Surgical retractor

- 28036 Madrid

ES 2 193 293 T3

DESCRIPTION

Surgical retractor.

Background

1. Technical field

The present description relates to minimally invasive surgical procedures and apparatus, and more particularly to a surgical retractor.

two. Background of the Related Art

Diagnosis and treatment of coronary disorders and related conditions typically require access to the heart, blood vessels, and associated tissues. Such procedures include cardiopulmonary bypass valves, valve repair and replacement, and treatment of aneurysms. Access to the patient's chest cavity can be achieved through a large longitudinal incision in the chest. This procedure, referred to as a median sternotome, requires a saw or other cutting instrument to cut the sternum and allow two opposing halves of the rib cage to spread apart. US Patent No. 5,025,779 to Bugge describes a retractor that is designed to grasp the opposing halves of the sternum and extend separating the thoracic cavity. The wide opening created by this technique allows the surgeon to directly visualize the surgical position and perform procedures on the affected organs. However, such procedures involving large incisions and substantial displacement of the chest cage are often traumatic to the patient with significant attendant risks. The recovery period can be long and is often painful. Additionally, patients for whom coronary surgery is indicated may need not to perform such surgery due to the risks involved in having access to the heart.

Jako Patent No. 5,503,617 describes a retractor configured to be held by the surgeon for use in cardiac or vascular surgery to retract and clamp the ribs apart to allow access to the heart or lung through an interventional window. The retractor includes a rigid frame and a translation frame slidably connected to the rigid frame. The upper and lower blades are rotatably mounted to the rigid frame and the translation frame respectively.

GB 21 02 681 on which the pre-characterizing part of claim 1 is based below describes a surgical retractor holder including a quick release ratchet mechanism that attaches the retractor blades to a ring element. The bracket has an open slot to receive the ring and a return spring whose end near the center of the ring is elongated to quickly close around the ring and keep the bracket engaged in the ring when retraction relaxes. The retaining spring only loosely retains the bracket so that the bracket can easily move along the ring.

US 3,965,890 describes a surgical retractor comprising a frame in which a plurality of retractor arm mounting elements are mounted to move along the frame. The mounting elements to carry the retractor arms are fixed in a certain position on the structure by tightening a nut carried by the mounting elements. In addition, the mounting elements carry the rotatable edges having a flange engageable in a channel on the lower surface of the frame, thereby providing a quick release mechanism to secure the mounting element to the frame.

Document 3,129,706 describes a collapsible structure to which the retractor arms are attached by means of clamps. The clamps are provided with a slot that opens outward to receive one end of the retractor support ring that was secured in position by a locking element, such as a screw.

Another retractor support is described in US 5,375,481. The retractor bracket includes a transverse groove that allows the bracket to slide into a support ring. To fix the circumferential position of the bracket along the ring, a pin is used that projects into the slot and engages indentations on the ring, thereby fixing its position. Any tension on the retractor blade pulls the retractor holder in a proper direction to engage the edge of the pin with the indentations on the ring to prevent circumferential slippage of the holder.

Once access to the chest cavity is achieved, surgery can be performed on the heart. Such procedures topically require that the heartbeat be stopped while maintaining circulation throughout the rest of the body. Cardioplegic fluid, such as potassium chloride (KCl) is delivered to the blood vessels of the heart to paralyze the myocardium. Seguón is described in WO 95/15715 by Sterman et al. for example, cardioplegic fluid is infused into the myocardium through the coronary arteries by a catheter inserted into the ascending aorta. Alternatively, the cardioplegic fluid is infused through the coronary veins in a retrograde manner by a catheter positioned within the jugular vein accessing through the neck of the patient. Such procedures require the introduction of multiple catheters into the blood vessels adjacent to the heart, which is a complicated procedure that requires the desired vessels to be properly located and accessed. The progression of the guidewires and catheters must be accurately controlled to determine proper placement. Additionally, the introduction of catheters forms punctures in the blood vessels that must be subsequently closed and there is an increased risk of trauma to the interior walls of the vessels in which the catheters must pass.

Therefore, there is a need for an apparatus and method that provides access to the thoracic cavity without causing extensive trauma to the patient. A procedure is needed to

ES 2 193 293 T3 less locally stabilize a predetermined area of ​​the surface of the heart that is relatively simple to perform and incorporates instruments that are simple and reliable. Additionally, there is a need for an apparatus and procedure that provides a stable frame to support the additional instruments that can be used during these procedures.

Summary

The present invention is defined in independent claim 1. The present description is directed to surgical instruments and methods. A retractor is provided having a substantially flat base defining an opening for resting in an intervening position on a patient, and at least one retractor blade slidably mounted to the base.

The base is positioned on the patient so that the opening overlies the intervention position, and the intervention position is accessed percutaneously through the opening. The obstructing tissue is retracted with one or more retractor blades to create an opening that provides access for the surgical procedure. A surgical instrument is provided that is dockable to the base and capable of operating in the interventional position. A surgical procedure is performed through the opening to the base with the surgical instrument.

In a preferred embodiment, the retractor blade includes a ratchet assembly, and the method includes securing the position of the retractor blade relative to the base with the ratchet assembly.

The retractor blade may also include an integral blowing, irrigating, or suction assembly operatively positioned adjacent the blade to remove blood, fluid, etc. In another embodiment, a light assembly may be incorporated to illuminate designated portions of the surgical field.

A heart manipulator is described for use in conjunction with the retractor and is releasably mounted on the base. The heart manipulator atraumatically helps to grasp and position the heart to facilitate access to it. In a preferred embodiment the heart manipulator includes a loop-shaped structure that supports a mesh framework.

A heart stabilizing instrument is also described. This instrument is preferably configured to be mounted to the base portion and has a core contact surface. The heart may be in contact with the contact surface of the heart to stabilize the position of a predetermined portion of the surface of the heart. A heart stabilizing instrument can be provided which is mounted to the base portion and movable relative to it. The predetermined portion of the core surface is substantially stabilized by applying pressure to it. In a preferred embodiment, the heart stabilizing instrument includes a structure configured to compress the coronary artery, and the step of stabilizing a predetermined portion of the heart surface includes applying pressure to the coronary artery with the heart stabilizing instrument. The position of the heart stabilizer device may be locked relative to the base.

The base can be provided to the hospital and / or surgeon in a case form that includes one or more retractors. The kit may also advantageously include a heart manipulator and / or heart stabilizer device.

The surgical method may further include providing an actuator associated with the retractor blade and configured to effect linear movement of the retractor blade.

These and other features of the retractor and method for heart surgery will become more readily apparent to those skilled in the art from the following detailed description of the preferred embodiments of the present disclosure.

