US 20050267529 A1
Devices, systems and methods are disclosed for repairing soft tissue. The surgical system allows for the creation of tissue repair by grasping, aligning and sewing or fixing tissue. For example, this system may be used for clipping together excessive capsular tissue and reducing the overall capsular volume. The deployment device includes a central grasping mechanism and an outer clip delivery system. The clip embodiments may be single or multi-component (penetration and locking base components) that penetrate tissue layers and deploy or lock to clip the tissue together. An example of the system is used to reduce the joint capsule tissue laxity and reduces the potential for subluxation or dislocation of the joint by either restricting inferior laxity (anterior or posterior) and resolving or eliminating pathologic anterior or posterior translation.
1. A system for transdermal repair of soft tissue, the system comprising:
a first element to pinch a portion of soft tissue that is to be repaired;
a second element to repair the portion of soft tissue that is pinched by the first element, such portion of soft tissue being accessed transdermally; and
a third element to deploy the first element and the second element in turn to repair the portion of soft tissue that is being pinched.
2. The system of
3. The system of
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9. The system of
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11. The system of
an anchor element having a shaft with two penetrating ends to penetrate soft tissue, wherein each penetrating end has a movable anchor stop that allows the end to penetrate tissue initially and then turns to lock the anchor stop on the side of the tissue that is opposite to the side of the shaft.
12. The system of
a first anchor element having a shaft with a penetrating end to penetrate soft tissue and a receiving end to accommodate the penetrating end, wherein the first anchor element at least partially contains a metallic interior to assist in the maintenance of its shape, and wherein the penetrating end and the receiving end communicate to plicate the soft tissue held within.
13. The system of
a penetrating element having a point and a perpendicular stop; and
an accommodating element having a point receiving slot and a perpendicular stop, wherein the penetrating point and the accommodating point plicate tissue between each of the perpendicular stops by mating the point on the penetrating element with the point receiving slot on the accommodating element.
14. The system of
a substantially planar surface having an opening therein and a plurality of teeth positioned inwardly toward the opening, wherein a portion of soft tissue that is pulled within the opening is plicated therein by the plurality of teeth when the tissue is released.
15. A system for plicating a capsular structure, the system comprising:
a pinching element to pinch a portion of an interior surface of a capsular structure to be plicated;
a plicating element to plicate the portion of the interior surface of the capsular structure that is pinched by the pinching element; and
a deployment element to deploy the pinching element and the plicating element in turn to plicate the portion of the interior surface of the capsular structure that is being pinched.
16. The system of
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19. The system of
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21. The system of
22. A method for arthroscopic plication of an interior concave surface of a capsular structure, the method comprising:
pinching a portion of the interior concave surface of the capsular structure; and
securing the portion of the interior concave surface that is pinched.
23. The method of
24. The method of
25. The method of
26. A method for arthroscopic repair of soft tissue within a hollow structure, the method comprising:
pinching a portion of soft tissue on an interior surface of the hollow structure; and
fixing the portion of soft tissue that is pinched.
27. The method of
28. The method of
29. The method of
This U.S. Utility Patent Application claims priority to U.S. Provisional Patent Application Ser. No. 60/570,627, filed May 13, 2004, and to U.S. Provisional Patent Application Ser. No. 60/584,585, filed Jul. 1, 2004, the contents of each of which are hereby incorporated by reference in their entirety into this disclosure.
1. Field of the Invention
The present invention relates generally to devices, systems and methods for tissue repair. More particularly, the present invention relates to devices, systems and methods for treating unidirectional and multidirectional instability of tissue structures.
2. Background of the Invention
Tissue instability or compromise is a common occurrence in all persons, whether induced by age, repeated use, disease, accident or natural and abnormal formation. Such instability may include, for example, intentional or accidental tears, cuts, stretching, loosening, deterioration of structure, loss of firmness, and the like. Furthermore, such tissue may relate to orthopedics, as in the skeletal system and its associated muscles, joints and ligaments and the like, or non-orthopedic systems, such as smooth muscles, gastrointestinal, cardiac, pulmonary, neural, dermal, ocular and the like.
No matter what type of instability is present or whether the tissue to be repaired is classified as orthopedic or non-orthopedic, similar issues and objectives are encountered by the surgeon, namely, creating a stable and reliable structure and doing so in as easy and reliable manner as possible. For example, a neurosurgeon aims to create a stable and reliable adhesion of two neural tissue structures, while at the same time creating minimal damage. The neurosurgeon desires a technique that is minimally invasive, highly reproducible and reliable, and highly effective in connecting the tissue to itself or other similar or dissimilar tissue. It would be even more beneficial to somehow have the tissue become induced to adhere to itself or the other tissue.
In another similar example, in orthopedics soft tissue surgery, the surgeon desires to repair the damaged or diseased tissue in such a manner such that the tissue binds with itself or other tissue in a firm but minimally damaging manner. In muscle or ligament repair, for example, it is necessary to suture the tissue together to promote strength and unity in the structure while at the same time, allow for natural movement to occur.
More broadly, traditional soft tissue repair is a common procedure that typically involves some form of conventional suturing or stapling. For example, certain joints, such as hips, knees, shoulders and elbows contain tissues that are common sources of problems, whether natural or induced, that require extensive physical therapy or surgery to correct. There are similarities between such examples of tissues that present a uniform set of issues for the health care worker such that a treatment of one type of tissue will be in many ways similar to the treatment of another type of tissue, even though the shape, properties and architecture of each tissue is uniquely different. Of such tissues or tissue structures, a common source of medical problems occurs in the joints. Although the below example will be described with respect to the shoulder joint as an example, similar problems are inherent in other soft tissue areas and one having ordinary skill in the art would be cognizant of such problems and how to apply the principles of the present invention to address the problems in such other tissues or tissue systems.
Joint instability is a complex clinical problem associated with a variety of treatment options that include the use of arthroscopic and open surgical methods. For example, for the shoulder joint, open surgical methods for producing a capsular shift to increase the capsular ligament tension and improving the joint stability have been demonstrated. However, adequate arthroscopic methods that approximate the clinical outcome achieved by open surgical methods for reducing excessive joint laxity have been slow to develop or have begun to show less than optimal long term clinical outcomes (e.g., thermal methods).
The shoulder joint, in particular, has inherent instability because of its large range and motion combined with the relatively shallow joint bony socket (glenoid). Anatomically, the rotator cuff acts as the primary dynamic joint stabilizer, while the inferior glenohumeral ligament acts as the primary static shoulder joint stabilizer. Damage to or laxity of one of these stabilizing structures can result in the presentation of clinically relevant shoulder instability.
The onset of shoulder instability is generally associated with a traumatic injury, an atraumatic motion injury, or chronic overuse of the shoulder. Most typically, the instability of the shoulder stems from disruption and/or looseness (excessive capsule laxity) of the shoulder capsule. The resulting subluxation or dislocation of the joint can be painful and debilitating for the individual. The overall approach of shoulder stabilization surgery is to first repair the disrupted/torn capsule and second to tighten the loose capsule ligaments. Of note there are instances where the capsule is intact (e.g., no tear) and only tightening of the capsule ligaments is required to restore joint stability. The ultimate goals of shoulder stabilization include restoring appropriate capsule tension, limiting of humeral head translation, and excessively decreasing range of motion.
