Devices for percutaneous surgery under direct visualization and through an elongated cannula

Related applications

This case is a partial continuation of the US application No. 08/620,933 filed by the same inventor on March 22, 1996, with the title of the invention "Apparatus and Method for Percutaneous Surgery".

The present invention relates to a device, instrument and method for performing percutaneous surgery, especially for performing surgery in the deep part of the body. The specific application of the present invention relates to devices, instruments and techniques for percutaneous and extremely low invasive spinal surgery. In another aspect of the present invention, percutaneous surgery is performed on any part of the body under direct visual inspection.

Traditional surgery for deep body lesions may cause significant trauma to the interventional tissues. This type of open surgery often requires long incisions, complete muscle peeling, long-term tissue traction, and removal of nerves and blood vessels in the tissue. For most of these operations, general anesthesia is used and the tissues are injured during the operation, so it is necessary to lie down in the recovery room for several hours, and the postoperative recovery time is as long as several weeks. In some cases, permanent scars and pain caused by such invasive surgery may be more painful than the pain of surgical intervention.

There are few invasive alternatives. For example, arthroscopic surgery can reduce pain, shorten postoperative recovery time, and reduce damage to healthy tissue. Orthopedic surgery patients can particularly benefit from very low invasive surgery. The lesion is approached through the orifice, rather than through an obvious incision, thus maintaining the integrity of the interventional tissue. These very low-invasive procedures often require only local anesthesia. The need for general anesthesia can shorten postoperative recovery time and reduce the risk of complications.

The extremely low invasive surgical technique is especially suitable for spinal and nerve surgery, because it must be close to the deep part of the body and there is a danger of damaging important related tissues. For example, the common developmental surgery of Hernia for the intervertebral disc, laminectomy followed by discectomy, requires the removal or removal of large back muscles to expose the spine. In the operation from the posterior side, the spinal nerves and blood vessels, ligaments and muscles surrounding the dural sac must be pulled to clear a passage from the skin to the intervertebral disc. This type of surgery usually takes at least one or two hours to be performed under general anesthesia and requires at least a few weeks of postoperative recovery. In addition to the long recovery time, destruction of tissue is a major disadvantage of open spine surgery. When discectomy is accompanied by joining two adjacent vertebrae, open surgery is more invasive. Many patients hesitate to seek surgery to resolve the pain caused by the intervertebral disc Hernia and other spine conditions. The reason is that muscle incisions can also cause severe pain.

In order to reduce the postoperative recovery time and pain of the spine and other operations, microsurgical techniques have been developed. For example, in microsurgical discectomy, the intervertebral disc is accessed by cutting a small incision from the surface of the patient's back to the intervertebral disc. A surgical microscope or a high-power magnifying glass is used to visually inspect the surgical site. Microsurgical instruments with small diameters enter the intervertebral disc through a small incision and through between the two vertebral plates. Because the incision is smaller, the related tissues are less injured. Although microsurgery is less invasive, there are still some complications caused by open surgery, such as injury to nerve roots and dural sac, scarring around nerves, re-enhancement of the surgical site, and excessive bone removal. Unstable.

Other attempts have been made to correct symptomatic spinal conditions with very low invasive surgery. One of them is chemical nucleolysis, which involves the injection of enzymes into the intervertebral discs to partially dissolve the nerve nuclei and improve the intervertebral disc Hernia. Unfortunately, the enzyme chymopapain is concerned about its effects and complications, such as severe cramps, postoperative pain, and allergic reactions including undefensive anaphylactic shock.

The development of percutaneous spinal surgery has achieved significant improvements in shortening the recovery time and reducing postoperative pain because it requires minimal (if any) muscle resection and can be performed under local anesthesia. For example, US Patent No. 4,545,374 of Jacobson discloses a percutaneous lumbar discectomy that uses a lateral direction, which is better than a fluorescent X-ray. This type of surgery is limited because it cannot directly visually inspect the discectomy site.

Other procedures have been developed, including arthroscopic examination of the spine and related tissues. Kambin's U.S. Patent Nos. 4,573,448 and 5,395,317 disclose a percutaneous release of Hernia's intervertebral disc compression from the posterolateral direction. Fragments of Hernia's intervertebral disc are extracted through a cannula that is positioned to hold the vertebral annulus. Kambin's '317 patent discloses a double-port surgery including percutaneous placement of a working cannula and a visual inspection cannula for endoscopy. This kind of operation can simultaneously perform visual inspection and extraction, washing and resection of the intervertebral disc.

Unfortunately, this kind of surgery and tools still have disadvantages because they are limited to specific uses or directions. For example, Jacobson, Kambin and other references require lateral or posterolateral percutaneous discectomy. This kind of surgical direction is to reduce damage to the soft tissue structure and need to remove the bone, because it is considered impractical to remove the bone through the channel. These surgical directions cannot solve other spinal conditions that require midline orientation, bone removal, or implant removal.

Shapiro's US Patent No. 5,439,464 discloses a method and instrument for performing arthroscopic spinal surgery such as laminectomy and bone joining in the midline or mid-posterior direction using three sleeves. Each casing needs to be cut individually at a time. Although the method disclosed by Shapiro is superior to the previous surgery which is limited to the posterolateral or lateral direction of the intervertebral disc surgery, the Shapiro surgery still has many related shortcomings of the prior art percutaneous spine surgery techniques and tools. One disadvantage of Shapiro surgery is the need for fluid working space. Another major disadvantage is that the operation requires multiple holes into the patient's body.

The prior art surgery requires fluid to maintain the working space so that the optical elements fixed inside the sleeve and percutaneously inserted in the prior art function properly. Washing or introducing fluid into the work space often has unreasonable shortcomings, and even harms the patient for several reasons. It is more difficult for fluid to be introduced into the working space to achieve a constant blood flow, which may damage surrounding tissues. Excess fluid dangerously dilutes the patient's bloodstream sodium concentration and causes seizures or exacerbations. The fluid environment also makes the drilling machine difficult due to the vortex vacuum effect. Fluid environments often increase the cost and complexity of surgery, partly because of the considerable amount of fluid required.

There is still a need for a device and method for percutaneous very low invasive surgery that can be used for all purposes and surgical directions. There is also a need for a transdermal method and device that does not require fluid to fill the working space, but can be adapted to a fluid environment if required.

In this field, there is a significant demand for techniques and equipment for performing surgery in the work space under direct visual inspection. It is also highly desirable to reduce the number of entry into the patient's body. In spinal and nerve surgery, there is a special need for devices and techniques that can reduce invasion of the patient's body, streamline, and have simple applications.

A brief description of one aspect of the present invention provides a device and method for performing percutaneous surgery under direct visual inspection even in deep parts of the patient's body. In a specific example, a device for percutaneous surgery includes an elongated sleeve having a first inner dimension and an outer dimension for percutaneous introduction into a patient's body. The sleeve includes a distal working end and an opposite proximal end. The sleeve defines a working channel between the two ends, which has a second dimension substantially equal to the first internal dimension. The size of the working channel can accommodate tools passing through it. The device also includes a viewing element, which is installed inside the casing adjacent to the working channel. The viewing element has a first end connectable to the viewing device and a second opposite end disposed adjacent to the distal working end of the sleeve. In some specific examples, the viewing element can be a fiber optic cable, a GRIN rod, a rod-lens device, or a remote optical element ("chip/rod") device.

In another aspect, a fixture for installing the inspection element on the casing is provided. The clamp contains a shell that can be overlapped to the proximal end of the sleeve. The shell defines a working channel opening passing through it and communicating with the working channel. The size of the working channel opening roughly corresponds to the second size of the working channel. The housing also defines an optical element boring adjacent to the working channel opening. The boring size of the optical element can accommodate the elongated viewing element passing through it.

In some specific examples, the fixture supports the inspection device for the inside of the bore of the optical element, moves along the longitudinal axis of the bore, and expands and contracts the lens relative to the distal end of the sleeve. In other specific examples, the fixture supports the inspection device for the inside of the boring of the optical element to rotate with the longitudinal axis of the boring as the axis. In some specific examples, the housing can rotate relative to the sleeve, so that the longitudinal axis of the optical element boring can be rotated around the longitudinal axis of the working channel.

In one aspect of the present invention, the working channel may be formed by components other than the tubular sleeve. For example, it is also contemplated to include tissue expanders or tissue retractors. With this modification, the clamp can engage the expander or retractor in its expanded condition.

In another aspect of the present invention, the optical inspection device is coupled to a tissue retractor, for example, a sight glass. This type of device is particularly useful for a variety of purposes, such as transnasal sphenoid surgery and pituitary surgery.

In another aspect of the present invention, the length of the working channel maintained by the cannula or similar component is calibrated so that the surgeon can maintain a familiarity with manipulating instruments through the working channel. In spinal surgery, by providing a sleeve whose length is slightly longer than the distance from the vertebral plate to the patient's skin surface during the operation from the posterior side, certain benefits can be obtained. The size of the viewing device relative to the sleeve makes the viewing end of the device protrude beyond the distal working end of the sleeve or the working channel, so that the surgeon can selectively search for the surgical site.