Brief description of the drawings

Various embodiments of the present surgical apparatus are described herein with reference to the drawings in which:

Figure 1 is a perspective view of a surgical retractor constructed according to a first embodiment of the present disclosure;

FIG. 2 is an enlarged perspective view with parts separated of a blade assembly of the surgical retractor of FIG. 1;

Figure 3 is an enlarged cross-sectional view of a portion of the retractor blade assembly, illustrating mounting of the retractor blade assembly on the base;

fig. 4 is an enlarged cross-sectional view following line 4-4 of FIG. 1 of the base-mounted retractor blade assembly;

fig. 5 is an enlarged top view, illustrating radially inward movement of the retractor blade relative to the base;

fig. 6 is an enlarged top view, illustrating the pawl on the retractor blade in engagement with the latch associated with the base;

Figure 7 is an enlarged top view, illustrating the latch associated with the displaced base from engagement with the retractor blade assembly;

fig. 8 is a perspective view of one embodiment of a core manipulator mounted to a base;

fig. 9 is a perspective view of a core manipulator mounted to the base and constructed according to another embodiment;

fig. 10 is a perspective view of a core mounted stabilizing instrument;

fig. 11 is a reduced-scale top view of the portion of the base positioned on the patient's chest;

fig. 12 is a top view, illustrating retractor blade assemblies mounted to the base portion and retracting the patient's ribs;

fig. 13 is a top view, illustrating a heart manipulator in a position adjacent to the patient's heart;

fig. 14 is an enlarged side view in cross section illustrating a core manipulator mounted to the base and spaced from the heart;

ES 2 193 293 T3 FIG. 15 is an enlarged side view in cross section, illustrating a heart manipulator in contact with the heart;

fig. 16 is a top view, illustrating the heart stabilizer instrument of FIG. 10 mounted to the base;

fig. 17 is a perspective view of the heart stabilizer instrument of FIG. 10 mounted to the base and spaced from the heart;

fig. 18 is a perspective view of the heart stabilizer instrument of FIG. 10 in contact with the heart;

fig. 19 is a perspective view of a surgical retractor assembly and base constructed in accordance with another embodiment of the present disclosure;

fig. 20 is an enlarged perspective view with parts separated of the retractor blade assembly;

fig. 21 is an enlarged perspective view from below of the retract knob, illustrating the gear pinion disposed on it;

fig. 22 is an enlarged cross-sectional view of the base mounted retractor blade assembly;

fig. 23 is an enlarged cross-sectional view of the retractor blade assembly in the process of being mounted to the base;

fig. 24 is an enlarged top view illustrating radially outward translation of the retractor blade;

fig. 25 is an enlarged top view of the latch associated with the base in engagement with the retractor blade;

fig. 26 is an enlarged top view, illustrating the latch displaced from engagement with the retractor blade;

fig. 27 is a perspective view of a heart manipulator constructed according to yet another embodiment of the present description;

fig. 28 is an enlarged cross-sectional view of the mounting assembly for the heart manipulator of FIG. 27;

fig. 29 is a perspective view of a heart stabilizing instrument constructed according to another embodiment of the present description;

fig. 30 is an enlarged cross-sectional view of the mounting assembly of the heart stabilizer instrument of FIG. 29 in an unlocked position;

fig. 31 is an enlarged cross-sectional view of the mounting assembly of the heart stabilizer instrument of FIG. 29 in a locked position;

fig. 32 is a cross-sectional view along line 32-32 of FIG. 31 illustrating the mounting assembly;

fig. 33 is a top view of the surgical retractor positioned on the patient's chest, illustrating the retractor blade assemblies, a heart manipulator, and a base-mounted heart stabilizer instrument;

fig. 34 is a perspective view of a surgical retractor constructed according to another embodiment of the present disclosure;

fig. 35 is a perspective view with parts separated of a retractor blade assembly of the surgical retractor of FIG. 3. 4;

fig. 36 is an enlarged side cross-sectional view of the retractor blade assembly, illustrating positioning adjacent to a rib and mounting of the retractor blade assembly on the base;

FIG. 37 is an enlarged side cross-sectional view of the base mounted retractor blade assembly and rib retraction procedure;

fig. 38 is a perspective view, illustrating the latch member and retractor blade in engagement;

fig. 39 is an enlarged cross-sectional view following line 39-39 of FIG. 37, illustrating the pawl on the retractor blade in engagement with the latch;

fig. 40 is an enlarged cross-sectional view, illustrating the latch associated with the displaced base from engagement with the retractor blade;

fig. 41 is a perspective view of another embodiment of a heart stabilizer instrument mounted to the base of FIG. 3. 4;

fig. 42 is a perspective view with parts separated of the heart stabilizer instrument of FIG. 41;

fig. 42A is a perspective view of the lever element, illustrating the cable mounting configuration;

fig. 42B is a bottom perspective view of the heart stabilizer instrument of FIG. 41;

fig. 43 is a cross-sectional view of the heart stabilizer instrument of FIG. 41;

fig. 44 is a partial cross-sectional side view of the heart stabilizer instrument in an unlocked configuration;

fig. 45 is an enlarged cross-sectional view of the toggle mechanism in an unlocked configuration;

fig. 46 is an enlarged cross-sectional view of a portion of the hinge arm, illustrating the cable in a loose configuration corresponding to the unlocking configuration of FIGS. 44-45;

fig. 47 is an enlarged cross-sectional view of the toggle mechanism in a locking configuration;

fig. 48 is a reduced-scale side view in partial cross-section of the heart stabilizer instrument in a locking configuration;

fig. 49 is an enlarged cross-sectional view of a portion of the link arm, illustrating the cable in a clamping configuration that corresponds to the locking configuration of FIGS. 47-48;

fig. 50 is a perspective view of a base mounted heart stabilizer instrument according to another embodiment of the present description;

fig. 50A is an enlarged perspective view of the attachment elements of the heart stabilizer instrument of FIG. fifty;

fig. 50B is an enlarged perspective view of the attachment elements of the heart stabilizer instrument of FIG. fifty;

ES 2 193 293 T3 FIG. 51 is a perspective view of a surgical retraction system according to another embodiment of the present disclosure incorporating a variety of retractors, a heart manipulator, and a heart stabilizer, all positioned on a base;

fig. 52 is a top view of the base of FIG. 51 illustrating suture assemblies positioned there;

fig. 53 is an enlarged perspective view of the suture assemblies of FIG. 52;

fig. 54 is a perspective view of a surgical retractor in accordance with the present disclosure incorporating an integral blow-out structure;

fig. 55 is a reverse perspective view of the surgical retractor of FIG. 54;

fig. 56 is an enlarged perspective view with parts separated of the surgical retractor of FIG. 54;

fig. 57 is a perspective view of a surgical retractor in accordance with the present disclosure incorporating a light;

fig. 58 is a reverse perspective view of the surgical retractor of FIG. 57;

fig. 58A is a top plan view in partial cross-section of a surgical retractor mounted to the base of FIG. 52;

fig. 58B is a top plan view in partial cross section of the surgical retractor in FIG. 58A dragged proximally relative to the base;

fig. 58C is a top plan view in partial cross-section of the surgical retractor in FIG. 58A released from engagement with the rack;

fig. 59 is a perspective view of another embodiment of a heart stabilizer instrument according to the present description;

fig. 60 is an enlarged perspective view of a portion of the heart stabilizer instrument of FIG. 59, illustrating a positioning flange formed therein;

fig. 61 is a perspective view with parts separated of the heart stabilizer instrument of FIG. 59;

fig. 62 is a perspective view of the mounting tab member of the heart stabilizer instrument of FIG. 59;

fig. 63 is a perspective view of the movable ratchet of a heart stabilizer instrument of FIG. 59;

fig. 64 is a top plan view in partial cross-section of the heart stabilizer instrument of FIG. 59 with the movable ratchet in the unlocking effortless position;

fig. 65 is a cross-sectional view following line 65-65 of FIG. 64, illustrating the position relative to the ratchet spring element;

fig. 66 is a top plan view in partial cross-section of the heart stabilizer instrument of FIG. 59 with the movable pawl in the locking non-effort position;

FIG. 67 is a cross-sectional view following line 67-67 of FIG. 66, illustrating the position relative to the ratchet spring element.

fig. 68 is a top plan view in partial cross-section of the heart stabilizer instrument of FIG. 59 with the movable pawl in the force and lock position;

fig. 69 is a cross-sectional view following line 69-69 of FIG. 68, illustrating the position relative to the ratchet spring element;

fig. 70 is a perspective view of another embodiment of a heart manipulator;

fig. 71A and 71B are front and rear perspective views of the rib elevator;

fig. 72 is a perspective view of a case assembly having a base, three retractors, a retraction knob, a heart manipulator, and a heart stabilizer instrument; and fig. 73 is a perspective view of a case assembly having a base, a retraction knob, and three retractors.

