Surgical retractor and stabilizing device and method for use
An adjustable surgical retractor and its use for improving a surgeon's ability to perform closed-chest video-assisted exploratory, diagnostic or surgical procedures on a patient. The surgical retractor has opposable blades which can be inserted into a surgical incision in a patient undergoing a surgical procedure then spread apart to form an elongated access opening through which a instrument may be inserted to perform exploratory, diagnostic or surgical procedures. The blades used in the surgical retractor may be flexible or rigid and are attachable to the retractor. The blades are of a width, depth and thickness to provide an access to an internal cavity or subcutaneous region to allow greater degrees of freedom to the surgeon in inserting instruments into the access opening. The use of the surgical retractor forms a substantially ovoid channel, through which a medical instrument can be inserted to perform surgical or other operations.
This is a continuation of application Ser. No. 10/371,756 filed Feb. 21, 2003, which is a continuation of application Ser. No. 09/672,110 filed Sep. 27, 2000, which is a continuation of application Ser. No. 09/171,206 filed Aug. 10, 1999, which is a National Stage application of international application number PCT/US97/06112 filed Apr. 10, 1997, which claimed the benefit of provisional patent application U.S. 60/014,922 filed Apr. 10, 1996 in the name of inventors Arthur Bertolero, Raymond Bertolero and Jerome Riebman. This application is related to applications PCT/US97/06533, PCT/US97/05910, PCT/US97/06070 and U.S. Utility Ser. No. 08/838,774, which were concurrently or almost concurrently filed with PCT/US97/06112, which is one of the application in the priority chain listed above. Each of the above-identified patent applications is incorporated by reference.
FIELD OF THE INVENTIONThis invention relates to an adjustable surgical retractor and its use for improving a surgeon's ability to perform closed-chest, video-assisted exploratory, diagnostic or surgical procedures on a patient. The invention also relates to unique blades useful in combination with the retractor.
BACKGROUND OF THE INVENTIONSurgery on the heart is one of the most commonly performed types of surgery that is done in hospitals across the U.S. Cardiac surgery can involve the correction of defects in the valves of the heart, defects to the veins or the arteries of the heart and defects such as aneurysms and thromboses that relate to the circulation of blood from the heart to the body. In the past, most cardiac surgery was performed as open-chest surgery, in which a primary median sternotomy was performed. That procedure involves vertical midline skin incision from just below the super sternal notch to a point one to three centimeters below the tip of the xiphoid. This is followed by scoring the sternum with a cautery, then dividing the sternum down the midline and spreading the sternal edges to expose the area of the heart in the thoracic cavity. This technique causes significant physical trauma to the patient and can require one week of hospital recovery time and up to eight weeks of convalescence. This can be very expensive in terms of hospital costs and disability, to say nothing of the pain to the patient.
Recently, attempts have been made to change such invasive surgery to minimize the trauma to the patient, to allow the patient to recover more rapidly and to minimize the cost involved in the process. New surgical techniques have been developed which are less invasive and traumatic than the standard open-chest surgery. This is generally referred to as minimally-invasive surgery. One of the key aspects of the minimally invasive techniques is the use of a trocar as an entry port for the surgical instruments. In general, minimally invasive surgery entails several steps: (1) at least one, and preferably at least two, intercostal incisions are made to provide an entry position for a trocar; (2) a trocar is inserted through the incision to provide an access channel to the region in which the surgery is to take place, e.g., the thoracic cavity; (3) a videoscope is provided through another access port to image the internal region (e.g., the heart) to be operated on; (4) an instrument is inserted through the trocar channel, and (5) the surgeon performs the indicated surgery using the instruments inserted through the access channel. Prior to steps (1)-(5), the patient may be prepared for surgery by placing him or her on a cardiopulmonary bypass (CPB) system and the appropriate anesthesia, then maintaining the CPB and anesthesia throughout the operation. See U.S. Pat. No. 5,452,733 to Sterman et al. issued Sep. 26, 1995 for a discussion of this technique.
