Abstract: A vitrectomy probe having a variable duty cycle cutting mechanism is disclosed. The probe includes a motor and a cam driver rotationally driven by the motor. The cam driver has a non-planar driver surface having surface features that vary at different radii. A follower mechanism is arranged to selectively interface with the driver surface at different radii on the driver surface in a manner to selectively interface with the varied surface features at the different radii. The follower is arranged to transfer rotational movement of the cam driver into linear movement of the follower mechanism.

Abstract: Various medical devices and methods for cutting and/or evacuating tissue are provided. The devices and methods may utilize a reciprocating mechanism or motor powered by suction from a vacuum source. The medical devices and methods may be used on tissue in various regions of a patient's body and for treating various conditions, e.g., for performing a polypectomy or discectomy.

Abstract: Various medical devices and methods for cutting and/or evacuating tissue are provided. The devices and methods may utilize a reciprocating mechanism or motor powered by suction from a vacuum source. The medical devices and methods may be used on tissue in various regions of a patient's body and for treating various conditions, e.g., for performing a polypectomy or discectomy.

Abstract: A biopsy device and method are provided for obtaining a tissue sample, such as a breast tissue biopsy sample. The biopsy device may include an outer cannula having a distal piercing tip, a cutter lumen, a side tissue port communicating with the cutter lumen, and at least one fluid passageway disposed distally of the side tissue port. The inner cutter may be advanced in the cutter lumen past the side tissue port to sever a tissue sample. After the tissue sample is severed, and before the inner cutter is retracted proximally of the side tissue port, the cutter may be used to alternately cover and uncover the fluid passageway disposed distally of the side tissue.

Abstract: An endoscopic bipolar forceps includes a housing and a shaft, the shaft having an end effector assembly at its distal end. The end effector assembly includes two jaw members for grasping tissue therebetween. The jaw members are adapted to connect to an electrosurgical energy source which enable them to conduct energy through the tissue to create a tissue seal. A drive assembly is disposed within the housing which moves the jaw members. A switch is disposed within the housing which activates the electrosurgical energy. A knife assembly is included which is advanceable to cut tissue held between the jaw members. A movable handle is connected to the housing. Continual actuation of the movable handle engages the drive assembly to move the jaw members, engages the switch to activate the electrosurgical energy source to seal the tissue, and advances the knife assembly the cut the tissue disposed between the jaw members.

Abstract: A surgical cutting instrument including a first elongated member, a second tubular member, a handpiece, a first hub, a second hub, and an actuator assembly. The first tubular member has cutting tip and is co-axially disposed within the second tubular member such that the cutting tip is exposed at a cutting window. The first hub is mounted to the first tubular member and is moveably coupled to the handpiece. The second hub is mounted to the second tubular member and defines a hub axis. The actuator assembly rotatably couples the second hub to the handpiece and includes an actuator. Movement of the actuator is translated to rotational movement of the second hub so as to effectuate spatial rotation of the cutting window. In this regard, the actuator movement is not co-axial with the hub axis.

Abstract: A tissue repair device. The tissue repair device includes a tubular shaft having a longitudinal bore for delivering biological material to a soft tissue defect, and an awl having a distal end configured for microfracturing bone underlying the defect. The tubular shaft and the awl are movable relative to one another such that the awl is at least partially positioned within the longitudinal bore of the tubular shaft.

Abstract: A surgical instrument includes a main unit and a suction conduit. The main unit includes at least one tubular body having a distal end, a proximal end, and an inlet disposed near the distal end. The suction conduit is slidably disposed over the main unit, and is slidably movable along the main unit between a retracted position, at which the suction conduit does not cover the inlet of the main unit, and an extended position at which the suction conduit covers the inlet of the main unit and a suction inlet of the suction conduit is placed in fluid-communication with the main unit inlet. The surgical instrument can be used as a suction tool by placing the suction conduit in the extended position and applying a vacuum through the inlet of the main unit and the suction inlet.