Detailed description of preferred embodiments

Preferred embodiments of the apparatus described herein will be discussed in terms of procedures and apparatus for heart surgery. However, the present description will not be limited to an apparatus to be used in conjunction with such heart surgery, although it may find application in surgery in which access to the surgical position is achieved through a small incision and retraction of the surrounding tissues. and / or desired bone.

Referring now in detail to the drawings in which like reference numbers identify similar or identical elements, a first embodiment of the surgical retractor of the present description is illustrated in FIG. 1, and was generally designated by reference number 10. Surgical retractor 10 has base 12 and retractor blade assembly 14, including mounting assembly 16 and retractor blade 18. As described below, the base 12 in this embodiment was configured to be placed on a patient's chest by encircling an incision. Retractor blade 18 includes latch 20 configured to atraumaotically engage a rib. Band 22 assists the surgeon by extracting retractor blade 18 radially outward and retracting a rib thereafter. A one-way ratchet assembly 23 on mounting assembly 16 holds retractor blade 18 in position. Base 12 was also configured to receive surgical instruments for mounting thereon, as will be described further below.

Base 12 preferably has a closed shape, such as an oval configuration as shown, or a circle, polygon, or the like. Base 12 is dimensioned large enough to include sufficient area to provide access to the intervention position. The lower portion of the base 12 is preferably configured to allow placement directly on the skin of the patient with the base substantially level with the skin of the patient. Suture assemblies 24a, 24b, 24c may be provided in various positions on base 12 to allow immobilization of the suture of internal tissue structures such as the pe5 sac

ES 2 193 293 T3 ricardial. The outer periphery 26 of the base 12 includes a series of outwardly extending teeth 27 formed therein to provide additional stability to the positioning of the mounting assembly 16 and other instruments on the base 12. The base 12 also includes a surface 28 internal beveled with a flange 30, and the upper surface 32. Base 12 has a low profile when placed on the body. Base 12 is rigidly supported by pressure from retractor blade assembly 14 on the ribs at three or four locations. Preferably, three retractor blade assemblies are disposed on base 12 spaced 120 apart. The retractor blade assemblies may be spaced 90 ° apart.

Turning now to fig. 2, the mounting assembly 16 allows rapid and stable mounting of the retractor blade assembly to the base 12. The mounting assembly 16 includes the mounting bracket 34, the retainer block 36, and the retainer spring 38. The clamping flange 40 on the mounting bracket 34 is configured to engage the internal flange 30 of the base 12 (Figs. 3 and 4). Sleeve 42 forms a channel 44 with an open side for sliding reception of retractor blade 18. The latch 46 is formed on the mounting bracket 34 and has a series of engagement teeth 48 communicating with the open side channel 44 to engage the retractor blade 18, which will be described further below. The mounting bracket 34 defines a cavity 49 for mounting the retainer block 36 there. The cavity 49 is partially defined by the outer retainer wall 50 with the upper flange 51 and by the internal wall 52 having the opening 53. The retainer block 36 is radially slidable within the cavity 49 and is biased inward by the spring 38 retainer so that engagement teeth 54 on retainer block 36 protrude through aperture 53, to engage teeth 27 disposed on periphery 26 of base 12. The retainer block 36 also includes the ratchet 56 which allows the surgeon to move the retainer block 36 toward the retainer wall 50 against deflection of the retainer spring 38, to disengage the teeth 54 from the base 12.

Retractor blade 18 includes hook 20 curved over a distal end portion and slot 57 over a proximal end portion to receive flexible aid band 22 therethrough. A series of ratchet teeth 58 are provided on a retractor blade edge 18 and teeth 48 of latch 46 engage when retractor blade 18 is disposed in channel 44 of mounting bracket 34.

They will continue to be illustrated in Figs. 3-4, the mounting assembly 16 mounts to the base 12 in a simple, one-handed operation. Fig. 3 illustrates a retainer block 36 offset toward retainer wall 50 against normal deflection of retainer spring 38. The handle 56 of the retainer block 36 facilitates the approach of the retainer wall 50 with the tab 51 of the retainer wall 50. The mounting assembly 16 is lowered onto the base 12 at an angle as shown so that the clamping flange 40 engages the internal flange 30 of the base 12. The coupling teeth 54 are at an angle to allow arrangement of the cams on top of outer flange 60. Fig. 4 illustrates the mounting assembly 16 in position with respect to the base 12, upon which the retainer block 36 is released, thereby returning inward toward the base 12 under the normal deflection of the spring 38. The coupling teeth 54 pass under the outer flange 60 and engage the teeth 27 on the periphery 26 of the base 12.

Returning to figs. 5-7, the progression of retractor blade 18 relative to mounting bracket 34 is illustrated. Ratchet assembly 23 includes latch 46 on mounting bracket 34 and teeth 58 on retractor blade 18. The latch 46 is normally deflected toward the retractor blade 18. The latch teeth 48 and the retractor blade teeth 58 are each configured with a sloping portion and a straight portion. This allows the retractor blade 18 to be progressively displaced in a radially outward direction as indicated by arrow "O" in FIG. 5. Next is illustrated in fig. 6, radially inward displacement of the retractor blade 18 is prevented by engagement of the engagement teeth 48 and the retractor blade teeth 58 under engagement normal deviation 46. The tooth arrangement, as shown in figs. 5-6 allows the retraction of a rib or other body structure and prevents slippage or loss of the retraction force exerted by the retractor 18. This is illustrated in fig. 7, retractor blade 18 is allowed to move radially inward as indicated by arrow "I" when tab 62 rotates clockwise causing it to move away from retractor blade 18 against its normal deviation due to lug action 62. Unrestricted movement of retractor blade 18 in both radially inward and radially outward directions is allowed when lug 62 is moved to the position of FIG. 7.

Fig. 8 illustrates a heart manipulator 64 for use in conjunction with surgical retractor 10 and for mounting on base 12. Heart manipulator 64 includes loop structure 66 that supports mesh surface 68. Structure 66 and mesh surface 68 together form a heart interface for manipulating the heart therewith. Preferably, structure 66 includes vertical portion 70, generally horizontally extending portion 72, and atraumaotic curved end portion 74, which provide a surface for engaging and manipulating the heart. Frame 66 is supported by mounting bar 76 which is slidably received in support bracket 78 for height adjustment. The adjusting screw 80 secures the mounting bar 76 with respect to the support bracket 78. Radial positioning of the support bracket 78 and the heart manipulator 64 is achieved by the slidable mounting of the support bracket 78 on the con6.

