US 2835253 A
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May 20, 1958 s. E. BORGESON SURGICAL APPLIANCE- Filed Aug. 14, 1956 PULMONARY ARTERY PULMONARY VEIN RIGHT AURICLE LEFT AURIOLE NITRAL VALVE LEFT VENTRICLE RIGHT VENTRICLE AORTIC VALVE 'FIG.4.
SIDNEY E.BORGESON ozc'u BY FLORENCE W. BORGESON,
' EXECUTRIX BY ATTORNEY United States Patent SURGICAL APPLIANCE Sidney E. Borgeson, deceased, late of Westfield, N. J., by Florence W. Borgeson, executrix, Westiield, N. J.
Application August 14, 1956, Serial N0. 603,896
9 Claims. 01. 128-303) The present invention concerns an improved method and appliance for performing surgical commissurotorny for aortic stenosis.
Aortic stenosis is essentially a narrowing of the opening between the cusps of the valve that is located at the entrance of the aorta vein. In one form of heart disease the aortic valve becomes gradually but a small opening and allows only a fraction of the blood to travel from the heart to the head and body. The constriction at this point causes the blood to back up in the lungs causing pulmonary edema and heart failure.
In recent years surgeons have attempted to enlarge the valve opening in an effort to restore it to normal, or nearly normal, size and function. One method of treatment consisted in the surgeon making a small incision in the lower part of the heart and, using a blunt ended wire passed into the ventricle, probing about until he was reasonably certain that the wire found and entered the residual opening in the aortic valve. Thereafter a triangular shaped dilating instrument was slid along the wire and forced into the aortic orifice to cause one or more of the fused commissures of the valve to separate. This was a purely instrumental commissurotomy by trans-ventricular passage without benefit of direct palpation of the valve or of accurate visual or digital guidance of the instruments. However, the operative mortality rate of patients treated in this manner remained relatively high mostly from failure properly to reach the aortic valve and from hemorrhaging at the site of the ventricular punctures.
Another approach to the aortic valve was tried by way of the left atrium and the mitral orifice. This procedure involved entering the pulmonary vein adjacent the heart and inserting a finger and probing for the aortic valve. After the aortic valve was found and digitally dilated the finger was withdrawn and the incision in the vein sutured. The operation was at best blind and presumably risky owing to the ever present possibility of inadvertently tearing the septa] mitral leaflet and therefore the practice has not been widely accepted.
Later still another approach to the aortic valve was made directly by an incision in the arch of the aorta vein itself, below the valve. In practicing this method of treatment the surgeon inserted his finger and probed for the opening in the valve. After it was found the dilating instrument was guided into the valve orifice with the finger and digital and instrumental commissurotomy of aortic stenosis was performed in a relatively safe manner.
The present invention concerns more especially, though not exclusively, the last mentioned method and relates more particularly to an improved method and means for gaining access to the aorta and heart without undue delay. Prior to this invention it was customary for the surgeon to clamp a portion of the outer arch of the aorta between the jaws .of a tool and make an incision in the excluded portion. Thereafter a strip of the pericardium was sutured about the incision so as to form a tubular extension. The surgeon inserted his finger into the tube and thelatter was secured with a purse string suture about the upper portion of his finger. Only after all of these time consuming preliminary operations were performed was the clamp removed and access to the aorta and its valve became possible. i
The present invention concerns a device that may be secured about the surgeons finger and one or more in strurnents before he approaches the patient and with the equipment in position the surgeon proceeds with the operation by placing his cassioned finger upon the aorta and fitting the lower part of the cassion to the curvature circumferentially and longitudinally. Thereafter a vacuum valve is opened and the cassion clamped securely to the slippery aorta vein. After clamping in this manner the incision in the aorta is made by a finger-guided knife within the sealed-on cassion and thereafter the finger is inserted and the valve located with certainty. After palpitating the valve digitally for knowledge of the condition, the dilatating instrument is guided carefully into the small opening and the valve expanded again to normal. The dilator is then withdrawn into the cassion as well as the surgeons finger and a Potts clamp applied to the aorta under the cassion, and this portion of the aorta is excluded from the flow stream. The vacuum seal is then broken, the cassion removed, and the incision sutured before the Potts clamp is removed. The operation, when performed in the manner outlined, consumes only a few precious minutes as against the time heretofore required in suturing and unsuturing a cassion to and from the aorta itself, and indeed with far greater assurance of success than has ever before been attainable.
Other objects and advantages will be in part indicated in the following description and in part rendered apparent therefrom in connection with the annexed drawings.
To enable others skilled in the art so fully to aprehend the underlying features hereof that they may embody the same in the various ways contemplated by this invention, drawings depicting a preferred typical construction have been annexed as parts of this disclosure and, in such drawings, like characters of reference denote corresponding parts throughout all the views, of which:
Fig. l is a line diagram representing the heart and illustrating diagrammatically the heart valves and portions of the veins and arteries connected therewith.
