US 2447169 A
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Description (OCR text may contain errors)
Aug. 17, 1948. E. DE sousA ,1
SURGICAL INSTRUMENT AND TECHNIQUE Filed Jan. 16, 1945 IH/h INVEN TOR. fuse/v10 de Sous ,4
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Patented Aug. 17, 1948 UNITED STATES PATENT OFFICE V V 2,447,169 j V v V SURGICAL INSTRUMENTAND TECHNIQUE I Eugenio de Sousa, Rio de J aneiro, Brazil I Application'January 16,1945, semi No. 573,020
. Surgical relief of abnormal enlargement of the prostate gland has, heretofore, been of two broad types: trans-urethral operations, in which access to the gland was had exclusivelyv by way of the urethra; and hypo-gastric or super-pubic incisions, involving as an exclusive means of accesstothe bladder an opening of the abdominal wall. In the latter, which may be classified as a major-operational form of therapy, the incision was made either in the abdomen, above the pubic bone, giving access to the bladder, or in the perineal region, giving direct access to the prostate gland, and eliminating the need of incising the bladder. In the super-pubic incision, the bladder wall was severed, permitting the surgeon to excise the prostatic tumor from the interior of the bladder. This excision might be made by the use of the customary surgical instruments, or by use of the electric knife. This transvesical technique, involving an opening of the bladder wall, with excision from within the vesica,
was attended with the constant danger of injury to the vesical wall; as the surgeon removed the tumo-rous growth it was necessary for assistants to guard the vesical wall adjacent the tmnorous .portion with flexible spatulate protectors. This was necessary, whether the surgeon employed instruments or the electric knife, but was especially essential in the use of the latter, and inevitably added to the complexity and difficulty of the operation.
The trans-urethal operation involved the insertion of an instrument into the urethra, and accurate positioning of the unit so that the cutting means at the inserted end, could be brought into contact with the tumor. This cutting means was commonly a type of electric knife comprising a loop of wire arranged to' be energized with high-frequency current, permitting severance with a minimum of bleeding, but the size and shape of the cutting edge were determined by the limitation of the relatively small urethral :passage. The normal prostate gland encircles the urethra adjacent its commencement at the vesical wall, and is a relatively large tough, body approximately 1 in thickness and 1% in length. Abnormal glandular growth of course increases the size of the prostate, so that the matter to be removed is many timesfas great in size as the cross-sectional area of the urethra,
through which the excised material must be re- 7 ting means which could be introduced through the urethra, and the capacity of the urethra in the removal of the excised growth. It was found that a proportion of cases required repeated trans-urethral prostatectomies, for depending upon the extent of the abnormal growth, only partial relief could be secured by one operation, due to the limitation on the amount that could be excised. v
vIt is therefore an object of the present invention to provide a means whereby the advantages of the trans-urethral and trans-vesical prostatectomy techniques may be combined in a sin-. gle operation, with a consequent obviating of disadvantages perculiar to each separate method.
A further objectis to make possible a prostatectomy in which the entire tumorous mass may be removed at one time, in a brief, simplified operational technique.
Anotheraobject is toafford a means whereby the entire abnormal mass is excised with a minimum of bleeding, and with substantially no danger of post-operational hemorrhage.
Another object of the present invention is to provide an instrumentality of the character described which, in the tumor excision'operation,
the vesical walls spaced from the cutting edge of the instrument during the severing operation, eliminating the need of separate protectors in the hands of surgical assistants.
Briefly described, performance of the pros tatectomy in accordance with the present invention involves both trans-vesical and transurethral operational techniques, the first being effected for the purpose of examination of the gland tumor and for'introduction of the cutting element and removal of the excised growth upon severance thereof, while the second is for the purpose of providing support and control of the cutting element from the exterior of the body. The instrument utilized for supporting and controlling the cutting element is in the form of a tubular body, .of a size'permitting the introduction through the urethral passage, from the .ex-
.ter-ior of the body, and, is provided with a detachable tip to facilitate the insertion and admission of the body through the passage and into the bladder. After the abdominal and vesical incisions have been made the tip is removed through the access thus afforded, and replaced by a. cutting element which has been selected as of the appropriate size for eifecting the tumoral excision. The surgeon then retracts the tubular body to .press the cutting element against the tumor, and then causes the cutting element to be electrified so that the severing operation may be effected. The current is supplied through the tube, and by means of a convenient handle on the tube the latter may be rotated to produce the complete excision,
Referring now to the drawings, Figure 1 is a vertical cross-sectional view of the portion of the male anatomy illustrating the prostate gland enlargement and with a portion of the instrument of my invention operatively inserted through the urethral passage.
