ES2349545T3 - Instrumento para obturar y cortar tejido. - Google Patents

Instrumento para obturar y cortar tejido. Download PDF

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ES2349545T3
ES2349545T3 ES05015635T ES05015635T ES2349545T3 ES 2349545 T3 ES2349545 T3 ES 2349545T3 ES 05015635 T ES05015635 T ES 05015635T ES 05015635 T ES05015635 T ES 05015635T ES 2349545 T3 ES2349545 T3 ES 2349545T3
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end effector
electrodes
tissue
chassis
bipolar
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Thomas Patrick Ryan
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Covidien AG
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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
    • A61B18/1442—Probes having pivoting end effectors, e.g. forceps
    • 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
    • A61B2018/00601—Cutting
    • 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
    • A61B2018/0063—Sealing
    • 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
    • A61B2018/00636—Sensing and controlling the application of energy
    • A61B2018/00696—Controlled or regulated parameters
    • A61B2018/00702—Power or energy
    • 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
    • A61B2018/00636—Sensing and controlling the application of energy
    • A61B2018/00773—Sensed parameters
    • A61B2018/00875—Resistance or impedance
    • 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
    • A61B2018/145—Probes having pivoting end effectors, e.g. forceps wherein the effectors remain parallel during closing and opening

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  • Health & Medical Sciences (AREA)
  • Surgery (AREA)
  • Engineering & Computer Science (AREA)
  • Life Sciences & Earth Sciences (AREA)
  • Biomedical Technology (AREA)
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  • Nuclear Medicine, Radiotherapy & Molecular Imaging (AREA)
  • Plasma & Fusion (AREA)
  • Physics & Mathematics (AREA)
  • Heart & Thoracic Surgery (AREA)
  • Medical Informatics (AREA)
  • Molecular Biology (AREA)
  • Animal Behavior & Ethology (AREA)
  • General Health & Medical Sciences (AREA)
  • Public Health (AREA)
  • Veterinary Medicine (AREA)
  • Surgical Instruments (AREA)

Abstract

Un instrumento quirúrgico bipolar para cortar y obturar vasos sanguíneos o tejido, que comprende: un mango (14) para la sujeción y manipulación por parte del cirujano; un chasis (15) portado por el mango (14), que tiene un eje longitudinal (A) dispuesto entre ellos; una extensión (17) que se extiende desde el chasis que tiene un primer efector (22) de extremo fijado al mismo, incluyendo el primer efector de extremo un primer electrodo (26); un tubo (19) dispuesto dentro del chasis que tiene un segundo efector (21) de extremo fijado al mismo, incluyendo el segundo efector de extremo un segundo electrodo (20) y siendo el segundo efector de extremo móvil con relación al chasis y el primer efector de extremo por medio de un activador mecánico (32) soportado sobre el mango a lo largo del eje longitudinal para agarrar tejido entre el primer y segundo electrodos, estando el primer efector de extremo situado transversalmente con relación al eje longitudinal y estando posicionado opuesto a un extremo de paciente del tubo en el extremo distal de la extensión; estando el primer y segundo electrodos adaptados a conectarse a un generador (28) electroquirúrgico que suministra selectivamente energía electroquirúrgica bipolar al primer y segundo electrodos; en donde el primer y segundo electrodos definen superficies curvilíneas complementarias y de contacto con los vasos acoplables de forma parcialmente conjugada una con otra e incluyen al menos un nervio y una ranura conjugados, en donde las superficies complementarias son para obturar y cortar los vasos sanguíneos o tejido mediante la aplicación de energía electroquirúrgica entre el primer y segundo electrodos; y un sensor (31) para medir la impedancia entre el primer y segundo electrodos.

Description

1. Campo del Invento
Este invento se refiere a un aparato para cortar y obturar vasos o tejidos sanguíneos usando un dispositivo de movimiento lineal bipolar que comprime el tejido
o vaso y después se aplica potencia RF para obturar el tejido y cortar el tejido.
2. Antecedentes de la Descripción
Para sellar vasos sanguíneos en operaciones de cirugía, con el propósito de desactivar el vaso sanguíneo o para detener o evitar el sangrado, se puede aplicar energía de radiofrecuencia (RF) a la estructura del vaso sanguíneo en lugar de grapas
o clips. Tradicionalmente, se usan fórceps para crear una única obturación por aplicación con energía RF bipolar. Normalmente, se abrazan sobre el tejido fórceps que tienen una bisagra entre los dientes que presionan contra cada lado del vaso sanguíneo y se aplica energía. A veces aparecen problemas con esta técnica debido al doblado de los fórceps o la falta de paralelismo entre los dientes afectando por consecuencia a cómo se comprime y obtura el tejido o vaso sanguíneo.
La patente de EE.UU. nº 4.985.030 se refiere a un instrumento de coagulación bipolar. El instrumento comprende un barril externo, cuyo extremo distal porta un manguito con un miembro de mordaza. Un barril interno, que porta otro miembro de mordaza en su extremo distal, es axialmente desplazable en el interior del barril externo, Los barriles interno y externo y sus respectivos miembros de mordaza coagulantes están conectados a una fuente de corriente de AF de manera conocida.
La patente de EEUU 5.585.896 tiene un dispositivo percutor para obturar aberturas en vasos sanguíneos. Se inserta un balón dentro del vaso y después se infla para forzar la pared del vaso dentro de un collarín de fijación.
