ES2258826T3 - Instrumento electroquirurgico bipolar para sellar vasos. - Google Patents
Instrumento electroquirurgico bipolar para sellar vasos.Info
- Publication number
- ES2258826T3 ES2258826T3 ES98957771T ES98957771T ES2258826T3 ES 2258826 T3 ES2258826 T3 ES 2258826T3 ES 98957771 T ES98957771 T ES 98957771T ES 98957771 T ES98957771 T ES 98957771T ES 2258826 T3 ES2258826 T3 ES 2258826T3
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- electrosurgical instrument
- bipolar electrosurgical
- ratchet
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- antagonist
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Classifications
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- A—HUMAN NECESSITIES
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- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods
- A61B17/28—Surgical forceps
- A61B17/2812—Surgical forceps with a single pivotal connection
- A61B17/2816—Pivots
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
- A61B18/04—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body by heating
- A61B18/12—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body by heating by passing a current through the tissue to be heated, e.g. high-frequency current
- A61B18/14—Probes or electrodes therefor
- A61B18/1442—Probes having pivoting end effectors, e.g. forceps
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods
- A61B17/28—Surgical forceps
- A61B17/2812—Surgical forceps with a single pivotal connection
- A61B17/282—Jaws
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods
- A61B17/28—Surgical forceps
- A61B17/2812—Surgical forceps with a single pivotal connection
- A61B17/2833—Locking means
- A61B2017/2837—Locking means with a locking ratchet
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods
- A61B17/28—Surgical forceps
- A61B17/29—Forceps for use in minimally invasive surgery
- A61B2017/2926—Details of heads or jaws
- A61B2017/2945—Curved jaws
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
- A61B2018/00315—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body for treatment of particular body parts
- A61B2018/00345—Vascular system
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
- A61B2018/00315—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body for treatment of particular body parts
- A61B2018/00345—Vascular system
- A61B2018/00404—Blood vessels other than those in or around the heart
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
- A61B2018/00571—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body for achieving a particular surgical effect
- A61B2018/00619—Welding
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
- A61B18/04—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body by heating
- A61B18/12—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body by heating by passing a current through the tissue to be heated, e.g. high-frequency current
- A61B18/14—Probes or electrodes therefor
- A61B2018/1405—Electrodes having a specific shape
- A61B2018/1425—Needle
- A61B2018/1432—Needle curved
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B90/00—Instruments, implements or accessories specially adapted for surgery or diagnosis and not covered by any of the groups A61B1/00 - A61B50/00, e.g. for luxation treatment or for protecting wound edges
- A61B90/03—Automatic limiting or abutting means, e.g. for safety
- A61B2090/033—Abutting means, stops, e.g. abutting on tissue or skin
- A61B2090/034—Abutting means, stops, e.g. abutting on tissue or skin abutting on parts of the device itself
Landscapes
- Health & Medical Sciences (AREA)
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- Molecular Biology (AREA)
- Animal Behavior & Ethology (AREA)
- Physics & Mathematics (AREA)
- Otolaryngology (AREA)
- Plasma & Fusion (AREA)
- Ophthalmology & Optometry (AREA)
- Surgical Instruments (AREA)
Abstract
Un instrumento electroquirúrgico bipolar (10) que comprende: miembros interior (11) y exterior (12) que cada uno tiene un mango de anilla (20, 21) cerca de un extremo próximo, y una superficie de sellado antagonista (18, 19) cerca de un extremo distante; un trinquete que tiene dientes de trinquete (26, 27) situados en cada uno de los miembros interior y exterior, proporcionando los dientes de trinquete al menos una posición del trinquete de enclavamiento en la que mantiene una fuerza de cierre entre las superficies de sellado antagonistas; una parte de vástago (14, 15) en cada uno de los miembros interior y exterior, limitada pos sus respectivos dientes de trinquete y un pivote, proporcionando la parte de vástago una carga de resorte contra la fuerza de cierre; un conectador eléctrico (22, 23) situado en cada mango de anilla; un circuito conductor eléctrico en cada uno de los miembros interior y exterior entre su respectivo conectador eléctrico y su respectiva superficie de sellado, para proporcionar circulación de corriente electroquirúrgica entre las superficies de sellado antagonistas; caracterizado porque: el instrumento electroquirúrgico comprende el pivote, que es un pivote aislado que une los miembros interior y exterior para permitir movimiento arqueado de cada superficie de sellado antagonista, comprendiendo el pivote aislado una espiga de hombro (34) que tiene una superficie en rampa (35) que varía el ajuste de apriete entre los miembros interior y exterior durante el movimiento arqueado de las superficies de sellado antagonistas.
Description
Instrumento electroquirúrgico bipolar para
sellar vasos.
Este invento se refiere a un instrumento
electroquirúrgico para cerrar permanentemente vasos en un ser humano
o en un animal, y más en particular a un instrumento
electroquirúrgico bipolar que sella vasos y tejido vascular
aplicando para ello una combinación de presión u corriente
electroquirúrgica.
Corrientemente se usa un hemostato en los
procedimientos quirúrgicos para coger, disecar y pinzar tejido.
Típicamente es un instrumento similar a unos simples alicates en el
que se hace uso de la acción mecánica entre sus mordazas para
apretar los vasos, sin cortarlos. Es también típico de un hemostato
tener un trinquete de enclavamiento entre los mangos, de modo que
el dispositivo pueda ser fijado y bloqueado en posición.
En un procedimiento típico de cirugía abierta se
usan muchos hemostatos. Una vez pinzado el tejido vascular con un
hemostato, es corriente que el cirujano ligue con una sutura
alrededor del tejido para cerrarlo por completo permanentemente
antes de retirar el hemostato. Se pueden dejar varios hemostatos en
el campo quirúrgico hasta que el cirujano tenga la oportunidad de
ligar con una sutura alrededor de cada sección de tejido
pinzado.