According to a specific example, the fixture also contains at least one injection/extraction port. Preferably, the port communicates with at least one injection/extraction channel of the optical inspection device. In this way, injection and/or extraction can also be applied to the surgical site. When single-line extraction, the port is connected to the vacuum or extraction source. The extraction also extracts the surrounding air through the working channel, across the remote working space, and into the flushing/extraction channel of the inspection device. This effect of extracting ambient air can remove the smoke generated by a variety of work tools, and remove the mist and debris from the lens of the optical element.

In a specific example, the clamp is installed at the proximal end of the sleeve and supported by the proximal end of the sleeve.

In another specific example, the clamp may be engaged with the outer surface of the sleeve to support the adjacent proximal end of the sleeve. In a specific example, the clamp is a barrel clamping mechanism, which is selectively actuated by a lever arm and a barrel cam. Using this specific example, the clamp itself can be translated along the length of the sleeve to extend and retract the inspection device lens relative to the working channel.

There is also a working channel through which a novel tool can be inserted into the sleeve. In a specific example, the tissue retractor includes a body and an integrated working tip, and its configuration can be non-invasively ectopic tissue when the retractor is manipulated through the tissue. The convex surface configuration of the main body fits with the inner cylindrical surface of the sleeve, and the opposite concave surface does not hinder the visual inspection of the working channel or the working space. There is also a cannula tissue expander, which can be inserted into a wire or another expander, and can be inserted into the working channel. In some specific examples, the tissue expander includes a push-pull working end that can ectopic tissue; and a grasping end with multiple peripheral grooves to facilitate grasping and manipulation of the expander.

According to the method of the present invention, spine and other operations can be performed percutaneously without the need for fluid to maintain a working space with direct visual inspection. In another aspect of the surgical technique of the present invention, all surgical steps are performed through a single working channel cannula under direct visual inspection. The light mirror or the inspection device moves inside the working channel, and various angles and orientations move throughout the working space to clearly inspect each operation step.

The technology of the present invention also includes multiple tools and instruments passing through a single working channel sleeve, and manipulating the instruments or tools inside the working space. In a specific embodiment, a tissue retractor is provided, which extends through the working channel without significantly reducing the size of the channel.

The purpose of the present invention is to provide devices and methods for percutaneous spinal surgery for all uses and directions. One advantage of the present invention is that percutaneous surgery can be performed in a dry environment because no fluid working space is required for the optical elements to function. The effect of the present invention is that the present invention provides a device and method that can reduce and shorten the cost, risk, pain, and recovery time associated with surgery. These and other objectives, advantages and features can be achieved by the device and method of the present invention.

<p>10Device</p><p>20Casing</p><p>21Remote working end</p><p>22 Relatively close</p><p>23Outer surface</p><p>25Working channel</p><p>26Internal cylindrical surface</p><p>27Mounting bracket</p><p>30Fixture</p><p>31Shell</p><p>32ditch</p><p>40Receptor boring</p><p>41Upper bore</p><p>35Open</p><p>50View components</p><p>51First end</p><p>52Second end</p><p>53Accessories</p><p>54Fiber optic sight glass; tube</p><p>55Lens</p><p>60Optical element boring</p><p>61C-shaped small clip</p><p>70 Tractor</p><p>71arm</p><p>72Clamping surface</p><p>75Work Tip</p><p>76Ontology</p><p>77First end</p><p>78Second end</p><p>80Convex</p><p>81Concave</p><p>81'Second concave surface</p><p>82Blunt curved end</p><p>84Bent plate</p><p>85First Board</p><p>86Second Board</p><p>90Relative Fate</p><p>100 Tractor</p><p>101arm</p><p>102Clamping surface</p><p>105Work Tip</p><p>106Ontology</p><p>107First end</p><p>110First convex surface</p><p>110'Second convex surface</p><p>111Relative to the first concave surface</p><p>111'Relative to the second concave surface</p><p>114Bent plate</p><p>115First Board</p><p>116Second Board</p><p>120The first two relative edges</p><p>120'The second two relative edges</p><p>130Expander</p><p>131Channel</p><p>132First opening</p><p>133Second opening</p><p>135Hollow sleeve</p><p>136Working end</p><p>137opposite end</p><p>138Pushing the tip</p><p>140Clamping part</p><p>141Outer surface</p><p>142ditch</p><p>143flat bar</p><p>150Wire</p><p>151Expander</p><p>152Expander</p><p>153Expander</p><p>160Flexible support arm</p><p>161wing nut</p><p>165Extraction cover</p><p>166Ontology</p><p>167Matching boring</p><p>168Tool opening</p><p>169Receptor boring</p><p>170Fixture</p><p>171Mirror body</p><p>172Clamping ring</p><p>173aClamping arm</p><p>173bClamping arm</p><p>174Long slot</p><p>175Inner clamping surface</p><p>176Support column</p><p>177Long slot</p><p>178Optical component mounting body</p><p>179stop margin</p><p>180Optical component boring</p><p>181Lighting hole</p><p>182Optical element coupling boring</p><p>183Coupling body</p><p>184Connector</p><p>185Camera</p><p>186Extraction port</p><p>187Flush mouth</p><p>190Optical element casing</p><p>191lens</p><p>192Working end</p><p>195Barrel clamping mechanism</p><p>196Barrel Cam</p><p>197Lever arm</p><p>198Shoulder Screw</p><p>199Threaded shank</p><p>200Bearing Shank</p><p>201Magnifying head</p><p>202Matching rib boring</p><p>203Bearing bore</p><p>204Bearing bore</p><p>205Bearing bore</p><p>206Head internal clearance</p><p>210arm</p><p>211Ontology</p><p>212Protrusion</p><p>213rounded tip</p><p>215Flat surface</p><p>216Cam surface</p><p>217Cam</p><p>218Slope</p><p>219Detent inner clearance</p><p>220stop</p><p>225Extraction tube</p><p>226Flow control valve</p><p>227Luer accessories</p><p>230Retractor device</p><p>231Tissue tractor</p><p>232Optical viewing device</p><p>234 Tractor plate</p><p>235Handle</p><p>236Proximal</p><p>237Remote</p><p>238Blunt Tip</p><p>239External Traction Surface</p><p>240Channel</p><p>245C clip</p>

Figure 1 is a side plan view of the device according to the present invention.

Figure 2 is a top plan view of the fixture in the casing of the supporting and inspecting device according to the present invention.

Figure 3 is a side cross-sectional view of the clamp shown in Figure 2.

Figure 4 is a side plan view of a tractor according to a specific example of the present invention.

Figure 4A is an end cross-sectional view of the tractor of Figure 4 taken along line AA.

Figure 5 is a top plan view of the tractor shown in Figure 4.

Figure 6 is an end plan view of the tractor shown in Figures 4 and 5.

Figure 7 is a side plan view of a tractor according to another embodiment of the present invention.

Figure 7A is an end cross-sectional view of the tractor of Figure 7 taken along line AA.

Figure 7B is an end cross-sectional view of the tractor of Figure 7 taken along line BB.

Figure 8 is a top plan view of the tractor shown in Figure 7.

Figure 9 is a side plan view of the dilator according to the present invention.

Figures 10(a)-(i) illustrate the steps of the method according to the present invention.

Figure 11 is a side cross-sectional view of a device according to a specific example of the present invention.

Fig. 12 is a side sectional view of the extraction cover shown in Fig. 11.

Figure 13 is a top perspective view of a device according to another embodiment of the present invention.

Figure 14 is a side perspective view of a jig supporting an inspection device that constitutes the components of the device shown in Figure 13.

Figure 15 is a side plan view of the device illustrated in Figure 13, showing the device connected to the optical device indicated by the dashed line.

Figure 16 is a side plan view of the mirror body forming part of the fixture illustrated in Figures 13 and 14.

Figure 17 is a bottom plan view of the mirror body shown in Figure 16.

Fig. 18 is a top plan view of the lever arm forming part of the barrel cam mechanism of the clamp used in Fig. 14.

Fig. 19 is an end cross-sectional view of the lever arm shown in Fig. 18 taken along the line 19-19 in the direction of the arrow.

Figure 20 is a top plan view of the barrel cam forming member incorporated into the barrel cam mechanism of the clamp shown in Figure 14.

Figure 21 is a side plan view of the barrel cam shown in Figure 20.

Figure 22 is a bottom view of the assembly, showing the assembly of the lever arm in Figures 18-19, the barrel cam in Figures 20-21, and the mirror body in Figure 14.

Figure 23 is a side plan view of the mirror body shown in Figure 14 connected to the extraction circuit.

Figure 24 is a cross-sectional view of the patient at the height of the lumbar spine. The device according to a specific example of the present invention is seated in the patient to define a working channel above the vertebral plate.

Figure 25 is a side plan view of a tissue retractor incorporating an optical inspection device.

Figure 26 is a top plan view of the tissue retractor shown in Figure 25 with an optical inspection device.

Description of preferred concrete examples

In order to improve the understanding of the principles of the present invention, specific examples are illustrated with reference to the drawings and specific terms are used to illustrate them. Having said that, it should be understood that it is by no means intended to limit the scope of the present invention. The changes and further modifications of the devices and methods described in the examples, as well as the further use of the principles of the present invention as described herein, are expected to be known to those in the industry. The relevant range.

