Abstract: An embodiment includes a system for preparing fusion of joints, such as joints in the toes or fingers of an animal such as a human. The system may include one or more of complementary ball and socket joint reamers. A reamer may be separable from an intramedullary fixation rod. The rod may include channels to prevent rotation of the rod once implanted in bone. Other embodiments are discussed herein.

Abstract: A disposable or re-usable handheld, one piece device is provided for pre-drilling and application of a shape memory or elastic staple for fixation in bone surgery. Various embodiments include a one piece device that has set holes at one end to allow for pre-drilling for the shape memory or elastic staple legs and includes an application feature at the other end to disengage the shape memory or elastic staple from the one piece device. The one piece device can come in different sizes depending on the size of the shape memory or elastic staple. The one piece handheld shape memory or elastic staple holder and drill guide allows for a handheld device to accomplish both pre-drilling and application of the shape memory or elastic staple for surgical bone fixation procedures.

Abstract: A patella drill guide includes a base portion rotatably mounted on a bone-gripping component. A trial portion with a contoured articulation surface is above the base portion. The base portion and trial portion have aligned drill guide bores. The base portion and trial portion can be rotated together on the bone-gripping component to optimize the positions of the drill guide bores with respect to the patella surface, thereby optimizing the locations of the mounting pegs of the patella implant component on the patella to optimize the orientation of the patella implant component. The base and the bone-gripping component may be unitary so that the entire assembly rotates on the patella about the central longitudinal axis of the bone-gripping component.

Abstract: In one embodiment an aspiration system includes an elongate tubular member having a lumen; an aspiration catheter configured to be inserted through the lumen of the elongate tubular member, and including a tubular aspiration member having a proximal end, a distal end, and a lumen, and configured to at least partially extend out of the lumen of the elongate tubular member at the distal end of the elongate tubular member; an elongate support member coupled to the tubular aspiration member and extending between a proximal end of the aspiration catheter and the proximal end of the tubular aspiration member; and an annular sealing member coupled to the tubular aspiration member and configured to create a seal against an inner surface of the elongate tubular member, when a vacuum sufficient to cause aspiration is actively applied to the lumen of the elongate tubular member.

Abstract: Methods and devices for controlling motorized surgical devices are provided. In general, the methods and devices can allow a surgical device to grasp and cut tissue. In some embodiments, the device can include at least one sensor and a motor, and an output of the motor can be configured to be adjusted based at least in part on an output from the at least one sensor. The output of the motor can be configured to provide power for translation of a cutting element along an end effector of the device. Adjusting the motor's output can cause the cutting element to translate through the end effector at different speeds, thereby allowing the cutting element to cut through tissue being grasped by the end effector at different speeds.

Abstract: Methods and devices for controlling motorized surgical devices are provided. In general, the methods and devices can allow a surgical device to grasp and cut tissue. In some embodiments, the device can include at least one sensor and a motor, and an output of the motor can be configured to be adjusted based at least in part on an output from the at least one sensor. The output of the motor can be configured to provide power for translation of a cutting element along an end effector of the device. Adjusting the motor's output can cause the cutting element to translate through the end effector at different speeds, thereby allowing the cutting element to cut through tissue being grasped by the end effector at different speeds.

Abstract: Methods and devices for controlling motorized surgical devices are provided. In general, the methods and devices can allow a surgical device to grasp and cut tissue. In some embodiments, the device can include at least one sensor and a motor, and an output of the motor can be configured to be adjusted based at least in part on an output from the at least one sensor. The output of the motor can be configured to provide power for translation of a cutting element along an end effector of the device. Adjusting the motor's output can cause the cutting element to translate through the end effector at different speeds, thereby allowing the cutting element to cut through tissue being grasped by the end effector at different speeds.

Abstract: Methods and devices for controlling motorized surgical devices are provided. In general, the methods and devices can allow a surgical device to grasp and cut tissue. In some embodiments, the device can include at least one sensor and a motor, and an output of the motor can be configured to be adjusted based at least in part on an output from the at least one sensor. The output of the motor can be configured to provide power for translation of a cutting element along an end effector of the device. Adjusting the motor's output can cause the cutting element to translate through the end effector at different speeds, thereby allowing the cutting element to cut through tissue being grasped by the end effector at different speeds.

