Narrative: Right Angle Harmonic Scalpel. Designer: Mark A. Carlson, MD

Transcription

1 Otoer 31, 2005 Right Angle Hrmoni Slpel, Pge 1 of 5 Nrrtive: Right Angle Hrmoni Slpel Designer: Mrk A. Crlson, MD Astrt. The Right Angle Hrmoni Slpel is n instrument esigne for minimlly invsive (lprosopi) surgery tht omines the tion of right-ngle issetor n Hrmoni Slpel (Ethion Eno-Surgery) into one evie. A prototype of the Right Angle Hrmoni Slpel hs not een onstrute. Introution. The ultrsoni shers (Figure 1) is hemostti utting instrument tht hs een in use for minimlly invsive surgery for out 10 yers. The ultrsoni shers, lso known s the Hrmoni Slpel, is mnufture y Ethion Eno-Surgery, susiiry of Johnson & Johnson. The Hrmoni Slpel onsists of lprosopi shers (Figure 1A-B) onnete to power soure (Figure 1C). The surgeon grsps tissue whih nees to e trnsete in the jws of the shers (Figure 1D). Power then is pplie to instrument in the form of high frequeny ( ultrsoni ) virtion to the rigi rm of the instrument. This virtory energy is trnsmitte to the tissue within the jws of the shers, n this energy entures, ehyrtes, n ogultes the proteins within the shers. Any loo vessel within the ffete tissue lmost instntneously is sele. After severl seons of power pplition, the jws slie through the grspe tissue. So the hrmoni slpel first hieves loo vessel hemostsis, followe y tissue trnsetion. The omintion of these two tions in one instrument, the Hrmoni Slpel, hs enle the minimlly invsive surgeon to e quiker n sfer thn wht ws fesile with oler, more onventionl instruments. Rtionle for moifition to the Hrmoni Slpel. In situtions where the tissue to e trnsete is plinly visile (suh s tht shown in Figure 1D), the onventionl Hrmoni Slpel works well. In situtions where physil reltionships of the tissue re not ovious, however, the use of the Hrmoni Slpel n e iffiult n umersome. In one ommon senrio, for exmple, surgeon my e presente with ns of tissue lying eep within reess forme y two jent orgns, s shown in Figure 2A-B. (A speifi exmple of this woul e the short gstri vessels whih lie etween the funus of the stomh n the superior pole of the spleen.) The ville ngles of instrument pproh limit the surgeon s ility to grsp n uterize tissue in suh eep reess. The surgeon n hnle this iffiulty y first isolting some tissue using lprosopi right-ngle issetor (Figure 2C-F). A right-ngle issetor hs 90 en in its jws, whih filittes the issetion n seprtion of tissues. This mneuvers shown in Figure 2 neessitte multiple instrument hnges through the lprosopi trors, whih n onsume time over the ourse of long proeure. In ition, lthough the rightngle issetor n isolte tissue for susequent pplition of the Hrmoni Slpel (Figure G-H), the isolte unle of tissue my retrt k to its originl position immeitely fter withrwl of the right-ngle issetor. The unle then woul no longer e visile for uteriztion/trnsetion y the Hrmoni Slpel. The sitution shown in Figure 2 emonstrtes shortoming of the onventionl Hrmoni Slpel: its poor ptility for the performne of issetion in iffiult-to-reh spes uring lprosopi surgery. One solution employe for this prolem involves the use of multiple instruments to perform the issetion, s shown in Figure 2; this pproh is umersome n ineffiient. Alterntively, the surgeon my try to fore the issue with the Hrmoni Slpel lone, i.e., ttempting to isset out the tissue with the non-ngle jws of the onventionl ultrsoni instrument. This ltter pproh is suoptiml t est, n ngerous t worst. A thir, unexplore, solution to this prolem (n the topi of this proposl) woul e to omine the utility of the rightngle issetor with the effiy of the Hrmoni Slpel into one instrument. The instrument omintion: the Right Angle Hrmoni Slpel. The surgil evie of this proposl is the Right Angle Hrmoni Slpel (Figures 3-7; etils of the instrument esign re inlue in the Figure Legens). As llue to ove, the Right Angle Hrmoni Slpel omines the isseting ility of the right-ngle issetor with the uteriztion/trnsetion ility of the Hrmoni Slpel. Suh n instrument shoul sfely spee n simplify the performne of lprosopi proeures whih involve iffiult issetion in eep reesses (suh s Nissen funoplition, splenetomy, renletomy, olon resetion, n gstri ypss). A oneptulize lterl view of the Right Angle Hrmoni Slpel is shown in Figure 3. The Right Angle

