US 1881250 A
Description (OCR text may contain errors)
. Filed JuneZO, ,1929
Patented Oct. 4, 1932 GEORGE MILTON TOMLINSON, 0F PHILADELPHIA, PENNSYLVANIA v ELECTROSURGICAL INSTRUMENT Application led .Tune 20,
My invention relates to a surgical instrument.
A purpose of `my invention is to mechanically guidean electro-surgical knife or wire. Where a clamp is used it may be made in one .instrument with the knife or wire.
A further purpose is to combine av clamp and means for applying high frequency current to tissue compressed in the clamp, using the clamp to temporarily stop the flow of blood or lymph in the tissue and the high frequency current applied to the tissue during its compression to permanently seal the compressed passages in the tissue7 thereby insuring. that there will be no bleeding or lymphatic discharge after the clamp .has been released.
A further purpose is to provide an instrument well adapted to safely remove the tonsil of a child, or any tonsil which is hypertrophied and exposed, combining means for clamping the tonsil at its basal support, with an electro-surgical knife for simultaneously severing the tonsil and eecting a sealing reaction upon the severed passages for blood and lymph. l
. A further purpose isto provide a spring retracted hemostat clamp with ratchet adjustment mechanism and a spring release for the ratchet, adapting the clamp to remain in any set position and to be quickly yopened y upon touching the spring release.
A further purpose is to avoid the need for crushing the basal attachment of a tonsil in order to prevent bleeding after a tonsil removal and to lessen the requisite operating voltage fora high frequency current of an electro-surgical knife by combining a clamp and electro-surgical knife.
A further purpose is to mount an electrosurgical member for applying high frequency current upon the front of a clamp member so as to adapt the instrument to clamp tissue to definite position and then to turn on the high frequency current and to push the clamp and applying member through the tissue.y
' Further purposes will appear in the specification and in the claim.`
I `have electedto show mylinvention applied to a tonsillotome in that it has proved 1929. serial N0.,372,370.
to be particularly advantageous in its application to this type of instrument and to show the broader features of my invention diagrammatically, selecting embodiments of my inventiony that are practical and eiicient in operation and that well illustrate the principles involved.
Figure 1 is a side elevation of an instrument embodying a desirable form of my invention and having a particular application for removing tonsils.
Figure 2 is a top plan view of Figure 1.
Figure 3 is a diagrammatic detail section illustrating a different form in which the frequency u member for applying the high current is mounted on the front ofthe clamping member for use first as a positioning clamp and then for removal'of the positioned tissue.
Figure 4 is a diagrammatic'view illustrating my combination of clamp and electrosurgical knife position to remove a hemorrhoid or the like.
Figure 'is a view of a slightly different application of the structure shown in Figure 4.
Figure 6 is a detail diagrammatic elevation illustrating a combination between a clamp and a spring closure carrying a scale adapted to show the pressure exertedl by the clamp.
Figure 7 is a view generally similar to Figyure 4 but showing an electro-surgical knife operating upon tissue inwardly from a clamp,y the clamped tissue being cut olf while clamped, the return circuit taking place through the tissue being cut away.
Like numerals refer to like parts.
Describing in illustration and not in limitation and referring to the drawing The' tonsillotome shown in F igures 1 to 3 combines a guillotine type of clamp and electro-surgical knife for easy and safe removal of tonsils. l
A fenestra or guillotine frame 10 adapted to surround a tonsil 11 comprises the outer end of a frame guideway structurev 12.
The fenestra slidably supports a clamp 13 in side grooves 14 and an electro-surgical -ll knife 15 in side grooves 16 and the frame structure 12carryi'ng the fenestra is supported uponthe body portion 17 of a hand grasping member 18. Y
The rearwardly extending frame 12 comprises a housing and guiding support for the shank portions 19 and 20 of the clamp and of the electro-surgical knife respectively.
The flat Shanks 19 and 2O are provided ywith guides 21 and 22 respectively toward the front and rear ofV the frame structure and are vertically slotted at 23 and24 to pass an operating kfinger 25 which is pivoted at 26 to the member 17 and'is'v preferably integral with a movable handlef27. f Y
The frame structure 12 is rigidly'fastened to the top' of thehand grasping member 18 as bya pin 2.8 extending'downward'from'the Vof the clamp in the fenestra is determined fairly closely by the angular position of the f handle 27 while the slot 24 through the shank 'of thel electro-surgical knife is considerably i longer than the width of the operating finger in its clampingposition.
' and compressed betweenv the'structure 12V 25 in order to permit the knife member to be moved forward after the clamp has been set YVI provide4 the lshank of the electro-surgical knife with a rearwardly extending rod 30 which passes throughthe guide 22 ofthe frame structure and carries a concaved flange thumb engagement member 31 at its rear- 'ward end.