Abstract: An endoscope treatment tool includes a sheath; a support part; a pair of forceps members that are arranged in front of the sheath and are supported so as to be relatively rotatable around a rotation shaft provided at the support part; a linear member that is inserted through the sheath so as to be capable of advancing into and retracting from the sheath, brings opposed surfaces, which are respectively provided closer to distal end sides of the pair of forceps members than the rotation shaft, closer to each other as the linear member is separated from the rotation shaft, and separates the pair of opposed surfaces from each other as the linear member approaches the rotation shaft; an elastic member that is supported by the linear member or the support part; and a locking portion that is provided on the linear member or the forceps members.

Abstract: A surgical instrument for cutting and grasping tissue comprising a handle assembly, an elongated member and first and second jaws. A first movable member moves the second jaw in a first direction about a first pivot axis in a grasping action and a second movable member moves the second jaw in a second direction different than the first direction and about a second pivot axis in a cutting action. A switch is positioned at the proximal portion of the instrument and a selecting member is actuated by movement of the switch, the selecting member movable between a first position to enable movement of the second jaw in the first direction and prohibit movement in the second direction and a second position to enable movement of the second jaw in the second direction and prohibit movement in the first direction.

Abstract: A medical manipulator includes an inserting section which is configured to be inserted in a body, a treatment section that is provided in a distal end portion of the inserting section, an operating section that operates the inserting section, and a control section that includes a retraction mode in which the treatment section is retracted to a proximal end side when the control section receives an instruction to move the inserting section from the operating section.

Abstract: A surgical endoscopic cutting device includes cutting elements fitted in a protective tube. The device has an inlet for fluid, a discharge outlet for tissue and fluid, and a further outlet that discharges most of the fluid.

Abstract: A fluid ejection device includes a fluid ejection unit including a plurality of nozzles and configured to eject fluid from at least any one of the nozzles in a pulse-like manner according to a drive signal, a fluid supplying unit configured to supply the fluid to the fluid ejection unit, an ejecting-instruction input unit configured to receive an ejecting instruction input, a mode-selection input unit configured to receive an input of selection information for selecting any one of a first mode for ejecting the fluid using a first nozzle unit including at least one nozzle and a second mode for ejecting the fluid using a second nozzle unit including at least one nozzle, and a fluid-ejecting control unit configured to output, when receiving the ejecting instruction input, according to the selection information, the drive signal such that the fluid is ejected from the first nozzle unit or second nozzle unit.

Abstract: A disposable scalpel, including a body portion having a proximal end and a distal end, a scalpel blade receiving slot formed in the distal end, and first and second parallel elongated flexible members, wherein the slot is positioned between the pair of parallel elongated flexible members, such that a scalpel blade received in and extending from the slot would be flanked by the pair of parallel elongated members.

Abstract: An endoscopic surgical device having a slotted clear cannula, a blade and a housing, wherein the cannula is attached to the housing, and wherein the blade is enclosed in the housing and is slidable into the cannula is disclosed. The blade is enclosed within the housing and cannula, and has a horizontally-oriented pushing component and a vertically-oriented cutting component that protrudes through the slot of the cannula. The device further has a device for locking a viewing device in place relative to other components of the device. A method for a performing an operative procedure on a target tissue in a subject using the endoscopic surgical device is also described.

Abstract: A tissue removal device including customizable tips and method of use thereof. The tissue removal device may include an outer shaft having a removable tip attached to the outer shaft and a rotatable inner shaft extending through the outer shaft and having a rotatable cutting portion extending from the inner shaft. Disc material may be cut and removed from a surgical area using an auger-like and/or suction mechanism to facilitate the transfer of removed tissue away from the surgical area.

Abstract: An ultrasonic surgical instrument including an ultrasonically actuated blade or end effector having a treatment portion. The blade can define a central axis and at least one axis which is transverse to the central axis, wherein the transverse axis can lie within a plane which is perpendicular, or normal, to the longitudinal axis and can define a cross-section of the treatment portion. Such a cross-section can include a central portion and a step extending from the central portion, wherein the central portion can comprise a width, and wherein the step can comprise a cutting edge. In at least one embodiment, the cutting edge can be defined by first and second surfaces which define an angle therebetween. In various embodiments, the position of the cutting edge and/or the angle between the cutting edge surfaces can be selected in order to balance the blade with respect to the transverse axis.