La patente de EEUU 5.383.897 tiene un dispositivo para obturar perforaciones en vasos sanguíneos conformándose al lumen interno del vaso y colocar arpones en el vaso con el fin de obturar.
La patente de EEUU 5.391.183 tiene un dispositivo para sellar perforaciones en vasos insertando un material hemostático dentro del lugar de la perforación y alrededor del exterior del vaso, con el fin de cerrar el lugar de la perforación.
La patente de EEUU 5.437.292 tiene un dispositivo percutor para obturar zonas de perforaciones arteriales o venosas, ya sean accidentales o intencionales, que mezcla fibrinógeno y trombina para formar un gel alrededor del lugar del lugar de la perforación para crear la oclusión.
La patente de EEUU 5.411.520 tiene un dispositivo para obturar vasos sanguíneos mediante percutores que desliza hacia abajo un catéter de sujeción y entra en el vaso sanguíneo con un ancla y un tapón de colágeno.
La patente de EEUU 5.415.657 tiene un dispositivo que se acerca a la perforación en el vaso sanguíneo, se acopla con la superficie exterior y aplica energía para crear hemostasis.
La patente de EEUU 5.429.616 tiene un dispositivo para obturar perforaciones en vasos aplicando un fluido y después comprimiendo los bordes cuando se obturan.
La patente de EEUU 5.441.517 tiene un sistema para obturar perforaciones en vasos sanguíneos insertando mecánicamente un tapón con un ancla para obturar la perforación.
La patente de EEUU 5.425.739 describe una espiral colocada dentro del vaso para obturarlo o colocarlo de tal modo que anastomose los bordes de los vasos.
La patente de EEUU 5.354.271 describe un revestimiento deslizante para cerrar lugares de perforación que tienen dos partes que se expanden radialmente hacia fuera y pueden usar una forma de acordeón de un catéter.
La patente de EEUU 5.342.393 es un dispositivo que repara perforaciones en vasos abrazando el tejido desde dentro y desde fuera del vaso. Se usa el remachado para cerrar las secciones abrazadas y se puede aplicar calor para separar el remache del sistema de suministro. Este dispositivo no aplica energía en forma de calor sino sólo para separar el remache del lugar de cierre.
La patente de EEUU 5.176.695 es un dispositivo de corte mecánico laparoscópico monopolar con una cuchilla oscilante lineal que corta de forma afilada tejidos que se sitúen en su ranura. El presente invento bipolar no contiene una cuchilla afilada puesto que obtura y corta usando energía RF.
La patente de EEUU 3.862.630 es un dispositivo en el que se usa energía de ultrasonidos para cerrar vasos sanguíneos mediante vibración mecánica y rozamiento de fricción. Cualquier calentamiento del tejido es un derivado mínimo y superficial de la vibración mecánica usada para obturar vasos.
La patente de EEUU 2.011.169 es un electrodo quirúrgico con mordazas de extremo que tienen forma de U y se encajan una dentro de la otra. No están aisladas una de otra y por tanto son monopolares. En el presente invento las mordazas están aisladas y son bipolares. Las mordazas del documento .169 están montadas en un endoscopio. No ajustan entre si como en el presente invento y están diseñadas más con el fin de retirar mordeduras del tejido y coagular al mismo tiempo.
Todos los dispositivos anteriores son diferentes de la descripción actual por varias razones. Estos dispositivos están hechos para el cierre de perforaciones de heridas. Esto implica que un canal de flujo viable permanecerá dentro del lumen del vaso sanguíneo después de que se aplique cada dispositivo. El dispositivo ahora descrito permanece externo al vaso sanguíneo donde no existirá una perforación ni antes ni después del procedimiento. El presente dispositivo y método obtura el vaso sanguíneo, y por consiguiente no crea un camino para la sangre como hacían los anteriores dispositivos discutidos. En la mayoría de los casos, después de obturar con el presente dispositivo y método, el vaso seguirá intacto, aunque con una obturación transversal a él. Además, el simple abrazo por medio del dispositivo descrito no obtura el vaso sanguíneo. Es la aplicación de energía RF lo que forma un grapado o abrazo de autotransfusión haciendo que una fusión de la íntima proporcione la obturación.
Por consiguiente, para resolver las dificultades de los dispositivos anteriores se muestra y describe un instrumento de contacto con el paciente para sujetar y aplicar energía eletroquirúrgica. Durante la disección quirúrgica, se encuentra frecuentemente que los vasos necesitan ser obturados y por consiguiente desactivados. Para hacer esto de una manera segura, fiable para que el vaso quede obturado y no tenga fugas, se requiere y es útil una herramienta que aplique energía para crear un clip de autotransfusión. Se describe brevemente el dispositivo y el método. Un tubo largo se conecta a un lado de un suministro de energía bipolar. El tubo se mueve longitudinalmente, es decir, a lo largo de su eje mayor para hacer tope contra y comprimir el vaso con una parte de extremo. Las dos partes que se ponen a cada lado del vaso podrían ser planas, curvas, triangulares, en ángulo, entalladas, o con otras formas, siempre y cuando ajusten entre si. Si las partes de extremo son de otra forma que no sea plana, esto aumenta el área de la superficie que atraviesa el vaso creando una mayor obturación en el vaso sin aumentar el diámetro de las partes de extremo. Un pulso de energía RF aplicado corta el tejido después de la obturación. El dispositivo y método, cuando se probó en vasos sanos producía una presión de ruptura adecuada para comprobar una obturación sólida.
