Surgical retractor

IS 2 197 263 T3

DESCRIPTION

Surgical retractor.

Background

1. Technical field

The subject description refers to minimally invasive surgical procedures and apparatus and, more particularly, to an instrument and method for performing surgery associated with the thoracic cavity.

two. Background of Related Art

Diagnosis and treatment of coronary heart disease and related conditions typically requires access to the heart, blood vessels, and associated tissues. Such procedures include extracorporeal circulation (cardiopulmonary bypass), 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, called a median sternotomy, requires a saw or other sharp instrument to cut through the sternum and allow the two opposing halves of the rib cage to separate. US Patent No. 5,025,779 issued to Bugge describes a retractor that is designed to attach to opposing halves of the sternum and separate the chest cavity. The large opening created by this technique allows the surgeon to directly view the surgical site and perform procedures on the affected organs. However, such procedures involving large incisions and substantial displacement of the rib cage are often traumatic for the patient, carrying significant risks. The recovery period can be long and often painful. In addition, patients for whom coronary surgery is indicated may need to forgo such surgery because of the risks involved in gaining access to the heart.

US Patent No. 5,503,617 issued to Jako describes a retractor configured for the surgeon to hold for use in vascular or cardiac surgery to separate and hold the ribs apart, to allow access to the heart or lung. through an operative opening. The spacer includes a rigid frame and a translation frame slidably connected to the rigid frame. Lower and upper blades are rotatably mounted to the rigid frame and the translation frame, respectively.

After gaining access to the chest cavity, surgery can be performed on the heart. Such procedures normally require the heartbeat to stop 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. As described in WO 95/15715 to Sterman et al., For example, cardioplegic fluid is infused into the myocardium through the coronary arteries via a catheter inserted into the ascending aorta. Alternatively, the cardioplegic fluid is infused through the coronary veins in a retrograde manner via a catheter placed in the internal jugular vein accessed in 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 catheters and guide wires should be closely monitored to determine proper placement. In addition, the introduction of catheters produces puncture wounds in the blood vessels that must be subsequently closed, and there is an increased risk of trauma to the inner walls of the vessels through which the catheters must pass .

Thus, there is a need for an apparatus and method that provides access to the thoracic cavity without causing considerable trauma to the patient. A procedure is needed to stabilize, at least locally, a predetermined area of ​​the surface of the heart that is relatively simple to carry out and incorporates instruments that are simple and reliable. In addition, there is a need for an apparatus and procedure that provides a stable framework to support additional instruments that can be used during these procedures.

WO 89/04 145 describes a separator apparatus including a separator sheet 14 having a malleable element 18 defining a perimeter of the sheet and an area of ​​the separator. A flexible element 16 is supported by the malleable element 18 and extends over the area of ​​the spacer.

Furthermore, US-A-3,965,890 discloses a surgical retractor comprising a frame on which a plurality of retractor arm mounting elements are mounted to allow movement along the frame, and the mounting elements carry the arms of the separator to allow movement of the arms transversely with respect to the frame, and the arms carry the foldable and extendable separator blades.

Furthermore, US-A-4,048,987 describes a surgical aid device for maintaining displaced material at a surgical site in its displaced position. The assistive device may be attached to a frame of the retractor attached relative to a surgical site. The assistive device further has a body part and a handle part which can be held by an assist or attached to the frame.

Finally, US-A-5,267,223 describes a generally U-shaped surgical instrument for separating and holding open the rib cage in open heart surgery. There is a stationary arm with a serrated cross bar attached to it. A movable arm similar in configuration to the stationary arm has a housing at one end that slides over the bore and can be angled open to force the sternum away. Summary

The present description refers to instruments and methods of surgery. A retractor is provided having a substantially flat base defining an opening to cover an operative site on a patient, and at least one spacer blade slidably mounted to the base.

The base is placed on the patient so that the opening thereof covers the operative site and the operative site is accessed percutaneously through the opening. The obstructing tissue is separated with one or more retractor blades to create an opening that provides access to perform the surgical procedure. A surgical instrument is provided that can be adjusted with the base and operated at the operative site. A procedure is carried out2

ES 2 197 263 T3 to surgery through the opening in the base with the surgical instrument.

It is an object of the present invention to provide access to a surgical site without causing considerable trauma to the patient. This object is solved by the features of claim 1.

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

A cardiac manipulator is described for use in conjunction with the spacer and mountable, removable, on the base. The cardiac manipulator aids in non-traumatic holding and positioning of the heart for easy access to the heart. In a preferred embodiment, the cardiac manipulator includes a curved structure that supports a mesh support.

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

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

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

These and other features of the surgical retractor and method for cardiac surgery will become readily apparent to those skilled in the art from the following detailed description of the preferred embodiments of the subject description. Brief description of the drawings

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

Figure 1 is a perspective view of one embodiment of a surgical retractor;

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

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

Figure 4 is an enlarged cross-sectional view taken along line 4-4 of Figure 1 of the base mounted separator blade assembly;

Figure 5 is an enlarged top view illustrating radially inward movement of the spacer blade relative to the base;

Figure 6 is an enlarged top view illustrating the pawl of the spacer blade in engagement with the detent member associated with the base;

Figure 7 is an enlarged top view illustrating the retainer member associated with the base removed from fit with the spacer blade assembly;

Figure 8 is a perspective view of one embodiment of a base-mounted cardiac manipulator;

Figure 9 is a perspective view of one embodiment of the base mounted cardiac manipulator;

Figure 10 is an enlarged perspective view of a base mounted heart stabilizer instrument;

Figure 11 is a reduced-scale top view of the portion of the base placed on the patient's chest;

Figure 12 is a top view, illustrating the retractor blade assemblies mounted to the base portion and separating the ribs from the patient; Figure 13 is a top view illustrating a cardiac manipulator adjacent to the patient's heart;

Figure 14 is an enlarged side view in cross section illustrating a cardiac manipulator mounted to the base and separated from the heart;

Figure 15 is an enlarged side view in cross section illustrating a cardiac manipulator in contact with the heart;

Figure 16 is a top view illustrating the heart stabilizer instrument of Figure 10 mounted on the base;

Figure 17 is a perspective view of the heart stabilizer instrument of Figure 10 mounted to the base and separated from the heart;

Figure 18 is a perspective view of the heart stabilizer instrument of Figure 10 in contact with the heart;

Figure 19 is a perspective view of one embodiment of a surgical retractor and base assembly;

Figure 20 is an enlarged perspective view with parts separated of the separator blade assembly;

Figure 21 is an enlarged perspective view from below of the separating knob, illustrating the differential pinion disposed thereon;