Abstract: Described is a tool positioning system comprising an introduction device, a first tool support and a second tool support. The introduction device is constructed and arranged to slidingly receive an articulating probe. The first tool support comprises at least one guide element constructed and arranged to slidingly receive a first tool. The first tool support is oriented toward a first operator location. The second tool support comprises at least one guide element constructed and arranged to slidingly receive a second tool. The second tool support is oriented toward a second operator location.

Abstract: A laparoscopic device with obturator. The device facilitates extraction of specimens from a female subject's abdominal cavity through the subject's vagina by also facilitating the suturing of a mesh to the anterior and posterior walls of the subject's vagina. The device includes an elongate sheath that has a flat surface on the front, a curved shape on the back, and an inner port opening formed within the flat surface, where the port opening that enables introduction of instruments or removal of specimens from the peritoneal cavity. An internal obturator can be inserted into the sheath to reduce the size of the port opening into the peritoneal cavity, or can be used to close the inner port opening into the peritoneal cavity. The obturator and sheath can be utilized as firm surfaces against which a user can suture a sacrocolpopexy mesh to the anterior and posteriors vaginal walls.

Abstract: A module for adjusting the launch of a includes: a cam plate slidingly moving longitudinally having a first and second catching parts; a cap lever rotatably coupled to a rotating shaft formed in parallel with the cam plate movement direction, and having a first protrusion moving while being inserted in the first catching part and a cap arm for catching a protective cap; and a collet lever rotatably coupled to the rotating shaft having a second protrusion moving while being inserted in the second catching part and a body arm for catching a lancet body. When the cam plate moves backward to a first point, the collet lever moves backward with respect to the cap lever separating the protective cap from the lancet body. When the cam plate moves backward to a second point, the cap lever and the collet lever rotate so that the lancet body moves forward.

Abstract: Aspects of the present invention are related to magnetic medical devices for the treatment of chronic medical conditions such as Vulvodynia, Vaginismus, Vaginal Stenosis, Vaginal Atrophy, among others. The magnetic medical device in accordance with the present invention is of a generally elongated shape having an ogive top end, a middle portion of an active diameter, and a bottom end of a passive diameter. The magnetic medical device has an array of magnets within, where the magnets generate a negative magnetic field adjacent to an external surface of the magnetic medical device.

Abstract: The present invention comprises systems, methods and devices for the delivery of compositions for occluding or of means for opening conduits. The implantable occlusive material may be delivered pre-formed or in situ cured and, may be a resorbable material that supports tissue ingrowth that eventually replaces the material leaving little or no original material in place. The delivery system is positioned to allow for placement of the occlusive material into the body conduit. Use of delivery systems, methods and devices for re-opening an occluded body conduit are also included.

Abstract: A cranial burr hole cover having an internal bracing member, a locking external cover member joined by one or more connecting members, and a locking mechanism that precludes movement of the external cover member relative to the connecting members in the proximal direction once the cover is secured onto the skull. The internal bracing member is longer than it is wide. For a given burr hole, the cover will be chosen such that the longitudinal dimension is greater than the diameter of the burr hole and the width dimension is less than the diameter of the burr hole. With this structure the interior bracing member of the burr hole cover may be inserted through the burr hole by tilting the internal bracing member such that a longitudinal end of the internal bracing member is able to be inserted into the hole and under the skull.

Abstract: Spine stabilization devices, systems and methods are provided in which a single resilient member or spring is disposed on an elongate element that spans two attachment members attached to different spinal vertebrae. The elongate element passes through at least one of the two attachment members, permitting relative motion therebetween, and terminates in a stop or abutment. A second resilient member is disposed on the elongate element on an opposite side of the sliding attachment member, e.g., in an overhanging orientation. The two resilient members are capable of applying mutually opposing urging forces, and a compressive preload can be applied to one or both of the resilient members.

Abstract: A pedicle screw implant construct kit, comprising at least one pedicle screw, at least one collar comprising a recess for receiving a rod, the collar configured to be coupled to a head of the pedicle screw, an elongated rod for connecting the collar to one more additional collars to couple between the pedicle screw and one or more additional screws, and a locking ring sized to be positioned over at least a distal portion of the collar to restrain relative movement of the screw head and rod by exerting radial compression force onto the collar. In some embodiments, the components of the kit are comprised of carbon reinforced composite material.

