webs 32, 34 and the clamping surfaces 52, 54 (FIGS. 3 and 4). The positioning hooks 72 on the webs 32, 34 serve to fix the LIMA 12 folded over on the webs and, with a corresponding hook length, also the CA 16, the position tioning hook 74 on the clamping surface 52, 54 for fixing the CA 16 in the area of the opening 18 of the LIMA 12 and, with a corresponding hook length, also the LIMA 12 (FIGS. 9 and 10).

From a side of the holder 20 which delimits the guide channels 56, 58, a holding wing 84 projects upwards at an angle of approximately 60 °. The holding wing 84 is equipped at its free end with a stop 86 and with a clamping plate 88, on which the device 10 can be clamped, for example with an operating forceps or with a robot gripper. The hollow cylindrical receiving parts 76, 78 make it possible to guide the device 10 with prepositioned helical needles into the operating area.

On the outlet side 24 of the holder 20, two positioning aids 90, 92 of different lengths projecting obliquely downwards and outwards are fixed in the region of the narrow sides of the guide slot 26, each via a flexible fastening wire 94, 96. The positioning aids 90, 92 serve to position the holder 20 with the LIMA 12 clamped in the CA 16 and are inserted into the CA 16 through the opening 18 in both directions.

The mutual positioning of the LIMA 12 and the CA 16 within the device 10 is explained in more detail below with reference to FIGS. 9 and 10.

When the jaws 44, 46 are open, the LIMA 12 is inserted into the guide slot 26 from the entry side 22 of the holder 20 and is thereby compressed to a flat cross section. After exiting the guide slot 26 on the exit side 24 of the holder 20, the end stump 14 is folded outwards around the webs 32, 34 and is positioned over the positioning hooks 72 to prevent it from folding back into its starting position and from slipping off on the outer walls 36, 38 Bridges 32, 34 secured. The holder 20 is guided over the opening 18 of the CA 16. The longer positioning aid 90 is first inserted into the CA 16 through the opening 18 in one direction. On- finally, the shorter positioning aid 92 is introduced into the CA 16 through the opening 18 in the other direction. The prepared terminal stump 14 of the LIMA 12 is now positioned in the opening 18 of the CA 16 in such a way that the inside of the CA 16 rests on the inside of the LIMA 12 which has been folded outwards and the CA 16 is secured via the positioning hooks 72. In this position, the clamping jaws 44, 46 are closed one after the other, and the CA 16 and the LIMA 12 are secured against slipping by the positioning hooks 74 projecting from the clamping surfaces 52, 54.

The helical needles 98 shown by way of example in FIGS. 11 to 13 are connected to an axis 102 at the end remote from the needle tip 100 and are rotated by the axis by hand or by an electrical, pneumatic, hydraulic or other type of drive through the guide grooves 60 , 62 moves. Each time the helix needle 98 is used in the guide groove 60, 62, the LIMA 12 and the CA 16 are pierced in the area of the webs 32, 34 and the needle tip 100 emerges in the area of the clamping surfaces 52, 54. the helix needle 98 screws through the tissue. A thread 104 carried by the helix needle 98 leads to the desired sewing connection. The thread 104 can be fastened to the needle end of the helix needle 98 and pulled by the needle (FIG. 11). Another One possibility is to carry the thread 104 in a hollow helical needle 98 (FIG. 12), but it is also possible to attach the thread 104 to the needle tip 100 (FIG. 13). 62, the thread 104 is gripped and the helix needle 98 is then rotated out of the guide groove 60, 62 in the reverse direction of rotation. The stitch spacing and the stitch height in the case of a sewing connection can be correspondingly The choice of the slope a and the diameter D of the helix needle 98 can be specified.

An alternative connection of the helix needle 98 to a drive unit is shown in FIG. 22 and described in more detail below in connection with the device according to FIGS. 17 to 22. It goes without saying that the ends of the threads remaining in the fabric must be secured against slipping out. Known fuses are, for example, knots, clips, clips, clamps and adhesive or welded connections.

