WO2007039036A1

WO2007039036A1 - Device for holding a trocar sleeve

Info

Publication number: WO2007039036A1
Application number: PCT/EP2006/008716
Authority: WO
Inventors: Yu-Mi Ryang; Veit Rohde
Original assignee: Rheinisch-Westfälische Technische Hochschule Aachen
Priority date: 2005-10-04
Filing date: 2006-09-07
Publication date: 2007-04-12
Also published as: DE102005047527A1

Abstract

The invention relates to a device for holding a trocar sleeve, comprising a fixture inside which a trocar sleeve can be fastened. Said fixture (6) is provided with at least three retaining arms (15, 16, 17). One end of at least one retaining arm, especially all retaining arms (15, 16, 17), is hingedly disposed on the fixture (6) such that the retaining arm can be fastened in a desired position while another end (20) thereof can be supported in a surgery zone, especially on a patient's skin.

Description

Device for holding a trocar sleeve

The invention relates to a device for holding a trocar sleeve, comprising a holder in which a trocar sleeve can be fastened, in particular a self-retaining device for use in operations e.g. at the spinal column, especially in microsurgical "minimal access" operations of the dorsal lumbar spine, such as herniated discs, spinal canal stenosis, etc.

1934 was the first description of the surgical removal of a lumbar disc herniation (LBSV) due to Lumboschialgien (Mixter and Barr). Until the 1960s and '70s, patients with LBSVs were sometimes even transdurally operated over extensive approaches with extensive bone resections. In 1977, microdiscectomy was introduced by the introduction of the surgical microscope, the so-called micro-neurosurgery for the operation of lumbar disc herniations (Yasargil, Caspar).

The advent of microsurgery was a breakthrough surgical innovation that allowed for much less invasive and less painful postoperative surgery on lumbar BSVs and reduced hospital stays, reduced operative morbidity, and faster outcomes Return to work and thus had a significant economic impact (Koebbe et al 2002).

In addition to the introduction of microsurgery, biochemical processes for the enzymatic dissolution of the soft nucleus of the intervertebral disc, the nucleus pulposus, followed around the same time. First successfully applied to humans by Smith in 1964. Since then, many advancements in the field of minimally invasive surgery of lumbar BSVs have followed.

In addition to microsurgery, more and more percutaneous techniques are now being used, which in some cases allow for even smaller and less invasive approaches to the surgical site than are already the case in microsurgery. Hijikata described the first percutaneous nucleotomy technique with partial resection of disc tissue via a posterolateral approach in 1975.

Further descriptions of percutaneous discectomies using various methods, i.a. e.g. percutaneous intradiscal radiofrequency thermocoagulation followed (Troussier et al 1995). In 1984, Ascher and Heppner first used an Nd-YAG laser to heat the nucleus pulposus and thermally shrink the disc herniation to achieve decompression of the nerve root. In addition to percutaneous methods, more and more video-assisted, endoscopic procedures have been used since the 1990s.

Due to better long-term study results, a higher familiarity and the possibility of spinal concomitant pathologies, e.g. concomitant ligamentous-osseous spinal canal stenosis, microsurgical discectomy is still regarded by many surgeons as the method of choice when compared to other percutaneous procedures. The most recent development is therefore the MED (1994) and most recently the further development, the METRx system (Medtronic Sofamor Danek, Minneapolis, MN, USA).

The METRx system consists of a tubular retractor system with concentric dilators of various lengths and diameters. It was developed for microsurgical Minimal Access ("minimal access") surgery Lumbar disc herniations. It allows a much less invasive access to the spine through a smaller incision and a special gentle muscle-splitting technique, compared to the conventional microsurgical method using the standard Caspar retractor, as the paraspinal ligamentomuscular structures can be left intact and not like usually have to be detached from the spine. While the MED system was still working with the endoscope, the operation is performed via the METRx system as in conventional microsurgery, using the surgical microscope. In 2001, Muramatsu and colleagues reported on their experience with the MED technique, reporting faster postoperative mobilization, less intraoperative blood loss, and lower postoperative painkillers.

In the present invention, trocars or trocar sheaths of various lengths and diameters, which have their origin in endoscopy, are also screwed into the paraspinal musculature in the minimally invasive muscle splitting technique and the operation continues in microsurgical technique.

