US 2256942 A
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P 1941- J. J. DUFFY SURGICAL INSTRUMENT I Filed Aug. 8, 1938 2 Sheets-Sheet l Sept. 23, 1941. v J. J. DUFFY 2256,94 2
SURGICAL INSTRUMENT 'Filed Aug. 8, 1958 2 Sheets-Sheet 2" aw whoa;
52 elJrraasfla g Patented Sept. 23, 1941 stares OFFICE The present invention relates to an instrument for performing certain surgical operations, and more particularly to a combined cannula and trochar adapted particularly for use in minor operations on the urinary bladders of human beings or-other internal cavities requiring drainage, for the purpose of introducing a self-retain ing soft rubber catheter through the cannula, for indefinite continuous drainage of the urinary bladder or other cavities, or when the trochar is removed, and a suitable cystoscope is introduced through the cannula, for examining the interior of the bladder or other cavities from above the symphysis by direct vision.
Although the device of my invention is designed mainly for use in connection with the urinary bladder of human beings, it may obviously be used for other purposes in surgery on human beings and also in connection with veterinary practice.
It is the general practice at the present time to employ catheters of soft rubber, or rubber composition base, or prepared silk, for emptying the human bladder in connection with various disorders or diseases such as for example, prostatic obstruction or urethral stricture. When periodical catheterizations are necessary, as in prostatic obstruction it is common to employ a soft rubber self-retaining catheter which comprises a soft rubber tube with any form of dilated end which passes through the normal urinary canal from the outside urinary meatus to the interior of the bladder. The dilated or extended end of the soft rubber catheter then rests upon the vesical orifice of the bladder so as to retain it without slipping from its place.
In serious cases of urinary bladder disturbance wherein the urinary bladder cannot be emptied voluntarily and wherein the obstruction, either because of stricture or hypertrophy of tissue in the parts, is such that it is not possible to pass any kind of catheter into the bladder, it then becomes necessary to make an artificial urinary opening through the abdominal wall for the purpose of emptying the bladder, such opening being made by surgical incision, dissection and isolation, all of which produces tremendous trauma. A drain is then placed in such an opening and such drain may be of glass, rubber, metal, or Bakelite. which when sewed into the bladder keeps them in position and from slipping out. Because the surgical operation in its present form produces a new opening into the bladder, a large amount of tissue is traumatized by the surgical incision,
Such drains have a dilated end dissection and instrumentation, and because a large amount of tissue is exposed to the decomposed and infected urine, an infectious process of the tissue is inevitable. This type or operation is objectionable therefore, although until the present time, no better method has been'khow'n.
In those cases of incomplete obstruction of the bladder or urethra wherein catheteriz'ation must be carried out through the normal urinary canal several times per day, the urinary tract, and all its accessory glands and contributing ducts usually become infected because of the fact that infection from the outside travels by capillary attraction along the foreign body, the catheter, and infection takes place also from the inside by the infected and decomposed urine,
The complicating infections due to frequent catheterizations are anterior and posterior urethritis, prostatitis, seminal vesiculitis, ep ididymitis, orchitis, inguinal lymphadenitis, and abscesses anywhere along the gento -urinary tract. By the use of the invention hereinafter described most of the disadvantages of the present method of supra-pubic drainage, and virtually all of the complications of urethral catheterization can be avoided.
One of the objects of the present invention is to provide an instrument which makes possible the installation of a soft rubber, self-retaining catheter into the urinary bladder of human beings by insertion through the abdominal wall without suturing either the abdominal wall, the tissue adjacent thereto or the bladder wall. This instrument and its accessories provides for the removal of the instrument from the bladder and abdominal wall, leaving a soft rubber, selfretaining catheter in place for continuous drainage of the bladder through the artificial opening. Another object of the invention is to provide a form .of cannula which in addition to being an instrument for introducing a soft rubber selfretaining catheter into the urinary bladder or other viscus, may also be used as a sheath for conducting an endoscope or cystoscope of proper form for the purpose of examining the interior of the bladder or viscus after the male portion of the instrument has first been removed Another object of the invention is to provide a form of cannula having means, rorminga part thereof, for holding the instrument firmly in position in the bladder wall or views wall which has been punctured.