After the LIMA 12 and CA 16 have been sewn together, the device 10 can be separated into two parts, for example at a predetermined breaking point, and removed from the operating area. The device 10 can also be cut open.

A device for opening and closing the clamping jaws 44, 46 shown in FIGS. 14 to 16 enables the device 10 to be handled safely during the duration of the medical intervention. The basis of the device is formed by an endoscopic forceps 108 with forceps jaws 112, 113 arranged at one end of a first guide tube 110, which jaws move towards and away from one another via a cable pull running in the guide tube 110 by means of an actuating handle 114 fixed at the other end of the guide tube 110 and by means of an Locking lever 116 can be locked in any clamping position. In use, the jaws 112, 113 rest against the stop 86 on the holding wing 84 of the device 10 and clasp the clamping plate 88.

From the endoscopic forceps 108, two further guide tubes 118, 120 extend along the guide tube 110 to the area of the forceps jaws 112, 113. These two guide tubes 118, 120 are each penetrated by a control wire 122, 124. Each control wire 122, 124 is equipped with a control disk 126, 128 at its end close to the actuating handle 114 of the endoscopy forceps 108. At the other end of each control wire 122, 124, after its exit from the guide tube 118, 120, an end piece 130, 132 is offset by a double opposite bend parallel to the control wire axis and at its free end with a bore 134, 136 provided.

One end of a tension thread 138, 140 is fastened to the rear of each clamping jaw 44, 46 of the device 10 held by the two jaws 112, 113. Each tensioning thread 138, 140 passes through the bore 134, 136 of one of the control wires 122, 124 and is attached with its other end to a spring arranged in a tubular thread receptacle 142 arranged parallel to the two guide tubes 118, 120.

To close the clamping jaws 44, 46 of the device 10, the control wires 122, 124 are rotated by rotating the control discs 126, 128 by about a quarter turn against the force of a torsion spring acting on the control discs 126, 128 and displaced in the direction of the clamping jaws 44, 46 , whereby these are rotated about their axis of rotation 48, 50 into the closed position. When the control disks 126, 128 are released, the end pieces 130, 132 automatically put on the back of the clamping jaws 44, 46 and lock them in their closed position. To open the jaws 44, 46, the control wires 130, 132 are withdrawn. At the same time, the clamping jaws 44, 46 are opened by the tension threads 138, 140 under tension.

A device for holding, positioning and executing the rotary movement of a helical needle 98 to be used with the device 10 shown in FIGS. 17 to 22 has a tubular guide 144 with a conical end piece 146. A flexible hollow shaft 148 with a central tensioning wire 150 is supported in the guide 144.

At its end emerging from the conical end piece 146 of the guide 144, the hollow shaft 148 has a stopper 152 with a stop surface 154 for a hollow cylindrical expanding part 156 made of rubber and penetrated by the tensioning wire 150. The end of the tensioning wire 150 emerging from the rubber expansion part 156 is a closing part 158 with a counter abutment surface 160 put on for the expansion part 156. At its other end, the hollow shaft 148 is connected to a shaft 162 with a longitudinal slot 164 emerging from the guide 144. A clamping piece 166 enclosing the shaft 162 and displaceable thereon has two grip parts 168, 170 projecting laterally from it. A locking screw 172 is arranged in one of the handle parts 168 for fixing the tensioning wire 150 emerging from the hollow shaft 148 and continuing in the longitudinal slot 164 in the shaft 162 on the tensioning piece 166. The free end of the shaft 162 is equipped with a rotary knob 174.