Figure 22 is an enlarged cross-sectional view of the base mounted spacer blade assembly;

Figure 23 is an enlarged cross-sectional view of the spacer blade assembly in the process of mounting to the base;

Figure 24 is an enlarged top view illustrating radially outward translation of the spacer blade;

Figure 25 is an enlarged top view of the retainer member associated with the base in engagement with the spacer blade;

Figure 26 is an enlarged top view illustrating the retainer removed from fit with the spacer blade;

ES 2 197 263 T3 Figure 27 is a perspective view of an embodiment of the cardiac manipulator;

Figure 28 is an enlarged cross-sectional view of the mounting assembly for the cardiac manipulator of Figure 27;

Figure 29 is a perspective view of one embodiment of the heart stabilizer instrument;

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

Figure 31 is an enlarged cross-sectional view of the heart stabilizer instrument mounting assembly of Figure 29 in a closed position;

Figure 32 is a cross-sectional view taken along line 32-32 of Figure 31 illustrating the mounting group;

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

Figure 34 is a perspective view of one embodiment of a surgical retractor;

Figure 35 is an exploded perspective view of a retractor blade assembly of the surgical retractor of Figure 34;

Figure 36 is an enlarged side cross-sectional view of the spacer blade assembly, illustrating placement adjacent to a rib and mounting of the spacer blade assembly to the base;

Figure 37 is an enlarged side cross-sectional view of the base mounted spacer blade assembly and in the process of spacing a rib;

Figure 38 is a perspective view, illustrating the retainer member and spacer blade in fit;

Figure 39 is an enlarged cross-sectional view taken along line 39-39 of Figure 37, illustrating the pawl on the spacer blade in engagement with the retainer member;

Figure 40 is an enlarged cross-sectional view illustrating the retainer member associated with the base removed from fit with the spacer blade;

Figure 41 is a perspective view of one embodiment of a heart stabilizer instrument mounted to the base of Figure 34;

Figure 42 is an exploded perspective view of the heart stabilizer instrument of Figure 41;

Figure 42A is a perspective view of the tilt member, illustrating the cable mounting configuration;

Figure 42B is a bottom perspective view of the heart stabilizer instrument of Figure 41;

Figure 43 is a cross-sectional side view of the heart stabilizer instrument of Figure 41;

Figure 44 is a partial cross-sectional side view of the heart stabilizer instrument in a non-closed configuration;

Figure 45 is an enlarged cross-sectional view of the tilt mechanism in a non-closed configuration;

Figure 46 is an enlarged cross-sectional view of a portion of the articulated arm, illustrating the cable in a loose configuration corresponding to the non-closed configuration of Figures 44-45;

Figure 47 is an enlarged cross-sectional view of the tilt mechanism in a closed configuration;

Figure 48 is a reduced-scale side view in partial cross-section of the heart stabilizer instrument in a closed configuration;

Figure 49 is an enlarged cross-sectional view of a portion of the articulated arm, illustrating the cable in a tensioned configuration, corresponding to the closed configuration of Figures 47-48; Figure 50 is a perspective view of a base mounted heart stabilizer instrument according to another embodiment of the present disclosure; Figure 50A is an enlarged perspective view of the attachment elements of the heart stabilizer instrument of Figure 50;

Figure 50B is an enlarged perspective view of the attachment elements of the heart stabilizer instrument of Figure 50;

Figure 51 is a perspective view of a surgical separation system according to another embodiment of the subject description, incorporating a variety of spacers, a cardiac manipulator and a heart stabilizer, all positioned on a base;

Figure 52 is a top view of the base of Figure 51 illustrating suture holders placed around it;

Figure 53 is an enlarged perspective view of the suture holders of Figure 52;

Figure 54 is a perspective view of one embodiment of a surgical retractor incorporating an integral blow-off structure;

Figure 55 is a reverse perspective view of the surgical retractor of Figure 54;

Figure 56 is an enlarged perspective view with the parts separated from the surgical retractor of Figure 54;

Figure 57 is a perspective view of one embodiment of a surgical retractor incorporating a lumen;

Figure 58 is a reverse perspective view of the surgical retractor of Figure 57;

Figure 58A is a partial cross-sectional top plan view of a surgical retractor mounted to the base of Figure 52;

Figure 58B is a partial cross-sectional top plan view of the surgical retractor of Figure 58A that is pulled proximally relative to the base;

Figure 58C is a partial cross-sectional top plan view of the surgical retractor of Figure 58A released from zipper engagement;

Figure 59 is a perspective view of another embodiment of a heart stabilizer instrument according to the subject description;

Figure 60 is an enlarged perspective view of a portion of the heart stabilizer instrument of Figure 59, illustrating a positioning flange formed thereon;

Figure 61 is an exploded perspective view of the heart stabilizer instrument of Figure 59;

Figure 62 is a perspective view of a mounting flange member of the heart stabilizer instrument of Figure 59;

Figure 63 is a perspective view of the movable handle of the heart stabilizer instrument of Figure 59;

Figure 64 is a partial cross-sectional top plan view of the heart stabilizer instrument of Figure 59, with the movable handle in the untensioned and unlocked position;

Figure 65 is a cross-sectional view taken along line 65-65 of Figure 64, illustrating the relative position of the handle spring member;

Figure 66 is a partial cross-sectional top plan view of the heart stabilizer instrument of Figure 59, with the movable handle in the untensioned and closed position;

Figure 67 is a cross-sectional view taken along line 67-67 of Figure 66, illustrating the relative position of the handle spring member;

Figure 68 is a partial cross-sectional top plan view of the heart stabilizer instrument of Figure 59, with a movable handle in the closed and tensioned position;

Figure 69 is a cross-sectional view taken along line 69-69 of Figure 68, illustrating the relative position of the handle spring member;

Figure 70 is a perspective view of another embodiment of a cardiac manipulator:

Figures 71A and 71B are front and rear perspective views of a rib elevator;

Figure 72 is a perspective view of a kit assembly having a base, three spacers, a separation handle, a cardiac manipulator, and a heart stabilizing instrument; and Figure 73 is a perspective view of a kit assembly having a base, a standoff handle, and three standoffs.

Detailed description of the preferred embodiments

The preferred embodiment of the apparatus described herein will be discussed in terms of procedures and apparatus for cardiac surgery. However, the subject description should not be limited to an apparatus for use in conjunction with such cardiac surgery, but may find application in surgery where access to the surgical site is achieved through a small incision and separation of the surgical site is desired. surrounding tissues and / or bones.