2 Otoer 31, 2005 Right Angle Hrmoni Slpel, Pge 2 of 5 Hrmoni Slpel is similr in pperne to the Hrmoni Slpel urrently is use (Figure 1), exept with the ition of the right-ngle mehnism n relte ontrols. Of note, the propose instrument hs shft imeter of 10 mm. The Hrmoni Slpel from Ethion omes in oth 5 n 10 mm versions. There is tren to employ nrrow imeter (5 mm n elow) instrument in lprosopi surgery, euse of the pereption tht there re fewer tror-relte omplitions with nrrower instrumenttion. The Right Angle Hrmoni Slpel hs een oneive initilly s 10 mm instrument in orer to filitte the engineering of its internl mehnis. If the instrument is suessful, then it is possile tht the instrument imeter eventully oul e reue to 5 mm. Another ifferene etween the Hrmoni Slpel from Ethion n the propose Right Angle Hrmoni Slpel is the presene of rotiultion ontrol in the former (see Figure 1A&B, n Figure 3), whih llows 360 rottion of the instrument shft. By turning lk kno on the instrument hnle with the inex finger (see inset Figure 1B), the surgeon n rotte the jws of the Hrmoni Slpel to est suit the tsk t hn. This ontrol hs not een inlue with the initil esign of the Right Angle Hrmoni Slpel in orer to filitte its engineering. It is oneivle tht rotiultion ontrol oul e e in t lter time. The lk of rotiultion ontrol woul e only minor etrtion from the propose instrument. The length of the propose instrument is stnr 45 m; it shoul e fesile to offer the instrument in 60 m or longer lengths for ritri surgery. Close up views of the jws of the Right Angle Hrmoni Slpel re shown in Figure 4, n the tion of the instrument jws is shown in Figure 5. The right-ngle portion of the Right Angle Hrmoni Slpel works similrly to onventionl right-ngle issetor, exept tht one jw (the lterl) of the former nees to fixe; the opposite (meil) jw provies the sissor motion. This is neessry euse effiient trnsmission of ultrsoni energy through the instrument shft into the tip (i.e., the lterl jw) requires stright, rigi rm with preise hrmoni qulities. The mehnism of the hrmoni lmp is shown in Figure 6; the stowe (retrte) position of the rm lso is shown in Figures 4 n 5. This hrmoni lmp is rotting rm whih the surgeon eploys to ompress the issete tissue ginst the right-ngle jws. Suh ompression is neessry for optiml trnsmission of the hrmoni energy into the tissue. As rwn, the hrmoni lmp requires slightly more thn 180 rottion for full eployment. To omplish this rottion, thumwheel mehnism is utilize in the instrument hnle (Figure 7). The rottion of the thumwheel is trnslte into rottion of the hrmoni lmp through mehnil linkge. An en-on view of the Right Angle Hrmoni Slpel is shown in Figure 8. The Right Angle Hrmoni Slpel in tion. As esrie ove, the Right Angle Hrmoni Slpel performs oth the tion of right-ngle issetor n onventionl Hrmoni Slpel (Figure 9). The surgeon first gets roun iffiult-to-reh segment of tissue/loo vessel with the right-ngle jws, n retes winow unerneth this tissue. After the trget is suffiiently issete, the surgeon eploys the hrmoni lmp, n then pplies the ultrsoni energy. Compre to the tehnique esrie in Figure 2, there is minimum of wste motion n time, with equivlent or improve ptient sfety.

3 Otoer 31, 2005 Right Angle Hrmoni Slpel, Pge 3 of 5 Figure Legens 1. The Hrmoni Slpel (k ultrsoni shers), prout of Ethion Eno-Surgery. (A) Close-up view of the instrument hnle n the sher-like tips. (B) Full lterl view. (C) The instrument power soure, n itionl lose-up views of the instrument tips. (D) Intropertive photogrph of the ultrsoni shers in tion. The shers re oming in from the right, n re grsping tissue with loo vessels lote etween the greter urve of the stomh n the spleen. The ultrsoni energy pplie y the instrument will ogulte the vessels n trnset the tissue. [All imges in Figure 1 were ownloe from the internet.] 2. Tissue trnsetion in eep reesses using the Hrmoni Slpel. (A) Hypothetil en-on view of some onnetive tissue strethe etween two intr-ominl orgns ( n ). There re loo vessels within this onnetive tissue tht the surgeon esires to trnset n sel. The Hrmoni Slpel () is shown superiorly, pprohing from n ngle whih is typil uring lprosopi proeure. (B) Overhe view of the orgns n tissue in A; this is wht the surgeon typilly sees through the lprosope. The surgeon will hve iffiult time grsping the onnetive tissue in the shers of the Hrmoni Slpel (), euse the tissue is protete in the reess forme y orgns n. (C-D) One pproh to this prolem of surgil exposure is to use lprosopi right-ngle issetor () whih, s its nme implies, hs 90 en in its jws. The right-ngle issetor n e insinute unerneth n roun segment of tissue etween orgns n, whih isoltes this segment in preprtion for the Hrmoni Slpel. (E) The spreing tion of the jws of the right-ngle issetor opens up winow eneth the isolte segment of tissue, whih will llow pssge of the lower jw of the Hrmoni Slpel. (F) The right-ngle issetor then is withrwn, leving the isolte segment of onnetive tissue etween orgns n rey for uteriztion/trnsetion y the Hrmoni Slpel. (G) The Hrmoni Slpel () then is inserte, the tissue segment is grspe in the instrument s jws, n ultrsoni energy is pplie. (H) After ompletion of the uteriztion/trnsetion, the Hrmoni Slpel is withrwn, leving two uterize ens of tissue. intr-ominl orgn intr-ominl orgn Hrmoni Slpel lprosopi right-ngle issetor 3. The Right Angle Hrmoni Slpel, full lterl view. The propose instrument hs similr shpe to the onventionl Hrmoni Slpel shown in Figure 1. e f g h instrument jws shft rotiultor ontrol utting n ogultion ontrol finger grips thum wheel for ontrol of hrmoni lmp oy of hnle lotion of power le insertion. 4. Right Angle Hrmoni Slpel, 90 views of instrument jws. A lose-up of the instrument tip, showing the reltionships of the jws n the hrmoni lmp in top n sie views. lterl jw meil jw hrmoni lmp