TheV member 31 receives the operators thumb 'whenk the electro-surgical knife is to be pushed forwardly to sever'the clamped tonsil, and the knife is spring-retracted by a suitableV spring 32 surrounding the rod 30 Y and the push flange 31.
y I `Vprovide a sector ratchet connection between the hand graspingmembers 18 and Y 27 showing the movable member 27 with a sector 33 adapted to lslide in a suitable arcuate .opening 34 kin the body 17 of the mem- The sector has ratchet teeth 34 along its inner side whichare engaged by a cooperating pawl member 35 spring pressedat 36 to its engagement position 'at which it vholds the sector from retraction. Y 'i f ber 18. Y
The pawl member 35.*is-.slidably mounted in a guiding recess37 in the member 17 be- :in'g'spring pressed into engagement with the ratchet bythe spring 36and carries all) member y38 for releasing the pawl from the teeth VVof the ratchet. Y
The release member38 is rigidly fastened t0 the pawl and is suitably placed for'eas'y engagement by the surgeons thumb to effect release of the ratchet and a spring opening'of the clamp; Y Y n vThe electro-surgical knife may desirably comprise a thin strip 40- of suitable metal or wire, as copper or silver, inserted between sheets 41 and 41 of insulation material. The
Y fenestra is also insulated as at 42.
The knife has electrical'connection at 43 to a conductor which in practice is connected at its other end to a source of high frequency current adapted to electro-surgical use. p
' The other terminalV of the high frequency current, vwhere a second terminal is used, is usually connected toa plate lthat is placed in close Contact or in Contact with'tissue being removed, as a loop or forceps or other vmeans of contact. This is ordinarilya plate applied tothe backof the patient. Other vconnections areshowndiagrammatically in Figures 4 to 6 for local return where this is desired.
In operation the open fenestra is pushed down over the tensile. In the case of a child the fenestra will pass through any adhesions, which in a childs tonsil are softf vWhen the fenestra is at the bottom of the tonsil the clamp is gradually tightened, which lifts the tonsil out of its seat between the pillars of the palate, exposing it in position for the cut. f v
YThe Vclamp is then tightened preferably merely enough to stop any circulationin the clamped tissue of lymphv or blood.V
The surgeon then movesthe electro-surgical knife slowly inward severing the tonsil, desirably moving the knife severalV times back and forth over the cut tof insure perfect sealing of the severed passages.
method has a great advantage over` the' practicehithertoof having tocrush the tissue in the clamp in order to prevent bleeding after the cut. y Y' Y After a surge-on' has closedthe Vclamp it is heldin its set position by the ratchet member. During closure the operator` should judge by feel as to the tightness of clamping and the ratchet makes it unnecessary for his attention to be directed to maintaining the clamp at the proper tightness while making the cut. n lf the cut is made fairly rapidly and the knife is operating at a relatively low voltage I prefer to move the knife backv and forth slowly over the severed tissue inv order to insure complete coagulation of the blood and lymph compressed in the tissue, this coagulation sealing thel severed passages so perfectly that there is no danger of bleeding after the clamp hasbeen loosened. l
.The operation is considerably'more rapid lli VVfandsinore safe than has been ypossible inthe the'tissue at the base .ofthe hitherto been usual the cut, and continued for about twominutes `thereafter in order to securea-merely fair :pressure .there has been no :I avoid the need for the intense crushing of tonsil which has preparatory to making degreeofsafety from subsequent bleeding `clamp or perhaps after a considera-ble period.
' I avoid to a great degree the possibility of secondary infection incident to bacterial kinvasion through open lymphatic' and vascular channels and to partial devitilization through intensive clamping of the parts.
I am also enabled to operate my electrosurgical knife more rapidly or `with lower voltages, either or bothyas compared with the electro-surgical knivesof the prior art in view of operation upon tissue under compression, the compressed passages of the tissue containing greatly reduced quantities of blood and lymph that is stationary and very easily coagulated by the high frequency current at lower voltages than has been necessary in the past.
I use a clamp to exactly position the tissue that is to be severed and preferably tighten the clamp, merely enough tohold the tissue in the desired position and to stop any circulation of lymph or blood in the tissue during the cutting, and cut by mechanically guiding the electro-surgical knife through the compressed tissue. If desired the tissue can be crushed by the clamp, as in prior practice, using the electrical coagulation for the purpose of ensuring the freedom from bleed- 1 ing which was sought but not reliably secured by the crushing.
I have in Figures 1 to 3 shown my invention embodied upon a tonsillotome in that it is particularly advantageous for this use; its broader features however apply to any combination between a clamp and means for 'applying high frequency current to tissue held in the clamp with a sealing of the tissue passages at the point of current application and with or without cutting ofthe tissue.
In Figure 4 the clamp 131 is shown applied to the normal tissues annexed to any growth 11v to be removed. v The surgical knifeL 151 is shown in position `to sever the growth at the same time preventing danger of bleeding after the clamp has been removed. 1
The conducting element 401 of the knife is embedded in insulation material 411 and is electrically connected at 44-to any suitable source of high frequency current.
The other terminal 45 of the source of current' is connected to the conducting body 131 sufcientvto insure a through-the clamp.
through ythe clamp where the tissue 112 ,enough to stop bleeding severed passages kthe return circuit -clamp being shown by the position of of the clampand also desirably to a. contact plate 46 inintimate contact with the body of the patient at anysuitable place.