Referring now in detail to the drawings, in which like reference numerals identify similar or identical elements, a first embodiment of a surgical retractor is illustrated in Figure 1, and is generally designated by reference numeral 10. The spacer Surgical 10 has a base 12 and a retractor blade assembly 14, including mounting group 16 and retractor blade 18. As will be described later, the base 12 in this embodiment is configured to be positioned on the chest of a patient surrounding an incision. Retractor blade 18 includes hook 20 configured to non-traumatic fit to a rib. Strap 22 assists the surgeon in pulling retractor blade 18 radially outward and separating a rib therewith. A one-way ratchet assembly 23 on mounting group 16 holds separator blade 18 in position. Base 12 is also configured to receive surgical instruments for mounting thereon, as will be described later.

Base 12 preferably has a closed shape, such as an oval configuration as shown, or a circle, polygon, or the like. The base 12 is large enough in size to enclose a sufficient area to provide access to the operative site. The bottom 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 holders 24a 24b, 24c may be provided at various locations on base 12 to allow suturing to internal tissue structures, such as the pericardial sac. The outer periphery 26 of the base 12 includes a series of outwardly extending teeth 27 formed thereon to provide additional stability to the placement of the mounting group 16 and other instruments on the base 12. the base 12 also includes a beveled inner surface 28 with an inner flange 30 and a top surface 32. Base 12 has a lowered profile when placed on the body. The base 12 is rigidly supported by the pressure of the spacer blade assembly 14 on the ribs in three or four positions. Preferably, three spacer blade assemblies are disposed on base 12 120 ° apart. The separator blade assemblies can be arranged 90 ° apart.

Turning now to Figure 2, the mounting group 16 allows the separator blade assembly to be quickly and stably mounted to the base 12. The mounting group 16 includes the mounting bracket 34, the retaining block 36, and the spring. 38 retention. The clamping flange 40 on the mounting bracket 34 is configured to fit the internal flange 30 of the base 12 (Figures 3 and 4). The sleeve 42 forms a channel 44 with the side open to slidably receive the sheet 18 of the separator. The retainer 46 is formed on the mounting bracket 34 and has a series of gear teeth 48 that communicate with the open side of the channel 44 to mesh with the separator blade 18, as will be described later. The mounting bracket 34 defines a cavity 49 for mounting the retaining block 36 therein. The cavity 49 is partially defined by the external retaining wall 50 with the upper flange 51 and by the internal wall 52 having the opening 53. The retaining block 36 is radially slidable within the cavity 49 and is internally biased by the retaining spring 38, such that the gear teeth 54 on the retaining block 36 protrude through the opening 53, to engage with the teeth 27 provided on the periphery 26 of the base 12. Retaining block 36 also includes handle 56 that allows the surgeon to move retaining block 36 toward retaining wall 50 against deflection of retaining spring 38 in order to disengage teeth 54 from base 12.

Retractor blade 18 includes hook 20 curved on a distal end portion and slot 57 on a proximal end portion for receiving flexible assist strap 22 therethrough.

IS 2 197 263 T3

A series of ratchet teeth 58 are provided on one edge of spacer blade 18 and mesh with teeth 48 of retainer 46 when spacer blade 18 is disposed in channel 44 of mounting bracket 34.

As illustrated in Figures 3-4, mounting group 16 mounts to base 12 in simple one-handed operation. Figure 3 illustrates the retainer block 36 moved toward the retainer wall 50 versus normal deflection of the retainer spring 38. The handle 56 of the retaining block 36 facilitates the approach of the retaining wall 50 with the flange 51 of the retaining wall 50. The mounting group 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 gear teeth 54 are angled to allow for interlocking. arrangement of the cams on the outer flange 60. Figure 4 illustrates the mounting group 16 in the position with respect to the base 12, in which the retaining block 36 is released, which thereby returns inward towards the base 12 under the normal deflection of the spring 39. The gear teeth 54 pass under the outer flange 60 and mesh with the teeth 27 on the periphery 26 of the base 12.

Returning to Figures 5-7, the progression of the spacer blade 18 relative to the mounting bracket 34 is illustrated. Ratchet assembly 23 includes detent 46 on mounting bracket 34 and teeth 58 on spacer blade 18. The retainer 46 normally biases toward the separator blade 18. The teeth 48 of the retainer and the teeth 58 of the separator blade are configured with an inclined part and a straight part. This allows the separator blade 18 to move progressively in a radially outward direction, as indicated by the arrow "0" in Figure 5. As illustrated in Figure 6, radially inward movement is prevented. the separator blade 18 by the engagement of the retainer teeth 48 and the separator blade teeth 58 with the normal deviation of the retainer 46. The arrangement of the teeth, as shown in Figures 5-6, allows the separation of a rib or other body structures and prevents slippage or loss of the separation force exerted by the separator 18. As illustrated in FIG. 7, the separator blade 18 is allowed to move radially inward, as indicated by arrow "I," when the retainer tab 62 is rotated clockwise. clock, causing it to move from the separator blade 18 against its normal deviation by actuation of the tab 62. Unlimited movement of the separator blade 18 in the radially inward and radially outward directions is allowed when the tab 62 is moved to the position of Figure 7.

Figure 8 illustrates a cardiac manipulator 64 for use in conjunction with surgical retractor 10 and for mounting on base 12. Cardiac manipulator 64 includes curved frame 66 that supports mesh surface 68. Frame 66 and mesh surface 68 together form a contact surface with the heart for manipulation of the heart therewith. Preferably, frame 66 includes vertical portion 70, generally horizontally extending portion 72, and non-traumatic curved end portion 74, which provides a surface for adjustment and manipulation of the heart. Frame 66 is supported by mounting bar 76 which is slidably received in support bracket 78 for height adjustment. Set screw 80 secures mounting bar 76 relative to bracket 78 is supported. Radial positioning of support bracket 78 and cardiac manipulator 64 is achieved by slidably mounting support bracket 78 onto mounting group 82 which is mounted to base 12 in a manner substantially similar to group 16 mounting, described above with respect to Figures 3-4. Set screw 84 secures radial position of cardiac manipulator 64 relative to mounting group 82. More particularly, support bracket 78 has an elongated slot 79 formed therein that allows bracket 78 to slide radially with respect to set screw 84 and mounting group 82. As shown in Figure 14, the mounting group 82, like the mounting group 16, has a mounting bracket 83 that fits the inner flange 30 of the base 12, the retaining block 81, and the spring. 87 retention. The handle 89 of the retaining block 81 allows for adjustment and displacement of the mounting group 82 in the same manner as the mounting group 16 described above.