The device and method provided by the present invention can be used to perform percutaneous surgery using a single working channel endoscopy, including spinal applications, such as laminectomy, laminectomy, foraminotomy, vertebral arthroectomy, or intervertebral discectomy Surgery. The inventors found that a variety of percutaneous procedures can be performed by using optical elements that move independently of the cannula without the need for a fluid working space. The present invention is intended to include techniques and devices that can be performed in environments with or without fluids.

The present invention enables the advantages of percutaneous surgery to be applied to applications that previously required open surgery. One advantage is based on the further discovery that bone surgery can be performed percutaneously through a large working channel. Another advantage is that a single port in the patient can be used to perform a wide variety of surgical procedures at the same time.

According to a specific example of the present invention, as illustrated in Figure 1, a device 10 for percutaneous surgery is provided, which includes an elongated sleeve 20 having a first inner diameter D_IAnd outer diameter D_O, Its size can be introduced into the patient's body percutaneously. The sleeve 20 also includes a distal working end 21 and a relatively proximal end 22. The sleeve 20 defines a working channel 25 between the two ends 21, 22, which has a first inner diameter D_IThe second diameter d₂, Its size can accommodate tools through it. The sleeve 20 has a length along its longitudinal axis L, and its size can pass through the patient from the skin to the surgical site or working space. In some cases, the working space can be adjacent to the spine or intervertebral disc or within the spinal canal.

An elongated viewing element 50 is installed inside the sleeve 20 adjacent to the working channel 25. The elongated viewing element 50 has a first end 51 that can be connected to a viewing device (for example, an eyepiece or a camera) and a second end 52 disposed adjacent to the distal working end 21 of the sleeve 20. The special elongated viewing element 50 has no particular limitation on the present invention. Any suitable viewing element is one that can form an optical frequency or image transmission channel. In a specific example, the elongated viewing element 50 includes a fiber optic sight glass 54 and a lens 55 at the second end 52. The preferred fiber optic sight glass includes an illumination fiber and an image transmission fiber (not shown). In addition, the viewing element can be a rigid endoscope or an endoscope with a steerable or bendable tip.

One advantage of the present invention is that it provides an optical element that can move relative to the sleeve 20. Since the optical element is movable, there is no need to provide a fluid to maintain the working space. When the cannula is positioned percutaneously in the working space of the patient, the optical element can be moved, cleaned and replaced. It is expected to include any structure capable of movably supporting the optical element adjacent to the working channel 25. In a specific example, as shown in FIGS. 1-3, a clamp 30 is provided for mounting the elongated inspection element 50 to the sleeve 20. Preferably, the clamp 30 includes a housing 31 that can be overlapped to the proximal end 22 of the sleeve 20. The size of the working channel opening 35 generally corresponds to the second diameter d of the working channel 25₂To accommodate tools. The clamp 30 includes a housing 31, which defines a working channel opening 35. When the clamp 30 is installed in the sleeve 20, the opening 35 is in communication with the working channel 25. The size of the working channel opening 35 can accommodate a tool to pass through the working channel 25 therethrough. In the specific example shown in FIGS. 1-3, the structure of the clamp 30 can install the elongated inspection element 50 inside the working channel 25.

The housing 31 also defines an optical element bore 60 which is adjacent to the working channel opening 35. The optical element boring 60 has a longitudinal axis<img file="TW375522B_D0001.tif" />, It is preferably substantially parallel to the axis L of the sleeve and the working channel. The preferred size of the optical element boring hole 60 is to movably receive the elongated viewing element 50 therethrough. The clamp 30 preferably supports the elongated viewing element 50, which is provided inside the boring 60 of the optical element along the longitudinal axis of the boring 60<img file="TW375522B_D0002.tif" />Move, so as to extend and retract the lens 55 relative to the distal working end 21 of the sleeve 20. The retractable feature of the optical element of the present invention provides advantages over prior art endoscopes because it can eliminate the need for fluid working space. Although the device 10 and its elongated viewing element 50 are easy to use in a fluid environment, contrary to the prior art, fluid is not necessary for system operation. In addition, many prior art endoscopes are not suitable for accessing certain areas because of their large diameter. For example, the prior art endoscope cannot be used for the spinal canal. However, with the present invention, access to the spinal canal is not limited by the diameter of the channel or sleeve. The cannula 20 can be left behind the soft tissue or supported by the vertebral plate, and the second end 52 of the elongated viewing element 50 can be advanced into the spinal canal along with any spinal equipment that has been inserted into the working channel 25.

Preferably, the fixture 30 also supports the inspection element 50 inside the optical element boring 60 with the longitudinal axis of the boring 60<img file="TW375522B_D0003.tif" />Is the axis rotation. The lens 55 of the viewing element 50 defines an optical axis A_O. Like many endoscopes, the optical axis A_OCan be bored relative to the optical element 60 longitudinal axis<img file="TW375522B_D0004.tif" />The included angle is offset. This feature makes the lens optical axis A_OSwipe through the cone-shaped field of view F to obtain a higher visibility of the work space. The clamp 30 can be configured such that the viewing element 50 can rotate relative to the sleeve 20. In this specific example, the housing 31 can rotate relative to the sleeve 20, so the second longitudinal axis of the optical element boring 60<img file="TW375522B_D0005.tif" />Rotate with the longitudinal axis L of the working channel 25 as the axis. The rotatable feature of the present invention allows the entire working space to be inspected. This feature also helps simplify the surgical procedure because the optical element 50 and accompanying accessories can be moved away from the path of the surgeon's hands and tools through the working channel.

In the specific example illustrated in Figure 3, the housing 31 defines a receptacle bore 40 with an inner diameter d_ISlightly larger than the outer diameter D of the casing 20_OIn this configuration, the proximal end 22 of the sleeve 20 can be contained in the receptacle bore 40, so the housing 31 can rotate with the proximal end 22 of the sleeve 20 as an axis. As shown in FIG. 3, the housing 31 also includes an upper bore 41, which is close to the working channel opening 35 and the receiver bore 40. In a specific example, the optical element boring hole 60 is disposed in the upper boring hole 41 of the housing 31.

In the preferred embodiment illustrated in FIG. 2, the boring hole 60 of the optical element is defined by a small C-shaped clip 61 arranged inside the upper boring hole 41. Preferably, the small C-shaped clip 61 is made of a resilient material, and the optical element boring 60 defined by the small clip 61 has an inner diameter D_ISlightly smaller than the outer diameter of the elongated viewing element 50. When the viewing element 50 is pushed into the optical element boring 60, it deflects the small C-shaped clip 61 with a resilience. The resilience of the small clamp 61 provides clamping force to the component 50, while keeping the component 50 in a desired position, and at the same time repositioning the component 50.

In addition, the optical element bore 60 has an inner diameter larger than the outer diameter of the viewing element. In this case, the inspection element 50 can be supported on the outside of the device 10 manually or by a separate support fixture.

Preferably, the device 10 is provided with an engaging device for a firm but rotatable engaging fixture 30 to the sleeve 20. Preferably, the clamp 30 is configured to engage a standard sleeve 20. When the clamp 30 is installed on the proximal end 22 of the sleeve 20, the engaging device can be arranged between the housing 31 and the sleeve 20 to provide clamping engagement between the housing 31 and the sleeve 20. In a specific example illustrated in Fig. 3, the engaging device includes a plurality of grooves 32 inside the bore 40 of the receiver, and a resilient sealing member, for example, an O-ring (see Fig. 11) is provided in each groove 32 Inside. The seal or O-ring is arranged on the outer diameter D of the housing 31 and the sleeve 20_OIn between, the rotating fixed clamp 30 to the sleeve 20. The O-ring provides sufficient resistance to movement, and the fixture 30 can be fixed at a selectable position on the sleeve. In another specific example, the housing 31 defines a receptacle bore 40 with an inner diameter d_IOnly slightly larger than the outer diameter D of the casing 20_OTherefore, the casing 31 can freely rotate with the sleeve 20 as an axis.

Both the working channel 25 and the working channel opening 35 can accommodate tools or equipment to pass through them. Preferably, the diameter D of the working channel opening 35 of the housing 31_WRoughly equal to the internal diameter d of the working channel 25₂Therefore, the effective diameter of the working channel is not reduced by the clamp 30. This configuration provides the maximum amount of space for the tool to be inserted into the working channel 25. The advantage of the present invention is that standard microsurgical spine tools can be inserted into the working channel and manipulated to perform surgery. The special advantage of the present invention is that the working channel 25 can accept multiple activity equipment at the same time. Prior art devices are not aware of any device that can receive more than one activity device through a single port at the same time. Therefore, according to the present invention, the entire percutaneous surgery process can be performed directly through the working channel 25 of the device 10 by using the viewing element 50 disposed inside the optical element boring 60.

According to the present invention, the device 10 assembly has a cylindrical configuration. In other words, the sleeve 20, the working channel 25, and the clamp 30 have a corresponding cylindrical configuration, and a variety of diameters D can be obtained._I, D_O, D_WAnd d₂. According to other specific examples that are expected to be part of the present invention, these diameters may be non-circular inner and outer diameters, for example, oval or square. For example, the sleeve 20 modified into a square section can still provide a large working channel, for example, the working channel 25. In the same way, the corresponding fixture 30 has a square cross-section, and a large working channel opening D can also be provided_W. Taking the non-circular configuration as an example, the clamp 30 according to the present invention cannot rotate around the periphery of the sleeve 20 like a circular configuration. On the other hand, even the non-circular configuration can still make the optical viewing element move in the axial direction and the viewing element can rotate with its own axis as the axis, as detailed in this article.