. Preferably there should be sufficient reactance in the circuit to avoid any danger of burning the tissue except at .the edge of the knife, the curr-ent being limited by this reactanceto a value so small as to make the contact between the clampand compressed tissue safe and ample return The reactance may be either in the portion of the circuit beyond the terminals 44 and 45 not shown or may be inserted by the operator as 47, Figures 5 and 6.
n advantage in making the return is the localiz'ing of the current to the affected part.
As before th-e simultaneouscutting and sealing of the tissue passages is accomplished by slowly moving the knife through the tissue, preferably moving the knife'back :and forth overthe cut tissues if the applied voltage be so low as to make this desirable.
I may use the apparatus as a hemostat without cutting, for example as in Figure. 5 projecting from the clamp 132 may have been cut with a nonelectric knife vand the clamp may have been applied vin order to stop bleeding.
The clamp may thenbe tightened merely by compressing the ofthe tissue and the high frequency current may be applied as before bya member` 152, which is shown directed .perpendicularly inwardly in Figure 5 instead of across the tissue as in Figure 4.
In Figure 5 I show kthe reactance 47 to insure Athatthere shall be no danger from short circuiting the contacts or from making wholly through the clamp.
In Figure 6, I show a clamp 133 spring pressed toward closure, the tension of the a scale 48 adjustably mounted upon a tie member 49 `across the clamp arms 50 and 5l. This is for the purpose yof enabling the operator to adjust the pressure nicely to the needs and to avoid crushing the tissue.
The clamp arms are pivoted together at 52 and the tie member 49 has ends `loosely passing 4through perforations in the arms.
The thumb nut 54 is used to tighten the clamp, themeasure of tightness being shown by the position of the scale 48 with respect lto the yinner side of the arm 50 of the clamp.
I show the means for applying high frequency current as ja wire member 55 carried in an vinsulating' glass tube 56.
' lIn the form shown in Figures 1'to 6 the cut is `made onthe tissue outside theclamp, the current flowing into the remaining tissue and returningeitlier through the body of the .clamp by reasonofthe contact thatthe clamp body makesaround the aected part or tol i HVVany suitable contact plate,l either or both.
In Figure 7V Irshow that the return may take place through the tissue that is 'being cut away and'that the cut may be made upon Vtheinner side ofthe clamp, an electro-surgi- -calknife or needle tbeing applied to the tissue back .of the clamp Y184 and the return circuit takingv place from the portion ofthe tissue 114 that is being cut away to the clamp.
Though I prefer to provide a definite return for the-'circuit either to an electrode` or the clamp, I recognize that this is not always particularly where the cutting or coagulating area is vsmalh doubtlessbecause the human body acts as a condenser avoiding supporting the instrument and Y including v relativelypivoted members adapted to close upon one another by compression of the hand to close .the clamp, and Yaratclfiet adapted to hold the clamp in any closed position in cornbination with an electro-surgical knife adapted to be moved. to tissue held inthe clamp,
a springprcssing the knife away from-the clamp and a thumbf engagement member to be engaged "by thek thumb and fastened tothe knife adapted to be pressed by the thumb to bring the knife to the tissue.
. i enonennrrrou ToivmiNsoN.
the necessity for acurrent return as' such or i because of an adequate grounding of one ter- :minal of the source and ofthe body operated A2o Y upon.
Forv this reasoninjmy claim I cover the Vconditionin whicha kclamp may be used for the purpose of constricting and holding the tissue so that the cutting and coagulation may be eected to the best advantage but infwhich the clamp not only need not be a return elec- .trode but in which no return electrode as such As shown in Figure 3 I may makethe clamp 13 and knife 15 a single member adapted to initially clamp' in order'to definitely posi- Y tion the tonsil or other growth with which itis being used for cutting and then after the part has been properly positioned to apply the high frequency current and to sever vthe tissue by closing movement of the clamp.
In this figure the metallic knife blade 15 terial .llllwhich slides'in the groove 14; of the fenestra. Y Y f v The fenestra as before may be metal and the closure of the clamp initially takes place while the high frequency current is shut off.
.The metal shouldy be insulated in some way. ,I
The operator closesy thevclampA until ,the
f v part thatv is vto bes'evered is seen to be definitei lshown,
' far as they fall'within thel reasonable spirit [1y in ,the
desired' position for severing. The current is theny applied and the clamp gradu- Vis lcovered-at the sides with insulation maally closed simultaneously cutting through thetissue and .sealing the compressed pas- `sages by coagulating the lymph and blood.
In view of my invention and disclosure variations and modifications to meet individualk whim or particular need will doubtless become evident4 to others skilled in the art, torobtain all or part of the benefits of my invention without copying the structure and I, therefore,` claim all such in so and scope of my invention. Y
Having thus describedY y Iclaim as new and desire to secureby Letk.ters Patent is: l .i Y Y. Y A surgicalN nstrumentincludiug `a clamp Y -f for :holding and compressing tissue, AAa handle my invention, what p