Disadvantage of all percutaneous / endoscopic procedures is the poor, partly incomplete visualization of the surgical area. Thus, only an indirect 2-dimensional view of the surgical field on a screen is possible, instead of 3-dimensional as usual in microsurgery by the surgical microscope. Since the operating area can not usually be seen in toto or design-related either visualized the surgical area or a working tool can be introduced, but both is not possible simultaneously, the surgeon is often forced to perform operations steps "blind" without visual inspection, so that a there is an increased risk to the patient.

An often necessary clearing of the disc space in directly related to the subject herniated discs, is therefore often not possible in the above method due to the lack of visual control and the limited choice of endoscopic instruments and also allows only certain maneuvers and thus only a limited number operational opportunities too. For example, as mentioned above, clearing out an intervertebral disc space, which is often necessary, is not possible, but only the herniated intervertebral disc prolapse portion can be removed.

Also, e.g. very large, scarred, ossified or recurrent BSVs can only be treated with a significantly increased risk or not at all via the above-mentioned methods, so that there is a relatively narrow range of indications for operating reasons, with only a small, carefully selected patient population for this method is suitable. Failure to meet certain criteria, e.g. that the BSV should not be too large and not too long, otherwise it could be severely scarred, glued or ossified, there is no concomitant spinal stenosis, etc., these methods are not suitable for surgical treatment. Furthermore, due to the unfamiliar instruments and the unfamiliar visualization of the surgical area, there is a relatively steep learning curve, which discourages many surgeons from using such procedures and requires a degree of operational experience and expertise from the surgeon.

The disadvantage of an inserted trocar without a holder is that while it allows access to the surgical area and keeps it open, but can not maintain the access direction in the desired position and repeatedly slips back into the, predetermined by the Eindrehwinkel and the paraspinal muscles, starting position.

Therefore, a trocar holder is necessary, over which it is possible to maintain a predetermined by the surgeon direction. All hitherto existing trocar holders have the disadvantage that they are not self-retaining, but always must be kept by a wizard. An operation without assistance is therefore not possible.

In addition, the assistant does not have both hands, as usual, but only one hand free to assist the surgeon, eg holding other instruments (suckers etc). Furthermore, the surgeon relies on the assistant, the Keep the holder as quiet as possible, as even slight changes in position can make the view of the trocar, which is only 1-2 cm wide, difficult and hinder the operation itself.

Just holding the trocar holder as accurately as possible requires an extremely steady hand and a high degree of concentration and experience of the assistant, so that the surgeon also depends to a high degree on the quality of the assistance, especially because of the relatively small diameter of the trocar and thereby small field of view of the surgical area frequent changes of perspective and associated change in position of the trocar to the surgical area are necessary.

The task of the newly developed, especially self-holding trocar holder is essentially the maintenance of a certain required by the surgeon angle of the trocar holder with respect to the surgical area, the setting can be changed quickly and easily by a few simple actions at any time, so that the trocar holder always exactly in the position set by the surgeon remains without having to be held by the assistant or surgeon. The surgeon is thus self-sufficient, so can operate alone, regardless of an assistant.

According to the invention, the object is achieved in that the holder comprises at least three support arms, wherein at least one support arm, in particular all support arms with one end in a desired position lockable on the holder is articulated and arranged with another end to a surgical area, in particular on the skin of a Patients is supportable.

Due to the inventive design that at least one articulated and lockable arm is provided on the holder, the trocar holder is self-holding, so that it retains the respective set by the surgeon position, even after the surgeon has released the holder.

The trocar holder according to the invention allows an operation in the usual microsurgical technique under the surgical microscope with the usual Instruments, so that there is almost no limitation with regard to suitable patients. Also, usually only a short period of getting used to the smaller access is necessary.

Already by using only one articulated and lockable holding arm all essential to the invention advantages are achieved by setting a holding arm in a specific position in which one end supported on the operating area a Trokarhülse be set and fixed at a certain angle to the operating area. If other orientations are required, the fixed angle can be changed or the trocar holder can be turned.

In order to avoid the latter, it is particularly preferred that at least three respectively hinged and lockable in the desired position retaining arms are arranged on the holder. Then the axis of a trocar sleeve can be adjusted in almost any direction without having to turn the holder for this. Preferably, three retaining arms are arranged at 90 degrees to each other and form a T-shape. Other angles are possible here. Preferably, the lockable axes of rotation of all support arms are in a common plane.