Another object of the invention is to provide a form of cannula which may be employed in place adjacent the bladder wall and which is provided with a passageway from the end portion thereof to conduct urine through the instrument externally of the body.
Another object of the invention is to provide a form of cannula having a passageway from substantially the end of the instrument to be inserted to the opposite end thereof, which may be controlled by a valve in the inserted part of the instrument, which valve may be manipulated or controlled from the exterior so as to open or close the valve or to adjust it to any intermediate position without disturbing the position of the cannula.
Another object of the invention is to provide a form of cannula and trochar adapted to make its own original route through the abdominal wall into the bladder, or other viscus and which may be used to draw off the fluid contents therefrom; the said instrument being provided with control means or handles adapted to regulate the passage of urine or fluid through the instrument without disturbing the position of the cannula in the wall of the bladder or viscus, and which may be operated, if desired, by one hand of the operator.
Another object of the invention is to provide a novel form of instrument which is adapted to be retained in the walls of the bladder or viscus by means of an anchorage comprising a fluted or undulated surface in which the walls of the bladder contract into the depressed portion of one of the undulations.
Another object of the invention is to provide a form of instrument in which the outer or tube portion is adapted to serve as a catheter or cannula and in which a trocar may be held in place during the insertion of the instrument to provide a proper incision into the bladder and which may be removed after the incision to permit the 1S8 of an endoscope or cystoscope through the cannula without disturbing the position thereof during replacement of the trocar by the endoscope.
A further object of the invention is to provide a form of instrument adapted for use as a trocar and cannula which instrument is provided with a form of puncturing device, preferably a threeedged knife which is triangular in cross section by means of which a three-way track is made by the blades through the tissues so that the bladder wall and adjacent tissues will fit snugly around the muzzle of the instrument at the serrated or undulated portion thereof so as to prevent leakage or passage of infected material around the instrument during installation or while the instrument remains inserted in the incision.
With these and other objects in view the invention comprises various features hereinafter more fully described.
It was formerly necessary, in cases of obstinate obstructions of the urinary bladder, to perform a major operation in order to make an artificial opening through the lower abdominal wall into the urinary bladder. This operation was generally performed by making a surgical incision and further dissection down to and through the wall of the bladder, thus releasing the infected or decomposed urine through the surgical incision to the surface.
In the usual case, where the urinary bladder is partially obstructed but requires periodic drainage through a catheter inserted through the urethra, Whether such drainage requires frequent catheterizations or is accomplished by an indwelling catheter, nevertheless the frequent catheterizations or use of the indwelling catheters generally produce a low grade of infection of the urinary canal and its tributaries, which infection not only adds to the discomfort of the patient but acts also to weaken him for further surgical procedure, or to retard his recovery from the foregone kidney damage.
When the indwelling catheter is installed by the conventional supra-pubic cystostomy procedure, the infection of the wound, together with the infection already present in the genito-urinary tract, often becomes a fulminating infection, and if not fatal to the patient, it produces so much scar tissue that future surgical intervention through the scar tissue becomes extremely diflicult and hazardous.
It is generally known that unless the obstructed bladder and its infected contents are freely drained away, the damaged kidneys will not regenerate satisfactorily, preparatory to a subsequent operation to permanently relieve or remove the obstruction.
Up to the present time, the operation involving supra-pubic cystostomy has been considered extremely dangerous and a large percentage of deaths have occurred due to complications from wound infections and in general the time of recovery from such operations is protracted.
By the use of the invention hereinafter described in detail, the danger from the operation above referred to is substantially entirely avoided and the supra-pubic cystostomy and subsequent draining and examination of the bladder by means of a form of cystoscope particularly adapted for use in connection with the device of my invention may be performed without inherent difficulty or danger.