While this procedure has the advantage of being less invasive or traumatic than performing a media, sternotomy, there are numerous disadvantages to using trocars to establish the entry ports for the instruments and viewscope. For example, the trocars are basically “screwed” into position through the intercostal incision. This traumatizes the local tissues and nerve cells surrounding the trocar.
Once in place, the trocar provides a narrow cylindrical channel having a relatively small circular cross-section. This minimizes the movement of the instrument relative to the longitudinal axis and requires specially-designed instruments for the surgeon to perform the desired operation (See, e.g., the Sterman patent U.S. Pat. No. 5,452,733). In addition, because of the limited movement, the surgeon often has to force the instrument into an angle that moves the trocar and further damages the surrounding tissue and nerves. The need to force the instrument causes the surgeon to lose sensitivity and tactile feedback, thus making the surgery more difficult. The surgical retractor of this invention is designed to reduce the initial trauma to the patient in providing access to the internal region, to reduce the trauma to the patient during surgery, to provide the surgeon with greater sensitivity and tactile feedback during surgery, and to allow the surgeon to use instruments of a more standard design in performing the non-invasive surgery.
Other less invasive surgical techniques include access to the region of the heart to be corrected by anterior mediastinotomy or a thoracotomy. In a mediastinotomy, an incision is made that is two to three inches in length of a parasternal nature on the left or the right of the patient's sternum according to the cardiac structure that needs the attention in the surgery. Either the third or the fourth costal cartilage is excised depending on the size of the heart. This provides a smaller area of surgical access to the heart that is generally less traumatic to the patient. A thoracotomy is generally begun with an incision in the fourth or fifth intercostal space, i.e. the space between ribs 4 and 5 or ribs 5 and 6. Once an incision is made, it is completed to lay open underlying area by spreading the ribs. A retractor is used to enlarge the space between the ribs.
At the present time, when either of these techniques are used, a retractor is used to keep the ribs and soft tissues apart and expose the area to be operated on to the surgeon who is then able to work in the surgical field to perform the operation. The types of retractors that are used may be seen, for example, in volume 1 of Cardiac Surgery by John W. Kirkland and Brian G. Barratt-Boyes, Second Edition, Chapter 2, at page 101. Commercial-type retractors for minimally-invasive surgery that are useful for a mediastinotomy or a thoracotomy are manufactured by Snowden Pencer (the ENDOCABG rib spreader and retractor), U.S. Surgical (the mini CABG system), and Cardiothoracic Systems (the CTS MIDCAB. System). The ENDOCABG retractor is two opposing retractor arms that are interconnected by a ratchet arm having a thumbscrew which can adjust the distance between the retractor arms. While this provides a useful retractor, it has certain shortcomings in its ease of use. The mini CABG System is an oval-based platform to which a number of retractors are then fitted around the extremity of the universal ring base and adjusted by a gear tooth connection. Each of the retractors have to be separately adjusted and there are other devices that can be connected to the universal base which can aid the surgeon in damping the heart movement to better work on the artery or vessel to which the surgeon is directing his attention. The CTS MIDCAB. System serves a similar function to the ENDOCABG retractor, but is more complex. The designation CABG refers to “coronary artery bypass graft.”
Major disadvantages of these systems include their limited positioning, complexity, and lack of reusability. It has now been discovered that the shortcomings of the retractors that are known in the prior art can be overcome with a new design as set forth in the following description.
SUMMARY OF THE INVENTIONOne aspect of this invention is an adjustable surgical retractor that comprises
(a) two handles suitable for grasping positioned opposite each other and connected so that the handles move reciprocatingly relative to each other,
(b) a head connected to each handle so that each head moves reciprocatingly relative to the other,
(c) a means for locking the heads at a preset distance from each other, and
(d) a blade connected to each head, each blade having a width, depth and thickness so that the width extends substantially parallel to the length of the handle and the depth extends downward from the top of the head wherein the blades taken together at the position of closest proximity to each other are of a size suitable to be inserted into a surgical incision in a patient undergoing a surgical procedure then spread apart to form an elongated access opening through which a medical instrument may be inserted to perform exploratory or surgical procedures.