The self-holding trocar holder eliminates all the disadvantages mentioned at the outset, the trocar and the non-self-retaining trocar holder. The holder makes it possible to maintain the desired position of the trocar. Due to the self-holding construction, an operation by a single surgeon without assistants is possible. A not inconsiderable advantage in the present time is the possibility of saving manpower and thus personnel costs, which has a significant economic and economic advantage.

Especially in many operative practices, there is no need for an assistant for cost reasons. With the developed holder, this no longer poses a problem. Thus, despite necessary personnel savings, outpatient surgery according to the latest state-of-the-art technology is sufficient. By the simple as possible, robust little prone design is probably also a cost-effective production of Trokarhalters possible, so that no high initial costs incurred.

The usual microsurgical instruments, if already available with this technique can be used, so that no additional costs incurred by the acquisition of instruments, new surgical sieves etc .. In addition, the surgeon is not dependent on the ability of the assistant to always keep the holder exactly in the position desired or required by the surgeon. Even slight changes in the position of the assistant's hand, and thus of the holder and the trocar, result in a significant impairment of the field of vision of the surgeon, which prevents an operation under constant visual control and can significantly impair the smooth operation procedure.

In the case of an existing assistant, moreover, the assistant is not only provided with one hand, as in the hitherto available holders, but both hands in order to assist the surgeon, e.g. To relieve by holding other instruments (vacuum cleaner, dissector etc), since he no longer has to lead the holder with one hand. The assistant also no longer has to deal with two tasks, namely keeping the trocar in place for the duration of the operation in the position desired by the surgeon and holding an instrument, but can fully rely on assisting in the operation focus on the true meaning.

Relieved by the self-holding trocar holder, the assistant can concentrate fully on the task that is actually his, namely the assistance and relieve and support the surgeon by holding certain additional instruments or by performing other minor surgical tasks without even having to do so Keeping the trocar holder in focus. It is also much easier and less cumbersome for the surgeon, instead of instructing his assistants, how to tilt and hold the holder, simply by quick, simple manipulations deliberately kept very simple construction, the holder in the desired position, which then also complies with the set position exactly.

Preferably, a supporting end of a holding arm may be formed to protect the tissue on which it is supported. This can e.g. be achieved in that at the end of a support surface is arranged, which is formed in a particularly preferred embodiment, at least partially rounded and, e.g. may have the shape of a sphere section, e.g. can be designed as a hemisphere or full ball. Also, a support surface may have a skin-friendly and / or optionally non-slip coating.

A trocar is sleeve-shaped in a known manner, the sleeve often having a head to handle the trocar can. For example, Such a head may be polygonal, preferably hexagonal, as in a machine screw.

A holder of the device according to the invention has a receptacle to hold such a trocar sleeve. Here, a recess is provided in the holder, which is adapted to receive a trocar, in particular at the head end. In this case, when receiving the trocar sleeve in the holder, a positive and / or non-positive connection can result, for example. can be held in the holder of the edge of the polygonal head.

In an advantageous embodiment, the holder may be frame-shaped, wherein the frame encloses a recess which may serve to receive the head of the trocar. In this case, the holder is preferably formed in two parts, wherein one holder part can be pivotable relative to another, e.g. by means of a hinge connection. Thus, the frame can be opened by pivoting one part relative to the other to insert the head of the trocar into the recess and then close the holder again, whereby the frame tightly encloses the trocar head.

In one embodiment, the frame-shaped holder may be formed so that one part is approximately U-shaped and another part is an open U-shape closing bow. This arcuate part can form a tensioning element with which a force directed into the U-shape can be generated in order to press the trocar head into the holder. For this purpose, the movable sheet may for example be provided with a clamping means, for example a screw, by means of which the sheet is drawn onto the U-shape.

In order to enable a fixed arrangement of a trocar by fastening the head of the trocar in the holder, it may be provided in one embodiment that on the inside of the recess inwardly facing land or wall areas are provided, wherein two parallel web / wall areas are spaced, to form a groove between them. Such a groove may be provided at least in regions at the inner edge of the recess, wherein the groove width is selected to receive the edge of the head of a trocar therein. Thus, such grooves form a guide and, if necessary, stop for a trocar head.

The wall / land areas may e.g. be formed as projections of the top and bottom of Trokarhalters invention.