According to another variation of the present invention, the sleeve 20 can be replaced by a similar device, which can maintain a large working channel 25. For example, the sleeve 20 can be replaced by an enlarged sleeve or dilator device. In a specific embodiment, the device may be a spirally wound tube, which is unrolled or enlarged to provide the size of the working channel. In addition, a variety of tissue expanders, for example, a large mirror can be expanded to form a working space. In these configurations, once the expandable expander or tissue retractor reaches its full working channel size, the clamp 30 can still be used to support the optical viewing element 50.

Although standard microsurgical equipment can be used in the present invention, the present invention is expected to also include some novel tools that help and enhance the advantages of the present invention.

According to a preferred embodiment of the present invention, the tissue retractor 70 is illustrated in FIGS. 4-6. The retractor 70 is movably and rotatably inserted through the working channel 25 and the working channel opening 35 of the device 10. The tissue retractor 70 includes a working tip 75 configured to displace tissue atraumatically when the retractor 70 is manipulated through the tissue; and a body 76 having a proximal first end 77 and a distal second end 78. The second end 78 can be integrated with the working tip 75, and the working tip 75 preferably has a blunt curved end 82. In addition, the working tip 75 is also preferably bent or bent away from the main body 76, as shown in FIG. The size of the body 76 can be rotatably accommodated inside the sleeve 20, and its length B from the first end 77 to the second end 78 is long enough, so when the body 76 is located inside the sleeve 20, the first end 77 and the working tip 75 can extend outside the sleeve 20.

The present invention is intended to include any suitable retractor for use through the working channel 25. However, the tractor 70 illustrated in Figures 4-6 is better, because the body 76 includes a bent plate 84, which is configured to conform to the inner cylindrical surface 26 of the sleeve, and work is generally not blocked. Channel 25. The bent plate 84 has a convex surface 80 and an opposite concave surface 81. In a specific example, the bent plate 84 includes a first plate portion 85 that defines a first convex surface 80 and a first concave surface 81 on the opposite side. The second plate portion 86 is integrated with the first plate portion 85 and is located between the first plate portion 85 and the working tip 75. The second plate portion 86 defines a second convex surface (not shown) and an opposite second concave surface 81'. The first plate portion 85 and the second plate portion 86 include two opposite edges 90 extending substantially parallel to the length B of the body 76.

Preferably, the arc A between the two opposite edges 90 of the bent plate 84 is opposite₁At least 200 degrees, best 270 degrees. In a specific example, the second plate portion 86, in particular, the second concave surface 81' is diagonally reduced in angle along the length of the tractor. In this way, in a specific example, the second concave surface 81 is adjacent to the first plate portion 85 at a diagonal angle of about 200 degrees, and is reduced to an angle of less than about 10 degrees at the end 78.

An alternative specific example of the tissue retractor according to the present invention is illustrated in Figures 8-11. The tractor 100 has a body 106 that includes a first plate portion 115, which defines a first convex surface 110 and an opposite first concave surface 111, and includes first two opposite edges 120 that extend substantially parallel to the length B of the body 106. The first plate 115 is located between the first two opposite edges 120 and faces the first arc A₂. The tractor body 106 also includes a second plate portion 116 which is integrated with the first plate portion 115 and is disposed between the first plate portion 115 and the working tip 105. The second plate portion 116 defines the second convex surface 110 and the opposite second concave surface 111 , and includes two second opposite edges 120 extending substantially parallel to the length B. The second plate 116 faces the second arc A between the second two opposite edges 120'₃, A₃Is related to the first arc A of this specific example₂different. Preferably, the first arc A₂The diagonal is less than 180 degrees, the second arc A₃The diagonal is greater than 180 degrees. Best, first arc A₂The diagonal is about 90 degrees, and the second arc A₃The diagonal is about 270 degrees.

The tractor of the present invention may be provided with a device for engaging the tractors 70, 100 inside the working channel 25 of the sleeve 20. For example, the structure of the convex surfaces 80, 110 may have a diameter larger than the diameter D of the inner cylindrical surface 26 of the sleeve 20_I. In this case, the bodies 76 and 106 can be made of a resilient material that can be deformed and inserted into the sleeve 20 so that the convex surfaces 80 and 110 contact the inner cylindrical surface 26 of the sleeve 20. When the bodies 76 and 106 are deformed, an outward force is applied to the surface 26 to frictionally fix the tractor at its selected position.

The structure of the preferred assembly provided by the present invention allows a plurality of tools and equipment to be accommodated in the working channel 25 of the sleeve 20 and manipulated therein. Each component is also configured so that multiple surgeons can manipulate the instrument through the working channel 25 of the cannula 20 at a time. For example, one physician manipulates the retractor, and another physician drills a hole in the bone. The curvature of the body 76, 106 of the tractor 70, 100 provides a larger working space and increases visibility. Another feature is that the longitudinal axis of the assembly is placed in the working channel 25, and the bending of the handle keeps the hand away from the channel 25, so multiple surgeons can work in the channel 25, and multiple tools can be placed in the channel 25. The retractors shown in FIGS. 4-11 each include an arm 71, 101 that overlaps the first proximal end 77, 107 of the body 76, 106. Preferably, as shown in Figs. 4-11, the angle α between the arms 71, 101 and the longitudinal axis of the length L of the main body 76 is less than 180 degrees. Preferably, the angle α is about 90 degrees, so the arms 71, 101 are substantially perpendicular to the length L of the body 76, 106. Preferably, the arms 71, 101 have a clamping surface 72, 102 to assist in manipulating the tractors 70, 100.

The present invention also provides a tissue expander that can be used in the device 10. It is contemplated to include any dilator that can be inserted into the working channel 25 of the cannula 20; however, the preferred dilator provided by the present invention is illustrated in Figure 12. The dilator 130 preferably includes a hollow sleeve 135 defining a channel 131. The channel 131 allows the dilator 130 to be placed over a guide wire (not shown) or other dilator. The hollow sleeve 135 has a working end 136 which defines a first opening 132 communicating with the passage 131 and an opposite end 137 which defines a second opening 133. The working end 136 is pushed to the pushing tip 138 to displace the tissue atraumatically. Preferably, the clamping portion 140 is provided on the outer surface 141 of the sleeve 135 adjacent to the opposite end 137. In a specific example, the clamping portion 140 is defined by a plurality of peripheral grooves 142 defined on the outer surface 141. The groove 142 is configured to manually grasp the dilator 130 and manipulate the dilator 130 through the tissue. Preferably, the groove 142 is partially cylindrical. As in the specific example shown in FIG. 12, the clamping portion 140 includes a plurality of peripheral flat strips 143 of peripheral grooves 142. The groove 142 has a first width W along the length of the sleeve 135₁, The flat strip 143 has a second width W along the length₂ 146. Preferably, the first width W₁With the second width W₂Roughly equal.

The present invention can be applied to a wide variety of operations, in particular, spinal operations, for example, laminectomy, laminectomy, foraminotomy, vertebral articular resection, and intervertebral discectomy. The prior art of these operations includes from grossly invasive open surgery to minimally invasive techniques, represented by the patent cases of Kambin and Shapiro. However, in each of the extremely low-invasive techniques, multiple entry into the patient's body is required. In addition, most of the extremely low-invasive techniques of the prior art are only designed to be suitable for approaching the spine from the posterolateral direction. The device and instrument of the present invention can be applied to the surgical technique of the present invention, allowing multiple operations to be performed through a single working channel. The present invention can also be applied to any other pathways and other areas besides the spine. For example, the present invention is expected to include devices of appropriate size that can be used for transnasal, transsphenoidal, and pituitary surgery.

According to one aspect of the present invention, the steps of the spinal surgery procedure are illustrated in Fig. 10. From each step (a)-(i), it is easy to know that the specific example of the present invention allows approaching the spine roughly in the midline or from the middle and rear direction. Of course, it must be understood that the following multiple surgical steps can be performed in other directions of the spine, for example, the posterolateral direction and the anterior direction. In the first step of this technique, the guide wire 150 can be advanced through the skin and tissues and into the vertebral plate M of the vertebra body V. Preferably, a small incision is made to the skin to assist in the penetration of the wire. In addition, the best wire (which can be a K-line) is inserted under the control of radiography or imaging guidance to confirm that it is properly located inside the vertebral plate L of the vertebra V. Of course, it must be understood that the guide wire 150 can be located at any position of the spine and any part of the vertebra V. The positioning of the guide wire is related to the operation to be performed through the working channel cannula of the present invention. Preferably, the wire 150 is firmly anchored to the vertebrae, and if necessary, it can be hammered in with this hammer.

In the subsequent steps of the preferred method, a series of tissue expanders are advanced through the guidewire 150 as illustrated in Figure 10, steps (b)-(d). In addition, the dilator advances through the incision and requires the help of a wire, and then the underlying tissue is cut through the blunt end. In the specific example, a series of dilators 151, 152, and 153 that become larger successively are arranged concentrically to enclose each other, and are arranged to enclose the guide wire 150, and enter the body before sequentially expanding the soft tissues around the spine. Optimally, the tissue expander is of the type shown in Figure 9 of this case. In a specific example, the diameter of the dilator sequentially increases, ranging from 5 mm to 9 mm to 12.5 mm (the largest dilator). It is expected to cover other dilator sizes, depending on the anatomical approach and the desired working channel size.