Abstract: An abrading device including an advanced burr and appliqué for a burr and a new process for making cutting tools for fine material removal applications such as in bone and tissue surgeries. An appliqué sheet is first engineered by CAD with an abrading surface having cutting facets. The appliqué is attached to a surface of a tool blank and then metallurgically bonded and coated by the BRAZOL® or Co—P process. The tool blank has a proximal shank attachable to a driver and a distal surface to which the appliqué is affixed. Since each facet is attached to surrounding facets and then strongly bonded to the tool, the facets do not dislodge when used to abrade a surface of an object. The BRAZOL® or Co—P coating imparts excellent wear resistance and lubricity to the cutting facets. This results in excellent operational and material removal characteristics. This approach to making surgical and fine industrial tools offers engineered flexibility in design rather than process dependent designs.

Abstract: An ultrasound catheter has an elongate flexible catheter body having a lumen extending longitudinally therethrough, and an ultrasound transmission member extending longitudinally through the lumen of the catheter body. The ultrasound transmission member has a proximal end that is coupled to a separate ultrasound generating device, and a distal tip that is attached to the distal end of the ultrasound transmission member and which is located at the distal end of the catheter body. The distal tip has at least one dimensional step. The ultrasound transmission member is directly attached to the catheter body and/or to a guidewire tube, either directly or via an attachment device. The catheter has an additional radiopaque marker positioned on the distal end the catheter.

Abstract: A dual function arthroscopic blade provides multiple cutting surfaces of differing cut aggressiveness for selective engagement of the desired cutting blade without retracting the instrument for changing cutting members to apply a different set of cutting edges, or blade. An inner rotating member within a stationary outer cutting member provide cutting edges defined by cutting windows on the inner and outer cutting members, and a rotational drive applies an oscillating rotation such that one of the cutting windows, corresponding to one of the sets of cutting edges, engages an extraction region such as tissue or bone. The use of different sized cutting windows allows variance in the aggressiveness of the cut, and allows selection of another cutting window by rotating the cutting member to align the selected cutting edges without requiring extraction and reinsertion in order to attach a different blade with a different cut aggressiveness.

Abstract: A method of removing material from a blood flow lumen includes providing a device having a cutting element and an opening, the cutting element being movable relative to the opening. The method then includes advancing the device through a patient's vascular system to the blood flow lumen. Finally, the method involves moving the cutting element and the opening relative to the blood flow lumen so that a continuous piece of material is severed by the cutting element and directed into the opening as the cutting element and opening move through the blood flow lumen, the continuous piece of severed material being directed into the device for removal from the patient. The method may include providing a device having a rotatable cutter that, in some embodiments, is not parallel to the longitudinal axis of the device, is movable, has retracted and deployed positions, or any combination thereof.

Abstract: A surgical instrument for removing bone, cartilage, or similar tissue is described. The surgical instrument has a shaft that extends in a longitudinal direction and supports a cutting plate which is inclined perpendicular or relative to the longitudinal direction, and a cutting element which is movably mounted on the shaft and supports a blade at the distal end in which the blade is pointing in the direction of the cutting plate and being advanced to the cutting plate in order to cut tissue.

Abstract: Vitrectomy probes and system related thereto are disclosed herein. The disclosure describes various example vitrectomy probes having an adjustable cutting port size. Various example features are described for adjusting the size of the cutting port. Further, the disclosure provides examples for adjusting the size of the cutter port while the vitrectomy probe is in operation.

Abstract: Vitrectomy probes and system related thereto are disclosed herein. The disclosure describes various example vitrectomy probes having an adjustable cutting port size. Various example features are described for adjusting the size of the cutting port. Further, the disclosure provides examples for adjusting the size of the cutter port while the vitrectomy probe is in operation.

Abstract: Vitrectomy probes and system related thereto are disclosed herein. The disclosure describes various example vitrectomy probes having an adjustable cutting port size. For example, one example vitrectomy probe includes a piezoelectric element adapted to adjust the size of the cutting port. Further, the disclosure provides examples for adjusting the size of the cutter port while the vitrectomy probe is in operation.

Abstract: An end effector assembly for a forceps includes jaws, a cutting assembly, and at least one cam assembly. At least one jaw is moveable relative to the other about a pivot between open and closed positions for grasping tissue. At least one jaw includes a control trough that extends therealong. The pivot has first and second pivot bosses defining a pivot hole therebetween. The cutting assembly includes a blade and blade control portion, and defines a longitudinal axis through the blade and the control portion. The control portion slidably translates through the pivot hole defined between the pivot bosses to allow selective advancement thereof through the trough. The blade is disposed distally of the pivot and extends farther from the axis than an outer surface of the control portion. The cam assembly is coupled to the moveable jaw and is actuatable to move the movable jaw between the positions.