Up to 98% of all shoulder joint dislocations occur in the anterior direction, 95% of which are first time dislocations. Over 70% of these individuals will have recurrent instability (subluxation or dislocation) within two years after the first event, potentially requiring surgical intervention.
Certain conventional devices serve to assist with repair of the shoulder capsule when it is disrupted, such as in the case of Bankart Lesions. It is noted that Bankart Lesions are identified by the characteristic stripping/tearing of the anterior inferior labrum from the glenoid. Treatment of these lesions is typically accomplished through a standard open incision or with existing arthroscopic technology.
Clinically described excessive joint laxity in the joint capsule can range from 1.0 to more than 20.0 mm in ligament elongation, resulting in recurrent glenohumeral subluxation or dislocation. A loose shoulder capsule may be tightened readily when a standard open incision is used, but tightening the shoulder capsule arthroscopically poses significant challenges with existing instruments. For example, the acute angles at which the surgical devices are able to approximate the soft tissue and identify regions where suturing would be desirable are limiting. Furthermore, the ability to pass a suture and tie snug surgical knots that compress the tissue in the desired plane with a reasonable suture time is difficult if not cumbersome. Finally, the ability to dictate the level of tissue tied is limited to the tissue needle bite size and remains difficult for the surgeon to reproducibly specify the level of tissue compression desired.
A recently introduced technology, thermal capsulorrhaphy, initially held significant promise as a means of facilitating and expediting arthroscopic shoulder capsule tightening. The premise of this technique is to manipulate the characteristics of the approximately 90% Type I collagen structure of ligaments by thermal exposure. It has been demonstrated that at temperatures above 65 degrees Celsius, collagen begins to denature (e.g., unwinding of the helical structure), resulting in tissue shrinkage. Collagen shrinkage of up to 50% has been demonstrated using thermal energy. However, this technology has yielded equivocal results and progressive skepticism from shoulder surgeons. Specifically, concerns related to long term clinical outcomes for shoulder instability with altered capsular structure have been noted. There is a strong current sentiment among shoulder surgeons that tightening the shoulder capsule by plication with sutures will prove to be more efficacious and more reproducible than the use of thermal mechanisms to reduce the ligament laxity in the capsule.
Additional concerns of thermal capsulorrhaphy application include potential injury to the axillary nerve, bleeding, pain, and excessive swelling of the capsule. More importantly, the technical methods used during thermal capsulorrhaphy do not allow the surgeon to control the level of plication that is desired or anticipated. Specifically, thermal methods are technique-specific and have a required learning curve associated with obtaining specified clinical plication outcomes. Moreover, once treated, the level or resulting tissue alteration achieved is irreversible. The paucity of data demonstrating the long-term mechanical characteristics and viability of these treated ligaments limits the confident and continued use of this technique.
Conventional methods for arthroscopic plication of the shoulder capsule with sutures typically involve freehand techniques that are technically challenging and often time-consuming. An additional shortcoming common to both thermal capsular shrinkage and existing suturing techniques is that neither method can effectively control the amount of capsular tightening in a calibrated fashion. “Over-tightening” of the anterior capsule can lead to problems such as excessive loss of external rotation, limiting shoulder joint function.
Thus, a need exists in the art for an alternative to the conventional methods of tissue repair. There is a need in the art for novel systems and methods for arthroscopic soft tissue repair and/or plication that is adaptable to any soft tissue or soft tissue system and can overcome the shortcomings of conventional methods and improve the clinical outcome as well as be generally adopted by surgeons.
The present invention provides an alternative and enhancement to conventional methods of tissue repair. More specifically, the present invention presents devices, systems and methods for arthroscopically treating unidirectional and multidirectional instability of tissue in general, and through suturing and/or plication by non-limiting example. An essential and powerful aspect of this invention is its wide applicability to a non-limiting extent of tissues and tissue systems of any shape or size, such as, for example the plication of loose tissue from the interior surface of a spheroidal capsule. One having ordinary skill in the art is cognizant of the applicability of the present invention to as diverse fields as reduction in gastric reflux to lung volume reduction to atrial valve repair and shoulder joint plication. The present invention is not limited to the examples set forth in this disclosure but is extended to all other procedures that would benefit from the devices, systems and methods as described herein. Thus, the scope of the present invention extends beyond the non-limiting examples set forth herein and encompasses that which would be or should be within the purview of one having ordinary skill in the art of tissue repair.
In one described embodiment, the invention relates to suture structures and related deployment devices to repair, plicate and/or reduce the capsular laxity at the glenohumeral joint, improving joint stability. However, the techniques disclosed in the examples below are adaptable and usable for all tissues and tissue systems where repair is beneficial to improve the health and function of the tissue or tissue system. Such techniques and uses, particularly relating to embodiments of the present invention, are particularly useful in applications requiring transdermal access to a particular internal tissue by penetrating one or more layers of tissue. However, such transdermal access is not limiting and the present invention may be applicable in non-transdermal applications as well, such as in fundoplication. Further, “repair” of such tissue, as defined herein and throughout this disclosure, is a slowing down or reversal of the instability such that the tissue is somehow manipulated to deal with or overcome the instability, usually involving some form of surgery. Common, but not limiting, examples include suturing, plicating, stapling, restructuring, adhering, tightening, attaching, firming or the like.
In one exemplary embodiment, the present invention is a system for transdermal repair of soft tissue. The system comprises a first element to pinch a portion of soft tissue that is to be repaired; a second element to repair the portion of soft tissue that is pinched by the first element, such portion of soft tissue being accessed transdermally; and a third element to deploy the first element and the second element in turn to repair the portion of soft tissue that is being pinched.
In another exemplary embodiment, the present invention is a system for plicating a capsular structure. The system comprises a pinching element to pinch a portion of an interior surface of a capsular structure to be plicated; a plicating element to plicate the portion of the interior surface of the capsular structure that is pinched by the pinching element; and a deployment element to deploy the pinching element and the plicating element in turn to plicate the portion of the interior surface of the capsular structure that is being pinched.
In yet another exemplary embodiment, the present invention is a method for arthroscopic plication of an interior concave surface of a capsular structure. The method comprises pinching a portion of the interior concave surface of the capsular structure; and securing the portion of the interior surface that is pinched.
In yet another exemplary embodiment, the present invention is a method for arthroscopic repair of soft tissue within a hollow structure. The method comprises pinching a portion of soft tissue on the interior surface of the hollow organ; and fixing the portion of soft tissue that is pinched.
The present invention relates to devices, systems, and methods that address deficiencies in conventional methods of tissue repair. The present invention may be applied to a number of different medical applications, including but not limited to repair and/or plication or attachment of soft tissue, such as lung reduction or resection, gastric reduction, intestinal, liver reduction or resection, kidney reduction or resection, esophageal modification, atrial appendage isolation or removal, and anatomic structures. These are mere examples of locations where such devices, systems and methods may be used and in no way are limiting of the broader scope of the present invention.