In the next step of the illustrated technique, the working channel sleeve 20 is advanced through the largest dilator 153 (as shown in step (e)); the dilator and guide wire 150 are removed as shown in step (f). Preferably, the inner diameter D of the working channel sleeve 20_I12.7mm, so it is easy to fit on the large expander 153 with an outer diameter of 12.5mm and advance. Depending on the anatomical area and surgery, it is expected to include a larger working channel cannula.

The sleeve 20 is in place to form a working channel between the patient's skin and the working space adjacent to the spine. It should be understood that the length of the cannula 20 is determined by the special operation performed and the anatomy around the working space. For example, in the lumbar spine, the distance between the vertebral plate M of the vertebra V and the skin of the patient requires a longer sleeve 20 compared to the cervical spine (where the vertebrae are close to the skin) for similar operations. In a specific example, the cannula 20 is used for lumbar intervertebral discectomy, and the cannula is 87 mm long, but the cannula that sits in the patient's body during the operation is only about half the length.

According to this surgical technique, the working channel sleeve 20 is at least initially supported only by the soft tissue and the patient's skin. Thus, in one aspect of the preferred embodiment, the sleeve 20 includes a mounting bracket 27 firmly fixed to the outer surface of the sleeve (Figure 10(f), 11). The mounting bracket 27 can be buckled to the flexible support arm 160 (which can have a known design). Preferably, the flexible support arm 160 is engaged to the mounting bracket 27 with a bolt and a wing nut 161, as shown in Fig. 10(i), the details are shown in Fig. 11, but other fasteners are also expected to be included. The flexible support arm 160 can be installed on the operating table to facilitate adjustment to a fixed position and provide firm support for the sleeve 20. The flexible support arm 160 is preferred, so its contour shape may be away from the surgical site as needed, so that the surgeon has enough space to manipulate various tools and instruments used during the operation.

Referring back to Figure 10, once the cannula 20 is seated in the patient, the clamp 30 can engage the proximal end of the cannula 20, as shown in Figures 2 and 3 and as previously described, the clamp 30 provides an optical element bore 60 , Which is used to support the elongated viewing element, such as the element 50 shown in step h. According to the present invention, the inspection element 50 advances into the jig 30 and is supported by the optical element bore 60 (see Fig. 2). In a specific embodiment, the element 50 is preferably a fiber optic sight glass, but rod lens sight glasses, "sheets/rods" or other sight glasses may also be used. In the final step (i) of the procedure shown in FIG. 10, the flexible support arm 160 is mounted on the mounting bracket 27 to support the sleeve 20, which in turn supports the optical inspection element 50. The last position of step (i) in Figure 10 is shown in Figure 11. The viewing element 50 can be of various types, including rigid endoscopes or flexible and steerable endoscopes.

The inspection element or sight glass 50 is supported by the clamp 30, and the surgeon can directly inspect the area under the working channel 25 of the cannula 20. The surgeon can freely manipulate the viewing element 50 inside the working channel 25 or beyond the distal end of the cannula to enter the working space. Taking a steerable tip end mirror as an example, the second end 52 of the viewing element 50 (which carries the lens 55) can be manipulated to different positions, for example, the position shown in FIG. 11. Generally, any type of viewing element is contrary to the prior art system, and the control and positioning of the sight glass are different from the limitation of the working channel 25.

Preferably, the positioning capability provided by the clamp 30 is used to extend the lens 55 into the working space or retract the inside of the sleeve 20, as shown by the arrow T in FIG. 1. Also, preferably, the fixture can accommodate the viewing element 50 to rotate around its own axis (as shown by arrow R in Figure 1), so as to change the viewing angle provided by the angle lens 55, or to make the entire viewing element 50 take the sleeve 20 as The shaft rotates, or rotates around the periphery of the working channel 25, as shown by the arrow N in the first figure. In this way, the surgeon obtains a complete and unrestricted view of the entire working space under the working channel 25. When the clamp 30 is rotated about the sleeve 20 as an axis, the viewing orientation of the optical element (ie, left and right and up and down) is not changed, so the surgeon's inspection operation and surrounding anatomy are not disturbed.

Another advantage provided by the single working channel cannula 20 of the present invention is that the cannula can be positioned to an appropriate target tissue or bone, so that the working space can be moved as needed for surgical procedures. In other words, because the working channel sleeve 20 sits freely in the skin or tissue of the patient, the sleeve 20 can be manipulated to make the working space below the sleeve 20 more properly centered on the target area of the spine. The repositioning of the sleeve 20 can be guided by a fluorescent mirror. In addition, the sleeve can be fitted with a position sensing device such as an LED for three-dimensional guidance. When the cannula is repositioned, the surgeon can also directly inspect the spine via the viewing element 50.

Once the position of the cannula 20 is determined and the working space is oriented to the appropriate target tissue, a variety of tools and instruments can be extended through the working channel 25 to perform a specific operation. For example, in the case of laminectomy, laminectomy, foraminotomy, or vertebral articular surface resection, a variety of bone forceps, curettes, and circular saws can extend through the working channel opening 35 (see Figure 2) and Enter the working space through the working channel 25 of the sleeve 20 (see Figure 11). It must be understood that these various tools and instruments are designed to fit through the working channel. For example, in a specific embodiment, the working channel 25 through the sleeve 20 has a maximum diameter d₂12.7mm. However, when the inspection element 50 extends into the working channel 25, in the specific example described in the specific example, the effective diameter is about 8mm, but a suitable space is provided around the inspection element 50 inside the working channel 25 so that the tools and instruments are more inside the working channel. Wide range of activities. The present invention is not limited to the special size and effective diameter of the working channel, because the component size will depend on the anatomy of the surgical site and the type of surgery performed.

Preferably, the tools and instruments used for the working channel sleeve 20 are designed to reduce the obstruction of the surgeon's vision and access to the working space at the distal end of the working channel sleeve. In the same way, the instruments and tools are designed such that the leading end of which is manipulated by the surgeon can be displaced by the working channel sleeve 20. An example is the tissue retractor shown in Figures 4-8. Wait for the tractor. The handle grasped by the surgeon is offset by about 90 degrees with respect to the longitudinal axis of the tool itself.

According to one aspect of the present invention, the operation performed through the working channel cannula 20 and performed inside the working space at the distal end of the cannula is a "dry type", in other words, no washing liquid is used. In the prior art surgical technique, the working space of the surgical site is filled with fluid to maintain the working space and assist in the use of inspection optical components. However, the inspection optical element in the prior art system is fixed inside the endoscope. On the contrary, the device 10 of the present invention allows the viewing element 50 to move widely, so the lens 55 can be completely retracted into the working channel 25 of the sleeve 20 to protect the lens 55 from contact with tissues or blood around the spine that may be generated at the surgical site. .

In addition, because the inspection element 50 is movable and replaceable, the inspection element 50 can be completely removed from the jig 30 to clean the lens 55, and then the inspection element 50 can be inserted into the jig again to return to the working space. In this case, the need for injection and washing is less necessary. This feature is particularly valuable when the cutting operation is performed with a power drill. The prior art surgery found that the use of a power drill in a fluid environment may cause fluid turbulence or vortex formation. This kind of turbulence will completely obstruct the surgeon's sight at least when the drill is in operation. The dry environment of the present invention permits continuous inspection of the operation of the power drill, so the surgeon can quickly and effectively perform the required cutting procedures.

When the present invention allows the surgeon to perform surgery in the working space in a dry environment, injection and washing can be provided through the working channel 25. In addition, the inspection device 50 itself may include a tube 54 supported by a fitting 53 through which an appropriate amount of fluid can be provided to keep the visual field clear. In addition, during discectomy, it is better to extract the cut tissue, and injection and washing often help to quickly remove the tissue. In this way, individual injection and washing elements and extraction elements can also be inserted through the working channel 25 according to the needs of the operation.

If necessary, extraction can be performed directly via the working channel 25 of the sleeve 20. In a specific example, as shown in Figs. 11 and 12, an extraction cover 165 may be provided. The cover 165 includes a body 166 that defines a matching bore 167 with an inner diameter d_bThe outer diameter D of the housing 31 larger than the clamp 30_h. A tool opening 168 is provided in communication with the matching bore 167. As shown in FIG. 11, when the extraction cover 165 is installed above the housing 31, the tool opening 168 directly communicates with the upper bore 41 and provides an entrance function as the working channel opening 35 of the housing 31. The extraction cover 165 is also provided with a tube receiver bore 169, and the receiver bore 169 crosses the matching bore 167. The structure of the receptacle bore 169 can accommodate an extraction tube through which a vacuum or extraction is applied. In this case, the tool opening 168 can be covered, and at the same time, the extraction is applied through the tool receiver bore 169 and the matching bore 167, and finally the extraction is applied through the working channel 25. Covering the tool opening 168 can achieve the best extraction effect through the working channel.