Los pequeños vasos sanguíneos han venido siendo
cerrados usando instrumentos electroquirúrgicos sin necesidad de
suturas. Por ejemplo, los neurocirujanos han usado instrumentos
bipolares para coagular en el cerebro los vasos de menos de dos
milímetros de diámetro. Estos instrumentos bipolares son típicamente
dispositivos similares a tenacillas, con dos brazos que pueden ser
desviados cada uno hacia el otro para coger el tejido. Sin embargo,
se ha comprobado que esos instrumentos no son capaces de sellar
vasos sanguíneos de diámetros mayores que aproximadamente dos
milímetros. Se viene sintiendo desde hace largo tiempo la necesidad
de hallar un modo fácil para sellar vasos mayores y mazos de tejido
vascular sin necesidad de sutura.
Se piensa que el proceso de coagulación de los
pequeños vasos es fundamentalmente diferente del de sellado de los
vasos. La coagulación se define como un proceso de desecación del
tejido, en el que las células del tejido se rompen y se secan. El
sellado de vasos se define como el proceso de licuación del colágeno
del tejido de modo que éste se entrecruce y se reforme
convirtiéndose en una masa fundida. Por consiguiente, la coagulación
de los pequeños vasos es suficiente para cerrarlos permanentemente.
Los vasos mayores precisan ser sellados para asegurar un cierre
permanente.
Son conocidos en el campo una serie de pinzas y
fórceps electroquirúrgicos bipolares. Sin embargo, estos
instrumentos no están diseñados para aplicar la presión correcta a
un vaso sanguíneo para conseguir un sellado duradero. Todos estos
instrumentos adolecen también del inconveniente de que no combinan
la simplicidad y la familiaridad de un hemostato con un circuito
electroquirúrgico bipolar.
Un ejemplo de curva de potencia
electroquirúrgica bipolar para el sellado de vasos se ha descrito en
una solicitud de Patente de EE.UU. titulada "Energy Delivery
System for Vessel Sealing" ("Sistema de Entrega de Energía
para el Sellado de Vasos"), número de serie 08/530.495,
presentada con fecha 19 de septiembre de 1995, y a la que por la
presente se hace aquí referencia.
En una solicitud de Patente de EE.UU. titulada
"Vascular Tissue Sealing Pressure Control and Method"
("Método y Control de la Presión para el Sellado de Tejido
Vascular"), número de serie 08/530.450, presentada con fecha 19n
de septiembre de 1995, se describe otro instrumento quirúrgico para
sellar vasos, y a la que por la presente se hace aquí
referencia.
En la Patente de EE.UU. 371.664 se describe un
par de fórceps eléctricos con polos eléctricos positivo y negativo
situados en las mordazas.
En la Patente de EE.UU. nº 728.883 se describe
un instrumento electrotérmico en el cual se usa la electricidad
para calentar una de las mordazas del instrumento.
En la Patente de EE.UU. nº 1.586.645 se describe
un instrumento bipolar para coagular tejido.
En la Patente de EE.UU. nº 2.002.594 se describe
un instrumento para laparoscopia bipolar para tratar tejido, de
modo que se puedan efectuar la coagulación y el corte del tejido con
el mismo instrumento.
En la Patente de EE.UU. nº 2.176.479 se describe
un instrumento para localizar y retirar partículas metálicas. Las
mordazas del instrumento están diseñadas para completar un circuito
eléctrico cuando se interpone material conductor entre ellas. Se
usan un pivote aislado y un trinquete aislado para evitar
cortocircuitos.
En la Patente de EE.UU. nº 3.651.811 se describe
un instrumento electroquirúrgico bipolar para cortar y coagular
tejido.
En la Patente de EE.UU. nº 4.671.274 se describe
un instrumento electroquirúrgico bipolar que comprende las
características que forman el preámbulo de la reivindicación 1 y de
la reivindicación 2.
En la Patente de EE.UU. nº 4.005.714 se
describen fórceps de coagulación bipolares con mordazas que se abren
y se cierran por medio de un manguito de accionamiento.
En las Patentes de EE.UU. números 4.370.980 y
5.116.332 se describen hemostatos para electrocauterización con los
que se pueden realizar la función de pinzado hemostático y la
función de electrocauterización con un solo instrumento. También se
ilustran y se describen diseños electroquirúrgicos monopolares.
En la Patente de EE.UU. nº 4.552.143 se describe
una familia de instrumentos de electrocauterización de conmutador
desmontable, que incluyen un hemostato para electrocauterización. Se
ilustran y se describen diseños electroquirúrgicos monopolares.
En la Patente de EE.UU. nº 5.026.370 se describe
un instrumento de fórceps de electrocauterización que tiene un
mecanismo de conmutación eléctrica. Se ilustran y se describen
diseños electroquirúrgicos monopolares.
En la Patente de EE.UU. nº 5.443.463 se
describen fórceps de coagulación que tienen una pluralidad de
electrodos.
En la Patente de EE.UU. nº 5.484.436 se
describen instrumento s electroquirúrgicos bipolares para cortar y
coagular tejido simultáneamente.
En el artículo, de Sigel y otros, "The
Mechanism of Blood Vessel Closure by High Frequency
Electrocoagulation" ("El Mecanismo de Cierre de Vasos
Sanguíneos Mediante Electrocoagulación por Alta Frecuencia"),
publicado en SURGERY GYNECOLOGY & OBSTETRICS, octubre 1965,
págs. 823-831, se describen experimentos realizados
en vasos sanguíneos de perros. La frase que comienza en la última
línea de la página 823 describe ``un fórceps de electrodo, estando
cada una de las hojas aislada de la otra, y cada una de ellas
conectada a un terminal del generador de alta frecuencia.
En el artículo de Bergdahl y otros, "Studies
on coagulation and development of an automatic computerized bipolar
coagulator" ("Estudios sobre la coagulación y el desarrollo de
un coagulador bipolar por ordenador automático") publicado en J.
NEVROSURG, VOL. 75, julio 1991, págs 148-151, se
expone, en la página 150, que "no fue posible coagular con
seguridad arterias de un diámetro de más de 2 a 2,5 mm". En la
página 151, línea 5, se indica que "se pueden coagular con
seguridad venas de hasta un diámetro de 3 a 4 mm".
En la Patente de Rusia 401.367 se describe un
instrumento bipolar con una transmisión articulada que lleva a
juntarse a las mordazas de trabajo manteniéndose paralelas.