Abstract: A polyaxial bone anchor assembly, comprising: a threaded screw portion comprising an externally threaded head end; a head body selectively disposed concentrically about the externally threaded head end of the threaded screw portion, wherein the head body defines an internally threaded hole in a bottom portion thereof; and an externally threaded compression saddle assembly selectively disposed within an interior portion of the head body and selectively engaging the externally threaded head end of the threaded screw portion; wherein the externally threaded compression saddle assembly and the externally threaded head end of the threaded screw portion are selectively disposed within the interior portion of the head body by engaging and passing through the internally threaded hole in the bottom portion of the head body.

Abstract: A uniplanar bone anchor including a housing and a bone screw is provided. The lower region of the housing defines mating elements that mate with engaging elements on the bone screw to limit movement of the housing relative to the bone screw to a single plane.

Abstract: A spinal construct comprises a fastener attached with sacral and/or pelvic tissue of a body. A connector is selectively movable in a coronal plane relative to the body. The connector has a first end connected with the fastener and a second end having a locking surface engageable with an implant. A lock element is engageable with the connector and defines an implant cavity. Systems and methods are disclosed.

Abstract: A spinal fixation device includes a bone screw, a nut, a bearing, a slider, and a plate construct. The screw has a head with a nut connection and a screw portion. The nut has an exterior wall and a bore connecting to the nut connection. The bearing has an exterior and defines a bore fitting therein the nut connection and the exterior wall of the nut. The slider defines a bore fitting the nut exterior wall therewithin and has an exterior with a given shape. The elongate plate construct has a first end defining a first opening shaped to accept the exterior of the bearing therein and a second end defining a second opening shaped to accept the slider therein and having a corresponding shape to the given shape to permit the slider to slide in at least a portion of the second opening.

Abstract: Systems and methods for placing orthopedic spine fixation hardware are provided.

Abstract: An orthopaedic implant knee brace and surgical method for minimally invasive insertion of the orthopaedic implant knee hinge. The apparatus and method stabilizes the knee in patients after conventional fixation of distal femur and/or proximal tibia fractures. The orthopaedic implant knee brace allows the body weight of the patient to be offloaded from the knee joint to allow for weight bearing on the leg within days, rather than months, from the surgery.

Abstract: The present invention is a method and device for the correction and reduction of bone deformities, such as metatarsus primus adductus, using a plate body with winged buttresses and dorsal loop. The method and device can be affixed to a bone without any drilling or violating of the bone and can use a tethering technique which does not require drilling into the second metatarsal, nor does it require the placement of a prominent suture knot/button device medially along the first metatarsal.

Abstract: A hook plate assembly includes a bone plate extending along a longitudinal axis from a first end to a second end and including an upper surface facing away from a bone, a bone contacting surface, a plate hole extending therethrough from the upper surface to the bone contacting surface and a connection section arranged at the second end. The plate hole is sized and shaped to receive a bone fixation element therethrough in combination with a hook including a connecting portion configured to connect the hook to the connection section of the bone plate and a fastening element releasably coupling the hook to the bone plate.

Abstract: A bone plate configured to accommodate fixation devices (such as screws, for example) inserted at various angles. The bone plate is formed of a material softer than the material of the fixation devices, and is provided with fixation holes with rounded, curved interior walls (i.e., non-threaded holes) that allow the fixation devices to be inserted at various angles. The fixation holes have a diameter smaller than that of the fixation devices. As a result of the difference between the materials of the plate and of fixation devices, and of the difference between the diameters of the fixation holes and of the fixation devices, the fixation devices deform the interior walls of the fixation holes, therefore self-threading the holes at an advantageous angle.

Abstract: The present invention relates in certain embodiments to medical devices for treating vertebral compression fractures. More particularly, embodiments of the invention relate to instruments and methods for controllably restoring vertebral body height by controlling the flow of bone cement into the interior of a vertebra and the application of forces causes by the cement flow. An exemplary system utilizes Rf energy in combination a conductive bone cement for selectively polymerizing the inflow plume to increase the viscosity of the cement. In one aspect of the invention, the system utilizes a controller to control bone cement flow parameters to either allow or disallow cement interdigitation into cancellous bone. A method of the invention includes pulsing the flows of bone cement wherein high acceleration of the flow pulses can apply expansion forces across the surface of the cement plume to reduce a vertebral fracture.