Once again, referring to the surgical technique of a specific example of the present invention, as illustrated in Figure 10 step (i) and Figure 11, once the working channel cannula 20 and the viewing element 50 are in place, the use of the aforementioned instruments can reflect the tissues around the spine. Laminectomy can be performed using various bone forceps, curettes, and drills. If necessary, the sleeve 20 can be angled to obtain a larger bone activity area, which is close to other parts of the spine anatomy. In some cases, it is necessary to cut a part of the vertebrae that is larger than the inner diameter of the working channel 25 when approaching the spinal canal and the mid-posterior direction of the intervertebral disc ring. In this way, the sleeve 20 needs to be manipulated to remove a larger portion of bone. In other operations, multi-level laminectomy or bone hole incision is required. In this case, the multi-level surgery can be performed in sequence by grasping the working channel sleeve 20 through a number of small skin incisions along the midline of the spine. In addition, several working channel sleeves 20 can be placed in various small skin incisions for multi-level bone resection.

Again, according to the preferred surgical technique described in the example, an opening is cut in the vertebral plate M of the vertebra V and the spinal canal itself can be directly visually inspected. If necessary, the surrounding tissues of the spinal nerve roots can be removed with a microscalpel and curette. Once the spinal nerve roots are exposed, the retractor shown in Figures 4-8 can be used to gently move and fix the nerve roots outside the working space. In the main aspect of the two retractors 70 and 100, the retractor part passing through the working channel 25 usually fits the inner surface of the sleeve 20, so that the working channel 25 is not damaged by the retractor tool. In particular, the effective internal diameter of the working channel 25 is only reduced by the thickness of the bent plates 84, 114 of the tractors 70, 100. In a specific example, the thickness is about 0.3 mm, and it can be seen that the tissue retractor will not significantly reduce the useful space inside the working channel 25 for inserting other tools and instruments.

The tissue retractor is positioned inside the working channel 25, and the bone inside the spinal canal, for example, the bone of a burst fracture can be removed with a curette or a high-speed drill. In addition, the fractured bone can be beaten back into the body of the vertebra with a bone impactor. At this time, if the spinal surgery to be performed is to remove the epidural spinal tumor, the tumor can be removed using a variety of microsurgery instruments. In other operations, the dura mater can be opened, and the intradural lesions can be approached through the working channel cannula 20 with microsurgery instruments. According to the technique illustrated in the special example, the middle and posterior intervertebral disc with the nerve root retracted can be easily removed directly from the diseased part by Hernia.

In another specific example of the present invention, the working channel sleeve, such as the sleeve 20, is provided with a clamp 170 for supporting the optical element and the injection/extraction assembly. According to this specific example, the clamp 170 includes a mirror body 171, which is most clearly shown in Figures 13, 14, 16, and 17. The sight glass body 171 includes a clamping ring 172 configured to cover the outer surface 23 of the sleeve 20. In particular, the clamping ring 172 includes an inner clamping surface 175 (see Figure 14). The inner clamping surface 175 generally has the same configuration and size as the outer surface 23 of the sleeve 20. The clamping ring 172 includes clamping arms 173 a and 173 b at the free ends of the clamping ring 172. The clamping arms 173a, b define a long slot 174 therebetween (see Figure 17).

The clamping ring 172 is integrated with the supporting column 176 forming a part of the mirror body 171. A long column slot 177 is formed on the support column 176, and the column long slot 177 is continuous with the long slot 174 between the clamp arms 173a, b. As detailed here, the long grooves 174 and 177 can compress the clamping arms 173a, b toward each other, thereby compressing the inner clamping surface 175 of the clamping ring 172 to fit the outer surface 23 of the sleeve 20. In this way, the clamp 170 can be fixed to a specific position of the sleeve 20. It should be understood that when the clamping ring 172 is loosened, the clamp 170 can rotate around the periphery of the sleeve 20 in the direction of the arrow N. In addition, the clamp 170 can be translated along the longitudinal axis of the sleeve 20 in the arrow T direction. Of course, the moving distance direction of the clamp 170 along the length of the sleeve 20 is limited by the proximal end 22, and the mounting bracket 27 is used to engage the flexible support arm 160 as described above.

Refer back to Figures 13-17 and consider the additional details of the fixture 170. In particular, the clamp 170 includes an optical element mounting body 178 which is supported by the support post 176 and is preferably integrated with the support post 176. The optical element mounting body 178 defines a stop edge 179 at the interface between the supporting column 176 and the mounting body 178. The stop edge 179 defines the height of the support column from the clamping ring 172 to the stop edge 179. The stop edge 179 of the optical element mounting body 178 can restrict the downward movement of the clamp 170 in the arrow T direction, which is particularly important for the specific example of the sleeve 20 without the mounting bracket 27.

According to this specific example, the optical element mounting body 178 defines an optical element boring hole 180 configured to receive and support the optical element sleeve 190. The optical element bore 180 can communicate with the illumination hole 181, which can accommodate an illumination source such as a fiber optic cable. The optical element boring hole 180 also communicates with the optical element coupling boring hole 182 protruding from the front surface of the jig 170. According to a specific example, the clamp 170 also includes a coupling body 183, which is preferably pressed into the coupling bore 182 of the optical element. As shown in FIG. 15, the coupling body 183 can be engaged by the coupling 184 to support the camera 185.

In another aspect of the optical element mounting body 178, an extraction port 186 and a flushing port 187 may be provided, which are communicated with the optical element boring hole 180. Preferably, the optical element sleeve 190 includes a channel along its length corresponding to the openings of the optical element mounting body 178. In a specific embodiment, the port 181 is not used, and the port 186 is used to accommodate the lighting element. As shown more particularly in Fig. 23, the injection and washing port 187 is connected to the extraction circuit. In particular, the port 187 is engaged with the extraction tube 225, which carries a flow control valve 226 and a luer fitting 227 at the free end. Depending on the special purpose of the corresponding channel inside the port 187 and the optical element sleeve 190, the lug fitting 227 can be engaged with an injection fluid source or a vacuum extraction pressure.

According to the method of the present invention, the port 187 is used as an extraction port, and a luer fitting 227 is attached to connect to the vacuum source. It should be understood that the port 187 is in fluid communication with the corresponding channel of the optical element sleeve 190, so the extraction applied via the tube 225 and the port 187 passes through the distal end or working end 192 of the optical element sleeve 190. The working end 192 is located at the surgical site, so the air is drawn through the working channel 25 of the cannula 20 to the surgical site and through the extraction/infusion channel of the optical element cannula 190. It is found that this method provides suction and extraction, which can eliminate the smoke generated during the operation of certain devices such as Bovie. In addition, extractable air is drawn through the port 187 through the lens 191 of the optical element tube 190 (see Figures 14 and 15) to prevent the lens from fogging. If another extraction tube extends through the working channel, the defogging of the lens 191 is best achieved by opening the extraction tube adjacent to the lens. In this way, an extraction vacuum is provided through the working channel and the working space, and the need to retract the optical element sleeve 190 and clean the lens 191 is generally eliminated. This is the opposite of the prior art device. In the prior device, the lens must be displaced from the operating part for cleaning, or the device must maintain a substantial fluid flow to keep the lens clean and clear.

Refer to Figures 18-22, which show details of the barrel clamping mechanism 195. The barrel clamping mechanism 195 compresses the clamping arms 173 a and 173 b of the clamping ring 172 to clamp the clamp 170 to the sleeve 20. The barrel clamping mechanism 195 includes a barrel cam 196 disposed just adjacent to one of the clamping arms 173b, and a lever arm 197, which operates to compress the barrel cam 196 to hold the clamping arm 173. Shoulder screws 198 secure the components together. In particular, the shoulder screw 198 includes a threaded shank 199 configured to engage a matching threaded bore 202 on one of the clamping arms 173a. The shoulder screw 198 includes a bearing shank 200, which is smooth and unthreaded. The bearing handle 200 is accommodated in the bearing bore 203 of the clamp arm 173b, the collinear bearing bore 204 of the barrel cam 196, and the bearing bore 205 of the lever arm 197. The shoulder screw 198 further includes an enlarged head 201, which is preferably accommodated in the head internal gap 206 of the lever arm 197 (see FIG. 19). Preferably, the enlarged head 201 of the shoulder screw includes an internal clearance of a driving tool, which is matched with the driving tool to bolt the threaded shank 199 of the screw into the matching threaded bore 202 of the clamp arm 173a. It should be understood that the barrel cam 196 and the lever arm 197 can freely rotate with the bearing handle 200 of the shoulder screw 198 as an axis.

With particular reference to FIGS. 18-19, the lever arm 197 includes an arm 210 which is integrated with the main body 211. The bearing bore 205 and the head internal clearance 206 are defined in the body 211. The body 211 defines a pair of protrusions 212 located on two opposite sides of the bearing bore 205. As shown in Figure 19, each protrusion 212 includes a rounded tip 213 to provide a smooth sliding surface.

With particular reference to Figures 20-21, the barrel cam 196 includes a flat surface 215 facing the clamp arm 173b. Preferably, the flat surface provides smooth rotation of the barrel cam 196 relative to the clamp arm 173b. The two opposite surfaces of the barrel cam 196 are cam surfaces 216, which include a pair of diametrically opposed cam portions 217. According to a preferred embodiment, the cam portion 217 defines a slope 218 that slopes upward to the internal clearance 219 of the catch. The internal clearance 219 of each pawl stops at a stop block 220. Compared with the bottom, the clearance 219 of the pawl is higher than the slope 218.