ES 2 193 293 T3 mounting joint 82 which mounts to base 12 in a manner substantially similar to mounting assembly 16 described above with respect to FIG. 3-4. Set screw 84 secures radial position of heart manipulator 64 relative to mounting assembly 82. More particularly, the support bracket 78 has an elongated slot 79 formed therein which allows the bracket 78 to slide radially with respect to the set screw 84 and mounting assembly 82. It is shown in fig. 14, the mounting assembly 82, like the mounting assembly 16, has a mounting bracket 83 that engages the internal flange 30 of the base 12, the retainer block 81, and the retainer spring 87. Handle 89 of retainer block 81 allows attachment and detachment of mounting assembly 82 in the same manner as mounting assembly 16 described above.

Returning to fig. 9, a heart manipulator 90 is shown according to another preferred embodiment. Loop structure 66 and mounting assembly 82 are substantially as described above with respect to heart manipulator 64 in FIG. 8. Mounting bar 92 supports frame 66 and has a substantially right angle turn 94 for slidable insertion into support bracket 96. Radial position of heart manipulator 90 is achieved by sliding mounting bar 92 relative to support bracket 96 and secured thereto by set screw 98. Although height adjustment of the heart manipulator 90 is not provided, access to the intervention position is improved by the one-piece design of the mounting bar 92.

Fig. 10 illustrates a heart stabilizing instrument 100, configured to apply pressure to the coronary artery, reduce blood flow in the artery, allow anastomosis to the coronary artery, and reduce movement of the heart muscle between legs 104a, 104b to allow the surgeon perform cardiovascular surgery. Heart stabilizer instrument 100 is mounted to base 12 by mounting assembly 82, substantially as previously described. Stabilizing instrument 100 includes frame 102 that supports legs 104a and 104b and cross bars 106a and 106b. The boss 108a is formed on the cross bar 106a, and the boss 108b was formed on the cross bar 106b. The projections 108a and 108b have an atraumaotic convex heart contact surface and allow the use of localized pressure on the coronary artery when the structure 102 is compressed on the surface of the heart. Mounting bar 110 is slidably received in support bracket 78 and secured relative thereto by adjusting screw 80. Radial positioning of the heart stabilizer instrument 100 relative to the mounting assembly 82 is ensured by a coupling means, such as a set of screw 84.

Turning now to fig. 11, the operation of the surgical retractor 10 will now be described. Conventional surgical techniques are used to determine the location of incision I by accessing cavity C of the chest. The base 12 was placed on the patient's chest with the opening covering the intervention position. Incision I is made, exposing various ribs

R1, R2, and R3.

This is illustrated in fig. 12, the retractor assemblies 14a, 14b, and 14c are mounted to the base 12 at various locations. The hitch 20a was positioned around a rib R1. Assist band 22a is used to provide a hold for the surgeon to deflect and retract rib R1 by pulling retractor blade 18 radially outward. The one-way ratchet assembly 23a holds the retractor blade 18 and consequently the rib R1 in position. Rib R2 is retracted in a substantially identical manner by engagement 20b on retractor assembly 14b. The additional retractors are mounted and used to retract the ribs to an opening O large enough in chest cavity C that is defined to provide access to the heart. Although three retractors are shown, it is contemplated that a smaller number or a larger number of retractors could be used, and these retractors may be mounted at any position along the base 12 to perform their function. For example, the sternum and the fourth and fifth ribs can be separated from each other to create a window. Alternatively, the fourth and fifth ribs are cut from the sternum and extended to create a larger window. Alternatively, a fifth rib can be cut, and the sternum, fourth, and sixth ribs are separated.

The base 12 is held at least partially in position above the tension intervention position created by retracting the ribs by the retractor blades 18. Internal tissue structures can be immobilized using sutures that pass through attachment points 24a, 24b, 24c, and 24d.

Turning now to fig. 13, heart manipulator 64 is mounted to base 12 to manipulate position H of the heart to facilitate surgery. With reference to fig. 14, the heart manipulator 64 was positioned in the chest cavity adjacent to the H position of the heart. Frame 66 and mounting bar 76 can be lowered and secured by adjusting screw 80 so that horizontal portion 72 and curved end portion 74 are positioned slightly below heart position H. This is illustrated in fig. 15, the heart manipulator 64 is displaced radially inward and against the heart position H by loosening the adjusting screw 84 and sliding the mounting bar 92 in the direction of the arrow. When enough pressure is placed on the heart to substantially fix its position, the heart manipulator 64 is secured by tightening the set screw 84.

With the heart manipulated to the desired position, fig. 16 illustrates the mounting of the heart stabilizer instrument 100 to the base 12. This is illustrated in FIG. 17, the heart stabilizer instrument 100 was positioned above the H position of the heart and more particu7

ES 2 193 293 T3 larly, above the coronary artery A. Radial positioning of instrument 100 is effected by movement relative to support bracket 78 relative to mounting assembly 82.

As illustrated in FIG. 18, frame 102 and mounting bar 110 are lower relative to support bracket 78 so frame 102 applies direct pressure to position H of the heart. Protrusions 108a and 108b localize this pressure to substantially limit blood flow from coronary artery A and 104a and 104b reduce movement of the cardiac muscle surface to facilitate surgery. Heart movement is limited by virtue of the foot pressure and the non-slip texture of the feet 104a and 104b. The position of the instrument 100 may be locked relative to the base as discussed in detail below.

Turning now to figs. 19-33, another preferred embodiment of the surgical retractor is described at reference number 200. Instrument 200 operates substantially as described above in relation to instrument 10, with the differences described below. In particular, fig. 19 illustrates surgical retractor 200 having a base 212 and retractor blade assembly 214, including mounting bracket 216, retractor blade 218, and retractor knob 220. The arrangement of the retraction knob 220 allows the surgeon to achieve additional mechanical advantage in retracting a rib.

Base 212 includes suture mounting portions 224a, 224b, 224c, and 224d to secure base 212 contiguous to the surgical position. Base 212 further includes beveled internal surface 228 with flange 230 and upper surface 232 in which a series of cylindrical recesses or apertures 240 is defined.

They are still illustrated in fig. 20, mounting bracket 216 includes sleeve 242 defining channel 244 with the side open for sliding reception of retractor blade 218. Latch element 246 has a series of ratchet teeth 248 configured to engage with ratchet teeth 258 on retractor blade 218 when blade 218 is slidably inserted into channel 244.

Retraction knob 220 is rotatably positioned in opening 236 in mounting bracket 216. With reference to fig. 20 together with fig. 21, retraction knob 220 includes a gear pinion 260 that cooperates with output rack 262 disposed on retractor blade 218. As will be described further below, rotation of knob 220 provides additional mechanical advantage in cooperation with one-way ratchet mechanism 23 to retract and / or advance retractor blade 218.