Another aspect of this invention is a blade suitable for use as part of a surgical retractor, which blade comprises a biocompatible material having dimensions defined by a width, depth and thickness, the width and the depth defining an first and an second face separated from each other by the thickness of the blade, wherein the blade has a connector means for attaching to a head means of the surgical retractor.
Another aspect of this invention is a method of providing surgical access to a patient, which method comprises making a surgical incision through the skin and soft tissue of the patient,
inserting two blades of a surgical retractor perpendicularly through the incision, and
spreading the blades of said retractor to provide a relatively symmetrical, elongated channel for internally accessing said patient, said channel being defined by said blades wherein the internal faces of the blades have a concave surface to define a substantially ovoid channel, each blade having a smooth, continuous upper surface.
Another aspect of this invention is a method of performing minimally invasive surgery on a patient, which method comprises
making a surgical incision through the skin and soft tissue of the patient,
inserting two blades of a surgical retractor, perpendicularly through the incision,
spreading the blades of said retractor to provide a relatively symmetrical, elongated channel for internally accessing said patient, said channel being defined by said blades wherein the internal faces of the blades have a concave surface to define a substantially ovoid channel, each blade having a smooth continuous upper surface,
inserting a surgical instrument through said substantially ovoid channel, and
performing a surgical procedure using the surgical instrument so inserted.
BRIEF DESCRIPTION OF THE DRAWINGS
While the description of the surgical retractor of this invention will be discussed primarily in relation to cardiac surgery procedures, it should be understood that the surgical retractor of this invention will find use in not only cardiac surgery but also laparoscopic surgery in which a surgeon wishes to gain access to an internal cavity by cutting the skin and going through the body wall in order to keep the incision spread apart so that surgical instruments can be inserted.
Thus the surgical retractor can find use in providing surgical access generally where a limited incision is desired. It is useful for subcutaneous access as well as for surgically accessing various body cavities such as the abdominal region, the thoracic region and the extremities.
It should also be understood that the surgical retractor of this invention can be used for direct access to an internal organ for surgical purposes with direct viewing of the work that's going on but it is preferably used in conjunction with video assisted cardiac surgery. In such a case, the surgical retractor of this invention is used in combination with a video endoscope that is positioned through a similar surgical retractor, a trocar or a percutaneous access opening which allows the scope to be positioned such that the internal work on the area to be operated on is transmitted to a video screen and the surgeon then performs the operation by viewing the screen and judging the use of the instruments with the assistance of the video endoscope. The surgical retractor has particular value in minimally invasive surgical techniques used in cardiac surgery.
One aspect of this invention is an adjustable surgical retractor. The retractor comprises
(a) two handles suitable for grasping positioned opposite each other and connected so that the handles move reciprocatingly relative to each other,
(b) a head connected to each handle so that each head moves reciprocatingly relative to the other,
(c) a means for locking the heads at a preset distance from each other, and
(d) a blade connected to each head, each blade having a width, depth and thickness so that the width extends substantially parallel to the length of the handle and the depth extends downward from the top of the head wherein the blades taken together at the position of closest proximity to each other are of a size suitable to be inserted into a surgical incision in a patient undergoing a surgical procedure then spread apart to form an elongated access opening through which a medical instrument may be inserted to perform exploratory or surgical procedures.
The blades, when taken together at the position of closest proximity to each other are of a size suitable to be inserted into a surgical incision in a patient undergoing a surgical procedure then spread apart to form an elongated, ovoid access opening through which a medical instrument may be inserted to perform exploratory, diagnostic or surgical procedures.
Preferably, the surgical retractor is designed so that each blade has an inside face and an outside face. The inside face of each blade faces the inside face of the other blade and the outside face of each blade is designed to (i) minimize the trauma to the patient's body at the incision when the head means and blades are spread apart, (ii) stabilize the blades in the incision and (iii) allow customization for each patient's anatomy.