In the assembled structure, when the lever arm 197 rotates with the shoulder screw 198 as an axis, the barrel clamping mechanism 195 operates to compress the clamping arms 173a, b of the clamping ring 172. Particularly, when the lever arm 197 rotates, the protrusion 212 slides along the slope 218 at its rounded tip 213 until the rounded tip 213 falls into the inner gap 219 of the opposing pawl. When the protrusion 212 moves upward along the slope 218, the protrusion 212 pushes the barrel cam 196 toward the clamping arms 173a, b. In particular, since the opposite clamping arm 173a is held relatively fixed by the threaded handle 199 of the shoulder screw 198, the movement of the barrel cam 196 forces the clamping arm 173b to hold the relatively fixed clamping arm 173a. When this happens, the clamping ring 172 tightens the outer surface 23 of the sleeve 20. When the protrusion 212 is seated in the inner gap 219 of the pawl of the barrel cam 196, the clamp is locked to the sleeve 20. It should be understood that the internal gap 219 is shallow enough and when the lever arm 197 rotates in the reverse direction, it is easy to manually remove the protrusion 212 from the internal gap 219.

In a specific example, the internal gaps 219 of the two pawls are opposite to each other at 180 degrees. The slope 218 is curved and has a diagonal angle of about 90 degrees. In this way, the lever arm 197 rotates at an angle of 90 degrees to move the protrusion 212 from one end of the slope 218 to the internal clearance 219 of the pawl. In a preferred embodiment, the 90-degree movement of the lever arm (arrow J in Figure 15) can move the lever arm from a first position where the lever arm 197 is substantially parallel to the sleeve to a second position where the lever arm 197 is substantially perpendicular to the sleeve. Optimally, in the second position, the lever arm is oriented next to the sleeve rather than protruding. In the first and second positions, the lever arm 197 maintains a low posture and does not interfere with the surgeon's manipulation of tools and instruments through the working channel. In a specific example, the first position of the lever arm corresponds to the loose or unlocked position of the barrel clamping mechanism 195, and the second position corresponds to the locked configuration.

For the barrel clamping mechanism 195 to function properly, it is preferable that the barrel cam 196 be kept fixed relative to the movable lever arm 197, but the barrel cam 196 can move freely along the length of the shoulder screw 198. As a result, the clamping arm 173b includes an internal gap 222 whose configuration is substantially similar to the outer periphery of the barrel cam 196. In this way, the barrel cam can be slightly recessed into the clamp arm 173b, so when the lever arm 197 is pivoted, the cam cannot rotate freely about the shoulder screw 198 as an axis.

According to a specific embodiment of the present invention, the clamp 170 assembly is made of flexible and resilient material. For example, the mirror body 171 can be made of plastic such as polycarbonate. The sight glass body 171 is particularly suitable for typical plastic molding techniques. Similarly, the barrel cam 196 and the lever arm 197 can be made of plastic materials. In a specific example, these components are made of Delrin because Delrin provides a smooth surface for relative movement between the protrusion 212 on the lever arm 197 and the cam surface 216 of the barrel cam 196.

It should be understood that the movement of the barrel clamping mechanism 195 can be fully calibrated to tightly press the clamping ring 172 that covers the sleeve 20. It is also necessary to understand that this compression force is no longer too large to damage the strength and integrity of the casing 20. In a specific example, the long groove 174 is larger than the maximum moving distance of the barrel clamping mechanism 195, so the protrusion 212 of the lever arm 197 can be properly parked in the inner gap 219 of the pawl of the barrel cam 196. According to a specific example, the long groove 174 has a size of 2.0 mm, and the barrel clamping mechanism 195 reached by the barrel cam 196 has a drop of 1.0 mm.

According to this embodiment of the present invention, the clamp 170 supports the optical element sleeve 190 in a fixed orientation relative to the mirror body 171. In other words, in this specific example, the optical element tube 190 cannot rotate around its axis like the mirror 50 in the specific example shown in FIG. 1. Therefore, the lens 191 is installed at an angle B relative to the distal end of the optical element sleeve 190. In a specific example, the lens 191 is positioned at an angle B of 30 degrees. In addition, in this specific example, the lens has an optical axis that faces the working channel 25 or the center of the sleeve 20 at an angle. Although the lens 191 has a fixed orientation relative to the mirror body 171, the lens can still be rotated around the outer surface 23 of the sleeve 20 via the clamp 170 to rotate around the working space. In addition, the depth of view provided by the lens 191 and the optical system allows the surgeon to inspect the external anatomy of the working channel 25.

Even in this specific example, the clamp 170 permits the optical element sleeve 190 to rotate around the working space, and the optical element sleeve 190 and the lens 191 translate along the longitudinal axis of the working channel 25. Of course, it must be understood that the surgeon can complete these movements by loosening the barrel clamping mechanism 195, and then by rotating the lever arm 197 to its locked position and then engaging the clamp. Preferably, the size of the optical element sleeve 190 is such that the lens 191 protrudes beyond the distal end 21 of the sleeve 20. Similarly, in a preferred embodiment, the clamp 170 can retract the lens 191 and the optical element sleeve 190 into the working channel 25 and the sleeve 20.

In a specific example, the clamp 170 is allowed to move in the direction of the arrow T to 15 mm, 7.5 mm is tied inside the working channel 25 and 7.5 mm is beyond the distal end 21 of the sleeve 20. According to this specific example, the 15mm travel distance is related to the height of the support column 176 from the clamping ring 172 to the stop edge 179 of the optical element mounting body 178. The amount by which the lens 191 of the optical element sleeve 190 extends beyond the distal end 21 of the sleeve 20 is also based on the total length of the optical element sleeve 190 relative to the total length of the working channel sleeve 20. In a specific example, the optical element sleeve 190 is measured from the lens 191 to the length of the stop edge 179 of the optical element mounting body 178 by 100 mm. Of course, it must be understood that the optical element sleeve is longer than this 100 mm distance, because part of the sleeve is supported inside the optical element bore 180 of the optical element mounting body 178. Again, in this specific example, the sleeve 20 has a total length of 92 mm from the distal end 21 to the proximal end 22 (see Figure 15).

In another aspect of the present invention, the total length of the sleeve, and as a result, the total length of the optical element sleeve 190 is determined by the anatomy of the spine. In particular, for the application of the present invention in the field of spinal surgery, it is found that the proximal end 22 of the working channel 25 is set too far from the surgical site of the distal end 21, which causes the surgeon to lose touch when manipulating certain instruments. In other words, when the surgeon passes the instrument through the working channel and manipulates the surgical site, a certain amount of "feeling" is required so that the surgeon can perform the operation correctly with the instrument. If the distance between the surgical site and the end of the manual control instrument is too large, the surgeon cannot control the instrument stably and comfortably.

According to an advantageous aspect of the present invention, it is found that the length of the working channel sleeve 20 is limited relative to the distance L between the vertebral plate and the skin surface (see Fig. 24). The distance from the lumbar spine is about 65-75mm. As a result, in a specific example of the present invention, the length of the first part of the working channel sleeve 20 is slightly smaller than the anatomical distance. In a specific example, the length from the distal end 21 to the first part of the mounting bracket 27 is about 66 mm. In some surgical applications, the mounting bracket 27 can reliably stop on the patient's skin, so that the distal end 21 of the working channel sleeve is closer to the surgical site.

Furthermore, according to the present invention, the length of the remaining second part of the sleeve 20 higher than the mounting bracket 27 is reduced. According to the present invention, this distance must be sufficient to allow the lens 191 to expand and contract with respect to the distal end 21 of the sleeve 20. As mentioned above, the travel distance of the optical lens 191 is preferably 15 mm, so that the remaining length of the sleeve 20 is about 26 mm to match this travel distance and provide a suitable surface for engagement by the clamping ring 172. Thus, in a preferred embodiment, the total length of the working channel sleeve 20 is 92 mm. According to one aspect of the present invention, it is found that the relative length ratio between the first part located in the patient's body and the second part located outside the patient's body of the sleeve is 2:1 to 3:1. In other words, the length of the first part is two to three times longer than the length of the second part.

It has also been found that it is desirable to reduce the height of the clamp 170 beyond the end of the working channel sleeve 20. According to the present invention, the height of the optical element mounting body 178 between the stop edge 179 and the top surface of the body 178 is about 21 mm. Such a distance will not be too large to prevent the surgeon from directly manipulating the instrument over the jig 170. Of course, it is preferable for the surgeon to manipulate the instrument in close proximity to the clamp 170, just above the proximal end 22 of the cannula 20.

In this preferred embodiment, the inner diameter of the working channel sleeve is about 15 mm and the outer diameter is about 16 mm. In addition, the cannula can be placed in other areas of the spine in a smaller size. In another specific example, the inner diameter of the sleeve is 12.7 mm and the outer diameter is 14 mm. In another aspect of the present invention, the total length and diameter of the working channel sleeve 20 are again calibrated relative to the anatomical distance L of the spine. With a larger diameter working channel, the surgeon can orient the instrument at an angle relative to the longitudinal axis of the cannula 20. In a specific example, this angle is about 5-6 degrees. It is found that this included angle and the large working channel 25 enable surgeons to have greater flexibility and mobility at the surgical site to perform various operations. To achieve this, the length and diameter of the working channel sleeve 20 must be appropriately sized to maintain such elasticity and not become too large. The working channel sleeve 20 with an excessively large diameter is less suitable for spinal anatomy.