Fig. 2 is a perspective view of the device of this invention in position on the aortic vein.
Fig. 3 is an elevational View of the device.
Fig.4 is a plan view of the device.
Fig. 5 is a transverse sectional view taken along line 5-5 of Fig. 4.
Fig. 6 is a bottom view of a portion of the device illustrating more clearly the marginal suction grooves.
Fig. 7 is a view of the device equipped with a flexible skirt having two operational openings.
With reference more particularly to Figs. 3 to 6 of the drawings, the device comprises preferably a relatively rigid ring member 10 of metal or plastic and an extended skirt or .sleeve portion 11 made of preferably flexible material such as sheet rubber or plastic. In the preferred embodiment the ring member 10 is somewhat comically shaped and formed with a marginal groove 12 about its upper end to provide an anchor for the lower portions of the sleeve i1. Inasmuch as the sleeve 11 must not only be securely fastened to the ring 10, but fastened tightly throughout the perimeter of the cassion member, it was found advisible to flare the sides 10a of the cassion outwardly so that the skirt-tying groove 12 took a curved and somewhat oval path about the ring member. When the lower portions of the skirt are telescoped over the grooved ring and overlaid by a tightly drawn cord, no crevice remains for possible seepage of air or liquid from between the skirt and the ring.
substantially The relatively rigid cassion portion is generally elongated and provides a generous opening within its margins through which the surgeon may pass a finger and one or more instruments. The lower end face 16 of the cassion for aortic commissurotomy is shaped so as to conform closely to the normal curvature of the aorta both longitudinally and transversely, as indicated at 17 and 18 in Figs. 3 and 5. The curvatureof the end face should in any given case match the exterior contour of the vein, artery, or other vessel upon which it is to be used, so that a fairly substantial area of face-to-face engagement is made at the location where the incision and operation is to be performed.
To effect tight clamping of the finger cassion to the membranous arterial wall, the invention proposes to form one or more annular grooves 24) in the end face in and when the device is fitted to the vessel in which the incision is to be made, to connect the groove or grooves with a source of suction. In a preferred form of finger cassion, two annular grooves are provided, the grooves being separated by a relatively narrow partition wall 21. Such a construction, as seen most clearly in Fig. 5, provides three lines of contact extending uninterruptedly about the end face of the cassion, which, when applied to the relatively soft and pliable membrane of the aorta or other vessel and the vacuum applied, causes annular undulations to form in the membrane about the locale of the incision that assist in producing an effective seal and a firm anchoring of the cassion to the pliable wall. As further assurance against slipping or inadvertent dislodgment of the cassion during the performance of a delicate operation, it is proposed to roughen the end face of the separating wall 21 as by forming shallow serrations therein or by knurling that face as indicated at 22 in Fig. 6.
The bottom of the groove or grooves are cross connected by a passageway 201: which in turn leads to the exterior of the cassion and forms the bore of a con nection fitting 20b by which the cassion may be con nected to a source of vacuum.
As illustrated more clearly in Figs. 2 and 3, the upper portion of the cassion sleeve is formed with a pursestring type of closure 25 which may be shirred and tied about the surgeons finger before placing the cassion on the part to be operated upon. For certain types of operations the instrument the surgeon will use in making the initial incision and/ or in performing the subsequent operation will also be shirred within the sleeve either with the finger or via a separate opening such as indicated at 25a in Fig. 7.
In using the device of this invention, the surgeon will have first taken all the preliminary steps necessary to expose the vein, artery, or other tube in which the incision is to be made. Thereafter an assistant will shirr the sleeve of the cassion about his finger and such instruments as he selects. The grooved end face of the cassion is then placed gently on the exposed vein at the proper location for the operation and the vacuum line opened to exhaust the air from the annular grooves. The operation of exhausting air simultaneously effects a secure clamping of the cassion to the vein and an effective liquid and air-tight seal about the margins. In a matter of instants, as compared with former methods of suturing an appendage around the zone of the incision and then suturing the appendage to the finger, the surgeon is ready to make the incision working from within the hermetically sealed cassion. By the present inven tion the finger cassion is aflixed almost instantaneously without needless stitching and Without expending precious time.
When the commissurotomy has been completed. the finger is again drawn into the cassion and a clamp placed on the vein beneath the cassion to exclude the incised portion from the remainder of the tube. The vacuum affixing the cassion to the tube is released and the cassion removed, after which the excluded incised portion of the vein is sutured in the regular manner, and the clamp is removed so that the vein again assumes its normal cylindrical form. As above indicated there is no time lost in suturing an appendage to the vein as a preliminary step to a commissurotomy nor is there any time lost in removing such appendage. With the aid of this invention an air lock may be effected around an area in seconds and the shock to the patient is reduced to its minimum.
Without further analysis, the foregoing will so fully reveal the gist of this invention that others can, by applying current knowledge, readily adapt it for various utilizations by retaining one or more of the features that, from the standpoint of the prior art, fairly constitute essential characteristics of either the generic or specific aspects of this invention and, therefore, such adaptations should be, and are intended to be, comprehended within the meaning and range of equivalency of the following claims.