Las ventajas del actual dispositivo y método son el cierre axial paralelo de las partes de extremo para crear un obturador bipolar compacto y evitar el cortocircuitado. Un transductor de fuerza en línea podría proporcionar información de realimentación sobre la fuerza aplicada usada durante la cirugía. El dispositivo es bipolar para asegurar seguridad añadida mediante el confinamiento de flujo de corriente RF a través del tejido entre los electrodos bipolares en el extremo del dispositivo.
SUMARIO DEL INVENTO
El presente invento está definido más adelante en la reivindicación 1. Las reivindicaciones dependientes están dirigidas a características opcionales o preferentes.
Un obturador o cortador de tejidos bipolar alargado axialmente para la aplicación de energía electroquirúrgica por parte de un cirujano al tejido y a fluidos corporales de un paciente, tiene preferentemente un mango para que el cirujano lo sujete y manipule. Un chasis colocado sobre el mango se extiende axialmente respecto al mango a lo largo del eje. El chasis tiene un extremo de mango y un extremo distal. Un tubo es llevado para movimiento axial respecto a, o a lo largo del, chasis. El tubo es alargado respecto al chasis y tiene un extremo de cirujano y un extremo de paciente dispuestos a lo largo de su eje.
Un efector sobre el extremo del paciente está en posición para hacer contacto primero con el tejido tras el movimiento axial desde el mango por parte del cirujano. El efector es preferentemente de un material para conducir energía electroquirúrgica. Un miembro está soportado por el extremo distal del chasis en una posición opuesta al extremo del paciente del tubo. Una parte sobre el miembro en el extremo distal de éste está situado más preferentemente transversalmente respecto al eje del tubo. La parte puede estar hecha de un material para conducir energía electroquirúrgica y para actuar como un efector de extremo opuesto.
Un primer electrodo electroquirúrgico bipolar está conectado eléctricamente al efector del extremo del paciente. Un segundo electrodo electroquirúrgico bipolar está conectado eléctricamente a la parte o efector de extremo opuesto. El segundo electrodo electroquirúrgico bipolar está aislado eléctricamente del primer electrodo electroquirúrgico bipolar. Un generador electroquirúrgico puede estar acoplado eléctricamente a los primer y segundo electrodos electroquirúrgicos. El generador electroquirúrgico puede estar dispuesto para proporcionar selectivamente energía electroquirúrgica bipolar a través del primer y segundo electrodos electroquirúrgicos bipolares.
Un activador mecánico está soportado de forma móvil sobre el mango para ser usado por el cirujano. El activador se conecta al tubo para mover axialmente el extremo del paciente y su efector de éste hacia o desde la parte o efector de extremo opuesto. El tejido y fluido corporal entre los efectores de extremo está obturado o cortado mediante la aplicación de compresión axial y energía electroquirúrgica bipolar entre el primer y segundo electrodos electroquirúrgicos.
El efector de extremo y la parte o efector de extremo opuesto incluyen superficies de obturación y corte complementarias de acoplamiento parcial tras el movimiento axial de uno hacia el otro a lo largo del eje. El efector de extremo y/o el puerto pueden ser unidos de forma separable al extremo y/o miembro del paciente. Las superficies complementarias son de acoplamiento parcial y curvilíneas para crear más área de contacto con tejidos de lo que lo harían las superficies planas. Alternativamente, pero no de acuerdo con el invento reivindicado, las superficies complementarias de encaje parcial pueden ser paralelas pero oblicuas al eje para crear un contacto alargado con movimiento axial entre el efector de extremo y el puerto. Las superficies complementarias de encaje parcial podrían ser esencialmente planas. Las superficies complementarias de encaje parcial pueden ser circulares. Las superficies complementarias de acoplamiento parcial podrían ser elípticas. Las superficies complementarias de encaje parcial podrían ser también triangulares. Las superficies complementarias de encaje parcial incluyen como mínimo un nervio y una ranura conjugados. Las superficies complementarias de encaje parcial incluyen uno o más nervios y correspondientes ranuras de encaje.
Un método para usar un obturador o cortador de tejidos de energía electroquirúrgica bipolar alargado a lo largo de un eje para ser aplicado por un cirujano al tejido o fluidos corporales de un paciente puede obturar o cortar. El método puede tener los pasos sujeción y manipulación del mango por parte de un cirujano. Un paso podría ser extender axialmente un chasis y/o un tubo portado por el mango. El método puede tener el paso de mover a lo largo del eje el chasis y/o el tubo con el mango. Un paso podría ser llevar el tubo para movimiento axial relativo a, y a lo largo del, chasis. El paso del método puede incluir situar un efector sobre un extremo de paciente del tubo para un primer contacto con el tejido después de que el cirujano realice un movimiento axial hacia fuera del mango. Usar un miembro soportado en un extremo distal del chasis en posición hacia fuera desde el extremo de paciente del tubo, puede ser un paso del método. El método puede tener el paso de tener una parte situada transversalmente respecto al eje y sobre el miembro.
El método de uso puede ser realizado con un primer electrodo electroquirúrgico bipolar acoplado al efector de extremo del extremo del paciente y un segundo electrodo electroquirúrgico bipolar acoplado a la parte. Aislar eléctricamente el segundo electrodo electroquirúrgico bipolar del primer electrodo electroquirúrgico bipolar es otro paso preferente del método de uso. El método preferentemente tiene el paso de acoplar eléctricamente selectivamente un generador electroquirúrgico al primer y segundo electrodos electroquirúrgicos para suministrar energía RF electroquirúrgica bipolar desde el generador electroquirúrgico al primer y segundo electrodos electroquirúrgicos bipolares. El método más preferente tiene el paso de que un cirujano use un activador mecánico que esté soportado de forma móvil sobre el mango. Mover axialmente con el activador el extremo del paciente y/o el efector del extremo opuesto para que el tejido y el fluido corporal entre ellos pueda ser obturado o cortado entre el efector de extremo y la parte a través de la aplicación de compresión y la energía electroquirúrgica bipolar entre el primer y segundo electrodos electroquirúrgicos es un paso preferente.