4 Otoer 31, 2005 Right Angle Hrmoni Slpel, Pge 4 of 5 e f g meil jw linkge horizontl lever rm vertil lever rm instrument shft 5. Right Angle Hrmoni Slpel, emonstrtion of right-ngle mehnism. Close n open positions of the right ngle jws, viewe from the top. Extension of the finger grips (not shown) rives spring-loe onneting ro forwr, whih swings the meil jw open vi the meil jw linkge. Susequent losure of the jws is performe y ompression of the finger grips, n is ie y the spring loing. e f lterl jw meil jw hrmoni lmp meil jw linkge horizontl lever rm vertil lever rm 6. Right Angle Hrmoni Slpel, emonstrtion of hrmoni lmp mehnism. (A) Stowe (retrte) position. The hrmoni lmp is reesse in its slot, so the instrument n e inserte n mneuvere without restrition from the lmp. (B-C) Phses of hrmoni lmp rottion. The thumwheel (not shown) is turne y the surgeon; mehnil linkge trnsltes this movement into lmp rottion. (D) After full eployment, the hrmoni lmp omes to rest on top of the lterl right-ngle jw (through whih the hrmoni energy is trnsmitte). To retrt the lmp k to the stowe position, the surgeon reverses the rottion on the thumwheel. e f lterl jw meil jw hrmoni lmp meil jw linkge horizontl lever rm vertil lever rm 7. Detils of the hrmoni lmp mehnism with thumwheel. (A-E) The hrmoni lmp is shown progressing from the stowe position to the lmpe position; eh progressive pnel of this Figure shows the thumwheel n hrmoni lmp going through 45 of rottion. A series of onneting ros links the rottion of the thumwheel with rottion of the hrmoni lmp; this tion filitte y two lever rms (offset y 90 ) on the hrmoni lmp. [Figure not to sle.] e f horizontl lever rm (re) vertil lever rm (lue) hrmoni lmp vertil lever linkge (re) horizontl lever linkge (lue) thumwheel 8. Right Angle Hrmoni Slpel, en-on view. The instrument is viewe en-on with the jws fing the viewer. The ulk of the hnle n grips (whih shoul e visile in the kgroun) re not shown. The surfe of the right-ngle jws re serrte. lterl jw

5 Otoer 31, 2005 Right Angle Hrmoni Slpel, Pge 5 of 5 meil jw hrmoni lmp slot for hrmoni lmp lever rms 9. Tissue trnsetion in eep reesses using the Right Angle Hrmoni Slpel. This Figure illustrtes the sme intropertive sitution presente in Figure 2, ut this time using the new instrument. (A) The Right Angle Hrmoni Slpel () is inserte into the omen in orer to sel n trnset loo vessel () lying within onnetive tissue tht is reesse etween 2 intr-ominl orgns ( & ). (B-C) The jws of the Right Angle Hrmoni Slpel re sli uner n roun the trget vessel, reting winow eneth the vessel. (D) The surgeon spres the jws of the Right Angle Hrmoni Slpel, whih enlrges the winow eneth the vessel in preprtion for seling n trnsetion. (E) With the instrument still in ple, the surgeon loses the hrmoni lmp over the trget vessel with the thumwheel (not shown) on the hnle of the Right Angle Hrmoni Slpel. (F) The surgeon pplies hrmoni energy to the instrument, whih sels n trnsets the trget vessel in the sme fshion s the onventionl Hrmoni Slpel. intr-ominl orgn intr-ominl orgn Right Angle Hrmoni Slpel trget loo vessel

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10 ADDENDUM Sie view of propose hrmoni right ngle A C 10 mm B (A) (B) (C) Stright rigi rm for trnsmission of ultrsoni energy Hrene plsti sheth Tip of right ngle Crlson, Mrk A. My 10, 2006

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