Based on the aforementioned two-part embodiment of the trocar holder, it can be provided that two holding arms are arranged on a holder part, in particular the larger U-shaped, which lie opposite each other in particular. At the small, in particular bow-shaped holder part, a holding arm may be arranged, which may be preferably arranged at 90 degrees to the two aforementioned arms.

Based on the frame or annular shape of a holder, a holding arm can then extend in the radial direction essentially relative to the center of the holder. Such a support arm may e.g. additionally have a weight-saving recess.

Each of these support arms may have an articulated connection to the holder which is lockable to secure a support arm in a desired position. In a simple and preferred embodiment can be used in the Hinge be provided a screw which forms the hinge axis and by means of which a determination is possible. To achieve good handling, such a screw can be designed as a thumbscrew.

In order to be able to achieve a setting that is as variable as possible, it can be provided that a holding arm can be pivoted from a plane parallel to the holder frame enclosing the recess by 90 degrees, at least in one direction towards an operating area, whereby a determination in each arbitrary angular position is possible is.

An embodiment is shown in the following figures. Show it:

FIG. 1: side view and top view of a metal trocar,

FIG. 2 shows a dilator to be introduced into a trocar;

FIG. 3: top view of the trocar holder in the opened state without trocar,

FIG. 4: a plan view of the trocar holder in the closed state with two angled holding arms and a trocar received,

FIG. 5: side view of the trocar holder without trocar with non-angled holding arm;

FIG. 6: side view of the trocar holder without trocar with angled holding arm;

The figures show a device according to the invention for holding a trocar sleeve in different spatial directions with respect to a patient, not shown here.

The trocar sleeve 1 is shown in Figure 1 in two views.

Such trocars 1 are used in minimally invasive surgery, usually in minimally invasive procedures in the abdominal area, the so-called laparoscopy. Trocars find for some years but also in the Spine surgery Use, especially in the microsurgical operation of lumbar disc herniation and lumbar spinal canal narrowing.

There, too, the trocar serves as an access route to the operating area, via which medical instruments are introduced and the respective spinal column pathology can be operated on.

In essence, such a trocar sleeve 1 is similar to a hollow machine screw with a central through-hole 2 and a hexagonal screw head 3. On the outside of the sleeve a thread 4 is arranged.

In a spinal surgery, e.g. initially a 1.6 cm long skin incision performed. Thereafter, the fascia of the posterior lumbar musculature is visualized and blunted, e.g. spread with scissors and the trocar 1 with inserted dilator 5, which is shown in Figure 2 and the trocar with its rounded tip 6 surmounted by a certain distance (here, for example, 1 cm), screwed into the back muscles in a clockwise direction until the trocar 1, which is equipped with an external thread 4, the bone window between two vertebral bodies is seated. Then the dilator 5, which is intended to prevent the penetration of soft tissue into the trocar 1 and spread the tissue as gently as possible, is removed.

Once inserted into the body, the trocar sleeve 1 aligns with a particular direction dictated by the anatomy of the body and the nature of the tissue layers. Although the trocar sleeve 1 can be tilted by hand in a different direction, but when it is released, always returns to its original position. By means of the holding device according to the invention, as shown in FIGS. 3 to 6, the trocar sleeve 1 can be held in a specific position after the holding device has been pushed onto the trocar 1.

The Trokarhülsenhalterung 6 comprises two holding parts 7 and 8, which are movably connected to each other, for example via a hinge 9, wherein the smaller arcuate part 8 can be folded away from the larger 7. By the two holding parts 7 and 8, a recess 10 is enclosed in the manner of a frame, which serves to receive the trocar head 3.

In this embodiment, the larger holding part 7 forms a U-shape which, when folded together with the smaller fold-away holding part 8 as an enclosed recess, forms a substantially symmetrical geometric shape. At the inner edge 11 are located above and below a projection (12, 13), which runs here over the entire U-shaped inner route and serves as a groove-shaped rail for the introduced hexagonal trocar head 3.

The edge of the trocar is held and guided between the supernatants 12 and 13.

When the two holding parts 7 and 8 are folded up after the trocar 1 has been inserted, the holding device can be closed by a screw cap 14.

A closure of any other kind, e.g. via a click closure or clamp closure would also be possible.

On the holder 6, and 7 and 8 at its three side regions, a respective holding arm 15, 16, 17 is attached to the outer end, so that they are arranged at right angles to each other when the holder is closed. These are each attached to the holder 7, 8 via a joint 18, by means of which each holding arm can be tilted vertically upwards or downwards, e.g. via a screw or worm thread.