Returning to FIG. 9 of another embodiment, a cardiac manipulator 90 is shown. Curved frame 66 and mounting group 82 are substantially as previously described with respect to cardiac manipulator 64 in Figure 8. Mounting rod 92 supports frame 66 and has a curve 94 directed substantially to the right for insertion. slidably in the support bracket 96. Radial position of cardiac manipulator 90 is achieved by slidingly mounting rod 92 relative to support bracket 96 and secured thereto by set screw 98. Although adjustment of the height of the cardiac manipulator 90 is not provided, access to the operative site is improved by the one-piece design of the mounting bar 92.

Figure 10 illustrates a heart stabilizer instrument 100 configured to apply pressure to the coronary artery, to reduce blood flow in the artery to allow anastomosis to the coronary artery, and to reduce movement of the heart muscle between pins 104a, 104b. in order to allow the surgeon to perform cardiovascular surgery. Heart stabilizer instrument 100 is mounted to base 12 by mounting group 82, substantially as previously described. The heart stabilizing instrument 100 includes the frame 102 that supports the pins 104a and 104b and the cross bars 106a and 106b. Boss 108a is formed on cross bar 106a and boss 108b is formed on cross bar 106b. The protrusions 108a and 108b have a non-traumatic, convex contact surface with the heart and allow localized pressure to be exerted on the coronary artery when the frame 102 is compressed on the surface of the heart. Mounting bar 110 is slidably received in support bracket 78 and secured relative thereto by set screw 80. Radial placement of the heart stabilizer instrument 100 relative to mounting group 82 is ensured6

ES 2 197 263 T3 is provided by a coupling means, such as a set 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 thoracic cavity C access incision I. The base 12 is placed on the patient's chest with the opening covering the operative site. Incision I is made, exposing several R1, R2, and R3 ribs.

As illustrated in Figure 12, the spacer assemblies 14a, 14b, and 14c are mounted to the base 12 at various locations. Hook 20a is placed around a rib R1. Assist strap 22a is used to provide the surgeon with a grip to retract and separate rib R1 by pulling retractor blade 18 radially outward. A one-way ratchet assembly 23a holds the spacer blade 18, and consequently the rib R1, in position. Rib R2 is separated in a substantially identical manner by hook 20b on spacer assembly 14b. Additional spacers are used and mounted to separate the ribs until a sufficiently large opening is defined in the thoracic cavity C to provide access to the heart. Although three spacers are shown, it is contemplated that fewer or more spacers could be used, and these spacers can be mounted anywhere along the base 12 in order to perform their function. For example, the sternum and the fourth and fifth ribs can be separated to create an opening. Alternatively, the fourth and fifth ribs are cut away from the sternum to create a larger opening. Alternatively, a fifth rib can be cut and the sternum and the fourth and sixth ribs are separated.

The base 12 is held at least partially in position over the operative site by the tension created in the separation of the ribs by the blades 18 of the retractor. Internal tissue structures can be attached using sutures that pass through securing points 21a, 24b, 24c, and 24d.

Turning now to Figure 13, the cardiac manipulator 64 is mounted on the base 12 in order to manipulate the position of the heart H, to facilitate surgery. Referring to Figure 14, the cardiac manipulator 64 is positioned in the thoracic cavity adjacent to the heart H. The frame 66 and mounting bar 76 can be lowered and secured by the set screw 80 so that the horizontal portion 72 and curved end portion 74 are positioned slightly below heart H. As illustrated in FIG. 15, cardiac manipulator 64 is moved radially inward and against heart H by loosening set screw 84 and slidably mounting rod 92 in the direction of the arrow. When sufficient pressure is applied to the heart to substantially fix its position, the cardiac manipulator 64 is secured by tightening the fixation screw 84.

With the heart manipulated to the desired position, Figure 16 illustrates the mounting of the heart stabilizer instrument 100 to the base 12. As illustrated in Figure 17, the heart stabilizer instrument 100 is placed over the heart H and, further particularly, on the coronary artery A. Radial positioning of instrument 100 is accomplished by relative movement of support bracket 78 with respect to mounting group 82.

As illustrated in Figure 18, frame 102 and mounting bar 110 are lowered relative to support bracket 78 so that frame 102 applies direct pressure to heart H. Protrusions 108a and 108b locate this pressure to substantially restrict blood flow from coronary artery A and 104a and 104b reduce movement of the heart muscle surface to facilitate surgery. Movement of the heart is restricted by virtue of the pressure of the temple and the anti-slip texture of the arms 104a and 104b. The position of the instrument 100 can be closed relative to the base, as explained in detail below.

Turning now to Figures 19-33, another embodiment of a surgical retractor is described at reference numeral 200. Instrument 200 operates substantially as described above relative to instrument 10, with the differences described later herein. In particular, FIG. 19 illustrates surgical spacer 200 having a base 212 and spacer blade assembly 214, including mounting bracket 216, spacer blade 218, and spacer handle 220. The provision of the spacer handle 220 allows the surgeon to achieve an additional mechanical advantage in spacing a rib.

Base 212 includes suture support portions 224a, 224b, 224c, and 224d to secure base 212 adjacent to the surgical site. Base 212 further includes beveled internal surface 228 with internal rim 230 and top surface 232, in which a series of cylindrical slits or openings 240 are defined.

As illustrated in FIG. 20, mounting bracket 216 includes sheath 242 defining channel 244 with the open side for sliding reception of separator blade 218. Detent element 246 has a series of ratchet teeth 248 configured to mesh with ratchet teeth 258 on retractor blade 218 when blade 218 is slidably inserted into channel 244.

Separation handle 220 is rotatably positioned in opening 236 in mounting bracket 216. Referring to FIG. 20, in conjunction with FIG. 21, the separator handle 220 includes the pinion pinion 260 which cooperates with the rack 262 provided on the separator blade 216. As will be described later, the rotation of the handle 220 provides the additional mechanical advantage in cooperation with the one-way ratchet mechanism 23 to separate and / or advance the separation blade 218.

As illustrated in Figures 22-23, the separator blade assembly 214 mounts to the base 212 in a simple, one-handed manner. The mounting bracket 216 includes a bolt 264 on a lower portion thereof with dimensions to be received in one of the cylindrical grooves 240 in the base portion 212. The length of bolt 264 is preferably substantially equivalent to the depth of slot 240, to provide stability for mounting bracket 216. In addition, the internal wedge-shaped portion 266 of the mounting bracket 216 cooperates with the internal surface 228.

ES 2 197 263 T3 is chamfered from the base 212 to facilitate placement and to provide resistance against tilting of the separator blade 218. The mounting bracket 216 is further secured in position by the tab 270 which includes a flange 272 that fits the outer edge 274 of the base 212. As illustrated in FIG. 23, removal and placement of mounting bracket 216 is accomplished by deflecting flange 272 of tab 270 free of outer margin 274. Tab 220 includes rigid lever arm 276 that facilitates such deflection of tab 270.