They will continue to be illustrated in Figs. 22-23, the retractor blade assembly 214 is mounted to the base 212 in a simple one-handed movement. The mounting bracket 216 includes the pin 264 on a lower portion of the same dimension as to be received in one of the cylindrical recesses 240 in the base portion 212. The length of pin 264 is preferably substantially equivalent to the depth of recess 240 to provide stability for mounting bracket 216. In addition, the internal cradle-shaped portion 266 of the mounting bracket 216 cooperates with the internal beveled surface 228 of the base 212 to facilitate positioning and provide resistance against tipping of the retractor blade 218. Mounting bracket 216 is further secured in position by lug 270 which includes a boss 272 that engages outer edge 274 of base 212. They are further illustrated in FIG. 23, the removal and placement of the mounting bracket 216 is effected by the deflection tab 272 of the lug 270 beyond the outer edge 274. Tab 220 includes rigid lever arm 276 which facilitates such deflection of tab 270.

Returning to figs. 24-26, the interaction of retractor blade 218 with respect to mounting bracket 216 is illustrated. The ratchet assembly 223, which includes the latch 246 and inclined teeth 258, functions substantially as described above with respect to FIG. 5, and allows retractor blade 218 to progressively radially outward while preventing radially inward movement. Initially, assist bands 22 (see FIG. 19) are used by the surgeon to retract a rib. The retraction blade 218 is moved radially outward as far as possible given the applied resistance of the surgeon. Subsequently, the additional retraction force can be applied to the rib by turning the retraction knob 220. Gear pinion 260 disposed on knob 220 engages rack 262 on retraction blade 218 and provides additional leverage to the surgeon. They are still illustrated in fig. 25, latch 246 is normally offset against retraction blade 218 such that ratchet teeth 258 on blade 218 and ratchet teeth 248 on latch 246 engage to prevent radially inward movement. It should be appreciated that the knob 220 is optionally removable so that it can be used to retract each of the retractor blades 218.

Fig. 26 illustrates that latch 246 can be rotated away from retraction blade 218 by pivot lever 262 to disengage teeth 258 and 248. Unlimited radial movement of retraction blade 218 is thus facilitated.

Figs. 27-28 illustrate another embodiment of a heart manipulator instrument designated by reference numeral 300. The heart manipulator 300 is used to manipulate the position of the heart and operate substantially as described above in relation to the heart manipulator 64, with the differences described below. In particular, the heart manipulator 300 includes the frame element 302, formed in a modified "U" configuration having a vertical portion in which the bars are parallel, including exactly spaced mounting portions 304a and 304b, plus mesh. widely spaced supporting portions 306a and 306b, and a portion

ES 2 193 293 T3

308 curved that extends horizontally. The mesh supporting the portions 306a and 306b and the horizontally extending portion 308 support a mesh surface 310 between them. The mounting portions 304a and 304b are snap-fit ​​within the perforations, formed in the support bracket 320. It is contemplated that elements 304a and 304b may be slidable with respect to clamp 320 and secured with set screws (not shown). Radial positioning of support bracket 320 is achieved by slidable mounting of support bracket 320 on mounting bracket 322. Set screw 324 is used to ensure radial positioning of the heart manipulator 300. Elongated slot 330 allows movement of support bracket 320 relative to set screw 324 and mounting bracket 322.

Turning now to fig. 28, the mounting bracket 322 is configured to mount on the base 212 substantially as described with respect to the mounting bracket 216 in FIGS. 22-23. Pin 364 of clamp 322 is received in one of the openings 240 in base 212. Lug 370 includes flange 372 that is removably coupled to outer edge 274 of base 212 and disengaged by lever arm 376 . Support bracket 320 is slidably mounted on mounting bracket 322 so that a portion of slot 330 aligns above threaded hole 332. Set screw 324 extends through slot 330 into bore 332 and includes collar 334 which supports an upper surface of support bracket 320 to secure against radial movement.

Figs. 29-32 illustrate a heart stabilizer instrument 350 following another preferred embodiment of the present disclosure. With reference to fig. 29, the heart stabilizer instrument 350 includes the frame 102 and the mounting bar 110. The frame 102 includes the legs 104a and 104b and the cross bars 106a and 106b which substantially have the projections 108a and 108b as described above with respect to fig. 10. Mounting bar 110 is slidably received in a hole in support bracket 352 and is secured relative thereto by adjusting screw 354. Support bracket 352 is slidable relative to mounting bracket 356.

They will continue to be illustrated in Figs. 30-31, the mounting bracket 356 is removably mounted on the base portion 212 substantially as described with respect to the mounting bracket 216 in FIGS. 22-23. The pin 358 is received in one of the cylindrical recesses or openings 240 in the base 212. The lug 360 includes the flange 362 for removably engaging the outer edge 274 of the perforation 212. The flange 362 is disengaged by actuating the arm 364 of the lever. With reference to fig. 32 together with figs. 30, 31, the support bracket 352 includes a pair of vertical walls 364a and 364b and a pair of horizontal walls 366a and 366b that rest on an upper surface of the mounting bracket 356. A lever mounting rod 368 extends upwardly from the mounting bracket 356 between the horizontal walls 366a and 366b. A pair of hinge pins 370a and 370b extend from rod 368 and are received in a key portion 372 of lever arm 374. The horizontal walls 366a, 366b of the support bracket 352 are disposed between the mounting bracket 356 and the key portion 372 of the lever arm 374.

Continuing with reference to Figs. 3031, key portion 372 is a substantially circular or elastic cross section in lateral cross section and is eccentrically mounted to hinge pins 370a and 370b. They are still illustrated in fig. 30, when the lever arm 374 is in a released position, the key portion 372 is spaced from the horizontal walls 366a and 366b and thereby allows unlimited radial movement of the support bracket 352. They are still illustrated in fig. 31, the pivotal movement of the lever arm 374 causes the portion 372 to apply a compressive force on the horizontal walls 366a and 366b on the top of the mounting bracket 356 to thereby secure the radial position of the mounting bracket 352. bracket relative to mounting bracket 356.

Returning to fig. 33, the operation of the surgical retractor 200 in conjunction with the heart manipulator and the heart stabilizing instrument proceeds substantially as described with respect to FIGS. 11-18. As seen above, the retractor blade assembly 214 mounting clamp 216a is positioned on the base 212 by actuation of the lever arm 276a (not shown). The heart manipulator 200 and the heart stabilizer instrument 350 are mounted to the base 212 in a substantially identical manner as described above. The surgical procedure is performed substantially as described above. Ribs R1, R2, and R3 are retracted by pulling the assist band 22 and by turning the retract knob 220. The heart position H is stabilized by the heart manipulator 300. The heart stabilizing instrument 350 is positioned and folded over the position H of the heart to apply pressure to the coronary artery and thereby substantially reduce the movement (movement) of the heart within the legs. The instrument 350 can be locked relative to the base. At this time, other surgical procedures may be performed, such as coronary bypass or valve surgery.

Turning now to figs. 34-52, another embodiment of the surgical retractor is described with reference number 400. Instrument 400 operates substantially as described relative to instrument 200, with the differences noted below. In particular, fig. 3. 4 illustrates a surgical retractor 400 having a base 412 and a retractor blade assembly 414, which includes the mounting bracket 416, retractor blade 418, and retractor knob 420. The arrangement of the retraction knob 420 allows the

ES 2 surgeon to achieve the additional mechaonic advantage by retracting a rib.

Base 412 includes suture mounting portions 424 to immobilize suture of internal tissue structures. Base 412 further includes beveled inner surface 428 with outer flange or edge 434. A channel or groove 436 is formed in upper surface 432. The outer periphery 438 of the base 412 includes a series of teeth 440 formed therein.