Referring now to
Each head means (which is shown as being unitary with the handle) has a connector means suitable for connecting a connector blade 22 to the corresponding heads 8L and 8R of elongated handles 4L and 4R. A blade 22 is connected to the head member of the elongated handle 4 by a connector means not shown, with each blade 22 having a width, depth and thickness dimensions that define the blade. The width, for purposes of this invention, is said to extend substantially parallel to the length of the head or handle. The top of the blade as seen as 23 in
Turning now to
Referring again to
Preferably, the surgical retractor blade will be designed so that the upper edge 22 of each blade when spread apart has a concavely smooth surface corresponding to a concave surface of the interface which will be suitable for resting a surgical instrument against. This allows for much better movement of the instruments, e.g. in dissection of an internal mammary artery (IMA) and suturing of vessels. This can be seen in
Alternatively, the blades may be preformed so that they have a lip or ridge on both the top 23 and the bottom 24 and have a preformed concavity that forms as the two interfaces rest against each other. This can be seen at
Preferably, the connector means on the head member of the surgical retractor that is suitable for connecting the blade is simply a male pivot pin as shown in
The blades which are useful in the surgical retractor of this device are of a width, depth and thickness which will allow the surgeon access to the internal organs of the patient once an incision is made. Generally, the width of each blade may vary between about 1 inch to about 4 inches preferably 1 inch to about 3 inches. The depth will be of a sufficient depth to be adequately retained within the surgical incision when the head of the retractor are spread apart. Generally this depth will be about 1 inch to about 3 inches depending on the size and weight of the patient. The thickness, of course, will be of sufficient thickness to withstand the pressures of spreading apart the ribs of the patient if that's how the retractor is to be used. The thickness will depend on the strength and flexibility of the material used in making the blade. Generally, the thickness will be about one-eighth inch to about three-quarters of an inch.
When the blades are flexible, it is preferable that the male pivot pin receiving means is designed to frictionally receive the blade and retain it without pivoting. If, however, the material is of a metallic nature such as stainless steel and is inflexible, then it's preferable that the pivot pin would allow the inflexible blade to pivot freely on the post. Thus if blades of the approximate dimensions mentioned above are used it can be seen that the surgical opening could have a length of about 1 inch to about 4 inches and a width of about one-quarter inch to about two inches.
Turning now to
These can be seen in both
Turning now to
Turning now to
In
Particularly useful configurations of the disposable blades of this invention are shown in
In use, the surgical retractor of this invention can be employed either in the anterior or lateral position on the chest for thoracic retraction. Preferably, it is employed laterally and in surgery the patient would be positioned to expose the lateral side of the patient to the doctor. This position is shown in
Turning now to
The bottom of the blade 24 sits inside the thoracic cavity. Ribs 4 and 5 are shown as 37 and 38. The flexibility of the opening 46 in such a case should be compared with the lack of flexibility in
Having described the details of the surgical retractor of this invention, one can now consider another aspect of the invention, namely a method of providing surgical access to a patient. The method comprises making a surgical incision through the skin and soft tissue of the patient, inserting two blades of a surgical retractor perpendicularly through the incision, and spreading the blades of said retractor to provide a relatively symmetrical, elongated channel for internally accessing said patient. The channel is defined by the blades wherein the internal faces of the blades have a concave surface to define a substantially ovoid channel, each blade having a smooth, continuous upper surface. The method of course, is best performed using the surgical retractor described hereinbefore.