Abstract: A biopsy device having a sample size control assembly for selecting the specimen size to be collected. The sample size control assembly includes a rotatable nose on the exterior of the biopsy device for actuating the operation of the sample size control assembly. A needle assembly of the biopsy device can extend through the rotatable nose. A tip protector can be coupled to the sample size control assembly, and can be engaged by a user to operate the sample size control assembly. Also disclosed is a method for making a biopsy device, including coupling a tip protector to a sample size control assembly.

Abstract: A biopsy apparatus having a disposable cutting element and a reusable handpiece is disclosed. The disposable cutting element includes an inner cannula that defines an inner lumen and terminates in a cutting edge. The inner cannula is slidably disposed within an outer cannula that defines an outer lumen that has a tissue-receiving opening. The inner cannula is driven by a rotary motor and a reciprocating motor. Both motors are constructed of a MRI compatible material.

Abstract: A microsurgical instrument including a cutting member and a base with an actuating mechanism that provides more efficient cutting of tissue.

Abstract: A rotating surgical system is provided that includes a base, a first member rotably engaged with the base, and a second member fixed with said first member such that said first member and said second member rotate together.

Abstract: The present invention is directed to improving the cutting efficiency and reducing the manufacturing costs associated with endoscopic cutting instruments by eliminating the distal bearing surfaces or providing means for making the contact at the distal bearing intermittent so that surfaces do no undergo high localized heat and galling. In one embodiment, this goal is achieved by modifying or removing the axial constraints on the inner sliding member that are characteristic of conventional endoscopic shavers. In another embodiment, the improved cutting efficiency and reduced manufacturing cost is achieved by eliminating a closed end characteristic of conventional endoscopic shavers (e.g., removing the closed end of either the inner sliding member or the outer sliding member to thereby eliminate the associated bearing surface formed therebetween).

Abstract: Improved method for removing large amount of bone and articulate surface including cartilage comprising a bone chipper, which can be adapted for usage with any large articular surface or bony structure through a small incision using minimally invasive surgical approach. The inventive device includes an oscillating chipper tip having a series of metallic blades with sharp cutting edges vertically situated and attached to a metallic circular platform. Said platform is situated at the distal end of shank blade. The circular platform and cutting blade will oscillate horizontally driven by the reciprocating eccentric cam with his attached proximally to a reciprocating central shaft. Each of the vertical blades has two sharp vertical cutting edges. The blade shank contains a suction channel, which allows of the removal of bone particles and tissue debris generated by the cutting process. The electromagnetic driver comprises three or four electromagnetic coils placed in a collinear fashion and in series.

Abstract: A biopsy device includes a body having a cannula, a cutter positioned at least partly within the cannula, a tissue collection chamber, and a vacuum source. In one example, the biopsy device includes a cutter loader for rotating the cutter into a loaded position (e.g., open position). A trigger is engaged with a portion of the cutter loader and may be activated to allow the cutter to rotate back to a closed position. During this rotation, the cutter severs a tissue sample, which may thereafter be drawn through the cutter lumen into the tissue collection chamber under the influence of a vacuum created by the vacuum source. The vacuum source includes a piston configured to be operated by squeezing a scissors grip. A user may apply a single stroke or successive strokes to the piston to produce the vacuum.

Abstract: A bipolar electrosurgical instrument has a pair of pivotable juxtaposed jaw members and a locking mechanism operatively associated with a second of the jaw members. The locking mechanism has a first position engaged with the second jaw member for preventing movement of the second jaw member between an axially aligned orientation and at least one angled orientation, and a second position. The second position is disengaged from the second jaw member allowing for movement of the second jaw member between the axially aligned orientation and the at least one angled orientation. The instrument has an actuation mechanism operatively connected to a first of the jaw members with the actuation mechanism operable to move the first jaw member between an axially aligned first orientation and at least one angled orientation. An articulation knob is operatively associated with the locking mechanism and effectuates independent operation of the locking and actuation mechanisms.