El método puede tener los pasos de aplicar el efector creado con las superficies de obturación o corte complementarias de acoplamiento parcial , y acoplamiento de encaje parcial de las superficies de obturación o corte complementarias tras un movimiento axial de una hacia la otra a lo largo del eje. El método podría usar el paso de unir de forma separable la parte y/o el efector de extremo al miembro y al chasis respectivamente. El método tiene el paso de usar superficies complementarias de acoplamiento parcial acoplables a lo largo de las trayectorias curvilíneas para proporcionar más área de contacto con el tejido que la que habría entre superficies planas. El método puede tener el paso de usar las superficies complementarias parcialmente acoplables preferentemente paralelas pero a lo largo de un plano oblicuo al eje para crear un contacto alargado con movimiento axial entre el efector de extremo y el puerto.
El método puede tener el paso de usar superficies planas complementarias de acoplamiento parcial que están quizás a lo largo de los planos de las superficies planas. El método podría tener el paso de usar superficies circulares complementarias de acoplamiento parcial que podrían estar a lo largo de los arcos de las superficies circulares. El método podría tener el paso de usar superficies elípticas complementarias de acoplamiento parcial que están preferentemente a lo largo de las curvas de elipses. El método puede tener el paso de usar superficies triangulares complementarias de acoplamiento parcial a lo largo de bordes de los triángulos. El método podría tener el paso de usar superficies complementarias de acoplamiento parcial acoplando como mínimo un nervio con una ranura conjugada. El método puede tener el paso de usar superficies complementarias de acoplamiento parcial que pueden incluir uno o más nervios y ranuras de acoplamiento.
BREVE DESCRIPCIÓN DE LOS DIBUJOS
La Figura 1 es una vista en perspectiva de un obturador o cortador de tejidos bipolar alargado tubular para la aplicación por parte de un cirujano de energía electroquirúrgica al tejido. El obturador o cortador se desliza a lo largo de su eje con una porción interna, deslizante concéntricamente para juntar axialmente los efectores de extremo.
La Figura 2 es una vista en sección transversal tal como se vería a lo largo de las líneas 2-2 de la Figura 1.
La Figura 3 es una vista lateral de un obturador o cortador de tejidos bipolar alargado tubular reutilizable como en la Figura 1 en el que uno de los variados efectores de extremo tiene superficies complementarias de acoplamiento parcial .
La Figura 4 es una vista lateral de un obturador o cortador de tejidos bipolar alagado tubular desechable como en la Figura 1 en el que uno de los variados efectores de extremo tiene superficies complementarias parcialmente acoplables.
La Figura 5 es una vista desde arriba ampliada de la parte y del efector de extremo con superficies complementarias de acoplamiento parcial que encajan entre si con mordazas conjugadas en forma de V.
La Figura 6 es una vista desde arriba ampliada de la parte y del efector de extremo con superficies complementarias de acoplamiento parcial que encajan entre si con mordazas conjugadas de nervio y ranura.
La Figura 7 es una vista desde arriba ampliada de la parte y del efector de extremo con superficies complementarias de acoplamiento parcial que encajan con un macho colocado en pedestal y una hembra a nivel en los que ambos son mordazas conjugadas en forma de V.
La Figura 8 es una vista desde arriba ampliada de la parte y del efector de extremo con superficies complementarias de acoplamiento parcial que encajan con un macho colocado en pedestal y una hembra a nivel en los que ambos son mordazas conjugadas en forma de U.
La Figura 9 es una vista desde arriba ampliada de la parte y del efector de extremo con superficies complementarias de acoplamiento parcial que encajan con un macho en forma de terraza y una hembra rebajada a los que se ha dado forma para que encajen como mordazas conjugadas.
La Figura 10 es una vista desde arriba ampliada de la parte y del efector de extremo con superficies complementarias de acoplamiento parcial que encajan con un par de nervios verticales y un par conjugado de entallas como mordazas.
La Figura 11 es una vista desde arriba ampliada de la parte y del efector de extremo con superficies complementarias de acoplamiento parcial que encajan con un único nervio vertical y una entalla conjugada como mordazas.
La Figura 12 es una vista desde arriba ampliada de la parte y del efector de extremo con superficies complementarias de acoplamiento parcial que encajan con un par de nervios verticales y entallas conjugadas en los que un nervio y una entalla están en el efector de extremo enfrente de su entalla y nervio complementarios sobre la parte como mordazas.
La Figura 13 ilustra las mordazas conjugadas de la Figura 5 con un vaso entre ellas antes de la obturación.
La Figura 14 ilustra las mordazas conjugadas de la Figura 5 con un vaso entre ellas durante la obturación.
La Figura 15 es una vista parcial ampliada del efector de extremo y la parte de la Figura 1 vista desde arriba con un vaso abierto abrazado entre ellas durante el proceso de obturación.
La Figura 16 es una ilustración en perspectiva de un vaso obturado.
La Figura 17 muestra la tensión, corriente, impedancia, potencia, y energía captadas durante la obturación de una arteria esplénica.