Las exposiciones anteriores no han proporcionado
un diseño para un instrumento electroquirúrgico bipolar capaz de
aplicar convenientemente una presión constante desde una fuente
cargada por resorte calibrada, retenida mediante un trinquete, que
sea suficiente para sellar vasos y tejido vascular.
De acuerdo con primer aspecto del presente
invento, se proporciona un instrumento electroquirúrgico bipolar
que comprende: miembros interior y exterior que cada uno tiene un
mango de anilla cerca de un extremo próximo y una superficie de
sellado antagonista cerca de un extremo distante; un trinquete que
tiene dientes de trinquete situados en cada uno de los miembros
interior y exterior, proporcionando los dientes del trinquete al
menos una posición de trinquete de enclavamiento que mantiene una
fuerza de cierre entre las superficies de sellado antagonistas; una
parte de vástago en cada uno de los miembros interior y exterior
limitada por sus respectivos dientes de trinquete y el pivote,
proporcionando la parte de vástago una carga de resorte contra la
fuerza de cierre; un conectador eléctrico situado en cada mango de
anilla; un circuito conductor eléctrico en cada uno de los miembros
interior y exterior entre su respectivo conectador eléctrico y su
respectiva superficie de sellado, para proporcionar circulación de
corriente electroquirúrgica entre las superficies de sellado
antagonistas; caracterizado porque: el instrumento
electroquirúrgico comprende un pivote aislado que une los miembros
interior y exterior para permitir movimiento arqueado de cada
superficie de sellado antagonista, comprendiendo el pivote aislado
una espiga de hombro que tiene una superficie en rampa que varía el
ajuste de apriete entre los miembros interior y exterior durante el
movimiento arqueado de las superficies de sellado antagonistas.
De acuerdo con un segundo aspecto del presente
invento, se proporciona un sistema electroquirúrgico bipolar que
comprende: el instrumento electroquirúrgico bipolar de acuerdo con
cualquiera de las reivindicaciones 1 a 21; y un generador
electroquirúrgico capaz de producir corriente de salida de alta
frecuencia de sustancialmente 2 Amperios de valor eficaz, o de
mayor intensidad.
Además, se proporciona un instrumento
electroquirúrgico bipolar que comprende: miembros interior y
exterior que cada uno tiene un mango de anilla cerca de un extremo
próximo y una superficie de sellado antagonista cerca de un extremo
distante, teniendo cada superficie de sellado antagonista una
longitud y una anchura; un trinquete que tiene dientes de trinquete
situados en cada uno de los miembros interior y exterior,
proporcionando los dientes de trinquete al menos una posición de
trinquete de enclavamiento en la que se mantiene una fuerza de
cierre entre las superficies de sellado antagonistas; una parte de
vástago en cada uno de los miembros interior y exterior limitada
por sus respectivos dientes de trinquete y el pivote, proporcionando
la parte de vástago una carga de resorte contra la fuerza de
cierre; un conectador eléctrico situado en cada mango de anilla; un
circuito conductor eléctrico en cada uno de los miembros interior y
exterior entre su respectivo conectador eléctrico y su respectiva
superficie de sellado para proporcionar circulación de corriente
electroquirúrgica entre las superficies de sellado antagonistas;
caracterizado porque: el instrumento electroquirúrgico comprende
una caja de bloqueo abierta que une los miembros interior y exterior
para permitir el movimiento arqueado de cada superficie de sellado
antagonista, comprendiendo la caja de bloqueo abierta un pivote y al
menos una pestaña que se extiende sobre el miembro interior y unida
al miembro exterior. En uso, el extremo próximo es retenido y
controlado por el cirujano, mientras que el extremo distante se usa
para manipular el tejido. La caja de bloqueo abierta une los
miembros interior y exterior para permitir movimiento arqueado de
cada superficie de sellado antagonista. La caja de bloqueo abierta
está diseñada en general para proporcionar soporte lateral de modo
que ambas superficies de sellado se muevan en aproximadamente un
mismo plano. Las superficies de sellado están preferiblemente
alineadas opuestas entre sí cuando las mordazas del instrumento
están cerradas juntas. Para proporcionar soporte lateral, la caja
de bloqueo abierta comprende un pivote y al menos una pestaña que
se extiende sobre el miembro interior y unida al miembro
exterior.
Se ajusta el instrumento para que proporcione
una fuerza de cierre apropiada mediante el ajuste de las dimensiones
de una parte del vástago en cada uno de los miembros interior y
exterior. La parte de vástago se define como la parte de cada
miembro limitada por su respectivo talón del trinquete y el pivote.
Durante el uso, el cirujano aprieta los mangos de anilla para
comprimir el tejido entre las superficies de sellado. La parte de
vástago de cada miembro flexiona a la manera de un resorte de
lámina, y puede ser bloqueada con el trinquete en una posición
desviada para que mantenga una fuerza constante. Un beneficio que
puede obtenerse mediante el invento es el de que proporciona un
margen de topes del trinquete que corresponde a un margen de fuerzas
de cierre apropiadas en las superficies de sellado del
instrumento.
Los dientes del trinquete están situados en cada
miembro cerca del mango de anilla. Los dientes del trinquete están
diseñados, en general, para enclavar contra la fuerza de resorte de
los vástagos. La fuerza de resorte es por lo tanto transmitida a
través del pivote para mantener las superficies de sellado cada una
contra la otra. Se requiere un margen de fuerzas de cierre en un
instrumento, que depende del tipo y del grosor del tejido que haya
de ser sellado. Es por lo tanto deseable tener varios topes del
trinquete, que cada uno proporcione una fuerza gradualmente mayor a
las superficies de sellado.
En cada mango de anilla hay situado un
conectador eléctrico. El conectador eléctrico puede ser un poste
metálico que esté formado integralmente con el miembro y el mango
de anilla, Cables eléctricos bipolares conectan desde un generador
electroquirúrgico con el instrumento en los conectadores eléctricos.
Un circuito conductor eléctrico en cada uno de los conductos de los
miembros interior y exterior conduce la corriente eléctrica a las
superficies de sellado.