According to the preferred use of the device 10 of the present invention, the working space is usually limited to the area directly adjacent to the vertebral plate. A cannula with an excessively large diameter will interfere with the spinal process when forming a working space, and a larger amount of tissue needs to be removed compared to percutaneous surgery. Therefore, according to one aspect of the present invention, the relationship between the length and the diameter of the working channel sleeve allows the tool to pass through the sleeve at an angle of 5-8 degrees. According to a specific aspect of the present invention, the sleeve has a length to diameter ratio of about 5.5:1 to 7:1. Furthermore, according to the present invention, the length of the working channel sleeve is longer than the distance L between the vertebral plate and the patient's skin (see Figure 24) but not more than 20-30 mm.

One of the major features of the present invention is achieved by the large diameter of the working channel 25 in the casing 20. This large diameter allows the surgeon performing the operation to introduce multiple instruments or tools into the work space at one time. For example, as described above, the tissue retractor and the resection instrument can extend through the working channel at the same time. In the specific example illustrated by this example, the resection instrument includes a circular saw for boring through the intervertebral disc annulus, and an electric tissue cutting angle for resection of the nucleus of Hernia's intervertebral disc. Similarly, the present invention is expected to include the specific needs of performing surgery, while introducing other types of instruments or tools. For example, a curette and a bone clamp of an appropriate size can extend through the working channel into the working space at the same time. Since all operations performed in the working space are performed under the direct visual observation of the surgeon through the viewing element 50, the surgeon can easily manipulate various instruments to perform tissue resection and bone resection operations without having to remove one tool to insert another tool. In addition, since the operation can be performed without flushing fluid, the surgeon has a clearer vision through the working space of the target tissue. In addition, the aspect of the present invention permits a wider range of motion relative to the viewing element 50, so that the surgeon can clearly see the target tissue and clearly observe the operation being performed inside the working space.

Surgeons have the advantage of performing extensive operations on a wide range of parts of the body. For example, vertebral arthroscopy can be performed through the working channel by simply orienting the working channel sleeve 20 to a specific articular joint. The insertion of the vertebral fastener can also be achieved by the device 10. In this type of surgery, an incision can be made in the skin behind the vertebrae where the fixture is to be implanted. When performing the steps shown in Fig. 10, the sleeve 20 can pass through the incision and tissue directly above the specific part of the vertebra where the device is to be implanted. The optical element extends through the working channel, and the insertion tool holding the vertebral fastener can be protruded through the sleeve 20 and manipulated in the vertebrae. In a specific embodiment, the fixing member may be a bone screw. The diameter of the working channel 25 is large enough to accept large half bone screws and related insertion tools. In many cases, the position of the bone screw inside the vertebrae is very important, so it is necessary to identify the position of the sleeve 20 on the bone. As mentioned above, this position can be confirmed by fluoroscopy or using stereo photography.

In many previous operations, the cannulated bone screws were screwed into the vertebrae along the K line. The invention can eliminate the need for K-wire and sleeved bone screws. Once the sleeve 20 is properly oriented with respect to the vertebra, the working channel itself can be effectively manipulated as a positioning guide. In addition, the device 10 permits the insertion of the Murex system to be performed under direct visual inspection. The surgeon can easily verify that the screw has properly entered the vertebrae. This is particularly important when the bone screw is to be inserted into the vertebral foot. The working channel sleeve 20 can be used to directly insert a self-tapping bone screw into the vertebral foot; or can accommodate a variety of tools and prepare threaded holes in the vertebral foot for accommodating bone screws.

The device 10 can also be used to prepare the joining site of two adjacent vertebrae and for implanting joining devices or materials. For example, in a surgical technique, an incision can be made in the skin behind a specific intervertebral disc space to be joined. The incision can be made in the anterior, posterior, or posterolateral direction. If the incision is performed from the front and the working channel is inserted from the front, it is expected that the path of the incision to the intervertebral disc space should be carefully followed to retract the tissues, muscles, and organs. However, the device 10 of the present invention allows such tissue retraction to be performed under direct visual inspection, so the surgeon can easily guide the cannula 20 to the intervertebral disc space without risk of damaging the surrounding tissues. When the tissue under the skin is sequentially removed or retracted, the working channel sleeve 20 can gradually advance toward the expected working space adjacent to the intervertebral disc. Once again, under direct visual inspection, the intervertebral disc space can be prepared for implantation of the joining material or joining device. Typically, this preparation involves preparing an opening in the intervertebral disc ring, and removing all or part of the intervertebral disc nucleus through the opening.

In the subsequent steps, a perforation is cut through the intervertebral disc ring and cut into the end plate adjacent to the vertebrae. Then, an engagement device such as a bone nail, a propelling implant, or a threaded implant can be advanced through the working channel of the device 10 into the prepared boring of the intervertebral disc space. In some cases, the preparation step includes reducing the end plate to exudate bone. In this case, it is better to perform extraction and injection washing. All of these procedures can be performed by the inspection element 50 under direct visual inspection with tools and instruments extending through the working channel sleeve 20.

In some cases, the graft material is simply placed in a prepared bore. This kind of graft material can also enter the intervertebral disc space through the working channel sleeve 20. In other operations, the graft material or bone fragments are placed across the back of the spine. Again, this kind of procedure can be carried out through the working channel cannula, in particular, so that the cannula can be moved to a different angle from the cut of the skin.

The present invention provides instruments and techniques for performing various operations. In the specific case illustrated by the example, these operations can be performed on the spine. But the same devices and techniques can also be used for other parts of the body. For example, a device 10 with a working channel of an appropriate size can be used to remove brain lesions. The present invention is particularly valuable for percutaneous surgery. At this time, it is hoped that the invasion to the patient is minimal, and tools and instruments need to be accurately manipulated at the surgical site. Although the preferred specific examples illustrated above are related to spinal surgery, the technology of the present invention can be applied to the whole body, for example, intracranial cavity, pituitary gland area, gastrointestinal tract, etc. If necessary, the inspection optics can be repositioned to inspect the surgical site, so that higher accuracy and control of the surgical process can be obtained. The invention permits the use of a single entrance to penetrate the patient's body, thereby greatly reducing the risk of open surgery or multiple invasions through the patient's skin.

According to another aspect of the present invention, a tissue retractor device 230 is provided, which combines the tissue retractor 231 and the optical inspection device 232. Referring to Figures 25-26, the tissue retractor device 230 includes a retractor plate 234 fixed to the handle 235 for manual operation of the retractor. The handle 235 is located at the proximal end 236 of the plate. The distal end 237 of the retractor plate preferably has a blunt tip 238 to prevent damage to the tissue during insertion and manipulation of the tissue retractor. Preferably, the blunt tip end 238 is slightly away from the tractor plate 234 at an included angle. The retractor plate 234 defines an external traction surface 239, which can be configured according to the type of surgery performed. In a preferred embodiment, the plate 234 has a semi-cylindrical shape to allow the tissue adjacent to the surgical site to be retracted non-invasively. In addition, the tractor plate 234 defines a channel 240, which helps to define a working channel. As described herein, the tractor 231 is substantially similar to the tractor 70 in FIGS. 4-6.

According to this specific example of the present invention, the optical inspection device 232 is supported by a plurality of C-shaped clamps 245 inside the tractor 231. Preferably, the C-shaped clip 245 is made of elastic material such as plastic or thin soft metal, and is fixed to the channel 240 of the tractor plate 234. According to a specific example, two C-shaped clamps 245 are provided to firmly install the optical inspection device 232 relative to the tractor 231. The size of the preferred clip 245 can support the optical inspection device 232, and its configuration is substantially similar to the aforementioned inspection element 50. In a preferred embodiment, the optical inspection device 232 has a distal end 52 with an angle lens 54 attached. According to this specific example, the C-shaped clip 245 provides elastic friction fit to the optical inspection device 232, while still allowing the optical inspection device 232 to slide and rotate relative to the tractor 231.

According to the present invention, the tissue retractor device 230 can be used for a variety of purposes, including non-vertebral uses. For example, this type of tissue retractor can be used for nasal penetration and sphenoid surgery and pituitary surgery. In this type of surgery, it is not necessary to provide a closed sleeve such as the working channel sleeve 20. In addition, a small working space is not enough to use a closed sleeve, which tends to limit the space available for manipulation of surgical instruments. As a result, the type of tissue retractor or mirror shown in Figures 25-26 is very suitable for this type of surgery. In this case, the working channel is partly defined by the patient's body, and partly defined by the tissue retractor. The optical inspection device 232 is supported with respect to the retractor to obtain the same degree of movement as previously described for the device 10.

Although the foregoing description and drawings illustrate the present invention and describe its details, it is only considered to be illustrative and not restrictive. It should be understood that only preferred specific examples are presented and described, but all changes within the scope of the present invention Both and modifications should be protected.

Device for percutaneous surgery