The devices, systems and methods according to the present invention may be applied to any tissue or tissue structure in any geometry. For example, exemplary embodiments of the present invention may be used to plicate a capsular joint from the interior concave surface of the capsular joint by connection to and mending or suturing of the interior capsular tissue. This ability is one of the advantages of the present invention and is characteristic of its diverse range of application in terms of tissue targets as well as target shape and/or geometry. Conventional methods of plication are either limited to repair from an exterior convex surface of a capsular joint or by traditional hand suturing.
For sake of demonstration, exemplary embodiments of the present invention are shown by providing a technically facile means of arthroscopic plication of the shoulder capsule using a tissue clip or suturing device deployed with a single calibrated hand-held device for the treatment of unidirectional and multidirectional instability of the shoulder joint. The exemplary embodiments of the invention address deficiencies in shoulder capsule ligament plication for shoulder joint stabilization. The same or similar techniques as shown with respect to the shoulder capsule may also be used in virtually any other tissue or tissue structure that could benefit from the embodiments of the present invention. In addition, the exemplary embodiments address similar deficiencies that are apparent in other applications involving plication of tissues such as lung reduction or resection, gastric reduction or bypass, intestinal modifications, liver reduction or resection, kidney, esophageal, atrial appendage isolation or removal, cardiac tissue plication or attachment, and other soft tissue attachment or plication reductions.
A primary purpose of the present invention as shown in some of the exemplary embodiments is to better enable the tightening of the shoulder capsule ligaments either concomitantly or as a primarily course of treatment rather than to specifically repair a disrupted capsule. The expected clinical outcome includes reducing or eliminating any excess anterior inferior translation of the joint as well as resolving any pathologic anterior or posterior translation of the joint, thereby stabilizing the shoulder.
The exemplary plication systems according to the present invention may also be used to reduce or plicate, or attach soft tissue structures for other applications including, but not limited to, applying tension to remove slack in other joint ligaments (e.g., anterior cruciate ligament, medial collateral ligament), re-attaching partially or completely torn soft tissue structures during applications such as meniscus repair, re-attaching partially or completely detached soft tissue structures to bones via bone anchors during rotator cuff repair, Bankart Lesion repair, or other soft tissue to bone attachment procedure, plicating hernias, clipping lung tissue during lung reduction or resection procedures that result in reduced lung volume, gastric reduction or bypass procedures involving plication of the stomach or intestines to reduce the volume of the anatomy, atrial appendage isolation or removal involving clipping the atrial appendage at the orifice to reduce the atrial volume and isolate the interior of the atrial appendage from the circulating blood pool, vessel ligation procedures, tubal ligation procedures, resection of cancer tissue (e.g., liver, breast, lung, colon, etc.), mitral valve repair (leaflet and annular ring) and other procedures which may require soft tissue plication or attachment.
Additionally, various exemplary embodiments of the present invention are described that may be used to repair, plicate and reduce capsular laxity by attaching the capsule to the glenoid labrum or surrounding bony structures in the glenohumeral joint. The deployment devices are capable of grasping the capsular tissues, aligning capsular tissues into the plication region of the device, and deploying a plication clip into the tissue to securely attach the folded tissues. The exemplary deployment devices have the ability to adjust the level of plication by variable pull back of the grasping element or by variable adjustment of the clip device. Furthermore, the exemplary deployment devices may be used to abrade the plicated tissue section to irritate the synovium, eliciting the biological healing and remodeling response of the soft tissue. The dimensions of the exemplary devices may be tailored for orthopedic access with standard arthroscopic equipment. Additionally, the exemplary deployment devices may reposition capsular tissue, or other tissue, and secure tensioned capsular tissue, or other soft tissue, to the labrum, bone, or other anatomy.
By example, the present invention relates to devices, systems and methods that enable plication of ligaments, tendons, and/or other soft tissue structures to reduce unidirectional and multidirectional instability of the shoulder, or other anatomic structure. The region of interest includes the entire 360 degrees of the joint capsule. However, more typically the repair covers approximately 180 degrees (from the 8 o'clock to 2 o'clock anterior position of the capsule). In the instance of multidirectional instability it is common for a surgeon to close the rotator interval that will restrict the anterior and posterior inferior joint laxity and thereby restricting or limiting translation.
In exemplary embodiments of the present invention relating to the shoulder joint, capsular tensioning regions of interest include, but are not limited to, the posterior—inferior and anterior—inferior quadrants of the glenohumeral joint capsule as well as the rotator cuff interval. Capsular plication with device clip embodiments or suture embodiments includes, but is not limited to, capsule-to-labrum plication and capsule-to-capsule interval closure/reduction. An advantage of the capsule-to-labrum plication includes augmentation of the labral shelf by increasing the size of the labral “bumper,” reducing the potential for joint subluxation or dislocation.
To accomplish joint stability using the exemplary devices, systems and methods described herein, standard surgical preparation of the site and arthroscopic portals for access of the shoulder joint are performed. The joint may be dilated with an arthroscopic pump. The deployment device is introduced through a standard 5, 6 or 8 mm cannula placed in the anterosuperior arthroscopy portal. The anterior and posterior sections of the capsule may be visualized via placement of the arthroscope through the accessory anterior inferior portal or the posterior portal. Regions of the anterior and posterior inferior glenohumeral ligament are assessed and identified for removal of excess capsule laxity by plication with the primary goal of reducing the overall capsular volume. The deployment device is moved into position over the ligament region to be reduced/plicated. The tissue grasping mechanism is deployed through the centerline of the deployment device jaws, creating a tissue fold that is drawn up to and into the jaws of the deployment device. To improve the angle of approach of the deployment device in relation to the capsular plication region, the shaft of the device can be designed to have different configurations, including but not limited to straight, angled, or curved (S or C-shaped) shaft or angled distal jaw region.
Various embodiments can be utilized for the tissue grasping mechanism and include, but are not limited to, jaw clamp with or without an active hinge, J-hook (made of deformable metal, superelastic material, or plastic), penetrating tip element with a deploying end (e.g., umbrella, balloon, or T-shaped) that resists pullout of the device, or a corkscrew design (made of deformable metal, superelastic material, or plastic). A common ability with tissue grasping mechanisms is the ability to grab, hold, and move tissue into the jaws of the deployment device. The advantage of using a grasping mechanism to align the tissue and bring the tissue into the deployment device jaws is the ability to adjust the level of plication that will be employed. The force required to pull back the tissue into the deployment device jaws is maintained by the grasping mechanism through a spring or elastic joint/hinge. The jaw of the deployment device may have a center channel which enables closing of the jaw without being impeded by the grasper.
An exemplary embodiment of the deployment device includes an electrode stimulator that can be engaged along with the grasping mechanism or the clamping mechanism. (See, for example,
Several strategic locations along the deployment device jaw will have embodiments that allow for tissue penetration (e.g., needles, barb) and/or abrasion (e.g., rasp or roughened) of select regions of the ligament tissue. This stimulation/abrasion of the ligament is intended to occur simultaneous with engagement of the deployment device jaw. The purpose of this penetration and/or abrasion is to elicit a biological response that promotes more rapid healing and remodeling/scarring of the plicated ligament tissue by irritating the synovium.