The surgical instrument of my invention is illustrated in its preferred form in the accompanying drawings, in which:
Fig, 1 is a longitudinal sectional view in elevation of a device in assembled form embodying my invention;
Fig. 2 is an end view taken from the right in Fig. 1 and illustrating in dotted lines the position of the handle in which the valve controlling the opening at the end of the cannula, or outer tube, is closed;
Fig. 3 is an end view of the knife portion or puncturing needle of the trochar, showing the knife edges extending about apart;
Fig. 4 is a sectional View taken on the section line 44 of Fig. 1 in the direction of the arrows showing the opening from the end portion of the cannula which is in registration with the groove or passageway in the end of the trocar by which liquid may flow from the bladder into the interior portion of the instrument;
Fig. 5 is a sectional view of the parts illustrated in Fig. 4 in which the cannula and trocar have been moved into the dotted line position illustrated in Fig. 2;
Fig. 6 is a detailed View in elevation showing the male portion or trocar of the instrument;
Fig. 7 is a detailed view in elevation showing the cannula or female portion of the instrument illustrating particularly the undulated or fluted end portion by which the device may be retained in place in the wall of the bladder or viscus;
Fig. 8 is a pictorial illustration indicating the position of the instrument of my invention after making its incision into the bladder in a position corresponding to the ordinary suprapubic cystostomy.
Fig. 9 is a pictorial representation illustrating the cannula of my invention in place, and in which in place of the trocar or cutting portion of the instrument, a cystoscope of proper size so as to make water-tight connections with the cannula or catheter portion of the device is employed for examining the interior of the bladder;
Fig. is a longitudinal view of a form of straight wire stylet which may beemployed in connection with the cannula or catheter for clearing the same; and
Fig. 11 is a longitudinal view of a form ofcatheter which may be employed in connection with the invention. 7
Referring more in detail to the drawings, the numeral 2 designates a cannula or outer tube which serves as a female part of the device for carrying a trocar or male part 4 designed so as to accurately fit the cannula portion of the device.
The cannula is provided with a serrated or undulated portion 6 so that when the device is inserted with the aid of the trocar, into the bladder or viscus, the walls of the bladder, or viscus, will press into one of the depressed portions of the undulations so as to form a tight fit and to prevent the passage of urine or fiuid from the bladder, or viscus, along the outside walls of the instrument.
At the fluted or undulated portion of the cannula, preferably in the lateral portion of the outermost flute, or undulation, is an opening 8 through which, when the passageway is clear to the interior of the instrument, urine or liquid may flow to the inner chamber It thereof.
At the other end of the cannula, a handle member i2 is provided having an opening l4 therein, adapted to receive a cylindrical portion I6 of the trocar or cutting instrument.
At the inner end of the trocar is an enlarged portion 48 adapted to fit within the portion 6 of the cannula or female part of the instrument. In the enlarged part I8 is "a groove 'or channel 28 adapted to coincide with or register with the opening 8 in the registering position of the handles [2 and 22 as indicated in Fig. 4, and also as shown in Fig. 1. At the outermost end of the trocar is a three-edged knife 24, the edges in the preferred form of the device as indicated in Fig. 3 being at an angle of 120 to each other and tapered gradually from a needlepoint inwardly, so as to gradually make the incision and to separate the faces of the incision when the instrument is used in suprapubic cystostomy. In order to conduct liquid passing into the chamber through the instrument to the outside, an opening '26 is provided through the enlarged cylindrical portion I6 of the trocar and through the enlarged handle portion 28 by which liquid may be readily conducted away. 7
The handle portion 12 which is connected'to the cannula is preferably provided with grooves 30, 32, and 34 which are spaced a sufficient distanoe from each other to accommodate the fingers of the operator. In a similar way, the handle member 22 connected with the trocar is provided with corresponding grooves 36, 38 and 4t positioned opposite to the grooves 30, 32 and 34 in the position of the handles as shown in Fig. 1 in which the inner fiat portions of the handles are substantially in registration.
Referring to Fig; 1, the groove 26 in the cylinder l5 and the adjacent end portion 28 of the trocar is shown parallel to the shaft '1, but it will be understood that the orifice may follow an oblique course from a point adjacent the shaft of the trocar to approximately the center of the boss 28. Obviously the passageway may be positioned in any other convenient location to communicate between the interior chamber ID of the cannula and the exterior portion of the instrument so as to conduct liquid from the chamher to the exterior part of the instrument.