The method is particularly valuable in cardiac surgery where the surgical incision is made intercostally for access to the patient's thoracic region. Generally, at least two surgical incisions are made intercostally and sufficiently spaced apart to allow for the insertion and spreading of the blades of two of said surgical retractors. Each pair of spread blades then provide a relatively symmetrical, elongated channel for accessing the internal thoracic region of the patient. Preferably, two surgical incisions are made laterally on said patient, although the incisions may also be made anteriorly on said patient. As shown in
Another aspect of this invention is a method of performing minimally-invasive invasive surgery on a patient. The method comprises
making a surgical incision through the skin and soft tissue of the patient,
inserting two blades of a surgical retractor, perpendicularly through the incision, spreading the blades of said retractor to provide a relatively symmetrical, elongated channel for internally accessing said patient (the channel is defined by the blades wherein the internal faces of the blades have a concave surface to define a substantially ovoid channel, each blade having a smooth continuous upper surface),
inserting a surgical instrument through said substantially ovoid channel, and
performing a surgical procedure using the surgical instrument so inserted. The method preferably employs the retractor described herein. The size and shape of the retractor blades are chosen for the exact size opening desired. The smooth continuous upper surface allows the surgeon to carryout the surgical procedures more easily. This method is particularly suited for cardiac surgery when said patient is maintained on a cardiopulmonary by-pass machine and the surgical incision is made intercostally for access to the patient's thoracic region. Preferably at least two surgical incisions (preferably lateral) are made intercostally and sufficiently spaced apart to allow for the inserting and spreading of the blades of two of said surgical retractors, each pair of spread blades providing a relatively symmetrical, elongated channel for accessing the internal thoracic region of the patient.
Claims
1. An adjustable surgical retractor that comprises
- (a) two handles suitable for grasping positioned opposite each other and connected so that the handles move reciprocatingly relative to each other,
- (b) a head connected to each handle so that each head moves reciprocatingly relative to the other,
- (c) a means for locking the heads at a preset distance from each other, and
- (d) a blade connected to each head, each blade having a width, depth and thickness so that the width extends substantially parallel to the length of the handle and the depth extends downward from the top of the head wherein the blades taken together at the position of closest proximity to each other are of a size suitable to be inserted into a surgical incision in a patient undergoing a surgical procedure then spread apart to form an elongated access opening through which a medical instrument may be inserted to perform exploratory or surgical procedures.
2. The surgical retractor of claim 1 wherein each blade has an inside face and an outside face, said inside face of each blade facing the inside face of the other blade and the outside face of each blade designed to (i) minimize the trauma to the patient's body at the incision when the head and blades are spread apart and (ii) stabilize the blades in the incision.
3. The surgical retractor of claim 1 wherein the upper edge of each blade when spread apart has a concavely smooth surface corresponding to a concave surface of the inner face and is designed to stabilize a surgical instrument when such instrument contacts it.
4. The surgical retractor of claim 3 wherein each blade comprises a flexible material with the outer face having a textured surface to stabilize the blade in the incision.
5. The surgical retractor of claim 4 wherein when the inner faces of the blades are in closest proximity, the width of each blade is parallel to the other.
6. The surgical retractor of claim 3 wherein each blade is a flexible material and the outer surface comprises a resilient material.
7. The surgical retractor of claim 1 wherein each blade is rigid and each inner face is concave relative to the other with an outwardly protruding lip on the upper and lower edge of each blade to assist in maintaining the blades in the incision when the head and blades are spread apart after insertion into the patient's surgical incision.
8. The surgical retractor of claim 1 wherein the blades are disposable.
9. The surgical retractor of claim 1 wherein the width of each blade is about one inch to about four inches, the depth is about one inch to about three inches and the thickness is about one-eighth inch to about three-quarters of an inch.
10. The surgical retractor of claim 1 wherein when the head and blades are spread apart a surgical opening is formed having a length of about one inch to about four inches and a width of about one-quarter inch to about two inches.
11. The surgical retractor of claim 1 wherein each blade is connected to each head by a post and a corresponding receptacle.
12. The surgical retractor of claim 11, wherein each blade can swivel on each post.
13. The surgical retractor of claim 11, wherein each post is formed of a locking pin, thereby preventing the blade from swiveling on the post.