Some exemplary embodiments of the suture device may include the use of flexible and rigid elements, suture or suture materials, and pledget backings that may allow for proper securing of the plicated or attached soft tissue. The embodiments of the deployment device jaw may include mechanisms to engage the suture to the jaws (e.g., at the distal tip, along the jaw flange). One flange of the jaws holds the penetrating element of the suture device, while the opposite side has locking ports to grab the suture tips. Engagement of the jaws is performed by user actuation of the proximal handle. Upon engagement of the deployment device jaw, with the plicated tissue grasped and aligned, the suture tips engage the tissue between the jaws, penetrate the tissue, and engages with the opposite locking ports. Once full engagement of the deployment jaw has been achieved, the suture ends have been fully deployed through the tissue fold to be plicated, the suture tips will be locked into the jaw flange. The deployment device jaw is then opened, and tissue released. The deployment device is then withdrawn from the site along with the suture ends. The suture ends are retrieved by the surgeon and standard sliding knots are tightened and locked by pulling the free end of the suture and advancing the knot to the plication site. The shoulder is then placed through a trial range of motion while the tension portion of the capsule is visualized with the arthroscope. Adequate fixation of the capsular plications is verified.
Exemplary embodiments of the suturing device mechanism may also include various locking port configurations which do not require passing of rigid suture tips, but rather suture ends. Further embodiments also includes passing of multiple sutures during one deployment that can be distributed in different configurations along the phalanges of the jaw (e.g., perpendicular, parallel, overlapped, cross-over, etc.). Other embodiments may also include pre-tied suture devices and/or pledget backings.
Surgically, the reduction in ligament laxity is continued and repeated along and round the capsule, deploying as many suture devices that may be required and in any 3-dimensional geometric pattern around the capsule to reduce capsular volume and stabilize the joint. Deployment of multiple devices can be required during the capsular laxity treatment procedure. This is particularly true for the treatment of multidirectional instability of the shoulder. The number, orientation and position of deployed clip devices will be user defined, no limitation is specified. Furthermore, the level of capsular plication or reduction in capsular laxity will be user defined, no limitation is specified. Furthermore, it should be noted that various embodiments of the suture device may be deployed in each case, particularly in cases where a combination of capsule to capsule and capsule to labrum or capsule to glenoid plication are indicated.
It should be appreciated that the plication devices described, including sutures and deployment mechanisms, can be applicable for use in other indications involving devices that are used for plicating and attaching tissue layers where small arthroscopic access is required. The embodiments of this invention can be tailored to human anatomy, however, they may also be tailored for use in other species such as horses, dogs, sheep, and pigs as well as invertebrates.
These plication systems can be used to reduce or plicate soft tissue structures or attach tissue layers for application including, but not limited to, other joint ligaments (e.g., anterior cruciate ligament, medial collateral ligament), rotator cuff repair, Bankart Lesions, meniscus repair, hernias, lung resection, gastric reduction procedures, cancer tissue removal (e.g., liver, breast, colon, lung, etc.), and other procedures which may require soft tissue plication. One having ordinary skill in the art would be cognizant of the procedure to use in performing the above operations using the exemplary devices described herein.
The exemplary embodiments of the present invention provide additional advantages that include, but are not limited to: providing an arthroscopic approach for the plication and reduction in ligament laxity; reducing the visible scars associated with open surgical procedures by small port access required by the deployment device; reducing the complexity associated with arthroscopic knot tying; reducing the incidence of axillary nerve damage by a verification of device positioning; enabling a maneuverable and rapid deployment of plication sutures, reducing the required surgical time as well as the level of complexity associated with the procedure; allowing for adjustable and reproducible levels of tissue plication; adding the option of releasability and removability of a device from the plication region; minimizing potential damage to the articular surface by using devices and materials that can be secured to the tissue as well as have less abrasive properties relative to tissue; and using active embodiments of the device which may allow for diagnostic measurement of positioning relative to neuromuscular tissues and active tensioning of plication regions.
Although many examples below are provided with respect to the shoulder capsule and using a plication procedure, these are only exemplary and are used for their sake of simplicity. Wherever the term “plication” is used with respect to the examples, the broader term “repair” may be substituted to refer to surgical procedures that may not necessarily be plication. Similarly, the shoulder capsule, as described in the examples below, may be substituted by any other tissue or tissue structure that could also benefit from the procedure as described below.
A conventional arthroscopic approach to the glenohumeral joint with the humeral head removed for clarity is shown in
The present invention may be used arthroscopically, shown in
An exemplary embodiment of the capsular grasper is shown in
In another exemplary embodiment of the invention shown in
It should be appreciated that in the embodiment shown in
Another exemplary embodiment for passing suture to secure the pleat of the capsule is shown in
An alternate embodiment includes the phalange spikes having a pre-loaded U-shaped short suture segment whose ends are attached to elastic barbs. The opposite phalange is pre-loaded with a short suture segment with rigid rings attached at both ends. The orifices of the non-spiked phalange dictate the position of the two suture rings. When the jaws of the plication deployment device are closed, the two barbs deploy into their two respective rings. This creates a closed ring of suture (in a horizontal mattress pattern) through the base of the capsular pleat.
In the exemplary embodiment shown, the jaws of the device 610 open as the grasper is retracted 611. In other embodiments, the jaws may be manipulated independently to the grasper mechanisms from the proximal handle of the device. The retracted grasper draws the tissue pleat 602 into position within the jaws of the device. As mentioned in the embodiment described in
In the embodiment shown, there may be one, two or more hollow penetrating spikes positioned in a horizontal or vertical position at the distal tip of the device, such as shown in
The exemplary embodiment shown in
In the exemplary embodiment shown in
The overall dimensions of the deployment shaft for device 1000 include the ability to be delivered through a 5 to 8 mm arthroscopic cannula. In addition, embodiments of the proximal end of the device can include a rotational translating mechanism associated with the shaft, allowing for adjustment in the rotational alignment of the shaft and hence the jaws with respect to the actuating handle. This rotational adjustment can be located at or adjacent to the pivot point of the jaws to the shaft, or along the shaft.
Alternatively, the shaft can be fabricated from a shape memory alloy configured to exhibit martensitic properties at the operational temperatures (e.g., 37 degrees Celsius). Therefore, the shaft can be bent into the desired curve, along with the inner cabling components. After the procedure, the device may be heated above the austenitic transformation temperature such that the instrument returns to its memory straight position. A primary purpose of changing the jaw actuation axis versus the handle axis is to allow the user to change the angle or position of the jaws relative to the ligament tissue without requiring the user to perform macroscopic manipulate the actuating handle, which is confined by the cannula and access point into the working cavity. In addition, a ratcheting rotating mechanism for positioning of the device shaft over up to 360 degrees enables locking the device shaft at a specified rotational position to the handle so the operator can access more capsular locations than would be available with a rigid straight shaft. The instrument shaft can alternatively be fabricated with a curve or bend, the instrument can be fabricated from a malleable alloy that doesn't exhibit shape memory properties provided the permanent bends do not affect the fatigue lifecycle of the instrument or render it aesthetically inadequate.
In practice, various clip device embodiments (see clip design embodiments) could be implemented at the distal tip of the device jaws. The centerline grasper embodiment has variations (see grasper embodiments). In the grasper embodiment shown, the deflection of the grasper is inherent in the design. The grasper may be constructed of material(s) that allow for elastic deformation of the arm elements (e.g., super-elastic materials such as Nitinol, stainless steel, 17-7, stainless steel 304, stainless steel 316, or other biocompatible stainless steel, other alloy, aluminum, superelastic polymers, sintered metals, machined metals, carbon fiber, gas impregnated nylon, polycarbonate, ABS, other polymers, or insert molded composite materials).