Abstract: Methods for treating pain resulting from osteoarthritis, and associated devices and instruments for such pain treatment are disclosed. These methods aim to prevent the progression of osteoarthritis of a joint, by biochemically diagnosing microenvironmental abnormalities in the subchondral bone, and subsequently treating the subchondral bone to prevent, or delay the onset or progression of, or otherwise treat, osteoarthritis as well as any bone marrow edema or lesion.

Abstract: A bone cement system according to the present disclosure includes a housing, a dispenser housing, a plunger, and a pressure release system. The housing has a proximal end, a distal end, and a throughbore that extends from the proximal end to the distal end. The dispenser housing is received in the throughbore and is adapted to receive bone cement. The plunger is releasably coupled to the proximal end of the housing and received into the dispenser housing so that movement of the plunger relative to the dispenser housing dispenses bone cement from the distal end of the housing. The pressure release system is coupled to the housing and includes a body that is movable within a plane perpendicular to a longitudinal axis of the housing, without translating the body along the longitudinal axis of the housing, to reduce the pressure of bone cement exiting the distal end of the housing.

Abstract: An instrument for selectively coupling with a pedicle screw is disclosed. The instrument includes an inner shaft, wherein the distal tip is configured to engage a pedicle screw and the proximal end configured to be selectively engaged with a knob, and a knob assembly configured to advance over the inner shaft, wherein the distal end is configured to engage the tulip of the pedicle screw and the proximal end is configured to selectively engage the inner shaft. A method for selectively coupling the instrument to a pedicle screw is also disclosed.

Abstract: A device (1) assisting with the placement of an orthopedic instrument (2) intended to be inserted in a receiving bone (3) by impaction, by means of an impacter (10) comprising at least one striking surface (11) designed to come into contact with an impact surface coupled to said orthopedic instrument in order to apply an impaction force to said orthopedic instrument (2), said device being characterized in that it comprises a force sensor (12) able to measure, upon each impact, said impaction force applied by the impacter (10) to said impact surface and to supply a measurement signal indicative of the temporal variation of said applied impaction force, said force sensor (12) being connected to processing means (30) designed to determine, on the basis of the temporal variation of said impaction force supplied for each impact in succession, an indicator representative of the degree of insertion of said orthopedic instrument (2) in the receiving bone (3).

Abstract: A method for optimizing emissions from simultaneous activation of electrosurgery generators is presented including delivering first energy to a first target tissue via a first energy module, the first energy represented as a first waveform having a first phase, delivering second energy to a second target tissue via a second energy module, the second energy represented as a second waveform having a second phase, applying the first energy in a first energy mode, and applying the second energy in a second energy mode. The method further includes the steps of comparing the first phase of the first energy waveform with the second phase of the second energy waveform and adjusting a relative phase between the first and second energy waveforms based on the comparison step.

Abstract: A thermal regulation catheter system and method of use are disclosed, for moderating the temperature and other parameters of tissue surrounding a target tissue for an ablation procedure, or for performing a thermal treatment procedure. In an embodiment, the device includes a catheter having a shaft with a fluid supply line and a fluid return line disposed therein, and an inflatable heat exchange vessel at a distal end of the shaft. The fluid supply line supplies fluid to inflate the heat exchange vessel, and the fluid return line conducts fluid away from the heat exchange vessel.

Abstract: In some implementations, a method of ablating body tissue includes (a) locating an inflatable balloon portion of a cryotherapy balloon catheter at a treatment site internal to a patient's body, and inflating the inflatable balloon portion; (b) employing electrodes that are disposed on an expandable surface of the inflatable balloon portion to electrically characterize body tissue at the treatment site; (c) ablating the body tissue by supplying a cryotherapy agent to the inflatable balloon portion to cool the body tissue to a therapeutic temperature; (d) employing the electrodes to determine whether the ablating caused desired electrical changes in the body tissue; and (e) repeating (c) and (d) when it is determined that the ablating did not cause the desired electrical changes.

Abstract: A modular electrosurgical generator platform is presented including a power supply module configured to output power, a first energy module configured to receive the power and convert the power into a first waveform having a first phase, and to deliver the power in a first energy mode, and a second energy module configured to receive the power and convert the power into a second waveform having a second phase, and to deliver the power in a second energy mode. The modular electrosurgical generator platform also includes a host controller module to control a type and a number of energy modalities, a comparator for comparing the first phase of the first waveform with the second phase of the second waveform in one or more of a plurality of sub-periods and an adjustment module for adjusting a relative phase between the first and second waveforms based on results obtained from the comparator.