Having thus revealed this invention, the following combinations and elements, or equivalents thereof are claimed by Letters Patent of the United States:
1. A cassion for surgical purposes comprising a ring like member having a relatively flat end face adapted to engage the surface of the membranous tissue about the zone where a surgical operation is to be performed, a pliable tubular sleeve member secured at one end to said ring-like member, means at the other end of said tubular sleeve member for securing same about a finger of an operator, and means at said flat end face of the ring-like member for attaching the ring-like member to the tissue to anchor the ring-like member in place and to form a seal about the incision to be made by the cassioned finger of the operator.
2. A finger cassion for surgical purposes comprising a ring-shaped member having a continuous side wall defining a central opening through which a surgical operation may be performed, a pliable sleeve member secured to said ring so as to form a tubular extension thereof, means at the free end of said pliable sleeve member for securing said end about the finger of the surgeon, means at the open end of said ring-shaped member for securing the ring to the tissue surrounding the area where the surgery is to be performed, said ring-shaped member having its tissue engaging end face contoured substantially complementary to the surface contour of the area of the surface surrounding the zone selected for the operation.
3. A device for assisting a surgeon in performing sur gical commissurotomy for aortic stenosis comprising an elongated ring-shaped member having one end face contoured substantially complementary to the surface con tour of the aortic vein adjacent the patients heart so as to engage the surface of the vein surrounding the site of the operation, said one end face of the member having an annular groove therein effectively dividing said end face into at least two perimetrical areas of contact with the surface of the said vein, conduit means communicating with the chamber formed by said groove and leading to the exterior of said ring-shaped member adapted to be connected with a source of vacuum whereby to effect a clamping of the ring member to the vein, and means for sealing the other end of said ring-shaped member about the finger of the surgeon and such instruments as may be employed in performing surgical commissurotomy.
4. An air-lock for surgical purposes comprising a relatively rigid tubular-shaped member having an end face adapted to be placed in engagement with tissue surrounding the area where the surgery is to be performed, vac-uum means for securing said tubular-shaped member to said tissue including vacuum chambers in said end face of the member adapted to be connected with a source of reduced pressure, said chambers being separated from one another and being open on their sides adjacent the tissue surrounding the area for the surgery so that when placed in position for an operation such tissue forms a closure to said chambers, portions of said tissue-engaging end face of the member being roughened to restrain the member against lateral movement on the tissue during the course of an operation, and sleeve means sealed about said member for enclosing the operating finger of the surgeon.
5. The combination of claim 4 in which said sleeve means is provided with an opening for an operating instrument in addition to the finger opening.
6. A cassion for surgical purposes comprising a metallic member having an end face adapted to engage the surface of the membranous tissue about the zone Where a surgical operation is to be performed, said member having a central opening through which the operation may be performed, a pliable tubular sleeve member secured at one end to said member, means at the other end of said tubular sleeve member for securing same about a finger of a surgeon, and vacuum means effective at said end face of the member for anchoring the member in place and to form an air lock about the incision to be made by the cassioned finger of the surgeon.
7. A finger cassion for surgical purposes comprising a member having a continuous side wall defining a central opening through which a surgical operation may be performed, a pliable sleeve member secured to said member so as to form a tubular extension thereof, means at the free end of said pliable sleeve member for securing said end about the finger of the surgeon, means at the open end of said member for securing the member to the tissue surrounding the area Where the surgery is to be performed, said member having its tissue engaging end face contoured substantially complementary to the surface contour of the area of the surface surrounding the zone selected for the operation, and having at least one groove extending therearound adapted to be connected with a source of suction.
8. A device for assisting a surgeon in performing surgical commissurotomy for aortic stenosis comprising an elongated ring-shaped member having one end face contoured substantially complementary to the surface contour of the aortic vein adjacent the patients heart so as to engage the surface of the vein surrounding the site of the operation, said one end face of the member having two annular grooves therein effectively dividing said end face into at least three perimetrical ridges adapted to engage with the said surface of the vein, and conduit means communicating with the chambers formed by said grooves and leading to the exterior of said ring-shaped member adapted to be connected with a source of vacuum whereby to effect a clamping of the ring member to the veing, and at least one of said ridges in said end face of the member being knurled to resist slipping.
9. An air-lock and seal for surgical purposes comprising a relatively rigid member having an end face adapted to be placed in engagement with the tissue surrounding the area Where the surgery is to be performed, said memher having an operating opening therein defined by said end face, vacuum means for securing said member to said tissue including vacuum chambers in said end face of the member adapted to be connected with an exterior source of reduced pressure, said chambers being separated from one another and open toward the surface on which the member is placed so that when in position for an operation such tissue forms a closure for said chambers, and means at the other end of said member for sealing the member about the finger of the surgeon.
References Cited in the file of this patent UNITED STATES PATENTS