The end of the grasper may be pre-shaped into the open position, opening to an angle from 0 to 90 degrees. The distal tip length of the grasper (which is deformed to a predetermined opening angle) may range, from, for example, from 1 to 50 mm in length. The grasper may be positioned in a central lumen of the deployment device. As shown in the figures, the upper and lower jaws of the deployment device may have tapered channels or guiding channels in which the undeployed grasper arms can sit during the initial advancement of the deployment device through the arthroscopic cannula. Furthermore, the shape of these channels aid in the guiding of the deployed grasper back into the jaws. Note the spacing between jaws allows room for both the clip device at the distal tip as well as the thickness of tissue drawing into the jaws with the grasper. The capsular tissue thickness varies between 1 and 7 mm.
Upon deployment (e.g., forward push out) of the centerline grasper, the specified angular deformation of the grasper tip will open up the arms 1010 because they are no longer constrained by the centerline channel. Pull back of the centerline grasper will result in closing of the clamps and pull back of a specified segment 1101 of tissue 1100 into the jaws of the deployment device. The level of plication will depend on the distance at which the grasper arms are drawn into the deployment device. The range of plication distance for capsular plication application is typically between 1 and 25 mm, more specifically between 2 and 10 mm. More or less tissue plication can be chosen by adjustment in the position of the grasper arms. The length of tissue plicated (e.g., plication distance), depending on the application and extent of the capsular laxity, will typically range between 1 and 50 mm; more specifically between 5 and 20 mm. It should be noted that for this and other non-capsular plication applications, the plication distance can be greater than 25 mm, depending on the application and soft tissue characteristics. The amount of tissue plication can be chosen by adjusting the position of the grasper arms relative to the plication clamp jaws. Force gauges can be connected to the grasper to measure the tension placed on the capsule during plication.
Alternatively, springs (static or adjustable) can be connected to the grasper to direct a specified amount of tension applied to the capsule by the grasper thereby producing a specific amount of tissue plication. In addition, axial distance of grasper movement relative to the plication clamp can be regulated to control the amount of plication as determined by distance as opposed to tension as described above.
The actuation of the jaws 1010 and grasper deployment 1020 can be linked or can be independent in motion. The benefit of individual independent motion is augmentation in clamping that the jaws can provide with this embodiment of grasping. In other embodiments, the benefit of independent motion may not demonstrate this distinct advantage. The mechanism of actuation of the deployment device jaws includes both forward and backward linkage actuation by simple linear motion from the actuating handle. The arrangement of the hinge linkage allow for considerable force generation at the distal tip of the deployment device. Moreover, the simplicity in design provides a relatively problem free hinge mechanism that can be cleaned easily. The shaft of the deployment device is made to have characteristics that allow for easy insertion though the arthroscopic cannula and no clinically relevant abrasion to the surrounding soft tissues.
Once the tissue has been drawn into space between the jaws of the deployment device and the grasper position is locked, the jaws of the deployment device can be fully actuated, engaging the tissue fold between the ends of the plication clip, as shown in
The exemplary clip shown in
The deployment device shown in
The exemplary deployment device embodiment shown in
The suture tip transfer mechanism incorporated in the plication clamp jaws can comprise a simple lock-fit/snap fit (as shown in
In the embodiment shown in
More specifically, as shown in
In the exemplary embodiment shown in
In some embodiments, a surgeon may agitate the synovium with a general rasping arthroscopic instrument in the region of interest prior to positioning of the deployment device and deployment of the plication clip. Furthermore, unlike the embodiment shown in
As shown in
The embodiment shown in
Activation of the axillary nerve 1540 (or other nerve or muscle tissue) would be caused if the grasper or plication clamp jaw is too close to the axillary nerve (or other nerve or muscle tissue). Activated response would be observed by twitching of muscles associated with the neurovascular structure. For example, activation of the axillary nerve will result in a muscle response from the deltoid muscles. The intended neuro-stimulation is intended to provide minimal excitation for positional identification only, not for diagnostic or treatment purposes.
Stimulation of the axillary nerve (or other nerve or muscle tissue) provides a clear warning that the grasper and/or plication clamp jaws are at risk of damaging the axillary nerve and indicates the physician should move the plication device to another location, thereby avoiding unwanted nerve (or muscle) damage.
Commercially available stimulators can be utilized to delivery the 0.1 mA to 50 mA pacing pulse. The waveform can be monophasic, biphasic, or other pattern known to evoke stimulation of nerve or muscle tissue. The pulse duration can vary between 1 msec to 500 msec. The amplitude determines the proximity of the probe element to the stimulated nerve or muscle. For example, a plication device that stimulates the axillary nerve by delivering a biphasic pacing pulse having a duration of 10 msec and an amplitude of 1 mA is closer to the axillary nerve than a plication device that requires 10 mA to stimulate the axillary nerve with the waveform and duration being the same. As such, the proximity of the axillary nerve can be determined by the amplitude of the pacing pulse thereby ensuring that plication does not damage the axillary nerve (or other nerve or muscle), and/or mapping the location of the axillary nerve to plan the location of tissue placations.
Although the exemplary embodiment of the invention as shown in
The exemplary embodiments shown in
The guiding tube 1631 can be advanced beyond the jaws as illustrated in
Once the suture is engaged, the jaws are released, and suture pulled through the tissue layers. The grasping mechanism may be maintained in position or released depending on the surgeon's preference. In some instances, the surgeon may elect to keep the grasping mechanism in position to maintain the tissue pleat until final plication is finished. Repeated passing of the suture is performed and knots tied to secure the region of plication. Coordinated movements of the jaws and deployment of the suture grabber add to the simplicity of the device embodiment. Various embodiments can be included in the jaws of this deployment device embodiment to accommodate the use of clip devices at the distal tip, as exemplified in
The anchor wings may be made from metals, shape memory metals, polymers and shape memory polymers that can be deployed and retraced into the guiding tube. The shape of the wing deployment can vary (e.g., elliptical, spherical, triangular, corkscrew, hook). The primary purpose of the wing shape is to provide an anchoring point to pull the tissue into the grasper. Other embodiments of the anchor deployment may also include inflation of balloon anchors of various configurations and materials (e.g., silicone, polyurethane, PET, Nylon, etc.). An advantage of the single armed grasping embodiment is the ability to leave the device engaged while releasing and rotating the overall device. This motion is allowable because of the wing shape or balloon tip anchoring mechanism, which is does not actively grasp the tissue as shown in
An embodiment of the deployment device has a total length (including the actuating handle) to be about 20-100 cm with the shaft of the device being about 12-92 cm of the length. The range in maximal width or maximum diameter of the shaft and working end of the device will range between 4.0 to 8.0 mm. The length of the deployment device jaws will range from 10 to 40 mm in length.