Turning to Figures 24-26, the interaction of spacer blade 218 relative to mounting bracket 216 is illustrated. The ratchet assembly 223, which includes the retainer 246 and inclined teeth 258, operates substantially as previously described with respect to FIG. 5 and allows the spacer blade 218 to move progressively radially outward while avoiding jamming. radial displacement inward. Initially, the surgeon uses the assist straps 22 (see Figure 19) to separate a rib. The separating blade 218 is moved radially outward as far as possible, depending on the force of the surgeon. Subsequently, an additional separating force can be applied to the rib by rotating the separating knob 220. Pinion 260 on puller 220 engages rack 262 on separator blade 218 and provides additional leverage to the surgeon. As illustrated in FIG. 25, the detent 246 is normally offset in front of the separating blade 218, so that the ratchet teeth 258 on the blade 218 and the ratchet teeth 248 on the detent 246 mesh to prevent the radial inward movement. It should be appreciated that the handle 220 can optionally be removed, whereby it can be used to separate each separator sheet 218.

Figure 26 illustrates that detent 246 can be rotated away from separating blade 218 by rotating lever 262 to disengage teeth 258 and 248. Unlimited radial movement of separating blade 218 is thereby facilitated.

Figures 27-28 illustrated another embodiment of a heart manipulation instrument designated by reference numeral 300. The cardiac manipulator 300 is used to manipulate the placement of the heart and functions substantially as described above with respect to the cardiac manipulator 64, with the differences described below. In particular, cardiac manipulator 300 includes frame member 302, formed in a modified "U" configuration having a vertical portion in which the bars are parallel, including closely spaced mounting portions 304a and 304b, portions 306a and more widely spaced mesh support 306b and a horizontally extending curved portion 308. The mesh support portions 306a and 306b and the horizontally extending portion 308 support a mesh surface 310 between them. Mounting portion 304a and 304b snap closed into perforations formed in support bracket 320. It is contemplated that elements 304a and 304b may be slidable relative to bracket 320 and secured with set screws (not shown). Radial positioning of support bracket 320 is accomplished by slidable mounting of support bracket 320 onto mounting bracket 322. Set screw 324 is used to secure radial positioning of cardiac 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, mounting bracket 322 is configured to mount to base 212 substantially as described with respect to mounting bracket 216 in FIGS. 22-23. Bolt 364 of clamp 322 is received in one of openings 240 in base 212. Tongue 370 includes removable flange 372 which is removable at the outer edge 274 of base 212 and is disengaged by the lever arm 376. Support bracket 320 is slidably mounted on mounting bracket 322 so that a portion of slot 330 aligns over threaded bore 332. Set screw 324 extends through slot 330 into bore 332 and includes neck 334 abutting the top surface of support bracket 320 to secure against radial movement.

Figures 29-32 illustrate another embodiment of a heart stabilizer instrument 350. Referring to FIG. 29, heart stabilizer instrument 350 includes frame 102 and mounting rod 110. Frame 102 includes tabs 104a and 104b and cross bars 106a and 106b having protrusions 108a and 108b substantially as described with respect to Figure 10, above. Mounting bar 110 is slidably received in a bore in support bracket 352 and is secured relative thereto by set screw 354. Support bracket 352 is slidable relative to mounting bracket 356.

As illustrated in Figures 30-31, mounting bracket 356 is removably mounted on base portion 212, substantially as described with respect to mounting bracket 216 in Figures 22-23 . The bolt 358 is received in one of the cylindrical slots or openings 240 in the base 212. The tab 360 includes the tab 362 for adjustment so that it can be removed with the outer margin 274 of the bore 212. Flange 362 is disengaged by actuation of lever arm 364. Referring to Figure 32, in conjunction with Figures 30-31, 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 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 bolts 370a and 370b extend from rod 368 and are received in a clevis 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 yoke portion 372 of the lever arm 374.

With continued reference to Figures 30-31, yoke portion 372 is substantially circular or elliptical in lateral cross section and is eccentrically mounted on hinge pins 370a and 370b. As illustrated in FIG. 30, when the lever arm 374 is in a released position, the yoke portion 372 is separated from the walls 366a.

ES 2 197 263 T3 and 366b horizontal and thus allows unlimited radial movement of the support bracket 352. As illustrated in FIG. 31, rotating the lever arm 374 causes the yoke portion 372 to apply a compressive force on the horizontal walls 366a and 366b on the top of the mounting bracket 356, thereby securing the mounting bracket. radial position of support bracket 352 relative to mounting bracket 356.

Returning to Figure 33, operation of the surgical retractor 200, in conjunction with the cardiac manipulator and the heart stabilizer instrument, continues substantially as described with respect to Figures 11-18. As noted above, the mounting bracket 216a of the spacer blade assembly 214 is positioned on the base 212 by actuation of the lever arm 276a (not shown). Cardiac manipulator 200 and heart stabilizer instrument 350 are mounted to base 212 in a manner substantially identical to that described above. The surgical procedure is carried out substantially as described above. The ribs R1, R2 and R3 are separated by pulling the assist straps 22 and by rotating the separation knob 220. The placement of the heart H is stabilized by the cardiac manipulator 300. Heart stabilizer instrument 350 is positioned and lowered over heart H to apply pressure to the coronary artery and thereby substantially reduce movement of the heart within the pins. Instrument 350 can be closed relative to the base. At this time, other surgical procedures may be performed, such as coronary artery bypass or valve surgery.

Turning now to Figures 34-52, another embodiment of a surgical retractor is described at reference numeral 400. Instrument 400 operates substantially as described relative to instrument 200, with differences noted hereinafter. In particular, FIG. 34 illustrates the surgical retractor 400 having the base 412 and the retractor blade assembly 414, which includes the mounting bracket 416, the retractor blade 418, and the retractor handle 420. The provision of the separating puller 420 allows the surgeon to achieve an additional mechanical advantage in separating a rib.

Base 412 includes suture mounting portions 424 for suture attachment of internal tissue structures. Base 412 further includes beveled inner surface 428 with inner rim or margin 430 and upper surface 432, which forms an outer rim or margin 434. A channel or groove 436 is formed in the upper surface 432. The outer periphery 438 of the base 412 includes a series of teeth 440 formed thereon.