El circuito conductor eléctrico puede discurrir
a lo largo de los miembros de acero inoxidable. Preferiblemente, va
pegado un recubrimiento aislante eléctrico a las superficies
exteriores de los miembros para proteger al cirujano y al paciente
contra quemaduras eléctricas inadvertidas.
Los siguientes términos o expresiones se definen
aquí como sigue. La fuerza aplicada del instrumento es la fuerza
total que es aplicada al tejido entre las mordazas. Las mordazas son
los miembros cerca del extremo distante del instrumento, desde la
caja de bloqueo hasta la punta del instrumento. Los electrodos son
las superficies metálicas que conducen electricidad al tejido. La
superficie de sellado es la parte del electrodo que entra en
contacto directo con el tejido. El vástago es la parte de cada
miembro entre la caja de bloqueo y el trinquete. Los mangos de
anilla son los elementos en los miembros, cerca del extremo próximo
del instrumento, que son asidos por el cirujano. La caja de bloqueo
en un aspecto es la estructura que permite que los miembros
pivoten, e incluye la espiga de pivote y otras superficies
cooperantes. El miembro interior es el miembro que es aprisionado
en general en el interior de la caja de bloqueo. El miembro exterior
es el miembro que está en el exterior de la caja de bloqueo. La
presión del electrodo se calcula dividiendo la fuerza aplicada por
el área completa de la superficie de sellado. La presión del tejido
se calcula dividiendo la fuerza aplicada por el área del tejido
situada entre las mordazas.
Para permitir una mejor compresión del presente
invento, y para mostrar como puede ser puesto en práctica el mismo,
se hará ahora referencia, a modo de ejemplo únicamente, a los
dibujos, en los cuales:
La Figura 1 es una vista en perspectiva de un
instrumento bipolar para fusión de vasos, representado parcialmente
en despiece ordenado;
La Figura 2 es una vista en planta esquemática
de un instrumento bipolar para fusión de vasos que tiene una
mordaza curvada más larga;
La Figura 3 es una vista lateral del instrumento
representado en la Figura 2;
La Figura 4 es una vista esquemática en planta
de una realización alternativa de un instrumento para fusión de
vasos que tiene una mordaza curvada más corta;
La Figura 5 es una vista lateral del instrumento
representado en la Figura 4;
La Figura 6 es una vista esquemática en planta
de una realización alternativa de un instrumento para fusión de
vasos que tiene una mordaza recta;
La Figura 7 es una vista lateral del instrumento
representado en la Figura 6;
La Figura 8 es una vista en perspectiva de
una
espiga de hombro;
espiga de hombro;
La Figura 9 es una vista lateral de una espiga
de hombro;
La Figura 10 es una vista frontal de una espiga
de hombro; y
Las Figuras 11A y 11B son vistas por arriba,
cada una de un par de superficies de sellado, en las que se han
representado regiones conductoras y regiones aislantes que impiden
el cortocircuito cuando se hacen coincidir las superficies de
sellado en oposición.
Con referencia a la Figura 1, el instrumento 10
tiene un miembro interior 11 y un miembro exterior 12. Los miembros
11 y 12 están conectados a través de una caja de bloqueo abierta 13,
la cual tiene un espacio de separación entre las pestañas 33. Los
términos "interior" y "exterior" se usan para diferenciar
los miembros 11 y 12, y sus partes componentes, de acuerdo con las
respectivas posiciones de los miembros en la caja de bloqueo
abierta 13. El miembro interior 11 está acoplado en general dentro
de las superficies interiores de la caja de bloqueo abierta 13 y es
aprisionado por las pestañas 33. El miembro exterior forma en
general las superficies exteriores de la caja de bloqueo abierta
13.
El miembro interior 11 tiene un vástago interior
14, una mordaza interior 16, y un mango de anilla interior 20.
Análogamente, el miembro exterior 12 tiene un vástago exterior 15,
una mordaza exterior 17, y un mango de anilla exterior 21. Los
mangos de anilla 20 y 21 están diseñados para que el cirujano sujete
y manipule el instrumento 10. Las mordazas 16 y 17 están diseñadas
para coger el tejido entre las superficies de sellado opuestas 18 y
19.
Cada vástago 14 y 15 tiene un talón de trinquete
respectivo 24 o 25. Los dientes de trinquete 26 y 27 están
diseñados para enclavamiento de manera que retengan a los miembros
11 y 12 en posición. Los vástagos 14 y 15 se desvían a la manera de
cómo la hace un resorte de lámina cuando el cirujano fuerza las
mordazas para juntarlas. La desviación de los vástagos 14 y 15
produce una fuerza de recuperación de resorte a la que se puede
oponer el enclavamiento de los dientes del trinquete 26 y 27.
El instrumento 10 no origina un cortocircuito
cuando están enclavados los dientes del trinquete 26 y 27. Esto se
logra mediante una adecuada selección y colocación de materiales
aislantes eléctricos. En una realización, los dientes del trinquete
26 y 27 están compuestos de un material polímero que es ajustado a
presión dentro de los talones de trinquete 24 y 25. Se usa un
tornillo de trinquete 28 en una realización para asegurar los
dientes del trinquete 26 y 27 dentro de los talones de trinquete 24
y 25. Durante la fabricación, los dientes de trinquete 26 y 27
pueden ser formados de una pieza elemental después de haber sido
ajustada a presión la pieza elemental dentro de los talones de
trinquete 24 y 25.
En una segunda realización, uno de los miembros,
11 ó 12, incluye el talón de trinquete y los dientes de trinquete
como partes integrantes del miembro, mientras que el otro miembro,
12 u 11, tiene una capa aislante que impide que se produzca un
cortocircuito entre los miembros 11 y 12 cuando estén aplicados los
trinquetes.
La caja de bloqueo abierta 13 tiene la función
de proporcionar una unión pivotante para los miembros 11 y 12.
Además, las pestañas 33 proporcionan soporte lateral para contribuir
a mantener la alineación de las mordazas 16 y 17. Típicamente se
usan diseños de caja de bloqueo cerrada en los diseños de hemostatos
normales, en los que un miembro interior es aprisionado por
completo a través de una ranura en un miembro exterior. La caja de
bloqueo abierta 13 de esta realización tiene un espacio de
separación entre las pestañas 33 que es diferente al del diseño de
la caja de bloqueo cerrada. El espacio de separación en la caja de
bloqueo abierta 13 proporciona acceso conveniente para instalar un
pivote aislado eléctricamente.