Figure 2 is a view similar to Figure l, but showing the instrument with the cutting element operatively positioned thereon.
Figure 3 is a side elevation partly in section of the instrument with the parts assembled for insertion through the urethral passage.
Figure .4 is a View similar to Figure 3, and showing the cutting element applied to the instrument.
Figure 5 is a bottom view of the element as shown in Figure 4, but detached from the instrument body.
Figure 6 is a side view of a slightly modified form of the cutting attachment.
The instrument, as will be clear from Figures 3 and 4, comprises a tubular body or shank I having a cylindrical exterior surface and arranged to enclose an electric conductor core 8 which extends longitudinally through the bore 9 of the shank and is arranged to be connected to asource of high-frequency electrical potential by means of a conductor I2 suitably attached to the rear end of the core, a convenient switch, not shown, being provided for controlling the current to the core.
The shank may be supported by a handle [3 at tached thereto, and both handle and shank are formedof an electric insulating material.
The forward end of the shank I is arranged to have removably affixed thereto Various attachments for use .in facilitating insertion of the shank through the urethra passage, and for excision of the prostate prominence. In the present embodiment, such attachments are designed to be secured to the shank by threaded engagement, .and in order to provide for such engagement, the core 8 is preferably terminated appreciably in wardly of the end of the shank, and the bore 9 is provided with an internally threaded portion IE5 at the forward end thereof.
In the preferred embodiment of the invention, different attachments ll and l8 are utilized. At-- tachment ll, as will be clear from Figure 3, is designed to serve as a guiding tip for facilitating insertion of the shank through the urethral passage, and it is preferably in the form of a slightly curved, conoidal head having at its base a threaded stud I 9 arranged to engage the threaded portion I6. The base portion of the head is of the same circumference as the shank, so that the head and shank join in forming a smooth and uninterrupted surface. Desirably the attachment ll is formed of electric insulating material, of a type similar to the shank I, not susceptible to contamination of the urethral tissue.
Attachment I8 is preferably in the form of a shank designed to form an extension of shank I, and as here shown .is provided with a portion 2| arranged to be aligned longitudinally with shank 1 and a portion 22 disposed at right angles to portion 2|. Extending from the outer end 23 of portion 22 to the base 24 of portion 2| is a cutting element 26, here shown in the form of a relatively thin wire, bowed outwardly in the general plane of the portions 2| and 22. Attachment I8 is provided with a threaded stud 21 similar to stud l9, and in order to effect an electrical connection for the'element 25 which is connected to the stud 21, the 'latteris formed of electric conducting material, and arranged to contact the core 8 when operatively positioned within the portion l6. In order to confine the cutting to the element 26*, portions 2| and 22 are formed of an insulating material similar to that employed for the shank I.
As will now be clear, the successful technique for the use of the present invention involves both trans-vesical and trans-urethral factors, and in performing the operation the super-pubic incision is made, exposing "the viscera, and the abdominal cavity, within which is contained the bladder. The vesical wall is then severed. The shank l, capped by the guide tip I1, is next inserted through the urethra until the tip is wholly 1 within the opened bladder, the shank being long enough to leave the handle exposed and accessible from without the urethra. The tip is then removed, by gripping it with forceps or other such device inserted through the abdominal incision j and rotating the shank i so as to release the threads joining the tip l1 and the stud l9, and
the cutting tip of an appropriately chosen size to correspond to the growth (which approximation has been made by the surgeon once the vesical incision has been made) is affixed to the tube in a like manner and also through the incision. The instrument is then drawn back longitudinally of the urethral passage and as the cutting element 26 begins to contact the vesical wall and growth, the current is turned on to energize element '26, and a rearwardly straight cut made, until the angular portion 22 strikes the tumor. At this point the instrument is slowly rotated and being centered by the urethral tube,
- causes the element to excise from the prostate growth a generally conical or pear shaped mass, tapering toward the normal urethral opening into the bladder, and curving and diverging outwardly in conformity to the vesical walls, such conformity being more closely approximated by reason of the bow in the element. Upon the completion of the rotation, the instrument is deenergized, the excised growth is removed from the bladder through the aforementioned abdominal incision, the cutting attachment disengaged and likewise withdrawn, and upon re-attachment of the guide tip, by reversing the previously described procedure by which it was removed, the shank is completely retracted from the urethra. Replacement of the tip is preferable in order to prevent entry of secretions within the shank. It will be found that little or no intervesical bleeding has taken place, thus eliminating much of the complexity of drainage means and pads. The vesical wall incision is then sutured, the abdominal incision closed, and aside from possible post-operational bladder drainage, the prostatectomy is complete.