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

Separator blade 418 includes a body portion 448 and a rib fitting portion 450. Body portion 448 defines a T-shaped handle 452 configured for the surgeon to grasp in order to slide retractor blade 418 into channel 446. Body portion 448 defines a rack gear 454 and a series of Angled 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 engage releasable by retainer 460. Mounting plate 444 defines a first channel 462 and second channel 464 for receiving retainer 460. Preferably, retainer 460 is a resilient member having a modified U-shaped configuration, including a crown portion 466, a first lug 468 defining a cutting portion 470, and a second lug 472. Second leg 472 is fixedly held within second channel 464 which has an elbow configuration. The junction of the second lug 472 and the crown 466 acts as a hinge or pivot, so that the first lug 468 can slide into the first channel 462. The retainer 460 is normally offset at this junction from the second lug 472 and crown 466 so that first lug 468 is partially disposed in first channel 462. The crown 466 can be pressed by the user toward the mounting plate 444 against normal deviation to slide the first lug 468 further along the first channel 462. The spacer blade 418 is positioned adjacent the mounting plate 444 and the retainer. 460 is positioned on top of blade 418 such that first lug cutting portion 470 is positioned on either side of a portion of blade 418 adjacent ratchet teeth 456. (See figure 38). As will be described later, the detent 460 biases normally, so that the first lug 468 engages one of the ratchet teeth 456. Pawl 460 and ratchet teeth 456 together define a one-way ratcheting mechanism 474.

Rack gear 454 is engaged by differential pinion 476 formed on separating puller 420, which is positioned in aperture 478 defined in housing 442. As will be described later, rotation of separating puller 420 provides an advantage. additional mechanics when used in cooperation with ratchet mechanism 474 to withdraw and / or advance blade 418 from the separator.

Rib tightening portion 450 is connected to body portion 448 with a dovetail joint and secured thereto with bolts 480a and 480b. Alternatively, the separator blade 418 can be constructed in a single piece. The rib fitting portion 450 includes the horizontal portion 482, the angle dependency portion 484, and the tip portion 486. Angular dependency portion 484 forms an acute angle with horizontal portion 482 to securely fit the rib. The rib bracing or flange 488 is formed on the outside of the rib fitting portion 450 to provide additional strength and to resist bending.

Referring to Figure 35, in conjunction with Figures 36-37, mounting plate 444 includes gear 490 on a front portion thereof, to mesh with peripheral gear teeth 440 on base 412 (see Figure 34 ).

As illustrated in FIG. 36, base 412 is positioned at the operative site on the patient's chest. Rib adjusting portion 450 is positioned adjacent rib R so that portion 484 of

The angular dependence and tip portion 486 at least partially surround the R rib. Housing 442 has a flat bottom portion and is positioned on top surface 432 of base 412.

Figure 37 illustrates the simultaneous mounting of the mounting bracket 416 to the base 412 and the spacing of the rib R toward the base 412, as indicated by the arrows. The spreader blade 418 moves laterally out of the 412 base, while the rib adjusting portion 450 is adjusted to the R rib. Mounting plate 444 is separated from the bottom of housing 442 in order to allow mounting plate 444 to slide under the outer margin 434 of base 412 and to allow teeth 490 to mesh with teeth 440 at the base 412. The mounting bracket 416 is secured to the base 412 by the compressive force created between the rib fitting portion 450 against the R rib and the mounting plate 444 against the outer edge 434 of the base 412. Removal of the spacer blade 418 from the rib R occurs by sliding the spacer blade 418 radially inward, thereby releasing the compression sufficiently to allow the mounting plate 444 to be released from the outer margin 434.

The one-way ratcheting mechanism 474 allows the spacer blade 418 to move increasingly in one direction, ie, radially outward to separate a rib, while resisting movement in an opposite direction, ie, radially inward. Figure 38 illustrates detent 460 normally offset such that first lug 456 engages ratchet teeth 456. As shown in FIG. 39, the inclined portions 490 of the teeth 456 allow the separator blade 418 to move more and more in a radially outward movement, while the transverse slopes 492 of the teeth 456 inhibit the radially movement. inward to hold retractor blade 418 and rib in position. As described above with respect to spacer 200, additional spreading force can be applied to the rib by rotating spreader knob 420. Differential pinion 476 disposed on spreader 420 engages rack 454 on spreader blade 418 to provide additional leverage to the surgeon. Upon removal of the rib to create sufficient access for the surgeon, the rotation handle 420 can be removed from the opening 478 in the housing 442 (see FIG. 35) and thus provide greater visibility and access for the surgeon.

The detent 460 can be moved against its normal deviation by lowering the crown 466 toward the mounting plate 444, causing the first lug 468 to disengage from the ratchet teeth 456, as shown in Figure 40. The cutting portion 470 is aligned so that the blade 418 can slide through it, allowing unlimited radial movement of the separating blade 418.

Figures 41-49 illustrate a heart stabilizer instrument 500 in accordance with one embodiment of the subject description. Referring to FIG. 41, heart stabilizer instrument 500 includes frame 502, articulated arm 504, and mounting group 506. The articulated arm 504 is configured to allow the frame 502 to be placed in the precise position and orientation relative to the heart of the patient. Mounting group 506 secures articulated arm 504 and frame 502 in a fixed configuration, as will be described later.

Frame 502 is configured to contact the heart and applies pressure to the heart without touching the coronary artery. Frame 502 includes a pair of pins 508a and 508b, each having teeth 510 for nontraumatic contact with the heart. Frame 502 is mounted to frame support 512 via bolt 514. The distal end of cable 516 mounts to frame 502 and passes into frame support 512 at opening 513.

Articulated arm 504 consists of a plurality of attachment elements 518a, 518b, 518c, 518d, each having a hemispherical convex distal portion 520, cylindrical body portion 522 including peripheral step 523 and concave proximal end 524. The bore 526 extends longitudinally through each junction 518 from the convex distal portion 520 to the concave proximal end 514. The link elements 518 are aligned so that the convex distal portion 520 is received at the concave proximal end 524 in a ball-type connection to allow a wide range of rotational movements between the adjacent link elements 518. The tie elements 518 are concatenated by the wire 516 that passes through each bore 526 and the most distal tie element 518a is attached adjacent to the frame support 512. Articulating arm 504 can be used to mount a light cable to illuminate the surgical site, a suction and / or irrigation device, a blowing device to disperse blood, or any other instrument to facilitate surgery.

Mounting group 506 mounts adjacent to the most proximal attachment element 518d and includes mounting flange element 530, mounting base 532, toggle housing 534, and toggle 536. As shown in Figure 42B, The mounting base 532 has a flat bottom surface 538 to rest on the top surface 432 of the base 412 and a protrusion or pin 540 configured and dimensioned to receive the flange 436 of the base 412. Continuing with reference to FIG. 42, the mounting flange element 530 and the toggle housing 534 are slidably mounted with respect to the mounting base 532 and normally deflected into a separate configuration from the mounting base 532 by springs 542 and 544, respectively. The mounting flange element 530 has the flange 546 to fit with the inner margin 430 of the base 412. The toggle housing 534 has the flange 548 to fit with the outer margin 434 of the base 412.