In a similar manner, although the opening 3 in the i'nner end of the cannula is shown as connected with the groove 20 in the enlarged part i 8, of the trocar, a flattened portion or other form of groove than that shown may be employed to conduct liquid from the opening 8 into the interior chamber It] of the cannula. The groove or depressed portion 20 is preferably of a depth so that a turn of the handle l2 of about 25 over the handle 22 will serve to close the valve at the muzzle or inner end portion of the cannula member.
While is to be understood that I do not wish to be limited to the size and proportions of the device as shown in the drawings, it may be stated that in a commercial form of the device, the following proportions and size of parts have been found to be particularly advantageous. The length of the handle from the hub to the end of the handle may be 9.5 cm. The length of the hub 16, which is preferably tapered, is about 10 mm. and the diameter thereof may vary from about 12 mm. at the smaller end thereof, to 12.6 mm. at its larger end. The shaft 1 of the trocar may also taper if desired, but I prefer the use of a diameter of about 4.5 mm. and a length of shaft measuring about 15.5 cm. from the hub portion to the expanded end portion Is. The ex panded portion I8 is preferably about 8 mm. in diameter and the width of the valve facing or groove therein may be about 6.8 mm. and of a length about 2.3 cm. At the inner end portion of the expanded portion I8, adjacent the knife member 24, that is beyond the valve opening 8, the part I8 is of the full diameter of about 8 mm. so as to fit tightly into the end opening 5 of the cannula so as to prevent the escape of liquid when the valve member is closed. From the inner end of the part [8, the knife member having three cutting edges tapers from 8 mm. diameter to the point of the knife member which has a length of about 2 cm. The edges of the knife member are preferably about apart and the surfaces between two of the edges, or between each pair of edges, are hollowed out so as to provide greater thinness to each edge of the knife member.
' The cannula is preferably made of steel and is smooth bored internally to a diameter of about 8 mm. so as to .produce a smooth fit with the trocar member. The outside diameter of the cannula may be about 10 mm. The inner end portion of the cannula which is to be projected into the bladder is provided on the exterior surface with three serrations or undulations measuring about 9 mm. at the depressions and 10 mm. at the crest of the undulations. The serrations or undulations are preferably 5 mm. apart and the distance of the outermost serration from the end of the muzzle is preferably 6' mm. In the outermost section 3, extending 6 mm. inwardly, is an opening 3 mm. in diameter which cooperates with the flat surface or groove 20 in the part 13. The hub portion I5 of the cannula may be 2.2 'cm. in length and is formed integrally with the barrel portion of the cannula. The outer diameter of the hub portion is preferably about 15 mm. and in the portion adjacent the barrel proper of the cannula a flange i9 extends in an abrupt curve outwardly to a diameter of about 2.5 cm. over a distance of about -5 mm. in axial length,
This flange memberserves the purpose of a finger hold when handling the instrument. The inner surface M of the hub is bored so as to taper to the same diameter as the male hub member I6 in order to make a tight joint. On the top of the hub, the handle-is preferably provided with a cut-away section I! substantially 1 cm. wide to permit the engagement or insertion of a commercial form of cystoscope, such for example as the Stern-McCarthy cystoscope.
In the form of the device as shown, when the cannula and trocar are combined or assembled with the two handles, registering in contact, the flute valve at the inner end of the instrument is open to its full width, and in this position will permit the free flow of fluid through the inlet opening at the inner end of the device and the outlet opening in the handle portion to the exterior of the instrument. When the handles are spread apart so that the handle 22 is rotated in a counterclockwise direction from about 25 to 45, for example, the flute valve is closed and no fluid is then permitted to pass through the valve.