El pivote aislado eléctricamente en el presente
invento comprende una arandela de hombro 29 que soporta a un
tornillo 30 de caja de bloqueo. La arandela de hombro 29 está
compuesta de un material aislante eléctrico que impide que se
produzca un cortocircuito entre los miembros 11 y 12. Una tapa de
tornillo grande 31 ajusta sobre la cabeza del tornillo de la caja
de bloqueo 30. Una tapa de tornillo pequeña 32 ajusta sobre el
extremo roscado del tornillo de la caja de bloqueo 30.
Cada miembro 11 y 12 está conectado a un polo de
un generador electroquirúrgico bipolar. Los conectadores eléctricos
22 y 23 están situados en los mangos de anilla 20 y 21 para
proporcionar un punto de conexión conveniente. Los miembros 11 y 12
están formados de un material conductor eléctrico, tal como de acero
inoxidable. Las superficies expuestas de los miembros, excepto para
los conectadores 22 y 23 y las superficies de sellado 18 y 19, son
preferiblemente recubiertos por rociado con un material
aislante.
Las características de la corriente
electroquirúrgica bipolar vienen determinadas por el diseño del
generador electroquirúrgico. En una realización adecuada, el
generador tendrá una salida en la que el voltaje entre picos no
excederá de 130 voltios. Esto es debido a que los voltajes más altos
pueden originar la formación de chispas, con el resultado de
quemaduras de tejido localizadas, las cuales pueden dar por
resultado el fallo de la soldadura del tejido. En una realización
que se describe tiene el generador capaz de producir corriente de
salida de alta frecuencia, de al menos 2 Amperios de valor eficaz.
Una corriente eléctrica de alta intensidad es importante, debido a
que la misma calienta el tejido lo suficiente como para fundir el
colágeno. Las corrientes eléctricas más bajas producirán
frecuentemente soldaduras de tejidos débiles, de baja resistencia al
estallido.
Durante la operación, se usa el instrumento 10
para coger tejido entre las superficies de sellado 18 y 19. El
cirujano aprieta los mangos de anilla 20 y 21 juntándolos, haciendo
que sea aplicada presión al tejido. Los dientes de trinquete 26 y
27 son enclavados con el ajuste de trinquete apropiado, que depende
del tipo de tejido y del grosor del tejido. A través del
instrumento y el tejido se aplica corriente electroquirúrgica
bipolar para hacer que se funda el tejido.
Las mordazas 16 y 17 tienen una estructura y una
sección transversal que resisten a la flexión bajo carga. Por
consiguiente, para fines de análisis de ingeniería, las partes de
vástago 14 y 15 actúan como una viga apoyada en voladizo, una vez
que hayan sido hechas coincidir las superficies de sellado 18 y 19.
La longitud de esta viga en voladizo ideal se extiende desde el
tornillo 30 de la caja de bloqueo hasta el lugar de los respectivos
talones de trinquete 24 ó 25. Es posible modelar cada vástago como
un resorte de lámina que tenga una constante de resorte. Cada
posición de trinquete está diseñada para transmitir una fuerza de
cierre particular a las mordazas 16 y 17, contra la acción de la
fuerza de restablecimiento del resorte de lámina.
La constante del resorte es en general función
del módulo de Young del material del vástago, del momento de
inercia del vástago, y de la longitud de las partes de vástago 14 y
15. Cuando se cierran, juntándolas, las mordazas 16 y 17 del
instrumento 10, cada vástago 14 y 15 se asemeja a una viga apoyada
en voladizo. Se supone, apropiadamente, que la desviación de cada
vástago 14 y 15 permanece dentro del margen lineal de su curva de
esfuerzo-deformación. El comportamiento de tal viga
es bien conocido por los ingenieros de materiales. Una constante
del resorte grande da por resultado grandes fuerzas de cierre entre
las superficies de sellado 18 y 19. Análogamente, una constante del
resorte pequeña dará por resultado fuerzas de cierre pequeñas entre
las superficies de sellado 18 y 19. La elección de una constante de
resorte apropiada dependerá de la longitud del vástago 14 ó 15, y
de la distancia entre los topes del trinquete 26 y 27.
Los resultados experimentales de estudios hechos
sobre animales sugieren que la magnitud de la presión ejercida
sobre el tejido por las superficies de sellado 18 y 19 es importante
para asegurar un resultado quirúrgico correcto. Se ha comprobado
que presiones en el tejido dentro de un margen de trabajo de 70
N/cm^{2} a 130 N/cm^{2} son eficaces para sellar arterias y
mazos vasculares. Es deseable ajustar la constante de resorte de
las partes de vástago 14 y 15, conjuntamente con la colocación de
los dientes de trinquete 26 y 27, de tal modo que las sucesivas
posiciones del trinquete produzcan presiones que estén dentro del
margen de trabajo. En una realización, las sucesivas posiciones del
trinquete están separadas a dos milímetros entre sí.
La presión sobre el tejido puede describirse de
varias formas. Los ingenieros reconocerán que la cantidad de
presión ejercida sobre el tejido depende del área de la superficie
del tejido que esté en contacto con las superficies de sellado. En
esa una realización, la anchura de cada superficie de sellado 18 y
19 está comprendida en el margen de 2 a 5 milímetros, y
preferiblemente es una anchura de 4 milímetros, mientras que la
longitud de cada superficie de sellado 18 y 19 está comprendida,
preferiblemente, en el margen entre 10 y 30 milímetros. Se ha
comprobado a través de la experimentación que al menos una posición
del trinquete de enclavamiento mantiene, preferiblemente, la fuerza
de cierre entre aproximadamente 4,00 y 6,50 newtons por milímetro
de anchura de la superficie de sellado. Por ejemplo, si la anchura
de la superficie de sellado 18 y 19 es de 4 milímetros, la fuerza
de cierre está preferiblemente comprendida en el margen de 16 N a 26
N. En una realización, la fuerza de cierre es de 5,2 N por
milímetro de anchura, lo que produce una fuerza de cierre de 21 N
para una superficie de sellado 18 y 19 de 4 milímetros de
anchura.