Rocker 536 includes cylindrical mounting portion 550 and rocker arm 552. The cylindrical mounting portion 550 is configured to receive within the cylindrical groove 554 defined within the rocker housing 534 and to be rotatably movable therein. Cable 516 extends through link members 518 and through mounting flange element 530, spring 542, mounting base 532, spring 544, and into the cylindrical groove 554 of rocker housing 534. The distal end portion of the cable 516 is attached to the rocker 536 by the bolt 556. As illustrated in Figure 42A, the portion 550 of mon19

ES 2 197 263 T3 cylindrical cut defines a slot 558 of arcuate section or laterally offset circular shape to define an "articulated" type closure mechanism, as will be described later.

As illustrated in FIG. 43, the heart stabilizer instrument 500 is configured such that the lead 516 extends through the instrument 500 from the frame 502 to the rocker 536. The perforation 526 in each link element 518 has a conical diameter that is largest adjacent to the convex distal portion 520 and narrower adjacent to the concave proximal portion 524. This configuration allows for relative articulation of link members 518 while cable 516 extends therethrough.

Figures 44-46 illustrate the heart stabilizer instrument 500 with lead 516 in an untensioned and relaxed configuration. As illustrated in Figure 44, the instrument 500 is positioned on the base 412 so that the pin 540 is disposed in the slot 436 and the mounting flange element 530 and the rocker housing 534 are separated enough to to allow tabs 546 and 548 to release from inner margin 430 and outer margin 434, respectively.

As illustrated in FIG. 45, toggle 536 is disposed in toggle housing 534 in a non-closed configuration such that toggle arm 552 and fixed arm 535 are spaced apart. The eccentrically mounted bolt 556 is arranged so that the cable 516 is slack. Figure 46 illustrates that the cable 516 loosely disposed in the conical perforations 526 of the link element 518 allows articulation of the adjacent link elements 518.

Figures 47-49 illustrate instrument 500 with cable 516 in a taut and taut configuration. As shown in FIG. 47, toggle 536 is rotated relative to toggle housing 534 such that toggle arm 552 approaches stationary arm 535. Simultaneously, the distal end of cable 516 connected to bolt 556 is moved into an "articulated" position, thereby tensioning cable 516 and closing surgical instrument 500 in position. The surgeon is allowed to perform other procedures without keeping pressure on the heart.

Another embodiment of the heart stabilizer instrument is illustrated in Figure 50 and described in reference numeral 600. Instrument 600 is constructed and operated substantially as described above with respect to instrument 500, with the differences described below. The heart stabilizing instrument 600 includes the frame 502, the articulated arm 606, and the mounting group 506. Articulating arm 606 allows frame 502 to be positioned at the proper height and angle, relative to the heart. Articulated arm 606 is comprised of link members 608 and 610 having a series of constant engagement teeth to positively mesh adjacent link members with one another.

As illustrated in Figures 50A and 50B, tie elements 608 are positioned adjacent to tie element 610. The connecting element 608 generally has a cylindrical body portion 612. A pair of rows of concave gear 614a and 614b are disposed at an axial end 616 of link 608. A second pair of rows of concave gear 618a and 618b is disposed at the second axial end 620 of link 608. Gear 614a and

614b are disposed 90 ° out of alignment with gear 616a and 616b. Longitudinal bore 622 extends through link 608 from axial end 616 to axial end 620 between each pair of gears.

The attachment element 610 has a body portion 624, to which the first gear pair 626a and 626b having a convex profile and a second convex gear pair 628a and 628b are attached to opposite sides thereof. The first gear pair 626a and 262b is disposed 90 ° out of alignment with the second gear pair 628a and 628b. A longitudinal bore (not shown) extends through body portion 624 and between each gear pair 626a and 626b and gear 628a and 628b.

Link element 610 is positioned adjacent to link element 608. Cable 516 extends through longitudinal bore 622 in link 608 and longitudinal bore (not shown) in link 610. When toggle 552 is moved to the "articulated" position (see FIG. 47), thereby tensioning cable 516, link elements 608 and 610 move closer together, such that convex gears 626a, 626b or 628a, 628b of the element Linkage 610 engages concave gears 614a, 614b and 618a, 618b of linkage element 608.

Figure 51 illustrates another preferred embodiment of the surgical retractor according to the subject description. This surgical retractor, generally designated 700, includes a base 702 and any one or more of the instruments shown including: the retractor blade assembly 704; the separator blade assembly with the structure 706 with suction / irrigation; lighted spacer blade assembly 708; cardiac manipulator 710; and the heart stabilizer instrument 712. These instruments are discussed in more detail later in this document.

Base 702 is configured according to accordance with the other bases discussed above and provides a lowered profile support for instrumentation used in the surgical procedure being performed. A plurality of suture holders 714 are defined in an upper peripheral portion 716 of base 702 and serve as attachment and anchor points for surgical field suture terminations 718. Referring to Figures 52 and 53, the suture holders 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 inner radial surface of suture holder 714. A groove 726 is formed on an outer radial surface of suture holder 714 beyond coil spring 720 and in axial alignment with ramp 724. This ramp / groove configuration facilitates easy access to placement of suture end 718 in the helical spring 720.

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

Figures 54-56 show the assembly of

ES 2 197 263 T3 blade of the surgical retractor with the blowing structure 706. Frame 706 can also be used for suction or irrigation to remove fluids from the surgical site. The separator blade assembly 704 is similar to the separator blade assembly 414 discussed in detail above. The separator blade assembly 704 includes the mounting bracket 734, the separator blade 736, and the removable separating handle 738.

As illustrated in FIG. 56, mounting bracket 734 includes housing 740 and mounting plate 742, which together form a channel through which separator blade 736 can slide reciprocally.

The separator blade 736 includes the body portion 744 and the rib fitting portion 746. Body portion 744 defines a flange grab handle 748 configured for the surgeon to grasp in order 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 meshed by retainer 756 mounted in housing 740. Operation of retainer 756 is substantially the same as retainer 460 described above in connection with separator blade assembly 414.

The rib fitting portion 746 extends distally from the body portion 744 and includes an angular dependency portion, including one or more strengthening ribs 748 to provide additional strength.