This is illustrated in fig. 35, mounting bracket 416 includes housing 442 and mounting plate 444 that are connected and allow retractor blade 418 to slide into channel 446 defined on a lower surface of housing 442.

Retractor blade 418 includes body portion 448 and rib engaging portion 450. Body portion 448 defines a T-handle 452 configured to be grasped by the surgeon to slide retractor blade 418 into channel 446. Body portion 448 defines a rack gear 454 and a series of inclined ratchet teeth 456 . Preferably, such gear 454 and ratchet teeth 456 are respectively disposed along elongated channel 458 defined within body portion 448.

Ratchet teeth 456 are releasably engaged by latch 460. Mounting plate 444 defines first channel 462 and second channel 464 for receiving latch 460. Preferably, latch 460 is an elastic member having a swivel configuration. U-shaped including a crown portion 466, the first leg 468 defining the cut portion 470, and the second leg 472. Second leg 472 was securely retained within second channel 464 which has an angled configuration. The junction of second leg 472 and crown 466 acted as a hinge or pivot so that first leg 468 slid into first channel 462. Hitch 460 was normally offset at this junction from second leg 472 and crown 466 so that the first leg 468 was partially disposed in the first channel 462. Crown 466 may be pressed by the user toward mounting plate 444 against normal deviation to further slide first leg 468 along first channel 462. Retractor blade 418 is positioned adjacent mounting plate 444, and latch 460 was positioned on top of blade 418 so that portion 470 cut from first leg 468 straddles a blade portion 418 contiguous with ratchet teeth 456. (Vóease, fig. 38). As described below, the latch 460 is normally deflected so that the first leg 468 is in engagement with one of the ratchet teeth 456. Latch 460 and ratchet teeth 456 together define a one-way ratchet mechanism 474.

Rack gear 454 was engaged by gear pin 476 formed on retract knob 310, which was positioned in aperture 478 defined in housing 442. As described below, turning of retract knob 420 provides the advantage

293 T3 18 additional mechanics when used in conjunction with ratchet mechanism 474 to retract and / or advance retractor blade 418.

The rib coupling portion 450 is connected to the body portion 448 with a dovetail joint and secured thereto with pins 480a and 480b. Alternatively, the retractor blade 418 can be constructed in one piece. The rib engaging portion 450 includes a horizontal portion 482, the angularly dependent portion 484, and the tip portion 486. The angularly dependent portion 484 forms an acute angle with the horizontal portion 482 to firmly engage the rib. Rib bracing or flange 488 is formed on the exterior of the rib coupling portion 450 to provide additional strength and resist flexing.

Referring to fig. 35 together with figs. 36-37, mounting plate 444 includes gear 490 on a forward portion thereof for engaging peripheral gear teeth 440 on base 412 (See FIG. 34).

This is illustrated in fig. 36, the base 412 is positioned in the interventional position on the patient's chest. The rib coupling portion 450 is positioned adjacent the R rib so that the angularly dependent portion 484 and the tip portion 486 at least partially surround the R rib. The housing 442 has a flat lower portion and is positioned over the rib. upper surface 432 of base 412.

Fig. 37 illustrates the simultaneous mounting of mounting bracket 416 to base 412 and retraction of rib R toward base 412 as indicated by arrows. Retractor blade 418 moves radially outward relative to base 412 as rib engaging portion 450 engages rib R. Mounting plate 444 was spaced from the lower portion of housing 442 to allow mounting plate 444 to slide under the outer edge 434 of base 412, and to allow teeth 490 to engage teeth 440 on base 412. The mounting bracket 416 is secured on the base 412 by the compressive force created between the rib coupling portion 450 against the R rib and the mounting plate 444 against the outer edge 434 of the base 412. Removal of retractor blade 418 from rib R occurs by sliding retractor blade 418 radially inward, thereby releasing compression sufficiently to allow mounting plate 444 to be released from outer edge 434.

The one-way ratcheting mechanism 474 allows the retractor blade 418 to be progressively moved in one direction, ie radially outward to retract a rib, while resisting movement in an opposite direction, ie radially inward. Fig. 38 illustrates latch 460 normally offset such that first leg 468 is in engagement with ratchet teeth 456. It is shown in fig. 39, the inclined portions 490 of the teeth 456 allow the blade to

ES 2 193 293 T3

418 of the retractor is progressively moved in a radially outward motion as transverse slopes 492 of teeth 456 inhibit radially inward motion to hold retractor blade 418 and rib in position. As described above with respect to retractor 200, additional retraction force can be applied to the rib by turning retraction knob 420. Gear pinion 476 disposed on retraction knob 420 engages rack 454 on retraction blade 418 to provide additional leverage to the surgeon. After the rib is retracted to create sufficient access for the surgeon, the turning knob 420 can be removed from the opening 478 in the housing 442 (see FIG. 35) and thereby provides greater visibility and access for the surgeon.

The latch 460 can be moved against its normal deviation by pressing the ring gear 466 toward the mounting plate 444, which causes the first leg 468 to disengage from the ratchet teeth 456 as shown in FIG. 40. The cut portion 470 is then aligned such that sheet 418 can slide through it so that unlimited radial movement of retraction sheet 418 is allowed.

Figs. 41-49 illustrate a heart stabilizer instrument 500 according to another preferred embodiment of the present disclosure. With reference to fig. 41, the heart stabilizer instrument 500 includes the frame 502, the articulation arm 504, and the mounting assembly 506. Articulating arm 504 is configured to allow frame 502 to be positioned in the precise position and orientation relative to the patient's heart. Mounting assembly 506 secures articulation arm 504 and frame 502 in a fixed configuration, as described further below.

Frame 502 was configured to contact the heart and apply pressure to the heart without touching the coronary artery. Frame 502 includes a pair of legs 508a and 508b, each having teeth 510 for atraumatic contact with the heart. Frame 502 was mounted to mounting frame 512 by pin 514. The distal end of cable 516 is mounted to frame 502, and passes into mounting frame 512 at opening 513.

Articulating arm 504 consists of a variety of joining elements 518a, 518b, 518c, 518d, each of which has a hemispherical convex distal portion 520, including cylindrical body portion 522, peripheral step 523, and proximal end 524. concave. The perforation 526 extends longitudinally through each joint 518 from the convex distal portion 520 to the concave proximal end 524. The connecting elements 518 are aligned so that the convex distal portion 520 is received at the concave proximal end 524 in a type of spherical connection to allow a wide range of pivotal movement between the adjacent connecting elements 518. The connecting elements 518 are concatenated by the cable 516 that passes through each perforation 526, and the most distal connecting element 518a concatenates the adjoining frame assembly 512. The articulating arm 504 can be used to mount a light cable to illuminate the surgical position, a suction and / or irrigation device, and a blowing device to disperse blood or any other instrument to facilitate surgery.

Mounting assembly 506 is mounted adjacent more proximal to joint element 518d and includes mounting flange element 530, mounting base 532, lever element housing 534, and lever element 536. This is shown in Fig. fig. 42B, mounting base 532 has a flat bottom surface 538 for resting on top surface 432 of base 412 and a protrusion or pin 540 configured and sized to be received in flange 436 of base 412. Continuing reference to fig. 42, the mounting flange element 530 and the lever element housing 534 are slidably mounted with respect to the mounting base 532 and are normally deflected into a configuration that extends away from the mounting base 532 by the springs. 542 and 544, respectively. The mounting flange element 530 has a flange 546 to engage the inner edge 430 of the base 412. The lever element housing 534 has a flange 548 for engaging the outer edge 434 of the base 412.