In the present embodiment, the arms are e.g. attached via a screw thread, each with a knurled screw 19 in a kind of hinge joint 18. The arms can each be moved out of the plane about 90 ° upwards and downwards by about 90 °, as shown in FIGS. 5 and 6, respectively, in which one arm is slightly angled.

The large range of motion thus allows for extreme orientation of the trocar in situ, which is often necessary in the operation on the spine, especially since the area of operation, which is visible at once, is severely restricted due to the small diameter of the metal trocar (here, for example, 13.5 mm), so that the entire operating area can be successively surveyed and, if necessary, processed only by a large number of alignment changes.

At the ends of the holding arms 15, 16, 17 is located as a bearing surface to the operating area in each case a spherical shape 20 or at least directed to the surgical area hemisphere 20 with which the support arms are supported on the skin of the patient, without the skin or the underlying To lazer lying tissue or injured by pressure. Optionally, the terminations of the support arms may also have a different shape. These must ensure protection of the underlying soft tissue and skin by a relatively large contact surface and should have no peaks or sharp edges.

When placing the holder 6 on a trocar 1, e.g. the support arms 15, 16, 17, aligned in the same plane as the holder 6 itself (Figure 5) and already screwed or can optionally also freely movable, hang loosely on the holder, so as not to hinder the process of pushing on the trocar and the Trocar should not inadvertently pull out of the muscles when inserted into the holding device, which could result in soft tissue entering the cavity of the trocar and obstructing the view of the surgical field. Thereafter, the support arms 15, 16, 17 can be brought in a few simple steps in their position and fixed, if this was not the case. Thus, the holder 6 no longer needs to be held with one hand.

Figures 3 and Figure further show weight-saving recesses 21 in the respective support arms.

The holding device is very robust due to its simple construction, easy to clean and sterilize, less susceptible to technical defects, requires little maintenance and above all is easy and fast and with little effort to operate.

Claims

claims

1. A device for holding a trocar, with a holder in which a trocar sleeve is fastened, characterized in that the holder (6) comprises at least three holding arms (15,16,17), wherein at least one holding arm, in particular all the holding arms (15 , 16, 17) is hingedly arranged with one end in a desired position on the holder (6) and can be supported with another end (20) on an operating area, in particular on the skin of a patient.

2. Apparatus according to claim 1, characterized in that a supporting end (20) of a holding arm (15,16,17) is designed to protect the tissue on which it is supported, in particular by a bearing surface arranged at the end (20), which is formed at least partially rounded, in particular as a hemisphere (20) is formed.

3. Device according to one of the preceding claims, characterized in that the holder (6) has a recess (10) for receiving a Trokarhülsenkopfes (3), wherein the holder (6) is divided into two and a holder part (8) relative to another holder part (7) is pivotable in order to open and close a frame of the holder (6) enclosing the recess (10).

4. Apparatus according to claim 3, characterized in that a holding part (7) is substantially U-shaped, wherein the other holding part (8) forms a U-shape closing bracket.

5. Apparatus according to claim 3 or 4, characterized in that on a holder part (7) has two holding arms (15,17) and on the other holder part (8), a holding arm (16) is arranged.

6. Device according to one of the preceding claims, characterized in that the holder (6) has a recess (10) for receiving a Trokarhülsenkopfes (3), wherein on the inside of the recess (10) at least partially by inwardly facing wall / Web areas or projections (12,13) is formed a groove into which a trocar head (3), in particular its edge region, a trocar sleeve (1) can be inserted.

7. Device according to one of the preceding claims, characterized in that an articulated connection (18) of a holding arm (15, 16, 17) to the holder (6) by means of a screw (19), in particular a rotatable with fingers knurled screw (19) detectable is.

8. Device according to one of the preceding claims, characterized in that a holding arm (15, 16, 17) has a weight-saving recess (21).

9. Device according to one of the preceding claims, characterized in that the closed holder (6) is substantially frame-shaped in particular ring-shaped, wherein a holding arm (15, 16, 17) extends relative to the holder center in the radial direction.

10. Device according to one of the preceding claims, characterized in that a holding arm (15, 16, 17) from a plane parallel to the recess enclosing the frame by 90 degrees at least in one direction to an operating area to be pivoted.