The opening 8 in the inner end of the cannula is so positioned with respect to the groove 20 in the enlarged part l8 of the trochar, that when the handles coincide, as when the instrument is being inserted through the abdominal wall, there is free passage of fluid into 8 and out of the handle of the instrument. .The valve is positioned as described so that the operator will know immediately when the cannula portion of the instrument has entered the bladder or viscus, by reason of the fact that the valve being open, fluid will immediately escape through the handle of the instrument. This is important, because at this point the operator should stop inserting the instrument, since it has reached its proper position either in the bladder or viscus.
After the bladder has been examined by means of a cystoscope, a soft rubber self-retaining catheter 42 of any suitable form, such as is shown in Fig. 11, may be passed through the barrel of the cannula, the catheter being first stretched over a rigid stylet, as 44, shown in Fig. 10, the catheter being lubricated with a suitable jelly or lubricating substance and then passed through the barrel or chamber l giving a free opening into the bladder.
The rubber catheter 42 is preferably of soft rubber of a form having an enlarged portion 46 near the end of the catheter to be inserted in which enlarged portion there are located four lateral fenestrations 48, through which fluid may enter the tube. The end 50 of the enlarged portion is preferably of solid rubber so that the end 58 of the stylet 44 may abut or contact with the central end portion 50 for the purpose of stretching the catheter lengthwise, thereby making the dilated portion 46 smaller in diameter so as to readily pass through either a cannula or a urinary canal. The other end 52 of the catheter may also be enlarged or thickened to a slight extent, if desired.
The stylet 44 is preferably a rod or spring wire which is of sufficient diameter so as to be rigid. The end portion 54 of the stylet is bent into a form resembling a pistol handle so that it may be readily grasped and manipulated with one hand. The end 56 of the handle portion is bent into a curve or hook around the adjacent body portion of the stylet so as to be in pressure engagement therewith, and so that by pressmg the handle portion, the bight of the loop or hook moves away from the adjacent body portion of the stylet to permit insertion of the end portion 52 of the catheter thereunder.
After the rubber catheter is stretched so that the end portion 52 comes under the hook portion 56, the rubber catheter may be controllably held through the spring tension of the hook or handle portion of the stylet. In other words, when the end 52 of the catheter is inserted under the hook portion 56 and the pressure on the handle 54 is released, the hook portion snubs the catheter against the adjacent body portion or shaft of the stylet, thus keeping the catheter in the stretched condition until the handle is again compressed for the purpose of releasing the catheter.
The stylet 44 thus affords a rigid support with in the soft rubber catheter, so that the tube may be readily pushed inside the cannula 2.
It will be understood that the form of handle or pistol grip as above described permits the operator to readily handle and introduce the oatheter into the cannula and it affords better vision and control during the insertion of the catheter than is possible with means heretofore employed for introducing drainage tubes or catheters in place.
The stylet may be of spring steel or other suitable metal and is preferably about 3 /2 mm. in diameter and about 55 cm. long. The distal end 53 of the shaft is preferably polished off to a flat blunt shape which will not penetrate the end 50 of the catheter or attach itself therein. At a point about 46 cm. from the distal end 58 of the shaft, the rod or wire is bent up sharply for a distance of about 4 cm. from which it takes an abrupt downward angle of approximately 45 degrees for a distance of about '7 cm., from which point it returns obliquely to the shaft for a distance of about 11 cm. The end portion is bent into the form of a hook or loop which is in a direction substantially transversely to the shaft.
While still holding the stylet, with the catheter firmly in the bladder, the cannula 2 may be withdrawn over the catheter, but leaving the catheter in the urinary bladder. The catheter may then be released from the rigid stylet and be retained in place in the incision for drainage purposes.
Preparatory to carrying out the operation with the instrument of my invention, an anesthetic comprising about 30 cc. of a 2% novocain may be injected through the route that the instrument will take through the lower abdominal wall. By the use of this special anesthetic, the danger from a general or spinal anesthetic is avoided.
It is believed that the advantages of the instrument of my invention will be apparent without detailed description thereof. By the use of the device of my invention, a patient does not have the prolonged convalesence as the use .of the instrument does not involve a major operation. The condition of the abdominal wall is virtually unchanged by the use of the instrument, so that if a suprapubic prostatectomy is to be performed there will be no infected scar tissue to cut through. Or, if a prostatic resection is to be performed, the suprapubic tube or cannula will render irrigation of the bladder which has been operated upon relatively simple, involving no substantial difficulties.