The lever element 536 includes a cylindrical mounting portion 550 and the lever element arm 552. The cylindrical mounting portion 550 was configured to be received within the cylindrical recess 554 defined within the lever element housing 534 and to be movably pivotally mounted therein. Cable 516 extends through attachment elements 518 and through mounting flange element 530, spring 542, mounting base 532, spring 544, and into cylindrical recess 554 of lever element housing 534. . The distal end portion of cable 516 was hinged to lever element 536 by pin 556. This is illustrated in FIG. 42A, the cylindrical mounting portion 550 defines a recess 558 in the bow or biscuit section laterally offset to define an "over-center" type locking mechanism, as described further below.

This is illustrated in fig. 43, the heart stabilizer instrument 500 is configured so that the lead 516 extends through the instrument 500 from the frame 502 to the lever element 536. The hole 526 in each element 518 has a progressive fine-tuning diameter that is larger larger than convex distal portion 520 and narrower than contiguous concave proximal portion 524. This configuration allows articulation in relation to the joining elements 518 as the cable 516 extends through it.

Figs. 44-46 illustrate heart stabilizer instrument 500 with lead 516 in a relaxed, non-stress configuration. This is illustrated in fig. 44, instrument 500 was positioned on base 412 so that pin 540 is disposed in groove 436, and

The mounting flange element 530 and the lever element housing 534 extend outward enough to allow the flanges 546 and 548 to go beyond the inner edge 430 and the outer edge 434, respectively.

This is illustrated in fig. 45, the lever element 536 was disposed in the lever element housing 534 in an unlocked configuration so that the lever element arm 552 and the arm 535 extend apart. The eccentrically mounted pin 556 is arranged so that the cable 516 is slack. Fig. 46 illustrates that cable 516 loosely disposed in conical perforations 526 of link element 518 allow articulation of adjacent link elements 518.

Figs. 47-49 illustrate instrument 500 with lead 516 in a tensioned configuration. This is represented in fig. 47, the lever element 536 pivots relative to the lever element housing 534 so that the lever element arm 552 approximates with the fixed arm 535. Simultaneously, the distal end of lead 516 connected to pin 556 moves into an "over-centered" position, thereby stressing lead 516 and locking position surgical instrument 500. The surgeon is allowed to perform other procedures without keeping pressure on the heart.

Another embodiment of the heart stabilizer instrument is illustrated in FIG. 50 and is described with reference number 600. Instrument 600 is constructed and operates substantially as described above relative to instrument 500, with the differences described below. Heart stabilizer instrument 600 includes frame 502, articulating arm 606, and mounting assembly 506. Articulating arm 606 allows frame 502 to be positioned at the proper height and angle with respect to the heart. The link arm 606 was comprised of link members 608 and 610, having a series of concatenations of teeth to positively couple adjoining link members together.

This is illustrated in figs. 50A and 50B, link elements 608 are positioned adjacent to link element 610. The connecting element 608 generally has a cylindrical body portion 612. A pair of concave gear rows 614a and 614b are disposed on an axial end 616 of link member 608. A second pair of concave gear rows 618a and 618b are disposed on the second axial end 620 of link member 608. Gear 614a and 614b is disposed 90 ° out of alignment with gear 616a and 616b. Longitudinal bore 622 extends through link member 608 from axial end 616 to axial end 620 between each pair of gears.

The link element 610 has a body portion 624, to which a first pair of gears 626a and 626b having a convex profile and a second pair of convex gears 628a and 628b are attached to opposite sides thereof. The first pair of gears 626a and 626b is set to 90^° out of alignment with the second pair of gears 628a and 628b. A longitudinal bore (not shown) extends through body portion 624 and between each pair of gears 626a and 626b and gears 628a and 628b.

Link element 610 was positioned adjacent to link element 608. Cable 516 extends through longitudinal perforation 622 in connecting element 608 and longitudinal perforation (not shown) in connecting element 610. When lever element 552 is moved to the "over-centering" position (see FIG. 47), thereby tightening cable 516, link elements 608 and 610 are brought together so that gears 626a, 626b or 628a Convex, 628b of link element 610 engage the concave gear 614a, 614b and 618a, 618b of link element 608.

Fig. 51 illustrates another preferred embodiment of the surgical retractor according to the present description. This surgical retractor, generally designated 700, includes a base 702 and one or more of the instruments shown including: retractor blade assembly 704; Retractor Blade Assembly with Suction / Irrigation Frame 706; light retractor blade assembly 708; heart manipulator 710; and instrument 712 stabilizer of the heart. These instruments are discussed in more detail below.

Base 702 is configured in accordance with the other bases discussed above and provides a low profile mounting for the instrumentation used in the surgical procedure being performed. A variety of suture assemblies 714 are defined in an upper peripheral portion 716 of base 702 and serve as anchor and attachment points for suture ends 718 from the surgical field. Referring to figs. 52 and 53, the suture assemblies 714 include a tightly wound coil spring 720 positioned in a cavity 722 with the coils oriented substantially transverse to the radians of the base 702. A triangular ramp 724 is formed on a radial inner surface of the suture mount 714. A groove 726 is formed on the outer radial surface of suture assembly 714 beyond the coil of spring 720 and in axial alignment with ramp 724. This ramp / slot configuration facilitates easy access to the position of the suture end 718 on the coil of spring 720.

The balance of the base 702 was configured in substantially the same manner as the bases previously described and includes the teeth 728, the beveled inner peripheral surface 730 and the inner flange 732.

The surgical retractor blade assembly with blower frame 706 is shown in FIGS. 54-56. Frame 706 can also be used for suction or irrigation to remove fluids from the surgical position. Retractor blade assembly 704 is similar to retractor blade assembly 414 discussed in detail above. Retractor Blade Assembly 704 includes Mounting Bracket 734, Retractor Blade

ES 2

736 retractor and removable retraction knob 738.

This is illustrated in fig. 56, mounting bracket 734 includes housing 740 and mounting plate 742 that together form a channel through which retractor blade 736 is alternatively slidable.

Retractor blade 736 includes body portion 744 and rib engaging portion 746. Body portion 744 defines a flanged grip handle 748 configured to be grasped by the surgeon to slide retractor blade 736 relative to mounting bracket 734. The body portion 744 further defines the longitudinally oriented rack gear 750 and a series of inclined teeth 752. Rack gear 750 and teeth 752 are disposed along elongated cavity 754 defined in body portion 744.

Teeth 752 are releasably engaged by latch 756 mounted to housing 740. The operation of this latch 756 is substantially the same as latch 460 described above in connection with retractor blade assembly 414.

The rib engaging portion 746 extends distally from the body portion 744 and includes an angularly dependent portion that includes one or more reinforcing ribs 758 to provide additional strength.

Blow structure 760 was integrally formed within the retractor blade assembly shown in FIGS. 54-56. This structure includes a tube 762 that extends the length of the retractor blade assembly and exits the ring engaging portion 764 to access the surgical position. A connecting tube 764 is positioned at a proximal end of tube 762 and is connected to an appropriate source such as a vacuum or pressure source (not shown) depending on whether frame 760 is used for blowing, irrigation, or suction. Molded wire 766 was positioned adjacent tube 762 and is deformable to configure tube 762 in a desired angular orientation. Alternatively, tube 762 may be remotely oriented or rotated from body portion 744 using known structure.