Grasper embodiments 1800 and 1900 shown in
Grasper embodiments 2000, 2100 and 2200 shown in
Alternative graspers include balloons incorporated at the distal tip of a central tube that can be expanded once positioned through or into the capsular tissue. The balloon can be oriented proximal to a needle or can incorporate a central lumen such that a separate needle can pass. Alternatively, a tube coupled to a vacuum source can be used as the grasper such that as suction is applied through the tube the tissue is pulled into engagement with the tube and can be manipulated by the vacuum grasper. To augment the vacuum grasper, a flexible flange can be incorporated to enlarge the vacuum orifice and better secure the vacuum grasper to the tissue surface. This flange can solely comprise a flexible silicone or polyurethane membrane (or other flexible polymer) or can incorporate strips of support material formed in an outward fashion and covered by a flexible membrane. The strips expand the flexible membrane outward as they are released from the confines of the guiding tubes and compress the flexible membrane as they are retracted into the guiding tubes. The enlarged opening increases the surface area of tissue that is contacted by the vacuum grasper increasing the grasping force.
The grasper embodiments shown can be connected to an external simulator for neuro-stimulation to verify the location and position of the plication relative to neurovascular structures (e.g., axillary nerve), in a similar way as that shown for
Grasper embodiment 2300 shown in
In various embodiments, different suture lengths can be incorporated to allow for delivery of one or more suture plications. The penetrating suture tips can have a variety of embodiments that allow for catching of the suture. As shown in
Similar to previously described embodiments, the jaws of the device can also incorporate roughed surfaces (e.g., rasp) and spikes with variable sizes for penetration. These embodiments may be static or can also be actuated both in the open or closed position of the jaws. In one instance, as tissue is withdrawing into the jaws using the grasping mechanism, the tissue would rub along the roughened embodiments or be pulled passed the roughened embodiments to irritate the synovium. In another instance, after engagement of the jaws, the device will penetrate the tissue, resulting in localized irritation of the synovium along distinct roughened or spiked locations along the flange of the jaw.
In addition, similar to that described for the embodiment shown in
A purpose of presenting
The suture side of the jaw can be removable and replaceable for use as a cartridge for additional sutures. In various embodiments, different suture lengths can be incorporated to allow for delivery of one or more suture plications. The penetrating suture tips can have a variety of embodiments that allow for catching of the suture. As shown in
An additional element shown with the exemplary embodiments in
Various embodiments show that different shapes and configuration with variable numbers of penetrating elements and position of penetrating elements can be chosen and not limited to those shown in
Similar to previously described embodiments, the jaws of the device can also incorporate roughed surfaces (e.g., rasp) and spikes with variable sizes for penetration. These embodiments may be static or can also be actuated both in the open or closed position of the jaws. For example, as tissue is withdrawing into the jaws using the grasping mechanism, the tissue would rub along the roughened embodiments or be pulled passed the roughened embodiments to irritate the synovium. In another example, after engagement of the jaws, the device will penetrate the tissue, resulting in localized irritation of the synovium along distinct roughened or spiked locations along the flange of the jaw.
In addition, similar to that described for the embodiment shown in
The exemplary embodiment in
Various plication devices were disclosed by example within the exemplary embodiments described above. Such plication devices may have a number of different shapes and sizes, which are all within the scope of the present disclosure. Various specific shapes and sizes will be discussed herein but the present invention is not limited to such exemplary embodiments.
The exemplary embodiment shown in
The embodiment shown in
The embodiment shown in
The outer covering can be fabricated form a resorbable material or a polymer such as polypropylene or other suture materials to cover the central support that can be fabricated from a metal or alloy, or a polymer with sufficient structural properties to engage the locking base and prevent release of the two components once engaged. The width of the device can range from 2 to 30 mm; more specifically from 2 to 10 mm. The height of the device can range from 2 to 20 mm; more specifically 2 to 6 mm. The thickness of the device components can range from 0.25 to 3 mm.
The embodiments 3710 and 3810 shown in
The embodiment in
The embodiment in
The embodiments in
Similarly, the embodiment shown in
The exemplary embodiment shown in
Another embodiment is shown in
Additional embodiments of this device would include variations in the cross-sectional profile of the device (e.g., circular). This embodiment can be deployed as shown in
An alternative reverse plication clip embodiment 4310 is shown in
The exemplary embodiments shown in
The embodiment depicted in
Variations of this embodiment are illustrated in FIGS. 47 to 51.
The embodiment shown in
In operation, the plication clamp is used to grasp the capsule and pull a fold of capsular tissue into the clamp jaws. The clamp jaws are then used to position the plication clip with one jaw passing through the capsular fold and the other jaw passing through the labrum and then the capsular fold. It should be noted that the capsule to labrum plication can be executed as a separate operation after placating the capsule (e.g., attached the already plicated capsule distal end to the labrum), a simultaneous step of placating the capsule directly to the labrum (as shown in
Various appropriate materials may be used to construct the elements or various parts of the elements that comprise the exemplary embodiments shown and described in this disclosure. For example, the locking base and arms of clips, spikes, needle, grasper, or deployment device components that require the ability to have elastic properties relative to being able to be deformed and deployed (returned to intended shape) using arthroscopic devices can be fabricated from various materials, including, but not limited to shape memory alloys (e.g., nickel titanium (Nitinol), shape memory polymers, polymers (e.g., PTFE, polyurethane, urethane, silicone, polyimide, polypropylene, Polylactic Acid, Polyglycolic Acid, or other thermoset or thermoplastic, or elastomeric materials) and metals (e.g., titanium, CoCrMo, stainless steel, nickel titanium, etc).
In some embodiments, the device clips or sutures may be resorbable, in other embodiments, the device components will have limited or no resorption characteristics. The clips components described in this disclosure can be made in part or solely of one material. Alternatively, the structures of the clips can be composed of metal and/or polymer components fabricated into composite devices. For example, low surface area and thin metal or metal alloy components that define the puncturing and/or locking components of the clips can be insert molded with a polymer (e.g., polypropylene) to produce a composite device that has very little radiopacity but exhibits excellent puncturing and locking characteristics. Some embodiments may include parts that are resorbable and some that are not.
Fabrication of these clip components can be performed using techniques familiar with manufacturing methods by those skilled in the art of metals, polymers, shape memory alloys, shape memory polymers, or composite materials. Sample techniques include, but are not limited to, extrusion, casting, press-forging, rolling, or pressing methods for the fabrication of parts for the above materials. In specific instances, the use of techniques related to modification of polymer chemistry to adjust the shape memory characteristics related to thermal conditions and elastic properties of the polymer will be utilized. With respect to shape memory metal materials, one skilled in the art will utilize the thermal characteristics of the specified composition to fabricate components with the geometry and features required for the device component. Proper thermal forming and quenching is required to process the material and is generally known to one skilled in the art of using, processing, and fabricating components out of shape memory materials.
In some embodiments several components may require parts using standard machining techniques typically known to one skilled in the art of machining. For example, use of CNC, EDM, laser cutting, water jet cutting, polishing methods, and other machining techniques. Several embodiments may also require bonding or welding of components and include adhesives, laser welding, soldering, or other means of attachment.
Clip components that include spikes or needles may be fabricated from any stock materials typically known to one skilled in the art of medical device manufacturing. Attachment of suture or other clip materials to these embodiments can be performed by tying, welding, bonding, clamping, embedding, or use of other such means for securing the spike or needle to the suture or other clip materials. In some embodiments, these spikes or needles can be mechanically polished or electropolished to produce smooth surfaces.