It will be understood that various changes or modifications may be made in the device of my invention as described without departing from the spirit or scope of the invention as defined in the claims.
Having thus described the invention, what is claimed as new is:
1. A surgical instrument comprising a cannula having an inner chamber and an opening at each end thereof, said cannula having an exterior end portion of undulated form to permit holding the cannula in place in the wall of the urinary bladder, a handle connected to said cannula, a trocar having a shaft portion adapted to extend substantially through the said inner chamber and provided with an enlarged portion adapted to fit within the undulated end portion of the cannula and to close the opening at the corresponding end portion thereof, said trocar having cutting edges extending outwardly from the said enlarged portion, a handl member connected to said shaft portion of the trocar, a lateral opening in the said undulated end portion of the cannula, a passageway in the said enlarged portion adapted to register with said lateral opening and extending to open into said chamber, an opening in the opposite end portion of th said trocar adapted to connect said chamber with the exterior during use of the instrument and means operated by said handles for opening and closing the said passageway.
2. A surgical instrument comprising a cannula having an inner chamber extending longitudinally therethrough so as to provide an opening at the forward and rearward end portions of said cannula, the exterior forward end portion of the cannula having undulations to permit holding the said cannula in place during an operation, a handle connected to the rearward portion of said cannula, a trocar having a shaft portion of'a length to extend substantially through the said inner chamber of said cannula and an enlarged portion at the forward end thereof adapted to fit within the exteriorly undulated portion of the cannula and to close the forward opening of the said chamber, said trocar having cutting edges extending forwardly from the said enlarged portion, a handle member connected to the rearward end portion of the said trocar, an opening through the rearward end portion of the said trocar connecting the said chamber with the exterior during use of the instrument, a passageway extending from the said forward nd portion of the instrument to the said chamber and means operated by said handles for opening and closing the said passageway.
3. In a surgical instrument of the class described, the sub-combination comprising a cannula having an inner chamber extending longitudinally therethrough so as to provide an opening at both the forward and rear portions thereof, exterior undulations at said forward end portion of the cannula to provide means for holding said cannula in place during an operation, a hub member at the rear end portion of the cannula, a handle member connected to the said rear end portion of the cannula and means at the said rear end portion for mounting and holding a cystoscope in place thereon.
4. A surgical instrument comprising a cannula having an inner chamber and an opening at each end thereof, exterior undulations at the forward end of said cannula, a handle connected to said cannula at right angles thereto, a trocar having a shaft portion and an enlarged portion adapted to close the opening at the forward end of the cannula, cutting edges extending forwardly from said enlarged portion, a handle connected to said trocar at right angles thereto, a lateral opening at the forward end of the cannula, a passageway in the said enlarged portion adapted to register a 5. A surgical instrument comprising a cannula having an inner chamber and an opening at each end thereof, said cannula having an exterior end portion of undulated form at the forward end thereof to permit holding the cannula in place in the wall of the urinary bladder, and an enlarged cylindrical portion at the rear end thereof, a handle connected to said cannula, a trocar having a shaft portion adapted to extend substantially through the said inner chamber and provided with an enlarged portion adapted to fit within the undulated end portion of the cannula and to close the opening at the corresponding end portion thereof, said trocar having tapering cutting edges about apart extending outwardly from the said enlarged portion, a
hub portion adapted to fit within said enlarged.
cylindrical portion, a handle member connected to said shaft portion through said hub portion, a lateral opening in the said undulated end portion of the cannula, a passageway in the said en-' larged portion of the trocar adapted to register with said lateral opening and extending so as to open into said chamber, an opening in the said hub portion of the trocar providing a passage from said chamber to the exterior of the instrument and means in connection with the said enlarged cylindrical portion of the cannula for removably mounting a cystoscope thereon when the said trocar is removed from the said cannula.
J. JAMES DUFFY.