DESCRIPCIÓN DETALLADA DEL INVENTO
La Figura 1 es una vista en perspectiva de un obturador o cortador 10 de tejidos bipolar alargado tubular para la aplicación por parte de un cirujano de energía electroquirúrgica al tejido. Un mango 11, para ser sujetado y manipulado por el cirujano, está sobre un extremo proximal 12 del obturador o cortador 10 de tejidos bipolar alargado. El mango 11 tiene ambos primer y segundo asideros 13 y 14 de mango, respectivamente. Un chasis 15, portado sobre el mango 11 por la conexión mecánica con el primer asidero 13 de mango, se extiende axialmente a lo largo del eje “A” relativamente al mango 11 y hacia fuera desde el cirujano una distancia adecuada para alcanzar el lugar de operación del paciente. El chasis 15 comprende al menos dos partes. La primera es un tubo exterior 16 que se extiende desde el mango 11 a lo largo del eje “A”. Un tubo interno 19 es móvil hasta y desde el mango 11 en la realización preferente. El tubo interno 19 está guiado a lo largo del eje “A”. El tubo interno 19 se conecta con el segundo asidero 14 de mango para el acceso del cirujano. Un extremo distal 20 está sobre el tubo interno 19 y frente al lugar de operación. El obturador o cortador 10 alargado tubular se desliza por consiguiente en parte a lo largo de su eje “A” con el tubo interno 19 que es una corredera interna, concéntrico, para juntar axialmente los efectores de extremo 21 y 22. El tubo interno 19 es llevado telescópicamente, en la realización preferente, sobre el chasis 15 para movimiento axial relativo hasta y desde él. El tubo interno 19 tiene, relativo al chasis 15, un extremo 23 de cirujano y el extremo 20 distal que están dispuestos a lo largo del eje “A” de este como se muestra en las Figuras 1 y 3. La Figura 2 es una vista de los tubos interno y externo 19 y 16 en sección transversal como se verían a lo largo de las líneas 2-2 de la Figura 1. Los tubos preferentes exterior e interior 16 y 19 son metálicos y por consiguiente deberían estar aislados uno de otro y con respecto al usuario mediante un recubrimiento 19’ como se ve en la Figura 2.
El efector de extremo 21 sobre el extremo distal 20 está en posición de hacer contacto con el tejido tras el movimiento axial del mango 11 mediante la manipulación del cirujano del segundo asidero 14 del mango. La Figura 3 es una vista lateral de la estructura tubular alargada reutilizable de la Figura 1 con ambos de los variados efectores de extremo 21 y 22 mostrados lateralmente. El efector 21 y 22 están hechos de materiales para conducir energía electroquirúrgica tal como metal, polímeros conductores o cerámica. El efector de extremo 22 tiene un miembro 24 soportado por la extensión de chasis 17 normal a este situada enfrente del extremo 20 del paciente del tubo interno 19. Una parte 25 sobre el miembro 24 de éste está situada transversalmente respecto al eje “A” de la Figura 1. Los efectores de extremo 21 y 22 están por consiguiente opuestos para acoplamiento tras un desplazamiento axial relativo del tubo interno 19 y/o el chasis 15. La Figura 4 es una vista lateral de una estructura tubular alargada desechable de la Figura 1 con uno de los variados efectores de extremo 21 y 22 mostrados lateralmente en la Figura 3. Como se muestra en la Figura 3, la extensión de chasis 17, el miembro 24, y la parte 25 están hechos para conducir energía electroquirúrgica. Por supuesto, se puede añadir aislamiento según se necesite para dirigir la electrocirugía bipolar al espacio entre los efectores de extremo 21 y 22.
Un primer electrodo 26 electroquirúrgico bipolar para hacer contacto con el tejido del paciente o fluidos corporales está acoplado eléctricamente al efector 22 más allá del extremo del paciente 18. Un segundo electrodo 27 electroquirúrgico bipolar está acoplado eléctricamente a los efectores 21 y 22 para hacer contacto con el tejido del paciente o fluidos corporales. El segundo electrodo 27 electroquirúrgico bipolar está aislado eléctricamente del primer electrodo 26 electroquirúrgico bipolar pero está en posición para entregar energía electroquirúrgica bipolar a través del tejido sujetado entre ellos. Un generador electroquirúrgico 28, en la Figura 3, está acoplado eléctricamente al primer y segundo electrodos electroquirúrgicos 26 y 27 mediante los terminales 29 y 30, respectivamente. El generador electroquirúrgico 28 puede estar dispuesto para suministrar selectivamente energía electroquirúrgica al primer y segundo electrodos 26 y 27 electroquirúrgicos bipolares. La aplicación selectiva de energía electroquirúrgica se hace en respuesta al control del cirujano y/o a un sensor 31 que hay en el generador 28 electroquirúrgico. El sensor 31 puede medir la impedancia a través del tejido entre los electrodos 26 y 27.
Un activador mecánico 32, en la Figura 3, está soportado preferentemente de forma móvil sobre el mango 11 para uso por parte del cirujano. El activador mecánico 32 se conecta al tubo interno 19 para mover axialmente el efector de extremo 21 desde éste hacia o desde el efector de extremo 22 en la realización preferente. El tejido y fluido corporal que entre medias puede ser obturado o cortado entre los efectores de extremo 21 y 22 mediante la aplicación combinada de compresión y
energía
electroquirúrgica bipolar entre los primer y segundo electrodos
electroquirúrgicos 26 y 27.