Se ha comprobado experimentalmente que se pueden
producir como resultado concentraciones de corriente locales por un
efecto de tejido desigual, y para reducir la posibilidad de que esto
se produzca, cada superficie de sellado 18 y 19 tiene un borde
redondeado en la presente realización. Además, se ha comprobado que
es ventajosa en ciertas realizaciones una superficie de sellado 18
y 19 con estrechamiento, debido a que el estrechamiento permite una
presión relativamente constante sobre el tejido a lo largo de la
longitud de las superficies de sellado 18 y 19. La anchura de las
superficies de sellado 18 y 19, en ciertas realizaciones, en las que
la fuerza de cierre dividida por la anchura sea aproximadamente
constante a lo largo de la longitud.
Se ha comprobado a través de experimentación que
un instrumento para la fusión de vasos (también designada aquí como
sellado de vasos) deberá comprimir el tejido con una cantidad
apropiada de presión entre las mordazas del instrumento. La presión
es preferiblemente la suficiente para cerrar cualquier lumen por el
que discurra sangre. La presión es, preferiblemente, lo
suficientemente baja como para que el tejido no se abra dividiéndose
dentro de las mordazas del instrumento.
Las mordazas del instrumento no deberán producir
cortocircuito durante el procedimiento. El tejido disminuirá
típicamente de grosor cuando se aplique corriente electroquirúrgica,
permitiendo con ello que las superficies de sellado se muevan
aproximándose entre sí. Esta disminución del grosor no deberá dar
por resultado que los electrodos hagan contacto directo entre sí.
De lo contrario, podría originarse un cortocircuito con paso de
corriente electroquirúrgica siguiendo un circuito preferencial
alrededor del tejido, y ello puede dar por resultado un sellado
deficiente.
En una realización, un tope 37, hecho de
material aislante, está situado en el instrumento para mantener una
separación mínima de al menos 0,3 milímetros entre las superficies
de sellado 18 y19, como se ha ilustrado en la Figura 1. El tope 37
reduce la posibilidad de cortocircuitos entre las superficies de
sellado 18 y 19.
En ciertas realizaciones, como la ilustrada en
la Figura 11, las superficies de sellado 18 y 19 comprenden
regiones conductoras 38 y regiones aislante 39, dispuestas de tal
modo que cada región conductora 38 está opuesta a una región
aislante 39 cuando las superficies de sellado antagonistas 18 son
hechas coincidir en oposición. Las superficies de sellado 18 y 19,
en cierta realizaciones, pueden ser desmontables de sus respectivo
miembro 11 ó 12, mediante interfaces mecánicas normales, tales como
una disposición de espiga y receptáculo.
En la Figura 2 se ha representado una
realización para una superficie de sellado curvada de treinta y dos
milímetros, La Figura 3 es una vista lateral de la Figura 2. Los
miembros 11 y 12 de la Figura 2 están formados de acero inoxidable
410. La longitud y el área de la sección transversal de las partes
de vástago 14 y 16 se han representado en las Figuras 2 y 3 para
producir una constante de resorte de 4,378 N/mm.
La realización representada en las Figuras 4 y 5
tiene una superficie de sellado curvada de veinte milímetros. La
realización representada en las Figuras 6 y 7 tiene una superficie
de sellado recta de treinta y dos milímetros. Cada realización de
las Figuras 2 a 7 está diseñada para que presente el aspecto y el
tacto de un hemostato normal.
En las Figuras 8, 9 y 10 se han representado
tres vistas de una espiga de hombro 34 que puede ser usada, en
ciertas realizaciones, en vez del tornillo 30 de la caja de bloqueo
para conectar los miembros 11 y 12. La espiga de hombro 34 tiene al
menos una superficie en rampa 35 que se aplica a uno de los miembros
11 ó 12 para producir una interferencia mecánica creciente a medida
que las mordazas 16 y 17 se van acercando la una a la otra. En una
realización, la espiga de hombro 34 forma parte de la caja de
bloqueo abierta 13 para contribuir a alinear las superficies de
sellado 18 y 19. En otra realización, la espiga de hombro 34 se usa
sin una caja de bloqueo abierta 13, y acopla de modo movible los
miembros 11 y 12 juntos sin una pestaña 33. El ajuste de
interferencia puede requerir la calibración del instrumento 10 para
asegurar que la fuerza aplicada sea suficiente para proporcionar la
presión de trabajo apropiada entre las superficies de sellado 18 y
19. Se usa preferiblemente una constante de resorte ligeramente más
alta en las partes de vástago 14 y 15, dependiendo del nivel de
interferencia originado por la espiga de hombro.
Un método para usar el instrumento
electroquirúrgico bipolar comprende los siguientes pasos. El
cirujano coge los mangos de anilla 20 y 21 del instrumento 10 para
manipular las mordazas 16 y 17. Se comprime un vaso o un tejido
vascular entre las superficies de sellado antagonistas 18 y 19. Las
superficies de sellado antagonistas 18 y 19 se juntan
preferiblemente en oposición alineada, debido a la acción de
alineación de la caja de bloqueo abierta 13, ó bien, en ciertas
realizaciones, debido a la acción de alineación de la espiga de
hombro 34. El cirujano desvía más las partes de vástago 14 y 15 de
los miembros 11 y 12 para aplicar los dientes de trinquete 26 y 27.
La aplicación de los dientes de trinquete 26 y 27 mantiene a las
partes de vástago 14 y 15 en sus posiciones desviadas, para
producir una fuerza de resorte constante que es transmitida como una
fuerza de cierre a las mordazas 16 y 17. Un generador
electroquirúrgico está conectado al instrumento 10 a través de
conectadores 22 y 23 en los mangos de anilla 20 y 21. Se usa un
conmutador eléctrico para cerrar un circuito entre el generador y
el instrumento 10. El conmutador puede ser un conmutador de pie, tal
como uno del número E6009 del catálogo de Valleylab, que puede
obtenerse de la firma Valleylab Inc., Boulder, CO /EE.UU.). La
corriente electroquirúrgica circula a través de un circuito
conductor eléctrico en cada uno de los miembros interior y exterior
11 y 12 entre su respectivo conectador eléctrico 22 ó 23 y su
respectiva superficie de sellado 18 ó 19. Un recubrimiento aislante
eléctrico 36 cubre sustancialmente a cada miembro 11 y 12, excepto
en las superficies de sellado 18 y 19, para proteger al cirujano
contra arcos
eléctricos.
eléctricos.