Various embodiments of the clip components described can be coated with or encapsulated with a covering of a polymer material that can allow for the use of anti-proliferative, antibiotic, angiogenic, growth factors, anti-cancer, or other pharmacological substances that may provide a benefit related to inhibiting or promoting biological proliferation. These substances would be loaded into the encapsulating coatings and be allowed to elute into the surrounding matrix, tissues, or space that it sits. The time course of delivery can be tailored to the intended application by varying the polymer or the characteristics of the coating. Such coatings with pharmacological substances can act as anti-proliferative treatments or can aid in the healing response of the tissue being treated. Furthermore, these coatings can act to reduce the local coagulation or hyperplastic response near the chip.
Various examples of surgical procedures using the devices, systems and methods of the present invention will be described in the non-limiting examples provided below. In each example described, one or more of the various embodiments shown in
Arthroscopic repair of Bankart lesion with arthroscopic suture plication of associated anterior capsular laxity.
Following examination under anesthesia and standard surgical prepping and draping, standard anterior and posterior glenohumeral arthroscopy portal are established. The patient may be positioned either in the lateral decubitus position or in a beach chair position. Following completion of diagnostic arthroscopy, attention is first focused on repair of the Bankart lesion. After the Bankart repair has been performed, residual anterior capsular laxity is assessed. The surgeon subsequently places the humerus in the desired position (in terms of external rotation and abduction; this will vary according to patient demand and individual surgeon preference). With the shoulder placed in the desired position, capsular redundancy is addressed via performing a suture plication. The capsular plication deployment device is introduced through a standard anterosuperior portal. Capsular grasper is deployed to create a capsular pleat delivering the capsular pleat into the jaws of the clip passing device. The clip device is subsequently deployed. Typically, two to four separate clip implant devices will be placed in a sequential posteroinferior to anterosuperior direction along the capsule. Additional clips may be placed to ensure that capsular redundancy has been adequately rectified. The amount of capsule delivery into the jaws of the clip passing device (and hence, the amount of capsular tightening) will vary according to surgeon preference and the amount of capsular laxity and patient demand. Of note, the Bankart repair must be conducted first in order to adequately assess the amount of residual amount of capsular laxity and determine the ideal required amount of capsular tightening. One of the advantages of exemplary devices according to the present invention is their ability to tighten the capsule a variable amount based upon individual situations. Following completion of placement of the desired plications, the arthroscopic probe is introduced and each of the plications is individually probed to confirm that the clip devices have been deployed in a stable fashion. The shoulder is place through a trial range of motion while the tensioned portion of the capsule is visualized to, once again, confirm that adequate fixation of each of the capsular plications has been achieved.
Capsular laxity without an associated Bankart lesion (e.g., anterior unidirectional atraumatic instability).
Following examination under anesthesia, standard anterior and posterior glenohumeral arthroscopic portals are established. A thorough diagnostic glenohumeral arthroscopy is performed with specific attention to determining the extent and distribution of capsular laxity. With the shoulder positioned in the desired amount of abduction and external rotation, the anterior capsule is tensioned via placement of anterior capsular plications in a posteroinferior to anterosuperior sequence via the anterosuperior portal. The sequence of placement of successive plication devices in a posteroinferior to anterosuperior direction is determined by virtue of the fact that if the anterosuperior capsule is tensioned first then placement of the capsular plication deployment device more inferiorly and posteriorly will be more difficult. However, tensioning the axillary pouch (posteroinferior section) first does not limit access further anteriorly and superiorly on the inferior glenohumeral ligament. Following completion of placement of the desired plications, the arthroscopic probe is introduced and each of the plications is individually probed to confirm that the exemplary clip devices have been deployed in a stable fashion. The shoulder is placed through a trial range of motion while the tensioned portion of the capsule is visualized to, once again, confirm that adequate fixation that each of the capsular plications has been achieved.
Multidirectional Instability (MDI).
Following examination under anesthesia, standard anterosuperior and posterior glenohumeral arthroscopic portals are established and a through diagnostic arthroscopy is performed. The redundant posterior capsule and posteroinferior capsule is tightened first. This is accomplished via visualization through an accessory anterior portal. The capsular plication deployment device is introduced through the standard anterosuperior portal. The posterior capsule is visualized via placement of the arthroscope through the accessory anterior portal. Posterior capsular redundancy is reduced via placement of successive capsular plications posteriorly (in an inferior to superior sequence). The arthroscope is subsequently reintroduced through the standard posterior glenohumeral viewing portal and the standard anterosuperior portal is utilized to perform the capsular plications. The inferior and anterior glenohumeral capsule is tensioned via placement of sequentially clip devices according to exemplary embodiments of the present invention in an inferior to superior direction. Following completion of placement of the desired plications, the arthroscopic probe is introduced and each of the plications is individually probed to confirm that the clip devices have been deployed in a stable fashion. The shoulder is place through a trial range o motion while the tensioned portion of the capsule is visualized to, once again, confirm that adequate fixation that each of the capsular plications has been achieved.
Lung volume reduction surgery (LVRS).
Preoperative imaging (e.g., radiographs, computed tomography) is performed to identify the segments of the lung requiring volume reduction. Following anesthesia induction, the patient is position in the lateral decubitus position to allow placement of thorascope as well as another access port for the plication delivery device positioning. The lung is collapsed using standard techniques. Using the plication delivery device grasping mechanism, the region of lung tissue to be reduced can be retracted into the device. Care is taken in the placement of the access port for the plication device to insure that when the device is engaged with the lung tissue that the tissue is not deformed or stressed to a point where excessive trauma occurs. The identified lung tissue section to be reduced is grasped by the device jaws. Axial rotation of the device jaw will result in wringing of the lung tissue,
Variations in the plication clip delivery may not require wringing of the tissue but rather only grasping of the tissue and then advancement of the clip over the tissue, as shown in the lung reduction procedure shown in
Laparoscopic gastric fundoplication with laparoscopic suture or clip tissue fixation.
Following anesthesia induction, the patient is positioned, prepped and draped in the standard fashion for an upper abdominal laparoscopic procedure. Using standard laparoscopic technique, a trocar is introduced through the abdominal wall and a laparoscope is advanced into the abdomen to provide visualization. Additional trocars (3-4) are inserted to accommodate required instrumentation. Under direct laparoscopic visualization, the surgeon elevates the liver to expose the junction between the stomach and the esophagus. Using sharp and blunt dissection, the hiatal hemia is reduced by freeing the esophagus and the stomach of surrounding soft tissue connections around the diaphragmatic hiatus and pulling the stomach and about 5 or 6 cm of the esophagus down into the abdomen. A space is created behind the esophagus and the fundus of the stomach, exposing the diaphragmatic hiatus. The size of the hiatus (defined by the arches of the left and right crural fiber bands) is reduced by approximating the muscles of the left and right crura behind the esophagus. The laparoscopic tissue fixation device is inserted through a trocar and advanced to the hiatus. Using a laparoscopic forcep through another trocar, the crural fibers are pulled so they are adjacent. The tissue grasper is deployed from the fixation device, and the adjacent fiber bands grasped together and pulled between the jaws of the fixation device. The fixation device is activated, securing the crural fibers with a suture, clip or other point fixation device. The process is repeated, until the opening of the hiatus is adequately reduced, usually requiring two or three adjacent fixations, as shown in
Using sharp dissection, the fundus of the stomach is freed of its connections, such as the short gastric vessels to the spleen and small ligaments connecting it to the left diaphragm. This mobilization creates a window behind the esophagus. The redundant portion of the stomach fundus on the left side is then pulled behind the esophagus to the right side and then around the front of the esophagus, forming a wrap, as shown in
Laparoscopic hernia repair with laparoscopic suture or clip tissue fixation.