Los
efectores de extremo 21 y 22 incluyen obturar o cortar
complementariamente las superficies 33 y 34 para acoplamiento de encaje parcial tras su movimiento axial de una hacia la otra a lo largo del eje “A”. La Figura 13 ilustra los efectores de extremo 21 y 22 de las mordazas conjugadas de la Figura 5 con un vaso entre ellas antes de ser obturado. De forma similar, la Figura 14 ilustra los efectores de extremo 21 y 22 de las mordazas conjugadas de la Figura con un vaso entre ellas durante la obturación. Los efectores de extremo 21 y 22 podrían estar unidos de forma separable al miembro 24 y/o al tubo interno 19, respectivamente. La Figura 15 es una vista parcial ampliada de los efectores de extremo 21 y 22 de la Figura 1 vistos desde el lateral con un vaso abierto abrazado entre ellos durante el método o proceso de obturación. Las superficies complementarias de encaje parcial 33 y 34 de la Figura 8 son curvilíneas para crear más área de contacto de tejidos de la que crearían superficies planas del mismo espesor. En la Figura 8, los efectores de extremo 21 y 22 tienen superficies complementarias conjugadas 33 y 34 que encajan configuradas con una parte macho 49 colocado en pedestal y un parte hembra 50 en forma de U acoplable con ella como mordazas. La Figura 9 es una vista superior ampliada de los efectores de extremo 21 y 22 que muestra superficies conjugadas que encajan con un parte macho 35 con forma de terraza y una parte hembra 36 a las que se ha dado forma para que ajusten como mordazas. La Figura 10 es una vista superior ampliada de los efectores de extremo 21 y 22 que muestra superficies conjugadas que encajan con un par de nervios 38 verticales y un par complementario de entallas 37 como mordazas. La Figura 11 es una vista superior ampliada de los efectores de extremo 21 y 22 que muestra las superficies conjugadas que encajan con un único nervio 39 vertical y una entalla 40 complementaria como mordazas. La Figura 12 una vista superior ampliada de los efectores de extremo 21 y 22 que muestra superficies conjugadas que encajan con un par de nervios 41 opuestos verticales y entallas opuestas 42 complementarios en los que un nervio 41 está sobre cada uno de los efectores de extremo 21 y 22 a través de su entalla complementaria 42 y los efectores de extremo opuestos 21 ó 22.
Cualesquiera mordazas curvilíneas acoplables complementarias incluso en forma de “S” o aquellas mostradas en la Figura 1 podrían estar dispuestas para proporcionar más área de superficie para contacto con las superficies planas definidas por los conductores a través de ellas. La Figura 5 es una vista superior ampliada de los efectores de extremo 21 y 22 que muestra las superficies conjugadas 33 y 34 que encajan con las mordazas en forma de V complementarias 43 y 44. La Figura 6 es una vista superior ampliada de los efectores de extremo 21 y 22 que muestra las superficies conjugadas 33 y 34 que encajan con un nervio 45 y un canal 46 como mordazas complementarias. La Figura 7 es una vista superior ampliada de los efectores de extremo 22 y 23 que muestra las superficies conjugadas 33 y 34 que encajan con una parte macho 47 colocado en pedestal y una parte hembra 48 en forma de V como mordazas complementarias.
No de acuerdo con el invento, las superficies complementarias acoplables 33 y 34 pueden ser paralelas pero oblicuas al eje “A” como en la Figura 15 para crear contacto alargado con movimiento axial entre el tubo interno 19 y el chasis 15 manteniendo así el tamaño del portal laparoscópico a través del cual los efectores de extremo 21 y 22 deben pasar a una dimensión transversal mínima. Las superficies complementarias de acoplamiento parcial 33 y 34 podrían ser esencialmente planas como en las Figuras 3 y 4. Las superficies complementarias de acoplamiento parcial 33 y 34 pueden ser secciones circulares tal como aparece en las Figuras 1 y 8. Las superficies complementarias de acoplamiento parcial 33 y 34 podrían ser elípticas y por tanto similares a las Figuras 1 y 8 siendo las curvaturas una parte de una elipse en lugar de un círculo. Debido a la perspectiva mostrada en la Figura 1, no se pueden percibir las diferencias observables en tal ilustración entre un círculo y una elipse. Las superficies complementarias 33 y 34 de acoplamiento parcial podrían también ser triangulares como en las Figuras 5, 7, 13 y 14. Las superficies complementarias de acoplamiento parcial 33 y 34 pueden incluir como mínimo un nervio y ranura conjugados como en las Figuras 6 y 11. Las superficies complementarias de acoplamiento parcial 33 y 34 podrían incluir varios nervios como en las Figuras 10 y
12.
Un método de aplicar el obturador o cortador 10 de tejidos bipolar alargado tubular a lo largo de un eje “A” incluye el uso por parte de un cirujano para suministrar energía electroquirúrgica bipolar al tejido y a los fluidos corporales de un paciente. El método tiene los pasos de sujetar y manipular el mango 11 por parte del cirujano. Un paso consiste en extender axialmente el tubo interno 19 y/o el chasis 15 llevado en el mango 11 hacia fuera del cirujano. El método puede tener el paso de mover el tubo interno 19 relativo al chasis 15 a lo largo del eje “A”. Llevar el tubo interno 19 para movimiento axial relativo a y a lo largo del chasis 15 es un paso del método preferente. El paso del método incluye colocar el efector de extremo 22 sobre el extremo del paciente 18 para hacer primero contacto con el tejido tras el movimiento axial del tubo interno 19 por parte del cirujano. Usando un miembro soportado 24 el chasis es un paso del método. El método puede tener el paso de usar una parte 25 situada transversalmente relativa al eje “A” y sobre el miembro 24.