Ventajosamente, ciertas realizaciones de este
invento proporcionan un instrumento electroquirúrgico bipolar que
puede fundir tejido sin necesidad de sutura ni de clips quirúrgicos.
El instrumento conduce corriente electroquirúrgica entre dos
superficies de sellado situadas en mordazas antagonistas. La
corriente electroquirúrgica pasa a través del tejido pinzado entre
las mordazas, y remodela el colágeno para fundir el tejido y formar
un sello permanente.
Otra ventaja más del invento es la de que se
pueden fundir vasos sanguíneos rápidamente y sellarlos
permanentemente contra el paso de sangre u otros fluidos. El
instrumento reduce por consiguiente el tiempo en la sala de
operaciones, proporciona un acceso mejorado a los tejidos objetivo,
y aumenta el rendimiento del procedimiento quirúrgico.
Otra ventaja es la de que no se requieren
suturas ni grapas para sellar permanentemente vasos sanguíneos, y
no quedan materias extrañas en el cuerpo del paciente.
Todavía otra ventaja es la de que se pueden
sellar los vasos cuando se aplica el instrumento, y se puede luego
retirar el instrumento de la zona quirúrgica. Esto mantiene la zona
quirúrgica libre de instrumentos extraños que pueden dificultar el
acceso del cirujano a la zona quirúrgica.
Todavía otra ventaja es la de que se puede
aplicar la cantidad apropiada de presión mediante el instrumento al
vaso o vasos, aumentándose con ello la probabilidad de conseguir el
éxito en la intervención quirúrgica.
Ha de quedar entendido que las realizaciones
antes descritas son únicamente ilustrativas de la aplicación de los
principios del presente invento. Quienes sean expertos en la técnica
podrán idear numerosas modificaciones y disposiciones alternativas,
sin rebasar el alcance de las reivindicaciones.
Claims (21)
1. Un instrumento electroquirúrgico bipolar
(10) que comprende:
miembros interior (11) y exterior (12) que cada
uno tiene un mango de anilla (20, 21) cerca de un extremo próximo,
y una superficie de sellado antagonista (18, 19) cerca de un extremo
distante;
un trinquete que tiene dientes de trinquete (26,
27) situados en cada uno de los miembros interior y exterior,
proporcionando los dientes de trinquete al menos una posición del
trinquete de enclavamiento en la que mantiene una fuerza de cierre
entre las superficies de sellado antagonistas;
una parte de vástago (14, 15) en cada uno de los
miembros interior y exterior, limitada pos sus respectivos dientes
de trinquete y un pivote, proporcionando la parte de vástago una
carga de resorte contra la fuerza de cierre;
un conectador eléctrico (22, 23) situado en cada
mango de anilla;
un circuito conductor eléctrico en cada uno de
los miembros interior y exterior entre su respectivo conectador
eléctrico y su respectiva superficie de sellado, para proporcionar
circulación de corriente electroquirúrgica entre las superficies de
sellado antagonistas;
caracterizado porque:
el instrumento electroquirúrgico comprende el
pivote, que es un pivote aislado que une los miembros interior y
exterior para permitir movimiento arqueado de cada superficie de
sellado antagonista, comprendiendo el pivote aislado una espiga de
hombro (34) que tiene una superficie en rampa (35) que varía el
ajuste de apriete entre los miembros interior y exterior durante el
movimiento arqueado de las superficies de sellado antagonistas.
2. El instrumento electroquirúrgico bipolar
(10) de acuerdo con la reivindicación 1, que comprende además:
una caja de bloqueo abierta (13) que une los
miembros interior y exterior para permitir movimiento arqueado de
cada superficie de sellado antagonista, comprendiendo la caja de
bloqueo abierta el pivote y al menos una pestaña (33) que se
extiende sobre el miembro interior y unida al miembro exterior.
3. El instrumento electroquirúrgico bipolar
de acuerdo con la reivindicación 1 ó la reivindicación 2, que
comprende además un recubrimiento aislante eléctrico que cubre
sustancialmente a cada mango de anilla, a cada parte de vástago, y
a la caja de bloqueo abierta.
4. El instrumento electroquirúrgico bipolar
de acuerdo con la reivindicación 1, 2 ó 3, en el que la fuerza de
cierre es un producto que se calcula multiplicando la anchura por un
valor comprendido en el margen entre sustancialmente 4,00 y 6, 50
newtons por milímetro de anchura.
5. El instrumento electroquirúrgico bipolar
de acuerdo con cualquiera de las reivindicaciones precedentes, en
el que la anchura de cada superficie de sellado está comprendida
sustancialmente en el margen entre 2 y 5 milímetros.
6. El instrumento electroquirúrgico bipolar
de acuerdo con cualquiera de las reivindicaciones precedentes, en
el que la longitud de cada superficie de sellado está
sustancialmente comprendida en el margen entre 10 y 30
milímetros.
7. El instrumento electroquirúrgico bipolar
de acuerdo con cualquiera de las reivindicaciones precedentes, en
el que cada superficie de sellado tiene un borde redondeado para
reducir la concentración de la corriente.
8. El instrumento electroquirúrgico bipolar
de acuerdo con cualquiera de las reivindicaciones precedentes, en
el que hay un tope (37) situado en el instrumento para mantener una
separación mínima de al menos 0,3 milímetros entre las superficies
de sellado.
9. El instrumento electroquirúrgico bipolar
de acuerdo con la reivindicación 8, en el que dicho tope está hecho
de un material aislante.
10. El instrumento electroquirúrgico bipolar
de acuerdo con cualquiera de las reivindicaciones precedentes, en
el que la anchura de las superficies de sellado se estrecha a lo
largo de la longitud.