Following anesthesia induction, the patient is positioned, prepped and draped in the standard fashion for an abdominal laparoscopic procedure. Using standard laparoscopic technique, a trocar is introduced through the abdominal wall and a laparoscope is advanced into the abdomen to provide visualization. Additional trocars (2-3) are inserted to accommodate required instrumentation. Under direct laparoscopic visualization, the hernia contents are reduced by taking down the adhesions to the abdominal wall and within the hernia sack itself. Once the abdominal wall is free, a tightly rolled prosthetic patch or mesh is inserted through one of the ports into the abdomen, where it is unrolled and positioned under the defect. The patch may be placed on the peritoneum or the peritoneum may be opened and the patch placed between the peritoneum and abdominal fascia. Several sutures may be used to anchor the patch in place to the abdominal fascia. The laparoscopic tissue fixation device is inserted through a trocar and advanced to the patch. Using a laparoscopic forcep through another trocar, the edge of the patch and peritoneum or fascia are pulled so they are adjacent. The tissue grasper is deployed from the fixation device, and the edge of the patch and peritoneum or fascia are grasped together and pulled between the jaws of the fixation device. The fixation device is activated, securing the patch to the peritoneum or fascia with a suture, clip or other point fixation device. The process is repeated, until the edges of the entire patch are secured to the peritoneum or fascia at 1 cm intervals to prevent internal hernia. The patch size is usually 8 to 10 cm larger than the defect, in effect reconstructing the abdominal wall. If the peritoneum was opened, this is now closed over the patch.
Thoracoscopic mitral valve repair with thoracoscopic suture or clip tissue fixation
Following anesthesia induction, the patient is positioned, prepped and draped in the standard fashion for a right chest thoracoscopic procedure. Using standard thoracoscopic technique, a trocar is introduced through the thoracic wall and a thoracoscope is advanced into the right pleural space to provide visualization. Additional trocars (2-4) are inserted to accommodate required instrumentation. CO2 insufflation may be used to displace the left lung and enhance visualization. A small intercostal incision may be used as a working portal in addition to the trocar ports.
Mitral valve reconstruction may be performed alone or as a part of another thoracoscopic cardiac procedure. Under direct thoracoscopic visualization, the pericardium is opened anterior to and parallel to the right phrenic nerve using scissors. The patient is systemically anticoagulated and cardiopulmonary bypass is instituted by cannulation by femoral approach or by direct cannulation through the thoracic incisions. The heart is arrested and vented.
Using sharp dissection, the left atrium is entered by incision either anterior to the right pulmonary veins or through exposure through the atrial septum. The mitral valve is exposed with retractors and inspected. Leaflet resection and repair may be performed as indicated by the underlying pathology. For example; isolated posterior leaflet cusp prolapse may be treated by a triangular or quadrangular resection. After resection of the flail cusp using scissors, the annulus diameter is reduced adjacent to the defect by plicating the annulus. Using a thoracoscopic forcep, the annular tissue is grasped and elevated. The tissue grasper is deployed from the fixation device, and the elevated annular tissue is grasped and pulled between the jaws of the fixation device. The fixation device is activated, plicating the annulus together with a suture, clip or other point fixation device. One or more adjacent plication points may be required to create sufficient annular reduction. Using a forcep, the cut edges of the valve leaflet are approximated. The tissue grasper is deployed from the fixation device, and the adjacent edges of the valve is grasped and pulled between the jaws of the fixation device. The fixation device is activated, securing the edges of the leaflet together with a suture, clip or other point fixation device. Two or more adjacent fixation points may be required to create a continuous line of fixation,
The valve repair is then reinforced with a partial or complete circumferential annuloplasty ring. A forcep is used to bring the ring to the annulus adjacent to one of the commissures, and the combination is gripped by the tissue grasper in the fixation device and pulled between the jaws of the fixation device. The fixation device is activated, securing the ring to the annulus with a suture, clip or other point fixation device. This is repeated at the other commissure. Using forceps to adjust the relative spacing, additional adjacent fixation points are serially fashioned to create a continuous line of attachment between the ring and the annulus. The valve is then tested to assure competency. The atriotomy edges are approximated, then grasped and secured using the fixation device. This is repeated at adjacent points along the edges until the incision satisfactorily closed. The heart is de-aired, reperfused, normal rhythm restored, and cardiopulmonary bypass terminated.
Thoracoscopic left atrial appendage ligation with thoracoscopic suture or clip tissue fixation.
Following anesthesia induction, the patient is positioned, prepped and draped in the standard fashion for a left chest thoracoscopic procedure. Using standard thoracoscopic technique, a trocar is introduced through the thoracic wall and a thoracoscope is advanced into the left pleural space to provide visualization. Additional trocars (2-4) are inserted to accommodate required instrumentation. CO2 insufflation may be used to displace the left lung and enhance visualization. Left atrial appendage ligation may be performed alone or as a part of another thoracoscopic procedure. Under direct thoracoscopic visualization, the pericardium is opened anterior to and parallel to the left phrenic nerve using scissors,
Using a thoracoscopic forcep, the edges of the opening in the pericardium are brought into approximation. The tissue grasper is deployed from the fixation device, and the pericardial edges are grasped and pulled between the jaws of the fixation device. The fixation device is activated, securing the pericardial edges together with a suture, clip or other point fixation device. One or more adjacent fixation points may be required to adequately re-approximate the pericardium. A drain may be brought through an opening in the chest wall and directed into a dependent area of the thoracic space for postoperative pleural drainage.
The foregoing disclosure of the preferred embodiments of the present invention has been presented for purposes of illustration and description. It is not intended to be exhaustive or to limit the invention to the precise forms disclosed. Many variations and modifications of the embodiments described herein will be apparent to one of ordinary skill in the art in light of the above disclosure. In particular, the many examples shown above that relate to the shoulder capsule and plication are not limited to such, and may be applied to any tissue or tissue structure as well as any type of repair performed thereon. The scope of the invention is to be defined only by the claims appended hereto, and by their equivalents.
Further, in describing representative embodiments of the present invention, the specification may have presented the method and/or process of the present invention as a particular sequence of steps. However, to the extent that the method or process does not rely on the particular order of steps set forth herein, the method or process should not be limited to the particular sequence of steps described. As one of ordinary skill in the art would appreciate, other sequences of steps may be possible. Therefore, the particular order of the steps set forth in the specification should not be construed as limitations on the claims. In addition, the claims directed to the method and/or process of the present invention should not be limited to the performance of their steps in the order written, and one skilled in the art can readily appreciate that the sequences may be varied and still remain within the spirit and scope of the present invention.