The blow structure 760 is integrally formed in the separator blade assembly shown in Figures 54-56. This structure includes a tube 762 that extends the length of the retractor blade assembly and exits through the portion 764 that fits the annulus to access the surgical site. A tubular connector 764 is placed at a proximal end of tube 762 and connected to an appropriate source, such as a vacuum or pressure source (not shown), depending on whether frame 760 is used for blowing, flushing, or suctioning. Forming wire 766 is positioned adjacent tube 762 and is deformable to configure tube 726 in a desired angular orientation. Alternatively, tube 762 can be oriented out of the way or rotated from body portion 744 using known structure.

Figures 57 and 58 illustrate a separator blade assembly with an integral light shown generally at 708. The basic configuration and operation of this assembly are identical to those described above, with the difference that a 768 light has been replaced with the suction / irrigation structure. It can fit a wide variety of lights. In the illustrated embodiment, a fiber optic bundle is disposed within a longitudinally extending shroud 770. A fiber optic coupler 772 is positioned adjacent the proximal end of the assembly and can be connected to an appropriate light source (not shown). It is also envisioned that a wide variety of diverging and focusing lenses can be used to adapt the light as required by the surgeon.

The one-way ratchet mechanism used in these embodiments of the spacer blade assembly is shown in Figures 58A-C. This ratchet mechanism functions in the same way as the ratchet mechanism discussed earlier with respect to Figures 39-40. It is to be noted that, as shown in FIG. 58B, the retractor blade 736 can be pulled in the direction of the arrow to separate bone and tissue. However, to move the separator blade 736 in the opposite direction, that is, in the direction of the arrow in FIG. 58C, the stopper 756 must be depressed.

Figures 59-63 illustrate another embodiment of a heart stabilizing instrument 800 in accordance with the subject description. The heart stabilizer instrument 800 is similar to the heart stabilizer instrument 500 discussed in detail above. The instrument includes frame 802, articulated arm 804, and mounting group 806.

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

Frame 802 connects to articulated arm 804 via connector 812. A positioning flange 814 is formed over connector 812 and facilitates placement of frame 802 on the surface of the heart, either by manually grasping flange 814, or by clamping. a gripping instrument (not shown) to flange 814 and positioning the frame in a desired location.

Mounting group 806 mounts adjacent to articulated arm 804 and includes mounting flange element 830, mounting base 832, rocker housing 834, and rocker 836. As shown in Figures 61-62, the Mounting base 832 has a flat bottom surface 838 to rest on top of base 702. Mounting flange element 830 and toggle housing 834 are slidably mounted relative to mounting base 832. The mounting flange element 830 has the flange 846 to fit the inside margin of the base 702. The rocker housing 834 has the flange 848 to fit the outside margin of the base 702.

The rocker 836 includes the cylindrical mounting bolts 850 and the ring 852. The cylindrical mounting bolts 850 are configured to be received within the slot 854 defined within the rocker housing 834 and to be rotatably movable therein. Cable 816 extends through articulated arm 804. The distal end portion of the cable 816 is attached to the rocker 836 by the clamp 856. The biasing spring 858 is positioned in the rocker housing 834 and serves to normally bias the mounting flange member 830 distally relative to the rocker housing 834.

Handle spring element 860 is integrally formed on toggle 836 and is configured to operatively interact with protrusion 862 formed in cavity 854 of toggle housing 834, as toggle 836 moves in and out of the approach with the rocker housing 834.

Figures 64-66 illustrate the heart stabilizer instrument 800 with lead 816 in an untensioned and unopened configuration. As illustrated

ES 2 197 263 T3 in Figure 64, instrument 800 is positioned on base 702 with mounting flange element 830 and toggle housing 834 spaced far enough to allow tabs 846 and 848 to be released from margin 830 inner margin and outer margin 833, respectively.

Toggle 836 is disposed in toggle housing 834 in a non-closed configuration such that ring 852 and ring 853 are spaced apart. Cable 816 is slack to allow manipulation of articulated arm 804.

Figure 65 illustrates the relative position of handle spring 860 relative to boss 862 within rocker housing 834.

Figures 66-67 illustrate instrument 800 with cable 816 in a first untensioned, closed, and tight configuration. As shown in FIG. 66, toggle 836 is rotated relative to toggle housing 834, so that ring 852 moves toward ring 853. The distal end of cable 816 is taut to approach link member 832. mounting flange and mounting base 832 closing surgical instrument 500 in position on base 702.

Figure 67 shows the progression of the toggle 836 relative to the toggle housing 834 in the closed, untensioned configuration. In this position, the articulated arm 804 can still be manipulated.

The final configuration, closed and tensioned, is shown in Figures 68-69. In this configuration, the rings 852 and 853 have been moved simultaneously, closely approaching, further tensioning the wire 816 to maintain a preset configuration desired by the surgeon, for example, to close the articulated arm 804 in situ. Once closed in this closed-tensioned configuration, the surgeon is allowed to perform other procedures without manually applying pressure to the heart using the heart stabilizing instrument.

Another preferred embodiment of the cardiac manipulator 900 according to the subject description is shown in FIG. 70. The cardiac manipulator includes a manipulator portion 902, an articulated arm 904, and a mounting group 906. The structure and operation of the mounting group 906 and the articulated arm 904 are substantially the same as that of the cardiac stabilizer 800 discussed above.

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

Figures 71A and 71B illustrate a rib elevator 980 that can be mounted on the bases described above to allow the patient's ribs 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 posterior surface 981 increase the rigidity of the rib elevator 980 and also provide a gripping surface for the user to bend the rib elevator 980 to facilitate attachment and removal of 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 separator assemblies 704, 706, 708. As can be appreciated, when the rib elevator 980 is mounted to the base 702, the assembled spacer assembly will twist toward the rib so that a separation force will be applied to the rib partially in an upward direction. This is an advantage, for example, to access and cut the IMA (internal thoracic artery). Rib elevator 980 can be subsequently removed and a spacer assembly mounted directly to base 702 in the manner described above.

Figures 72 and 73 illustrate two preferred kit configurations. Kit 950 (Figure 72) is formed to accommodate Basic Blade Separator Assembly 704, Suction Irrigation Blade Separator Assembly 706, Light Blade Separator Assembly 708, Base 702, Separator Puller 738 , a heart stabilizing instrument 800 and / or a cardiac manipulator 900 therein. Cavities 952, 954, 956, 958, and 960 are formed in cover 962 to accommodate these elements. The cover 962 can be attached to the bottom 964 by adhesive, ultrasonic welding, heating, etc.

The 970 kit is substantially similar to the 950 kit, except that the heart stabilizer instrument 800 and the cardiac manipulator 900 are excluded. Cover 972 includes cavities 952, 958, and 960 to accommodate standoffs 704, 706, 708, base 702, and standoff knob 738. Cover 972 and bottom 974 can be attached in the same way as described for the 950 kit above.

Rib Riser 980 can optionally be included in kits.

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