Abstract: A non-transitory computer-readable storage medium is presented including a power supply module configured to output power, a first energy module configured to receive the power and convert the power into a first waveform having a first phase, and to deliver the power in a first energy mode, and a second energy module configured to receive the power and convert the power into a second waveform having a second phase, and to deliver the power in a second energy mode. A host controller module is configured to control a type and a number of energy modalities provided by the generator platform and a comparator compares the first phase of the first waveform with the second phase of the second waveform in one or more of a plurality of sub-periods. An adjustment module adjusts a relative phase between the first and second waveforms based on results obtained from the comparator.

Abstract: A connection system for an electrosurgical instrument comprises first and second connectors capable of being mated one with the other, the first connector (5) being associated with an electrosurgical generator (1) and the second connector (12) being associated with the electrosurgical instrument (9). The first and second connectors each include at least three connector components, each of the three connector components of the first connector (5) being capable of being connected and disconnected to a to respective one of the three connector components of the second connector (12). When the first connector components (14, 19) are connected to each other they are capable of delivering an RF energy output from the electrosurgical generator (1) to the electrosurgical instrument (9). When the second connector components (16, 22) are connected to each other they are capable of delivering a supply of ionisable gas to the electrosurgical instrument (9).

Abstract: An electrosurgical generator and associated methods determine a real part of the impedance of treated tissue. The electrosurgical generator includes an output stage, a plurality of sensors, and a controller that controls the output stage. The controller includes a signal processor that determines an RMS voltage, an RMS current, an average power, and a real part of the impedance of the treated tissue based on measured voltage and current by using a plurality of averaging filters. The controller controls the output stage to generate electrosurgical energy based on at least the determined real part of the impedance.

Abstract: Symmetrical and asymmetrical snares are used for endoscopically controlled methods by which tumors in hollow organs of the gastrointestinal tract can be ensnared and RF-surgically removed from the organ wall for diagnostic and/or therapeutic purposes. These snares are characterized in that one of the two snare portions, in the case of asymmetrical snares the longer of the two snare portions, is completely electrically insulated or is made from electrically non-conductive material and that the other of the two snare portions is made from electrically conductive material and its surface is not electrically insulated. In one embodiment, the asymmetrical snare is characterized in that the long snare portion is so much flexurally stiffer than the short snare portion that it tensions the short snare portion like the string of a bow.

Abstract: A removable electrode assembly for use in combination with a forceps having opposing end effectors and a handle for effecting movement of the end effectors relative to one another. The electrode assembly includes a housing which is removably engageable with the forceps and a pair of electrodes which are attachable to a distal end of the housing. The electrodes are removably engageable with the end effectors of the forceps such that the electrodes reside in opposing relation relative to one another. The electrode assembly also includes a cover plate which is removably attachable to the housing and at least one stop member for controlling the distance between the opposing electrodes. The stop member is selectively engageable with the electrodes.

Abstract: A surgical instrument in HF design includes two tissue branches, at least one of the tissue branches being movable relative to the other tissue branch and being able to be applied to the other tissue branch with a predetermined or predeterminable contact pressure via an actuation mechanism while clamping body tissue between the tissue branches. A clamping pressure controlling or adjustment device is interconnected in a force or torque gear train between the actuation mechanism and the at least one movable tissue branch.

Abstract: An end effector assembly for an electrosurgical device includes first and second jaw members movable between spaced-apart and approximated positions. The jaw members define opposed tissue-contacting surfaces that cooperate to define a tissue grasping area within which tissue is grasped when the jaw members are moved to the approximated position. At least one of the jaw members includes an interior electrode and at least one of the jaw members includes first and second exterior electrodes. The interior and exterior electrodes are configured to conduct energy through tissue grasped within the tissue grasping area to seal tissue. The interior electrodes are disposed interiorly of outer bounds of the tissue grasping area, while the exterior electrodes are disposed exteriorly. As a result, upon conduction of energy through tissue grasped within the tissue grasping area, tissue disposed adjacent the exterior electrodes is boiled before boiling of tissue disposed adjacent the interior electrodes.