El método de uso tiene un primer electrodo 26 electroquirúrgico bipolar acoplado al efector de extremo 22 que se extiende desde el extremo de paciente 18 y un segundo electrodo electroquirúrgico 27 bipolar acoplado al efector de extremo 21. Otro paso preferente del método de uso es aislar eléctricamente el segundo electrodo 27 electroquirúrgico bipolar del primer electrodo 26 electroquirúrgico bipolar. El método tiene preferentemente el paso de acoplar eléctricamente selectivamente un generador 28 electroquirúrgico al primer y segundo electrodos electroquirúrgicos para suministrar energía electroquirúrgica bipolar desde el generador electroquirúrgico al primer y segundo electrodos 26 y 27 bipolares electroquirúrgicos. El método más preferentemente tiene el paso de que un cirujano use un activador mecánico 32 soportado de forma móvil sobre el mango 11. Mover axialmente, con el activador mecánico 32, el tubo interno 19 y el efector de extremo 21 de éste hacia o desde fuera del efector de extremo 22 para que el tejido y el fluido corporales entre medias puedan ser obturados o cortados entre los efectores de extremos 21 y 22 la aplicación de compresión y energía electroquirúrgica bipolar entre el primer y segundo electrodos electroquirúrgicos 26 y 27 es un paso preferente.
El método puede tener los pasos de aplicar los efectores de extremos proporcionados con superficies obturadoras o cortadoras 33 y 34, y acoplar con encaje parcial las superficies 33 y 34 complementarias obturadoras o cortadoras tras el movimiento axial de una hacia la otra a lo largo del eje “A”. Figura 16 es una ilustración en perspectiva de un vaso obturado 51 como consecuencia de realizar el método para formar la obturación 52. El método puede usar el paso de elegir unir de forma separable los efector de extremo 26 y 27, el tubo interno 19 y el chasis 15, respectivamente. El método tiene el paso de usar superficies 33 y 34 complementarias de acoplamiento parcial acoplables a lo largo de caminos curvilíneos para proporcionar más área de contacto con los tejidos que la que hay entre superficies planas. El método tiene el paso de usar las superficies 33 y 34 complementarias de acoplamiento parcial preferentemente paralelas a lo largo de un plano oblicuo al eje “A” para crear contacto alargado con movimiento axial entre el tubo interno 19 y el chasis 15.
El método tiene el paso de usar superficies planas 33 y 34 complementarias de acoplamiento parcial que estén quizás a lo largo de los planos de superficies planas. El método tiene el paso de usar las superficies 33 y 34 circulares complementarias de acoplamiento parcial que estén a lo largo de los arcos de las superficies circulares. El método puede tener el paso de usar superficies 33 y 34 elípticas complementarias de acoplamiento parcial que estén preferiblemente a lo largo de las curvas de las elipses. El método tiene el paso de usar las superficies 33 y 34 triangulares complementarias de acoplamiento parcial que estén a lo largo de bordes de los triángulos. El método tiene el paso de usar las superficies 33 y 34 complementarias de acoplamiento parcial acoplando como mínimo un nervio y una ranura conjugados. El método tiene el paso de usar las superficies complementarias 33 y 34 de acoplamiento parcial que incluyan uno o más nervios.
Un resultado de los resultados de una prueba de laboratorio de un modelo del obturador o cortador de tejidos bipolar ha mostrado un comportamiento excelente obturando un rango de vasos de varios tamaños. El obturador o cortador de tejido bipolar con recorrido lineal fue probado en arterias esplénicas porcinas cortadas en fresco variando desde 1,8 hasta 3,3 mm. Se usó una única potencia de activación (14W, 500 kHz) en cada vaso abrazado firmemente entre los electrodos bipolares de efectores de extremo. La Figura 17 muestra la tensión, corriente, impedancia, potencia, y energía durante la activación de una arteria esplénica de porcino de 2,6 mm con el dispositivo bipolar mostrado en la Figura 15. La tensión varía desde 18-23 voltios hasta que la impedancia sube hasta aproximadamente 14 s. En este punto, el vaso es obturado y se apaga el suministro de energía manualmente. La curva de impedancia muestra un decremento inicial cuando el vaso es calentado con energía de radiofrecuencia, hasta aproximadamente 20 ohmios. El aumento rápido hasta aproximadamente 200 ohmios muestra que el vaso está seco y que el proceso de obturación ha finalizado.
Los datos, mostrados en los gráficos de la Figura 17, muestran la tensión, corriente, impedancia, potencia y energía durante la activación de 17 s lograda con un obturador o cortador de tejidos bipolar alargado tubular como se muestra en la Figura
15. Los tiempos de activación varían de 12 a 28 s. La energía aplicada varía de 170 a 400 julios. La impedancia de contacto variaba desde 20-80 ohmios, dependiendo del tamaño del vaso y la forma de los efectores de extremo. Si se usasen los efectores de extremo de la Figura 5, la impedancia de contacto disminuiría debido a un mayor área de contacto con el vaso. El tamaño del vaso afecta también a la impedancia.
Se examinaron atentamente los vasos después de cada obturación y se encontró que no tenían carbonización. En 2 de 13 pruebas, el vaso era adherente a uno de los efectores de extremo. El análisis histológico mostró que las paredes del vaso estaban soldadas completamente con la integridad de la íntima, la túnica adventicia y medios completamente perdidos. Las proteínas se fundieron y resultó una soldadura semitraslúcida. la pared del vaso estaba relativamente norma, en la zona adyacente a la posición de la soldadura.