As shown in FIG. 21, the expanding part 156 made of rubber surrounding the tensioning wire 150 is inserted into the helical needle 98 from the end in order to produce a drive coupling when the tensioning wire 150 is not tensioned. The tensioning wire 150 is then pulled back by moving the tensioning piece 166 on the shaft 162 against the rotary knob 174. As a result, the end part 158 with the counter abutment surface 160 sitting on the end of the tensioning wire 150 is displaced in the direction of the stopper 152 with the abutment surface 154. The rubber expansion part 156 compressed in the tensioning wire axis deviates in the radial direction and lies down with the formation of a non-positive connection Connection to the turns of the helix needle 98 (Fig. 22). In this position, the clamping piece 166 is fixed on the shaft 162 by means of a locking screw 176, and the helix needle 98 can be set into a corresponding rotary movement by manually actuating the rotary knob 174. Instead of manually operating the device via the rotary knob 174, the shaft 162 can also be connected to a drive motor. After the sewing process has been completed, the expansion part 156 is relieved by loosening the locking screw 176 and can thus be pulled out of the end of the helix needle 98 again. Instead of a rubber expansion part 156, it is also possible, for example, to use multi-part expansion bodies with wedge surfaces sliding on one another.

Claims

claims

1. Device for performing an anastomosis with a sewn connection between a terminal stump (14) of a first hollow organ (12) and a side wall of a second hollow organ (16), comprising - a holder (20) with one of these from an entry side (22) to an exit side (24) penetrating guide slot (26) for carrying out the terminal stump (14) of the first hollow organ (12), - an anvil (32, 34) arranged on the outlet side (24) of the holder (20) for folding the terminal Butt (14) of the first hollow organ (12) outwards against an outer wall (36, 38) of the anvil (32, 34) and insertion into an opening (18) in the side wall of the second hollow organ (16), - two on the holder ( 20) pivotably articulated clamping jaws (44, 46), each with one in a closed position of the outer wall (36, 38) of the anvil (32, 34) and the end stump (14) of the first hollow organ (12) in the region of the opening that has been folded over (18) list the clamping surface (52, 54) adjacent side wall of the second hollow organ (16), - two guide channels (56, 58) formed in the area of the anvil (32, 34) in the closed position by the holder (20) and the clamping jaws (44, 46) , and - . two helical needles (98) which can be inserted into the guide channels (56, 58) for piercing the parts of the hollow organs (12, 16) lying on the outer wall (36, 38) of the anvil (32, 34) and introducing one of the hollow organs (12, 16) connecting thread (96).

2. Device according to claim 1, characterized in that the anvil comprises two webs (32, 34) arranged on the outlet side (24) of the holder (20) on both sides of the guide slot (26).

3. Device according to claim 1 or 2, characterized in that the Guide slot (26) on the entry side (22) of the holder (20) is expanded.

4. Device according to one of claims 1 to 3, characterized in that the opening of the guide slot (26) has a ratio of length (I) to width (b) of about 1: 3 to 1:20, preferably 1:10 to 1 : 20 has.

5. Device according to one of claims 1 to 4, characterized in that from the outer wall (36,38) of the anvil (32,34) and from the clamping surfaces (52,54) positioning hooks (72,74) for positioning and securing the Hollow organs (12, 16) are arranged.

6. Device according to one of claims 1 to 5, characterized in that a helical guide groove (60, 62) is arranged in the wall of each guide channel (56, 58).

7. The device according to claim 6, characterized in that the side walls of the guide groove (60, 62) are formed by a guide web (64, 66) offering a support surface (68, 70) for the hollow organs (12, 16).

8. Device according to one of claims 1 to 7, characterized in that from each clamping jaw (44, 46) laterally a coaxial to the guide channel (56, 58) arranged hollow cylindrical receiving part (76, 78) protrudes for one helical needle (98).

9. The device according to claim 8, characterized in that each receiving part (76, 78) on the opposite side of the clamping jaw (44, 46) projects from this, coaxial to the guide channel (56, 58) arranged hollow cylindrical shell part (80, 82) assigned.

10. Device according to one of claims 1 to 9, characterized in that a holding wing (84) projects from one side of the holder (20).

1. Device according to one of claims 1 to 10, characterized in that on the outlet side (24) of the holder (20) in the region of the guide slot (26) two positioning aids (90, 92) provided for insertion into the second hollow organ (16). are fixed for the holder (20) via a flexible fastening wire (94, 96).