11. El instrumento electroquirúrgico bipolar
de acuerdo con cualquiera de las reivindicaciones precedentes, en
el que el instrumento está construido de tal manera que, en el uso
del instrumento, la fuerza de cierre dividida por la anchura es
aproximadamente constante a lo largo de la longitud de cada
superficie de sellado.
12. El instrumento electroquirúrgico bipolar
de acuerdo con cualquiera de las reivindicaciones precedentes, que
comprende además regiones conductoras (38) y regiones aislantes (39)
situadas en cada una de las superficies de sellado antagonistas,
dispuestas las regiones conductoras y las regiones aislantes de tal
modo que cada región conductora se opone a una región aislante
cuando las superficies de sellado antagonistas son hechas coincidir
en oposición.
13. El instrumento electroquirúrgico bipolar
de acuerdo con cualquiera de las reivindicaciones precedentes, en
el que cada superficie de sellado antagonista está unida de modo
desmontable a su respectivo miembro.
14. El instrumento electroquirúrgico bipolar
de acuerdo con cualquiera de las reivindicaciones precedentes, en
el que dicho pivote está hecho de un material aislante.
15. El instrumento electroquirúrgico bipolar
de acuerdo con cualquiera de las reivindicaciones precedentes, en
el que dichos dientes de trinquete son susceptible de aplicación
removible con dichos miembros interior y exterior, y dichos dientes
de trinquete están hechos de un material polímero.
16. El instrumento electroquirúrgico bipolar
de acuerdo con cualquiera de las reivindicaciones precedentes, en
el que el trinquete tiene al menos una posición de enclavamiento en
la que mantiene una fuerza de cierre para mantener una presión de
cierre entre las superficies de sellado antagonistas en el margen
entre sustancialmente 70 N/cm^{2} y sustancialmente 130
N/cm^{2}.
17. El instrumento electroquirúrgico bipolar
de acuerdo con la reivindicación 16, en el que el trinquete tiene
una pluralidad de partes de enclavamiento, cada una para mantener
una presión de cierre entre las superficies de sellado
antagonistas, en el margen entre sustancialmente 70 N/cm^{2} a
sustancialmente 130 N/cm^{2}.
18. El instrumento electroquirúrgico bipolar
de acuerdo con cualquiera de las reivindicaciones precedentes, en
el que el trinquete está hecho de un material aislante
eléctrico.
19. El instrumento electroquirúrgico bipolar
de acuerdo con una cualquiera de las reivindicaciones 1 a 16, en el
que el trinquete incluye una capa aislante.
20. El instrumento electroquirúrgico bipolar
de acuerdo con cualquiera de las reivindicaciones precedentes, en
el que los miembros interior y exterior incluyen miembros de mordaza
curvados (16, 17) dispuestos en los extremos distantes de los
mismos.
21. Un sistema electroquirúrgico bipolar
que
comprende:
comprende:
el instrumento electroquirúrgico bipolar de
acuerdo con cualquiera de las reivindicaciones 1 a 20; y
un generador electroquirúrgico capaz de producir
corriente de salida de alta frecuencia de sustancialmente 2
Amperios de valor eficaz, o de mayor intensidad.
Applications Claiming Priority (2)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| US08/968,779 US6187003B1 (en) | 1997-11-12 | 1997-11-12 | Bipolar electrosurgical instrument for sealing vessels |
| US968779 | 1997-11-12 |
Publications (1)
| Publication Number | Publication Date |
|---|---|
| ES2258826T3 true ES2258826T3 (es) | 2006-09-01 |
Family
ID=25514769
Family Applications (2)
| Application Number | Title | Priority Date | Filing Date |
|---|---|---|---|
| ES05019429T Expired - Lifetime ES2323877T3 (es) | 1997-11-12 | 1998-11-11 | Instrumento electroquirurgico bipolar para sellar vasos. |
| ES98957771T Expired - Lifetime ES2258826T3 (es) | 1997-11-12 | 1998-11-11 | Instrumento electroquirurgico bipolar para sellar vasos. |
Family Applications Before (1)
| Application Number | Title | Priority Date | Filing Date |
|---|---|---|---|
| ES05019429T Expired - Lifetime ES2323877T3 (es) | 1997-11-12 | 1998-11-11 | Instrumento electroquirurgico bipolar para sellar vasos. |
Country Status (8)
| Country | Link |
|---|---|
| US (1) | US6187003B1 (es) |
| EP (3) | EP1611859B1 (es) |
| JP (1) | JP4074747B2 (es) |
| AU (1) | AU743708B2 (es) |
| CA (2) | CA2309724C (es) |
| DE (2) | DE69840696D1 (es) |
| ES (2) | ES2323877T3 (es) |
| WO (1) | WO1999023959A1 (es) |
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- 1998-11-11 JP JP2000520061A patent/JP4074747B2/ja not_active Expired - Fee Related
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Also Published As
| Publication number | Publication date |
|---|---|
| EP1611859A3 (en) | 2008-06-04 |
| EP1611859A2 (en) | 2006-01-04 |
| JP4074747B2 (ja) | 2008-04-09 |
| EP1033940A1 (en) | 2000-09-13 |
| EP1033940A4 (en) | 2001-09-26 |
| DE69833505D1 (de) | 2006-04-20 |
| EP2050410A2 (en) | 2009-04-22 |
| CA2716415C (en) | 2012-03-27 |
| EP1611859B1 (en) | 2009-03-25 |
| DE69840696D1 (de) | 2009-05-07 |
| CA2309724A1 (en) | 1999-05-20 |
| AU743708B2 (en) | 2002-01-31 |
| EP1033940B1 (en) | 2006-02-15 |
| CA2716415A1 (en) | 1999-05-20 |
| US6187003B1 (en) | 2001-02-13 |
| ES2323877T3 (es) | 2009-07-27 |
| AU1395199A (en) | 1999-05-31 |
| JP2001522632A (ja) | 2001-11-20 |
| WO1999023959A1 (en) | 1999-05-20 |
| EP2050410A3 (en) | 2009-05-27 |
| DE69833505T2 (de) | 2006-11-02 |
| EP2050410B1 (en) | 2013-01-23 |
| CA2309724C (en) | 2010-10-12 |
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