It is important to note that not only does the attachment portion 22 serve to indicate the appropriate penetration of the cutting element preparatory'to the annular cutting operation, but the .end 23 keeps the vesical wall adjacent the tumor spaced from contact with the cutting element and thus avoids the need for use of spatulas or other protecting means for holding the unaffected wall portions away from the element during the cutting operation. It will always be seen that the rigidity of the portions 2| and 22 will confine the travel of the cutting element 26 to a conic surface regardless of the amount of resistance which may be encountered in its passage through the tumor. In this connection, if desired and as shown in Figure 6, the portion 22 of attachment l8, which is otherwise similar to attachment [8, may be extended considerably beyond the wire 26 as at 25 so that the end 23 will afford a greater spacing or shield for the vesical wall.
Preferably the handle I3 is formed of sections one rotatable with respect to the other and connected to the shank so that the instrument may be conveniently supported in the hand by one section and the shank rotated with the other.
Furthermore, while I have here shown and de-' scribed the shank as designed for rotation with the attachment, it will be evident that the shank or a sheath therefor may be made revolvable so that during rotation of the instrument within the urethra passage no relative movement of any portion of the instrument against the passage wall will be required.
1. The method of excising a tumerous growth from the neck of the urethra passage where the latter enters the bladder with a cutting instrument large enough to efiect a complete excision of the abnormal growth on substantially a single rotation of the instrument and whose minimum width inhibits passage of the instrument through the urethra passage when the latter is distended to its fullest permissible extent, which comprises providing a passage through the abdominal and vesical walls sufli'cient to admit the insertion of the instrument into the bladder, inserting through the urethra a supporting means for the instrument and in such manner as to leave a portion for gripping outside the body and with a portion extending into the bladder, securing the cutting instrument to said latter portion while the cutting instrument is inside the bladder, and in such manner that rotation of the supporting and cutting instrument will sever the excess growth as aforesaid, separating the cutting instrument from the holding means, and withdrawing the cutting instrument and means from the bladder and urethra respectively.
2. An instrument for use in excision of prostate gland enlargements about the neck of the urethra passage where the latter enters the bladder, comprising a shank for insertion through and rotation in the urethra and having its outer walls of an electric insulating material, a cutting attachment designed to form an extension of said shank, said cutting attachment being insertible into the bladder other than through said urethra passage, cooperating means on said shank and the end of said attachment for detachably securing said shank and attachment together, said attachment including an electrode extending angularly from adjacent the connected end of the attachment to a point forwardly and outwardly thereof to describe a substantially conical figure upon rotation of the shank in the urethra with the circumference of the base exceedingthat of the urethra in its most distendible condition, means on said attachment formed of dielectrical material support- 1 ing said electrode fixedly in said position and including a portion coaxial with said shank and a transversely extending portion permanently disposed in angular relationship with said first mentioned portion, said second mentioned portion being greater in length than the permissible maximum distention of said urethra, means connected with said electrode for establishing contact with 7 a source of electrical current, and protective means on the attachment positioned radially outward beyond the most outward point of the electrode for holding adjacent portions of the bladder spaced from said electrode.
EUGENIO DE SOUSA.
REFERENCES CITED The following references are of record in the file of this patent:
UNITED STATES PATENTS