El obturador o cortador 10 de tejidos bipolar alargado tubular para aplicación de energía electroquirúrgica al tejido por parte de un cirujano como se recoge en las reivindicaciones que siguen tiene una estructura que se desliza a lo largo de su eje “A” con una parte deslizante interna, concéntrica. El tubo deslizante 10 interno o interior está unido al efector 21 de extremo proximal y el tubo o chasis 15 fijo externo se conecta al efector 22 de extremo distal en la realización preferente. Los dos efectores 21 y 22 de extremo se emparejan para que el efector 22 de extremo distal ajuste bien ajustado contra el efector 21 de extremo proximal. Estos efectores 21 y 22 de extremo pueden ser cualquiera de un número de pares de formas conjugadas incluyendo triangular, esférica, rectangular, con o sin entalla. La entalla no sólo es para la alineación sino que también define un borde afilado para cortar el tejido o vaso mediante la aplicación de un pulso de RF de alta potencia al lugar de tejido abrazado
5 entre los efectores de extremos 21 y 22. En la realización preferente, el mango 11 es apretado para que el tubo interno 19 se deslice hacia fuera del usuario y el chasis 15 está fijo en relación con el tubo interno 19 cuando los efectores 21 y 22 de extremo actúan sobre el tejido que hay entre ellos. Por supuesto, esto se puede invertir para que el chasis 15 se mueva y el tubo 19 esté fijo.
10

Claims (6)

  1. REIVINDICACIONES
    1. Un instrumento quirúrgico bipolar para cortar y obturar vasos
    sanguíneos o tejido, que comprende: un mango (14) para la sujeción y manipulación por parte del cirujano; un chasis (15) portado por el mango (14), que tiene un eje longitudinal (A) dispuesto entre ellos; una extensión (17) que se extiende desde el chasis que tiene un primer efector
    (22) de extremo fijado al mismo, incluyendo el primer efector de extremo un primer electrodo (26); un tubo (19) dispuesto dentro del chasis que tiene un segundo efector (21) de extremo fijado al mismo, incluyendo el segundo efector de extremo un segundo electrodo (20) y siendo el segundo efector de extremo móvil con relación al chasis y el primer efector de extremo por medio de un activador mecánico (32) soportado sobre el mango a lo largo del eje longitudinal para agarrar tejido entre el primer y segundo electrodos, estando el primer efector de extremo situado transversalmente con relación al eje longitudinal y estando posicionado opuesto a un extremo de paciente del tubo en el extremo distal de la extensión; estando el primer y segundo electrodos adaptados a conectarse a un generador (28) electroquirúrgico que suministra selectivamente energía electroquirúrgica bipolar al primer y segundo electrodos; en donde el primer y segundo electrodos definen superficies curvilíneas complementarias y de contacto con los vasos acoplables de forma parcialmente conjugada una con otra e incluyen al menos un nervio y una ranura conjugados, en donde las superficies complementarias son para obturar y cortar los vasos sanguíneos o tejido mediante la aplicación de energía electroquirúrgica entre el primer y segundo electrodos; y un sensor (31) para medir la impedancia entre el primer y segundo electrodos.
  2. 2.
    El instrumento bipolar de acuerdo con la reivindicación 1, en el que el primer efector de extremo se puede separar de la extensión.
  3. 3.
    El instrumento bipolar de acuerdo con la reivindicación 1 ó 2, en el que el segundo efector de extremo se puede separar del tubo.
  4. 4.
    El instrumento bipolar de acuerdo con la reivindicación 1, 2 ó 3, en el que la superficie en contacto con los vasos del primer electrodo tiene una primera sección transversal y la superficie obturadora de los vasos del segundo electrodo tiene una segunda sección transversal que se complementa con la primera sección
    5 transversal para agarrar tejido entre ellas.
  5. 5. El instrumento bipolar de acuerdo con una cualquiera de las reivindicaciones precedentes, en donde el segundo electrodo está eléctricamente aislado del primer electrodo.
    10
  6. 6. El instrumento bipolar de acuerdo con una cualquiera de las reivindicaciones precedentes, en donde las superficies de contacto complementarias incluyen pares conformados conjugantes de una parte macho (49) colocada en pedestal y un parte hembra (50) en forma de U o V acoplable con ella.
ES05015635T 1997-09-09 1998-09-04 Instrumento para obturar y cortar tejido. Expired - Lifetime ES2349545T3 (es)

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US20050101965A1 (en) 2005-05-12
US20060020265A1 (en) 2006-01-26
AU9223598A (en) 1999-03-29
EP1011492B1 (en) 2005-11-16
DE69841834D1 (de) 2010-09-23
EP1586279B1 (en) 2011-11-02
DE69832391T2 (de) 2006-08-03
EP1011492A4 (en) 2000-12-20
EP1586280A2 (en) 2005-10-19
US6267761B1 (en) 2001-07-31
EP1586279A2 (en) 2005-10-19
WO1999012487A1 (en) 1999-03-18
US20080004616A1 (en) 2008-01-03
DE69832391D1 (de) 2005-12-22
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EP1586280B1 (en) 2010-08-11
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EP1586280A3 (en) 2005-12-07
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US7270660B2 (en) 2007-09-18
US6932810B2 (en) 2005-08-23
ES2376063T3 (es) 2012-03-08

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