14. The surgical retractor of claim 11 wherein said post is frictionally held in said receptacle.
15. The surgical retractor of claim 11 wherein the blade is removably connected to the head.
16. A method of providing surgical access to the internal thoracic region of a patient, which method comprises making an intercostal, surgical incision through the skin and soft tissue of the patient, wherein the incision is sufficiently sized to allow for the insertion of a surgical retractor in the incision;
- providing a surgical retractor including: (a) two handles suitable for grasping positioned opposite each other and connected so that the handles move reciprocatingly relative to each other; (b) a head connected to each handle so that each head moves reciprocatingly relative to the other; (c) a means for locking each head at a preset distance from the other; and (d) a blade connected to each head, each blade having a width, depth and thickness so that the width extends substantially parallel to the length of the handle and the depth extends downward from the top of the head;
- inserting two blades of said surgical retractor perpendicularly through the incision; and
- spreading the blades of said retractor to provide a relatively symmetrical, elongated channel for accessing the internal thoracic region of the patient, said channel being defined by said blades wherein the internal faces of the blades have a concave surface to define a substantially ovoid channel, each blade having a smooth, continuous upper surface.
17. The method of claim 16, wherein at least two surgical incisions are made intercostally and sufficiently spaced apart to allow for the insertion and spreading of the blades of two of said surgical retractors, each pair of spread blades providing a relatively symmetrical, elongated channel for accessing the internal thoracic region of the patient.
18. The method of claim 16, wherein said two surgical incisions are made laterally on said patient.
19. The method of claim 16, wherein said two surgical incisions are made anteriorly on said patient.
20. The method of claim 16, wherein said two surgical retractors are interconnected by a stabilizing bar to fix their positions relative to the other.
21. The method of claim 16, wherein a third incision is made to provide access to the patient's thoracic cavity sufficient to insert an image transmission means to transmit an image of the patient's internal thoracic region.
22. A method of performing minimally-invasive cardiac surgery on a patient, which method comprises
- providing a surgical retractor including: (a) two handles suitable for grasping positioned opposite each other and connected so that the handles move reciprocatingly relative to each other, (b) a head connected to each handle so that each head means moves reciprocatingly relative to the other, (c) a means for locking each head at a preset distance from the other, and (d) a blade connected to each head, each blade having a width, depth and thickness so that the width extends substantially parallel to the length of the handle and the depth extends downward from the top of the head;
- making an intercostal surgical incision through the skin and soft tissue of the patient, wherein the incision is sufficiently sized to allow for the inserting and spreading of the blades of said surgical retractor,
- inserting two blades of a surgical retractor, perpendicularly through the incision,
- spreading the blades of said retractor to provide a relatively symmetrical, elongated channel for accessing the internal thoracic region of said patient, said channel being defined by said blades wherein the internal faces of the blades have a concave surface to define a substantially ovoid channel, each blade having a smooth continuous upper surface,
- inserting a surgical instrument through said substantially ovoid channel, and
- performing a surgical procedure using the surgical instrument so inserted.
23. The method of claim 22, wherein said surgery is cardiac surgery and said patient is maintained on a cardiopulmonary by-pass machine.
24. The method of claim 23, wherein at least two surgical incisions are made intercostally and sufficiently spaced apart to allow for the inserting and spreading of the blades of two of said surgical retractors, each pair of spread blades providing a relatively symmetrical, elongated channel for accessing the internal thoracic region of the patient.
25. The method of claim 22, wherein said two surgical incisions are made laterally on said patient.
26. The method of claim 22, wherein said two surgical incisions are made anteriorly on said patient.
27. The method of claim 22, wherein said two surgical retractors are interconnected by a stabilizing bar to fix their positions relative to the other.
28. The method of claim 22, wherein a third incision is made to provide access to the patient's thoracic cavity sufficient to insert an image transmission means to transmit an image of the patient's internal thoracic region.
29. The method of claim 28, wherein the surgery is performed by the surgeon by manipulating the instruments viewing the image surgery so transmitted by the transmission means.
Type: Application
Filed: May 3, 2005
Publication Date: Dec 1, 2005
Inventors: Arthur Bertolero (Danville, CA), Raymond Bertolero (Danville, CA), Jerome Riebman (Sunnyvale, CA)
Application Number: 11/122,272