Figs. 57 and 58 illustrate a retractor blade assembly with an integral lumen shown generally at 708. The basic configuration and operation of this assembly is identical to that described above with the difference that lumen 768 has been replaced by a suction structure. / irrigated. A wide variety of lights can be housed. In the illustrated embodiment, a fiber optic package is disposed within a longitudinally extending protective envelope 770. An optic fiber splice 772 is positioned adjacent the proximal end of the assembly and can be connected to an appropriate light source (not shown). It is envisioned that a wide variety of divergent and coincident lenses can be used to adapt the light as required by the surgeon.

The one-way ratcheting mechanism used in these embodiments of the blade assembly of the

293 T3 24 retractor is shown in figs. 58A-C. This ratchet mechanism operates in the same manner as the ratchet mechanism discussed above with respect to FIGS. 39-40. Notice that it is shown in fig. 58B, retractor blade 736 can be pulled in the direction of the arrow to retract bone and tissue. However, to move the retractor blade 736 in the opposite direction, ie the direction of the arrow in FIG. 58C, latch 756 must be pressed.

Figs. 59-63 illustrate another embodiment of a heart stabilizer instrument 800 according to the present description. The heart stabilizer instrument 800 is substantially the same as the heart stabilizer instrument 500 discussed in detail above. The instrument includes frame 802, articulating arm 804, and mounting assembly 806.

Frame 802 was configured in the same manner as frame 502 and includes a pair of legs 808a and 808b, each having teeth 810 for atraumatic contact with the surface of the heart.

Frame 802 is connected to articulation arm 804 by connector 812. A positioning tab 814 is formed on connector 812 and facilitates positioning of frame 802 on the surface of the heart by manually grasping boss 814 or attaching a gripping instrument. (not shown) to tab 814 and positioning the frame in a desired position.

Mounting assembly 806 was mounted adjacent to hinge arm 804 and includes mounting flange element 830, mounting base 832, lever element housing 834, and lever element 836. It is shown in FIGS. 61-62, the mounting base 832 has a flat bottom surface 838 to rest on top of the base 702. Mounting tab member 830 and lever member housing 834 are slidably mounted relative to mounting base 832. The mounting flange element 830 has the flange 846 to mate with the inner edge of the base 702. The lever element housing 834 has the flange 848 to mate the outer edge of the base 702.

The lever element 836 includes the barrel mounting pins 850 and the finger handle 852. The cylindrical mounting pins 850 are configured to be received within the recess 854 defined within the housing 834 of the lever element and to be movable therein pivotally mounted. Cable 816 extends through articulating arm 804. The distal end portion of cable 816 was hinged to lever element 836 by clips 856. Biasing spring 858 was positioned in lever element housing 834 and serves to normally bias mounting flange element 830 distally relative to lever element housing 834.

The crank spring element 860 is integrally formed on the lever element 836 and configured to interact operatively with the protrusion 862 formed at

The cavity 854 of the lever element housing 834, since the lever element 836 moves in and out of approximation with the lever element housing 834.

Figs. 64-66 illustrate heart stabilizer instrument 800 with wire 816 in a no-effort release configuration. They are still illustrated in fig. 64, the instrument 800 is positioned on the base 702 with the mounting flange element 830 and the lever element housing 834 are extended sufficiently out of the way to allow the tabs 846 and 848 to go beyond the inner edge 830 and the edge 833. external, respectively.

The lever element 836 is disposed in the lever element housing 834 in an unlocked configuration, so that the finger handle 851 and the finger handle 853 extend apart. Cable 816 is slack to allow manipulation of link arm 804.

Fig. 65 illustrates position relative to ratchet spring 860 relative to boss 862 within housing 834 of the lever element.

Figs. 66-67 illustrate instrument 800 with lead 816 in a first tensioned, immobilized, non-stress configuration. They are still represented in fig. 66, lever element 836 is pivotally mounted relative to lever element housing 834 so that finger handle 852 moves toward finger handle 853. The distal end of cable 816 is stressed to approximate mounting flange element 832 and mounting base 832 which locks surgical instrument 500 in position on base 702. FIG. 67 shows the progression of lever element 836 relative to lever element housing 834 in the non-stress, locking configuration. In this position, the link arm 804 can still be manipulated.

The final, stressed and locked configuration is shown in FIGS. 68-69. In this configuration, finger handles 852 and 853 have been simultaneously moved in close approximation, further stressing cable 816 to maintain a preset configuration desired by the surgeon, for example locking articulation arm 804 in position. Once locked within this stressed, locked configuration, the surgeon is allowed to perform other procedures without manually applying pressure on the heart via the heart stabilizing instrument.

Another preferred embodiment of the heart manipulator 900 following the present description is shown in FIG. 70. The heart manipulator includes a manipulator portion 902, an articulation arm 904, and a mounting assembly 906. The structure and operation of the mounting assembly 906 and the link arm 904 are substantially the same as in the heart stabilizer 800 discussed above.

The manipulator portion 902 includes a frame 908 that supports the mesh 910 and is preferably provided with a curved section contiguous to the distal end thereof to aid in manipulation of the heart.

Figs. 71A and 71B illustrate a rib elevator 980 that can be mounted to the bases described above to allow the patient's rib to be elevated. Rib riser 980 includes a set of tabs 982 that engage internal flange 732 to attach to the base.

The reinforcing ribs 984a, 984b formed on the rear surface 981, increase the rigidity of the rib riser 980 and also provide a gripping surface for the user to flex the rib riser 980 to facilitate attachment and removal from the base. The teeth 986 function in the same way as the teeth 728 of the base 702, that is, to mount one or more of the sets 704, 706, 708 of the retractor. It will still be appreciated, when the rib elevator 980 is mounted to the base 702, the assembled retractor assembly will be angled toward the rib so that a retraction force will be applied to the rib partially in an upward direction. This is a disadvantage, for example, for IMA access and cut-off. The rib elevator 980 can subsequently be removed and a retractor assembly mounted directly to the base 702 in the manner described above.

Figs. 71 and 72 illustrate two preferred case configurations according to the present description. Case 950 (fig. 71) is formed to house there a basic blade retractor assembly 704, a suction retractor blade assembly, irrigant 706, a lighted blade retractor assembly 708, a base 702, a knob 738 retraction device, a heart stabilizer instrument 800 and / or a heart manipulator 900. Cavities 952, 954, 956, 958, and 960 are formed in cover 962 to house these elements. The cover 962 can be attached to the bottom 964 by adhesive, ultrasound welding, heating, etc.

The 970 case is substantially similar to the 950 case except that the heart stabilizer instrument 800 and the heart handler 900 are excluded. Cover 972 includes cavities 952, 958, and 960 to house retractors 704, 706, 708, base 702, and retraction knob 738. Cover 972 and bottom 974 may be attached in the same manner as described for case 950 above.

The rib riser 980 can optionally be included in the kits.

It will be understood that various modifications can be made to the embodiments shown herein. Therefore, the above description should not be construed as limiting, but merely as examples of the preferred embodiments. The claims that follow identify embodiments additional to those described in detail below.