Abstract: A device and method of using the device to access a desired tissue site within a patient's body and separating a tissue specimen from the tissue site suitable for evaluation. The device includes a probe member having an arcuate tissue-cutting RF powered electrode secured to and distally spaced from the distal end of the probe and a small dimensioned distal extremity which when an inner lumen thereof is subjected to a vacuum, secured tissue for the specimen to the surface of the distal extremity. A circular tissue-cutting blade preferably secured to the distal end of a supporting tube is configured to rotate and move longitudinally along the shaft of the probe member effective to sever a tissue specimen from tissue secured to the surface of the distal extremity of the probe member. The supporting tube covers the separated specimen, and may be disposed within an accessing cannula.

Abstract: A tissue cutting device that is especially suited for neurosurgical applications is disclosed and described. The device includes a handpiece and an outer cannula in which a reciprocating inner cannula is disposed. The device is configured to provide multiple functions during a surgical procedure, in addition to resecting tissue, with a single insertion of the device into a patient.

Abstract: A surgical tool includes a surgical blade configured to be moved to form an incision. The surgical tool also includes a wire configured to cause movement of the surgical blade. The surgical tool further includes an actuator configured to shorten a length of the wire to cause the movement of the surgical blade. The surgical tool could be configured to move the surgical blade in a first direction and then in a second direction in response to a single shortening of the wire. Also, the wire could represent a first wire, the surgical tool could include a second wire, and the surgical tool could be configured to move the surgical blade in a first direction in response to shortening the first wire and to move the surgical blade in a second direction in response to shortening the second wire.

Abstract: A surgical tool includes a surgical blade configured to be moved to form an incision. The surgical tool also includes a wire configured to cause movement of the surgical blade. The surgical tool further includes an actuator configured to shorten a length of the wire to cause the movement of the surgical blade. The surgical tool could be configured to move the surgical blade in a first direction and then in a second direction in response to a single shortening of the wire. Also, the wire could represent a first wire, the surgical tool could include a second wire, and the surgical tool could be configured to move the surgical blade in a first direction in response to shortening the first wire and to move the surgical blade in a second direction in response to shortening the second wire.

Abstract: The body tissue harvesting instrument is provided with a cutter which is disposed at the distal end of an insertion member that is inserted into the body to sever tissue inside the body. The cutter includes a slit that extends from the distal end toward the base end; a first high-frequency electrode disposed along the two side edges of the slit on the outer surface of the cutter body and a second high-frequency electrode disposed at the base end of the slit; and a mechanism which is disposed on both sides of the distal end of the slit in the projection of the cutter body which rotates as a result of being pressed by the tissue, and which feeds the tissue toward the interior of the slit. Parts located on both sides of the distal end of the slit in the projection may mutually separate in the thickness direction.

Abstract: Disclosed herein are devices and methods for removing tissue. In one aspect, a device for removing tissue includes a hollow elongate member having an outer wall and a lumen, a selectively deployable tissue-cutting element extending from the hollow elongate member, and an actuation member extending through the lumen and coupled to the hollow elongate member at a location that is distal to the tissue-cutting element. Movement of the actuation member can cause the tissue-cutting element to move from the insertion configuration where the tissue-cutting element is not deployed to a tissue-cutting configuration where the tissue-cutting element is deployed such that it is radially extended relative to the insertion configuration.

Abstract: A surgical rasping system functional in multiple orthopedic applications, including but not limited to shoulder, knee, hip, wrist, ankle, spinal, or other joint procedures. The system may comprise a tissue removal member with a rasping head which may be low profile and offer a flat cutting/rasping surface, or with a cutting head with at least one cutting edge. The tissue removal member is configured to be driven by an attached hub that translates a rotational movement into a reciprocating motion. Suction for removal of bone fragments or other tissues is provided through an opening spaced apart from or adjacent to the rasping surface. A radiofrequency ablation (RF) electrode may be carried on the rasping system to provide ablation or coagulation of soft tissues.

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: A reciprocating surgical file system for precisely removing bone and/or other tissue is described. The system allows a user to maneuver the system and navigate into hard-to-access sites under a direct vision mechanism. A transmission mechanism converts rotary motion from a motor into reciprocating motion and provides it to the surgical file for precision removal of bone or other tissue. A pulsatile pump mechanism is operatively coupled with the transmission mechanism and provides irrigating fluid to the surgical site.

Abstract: The invention provides an apparatus having a tubular member for receiving an endocardial lead implanted within a patient's body. Disposed generally at a distal end of the tubular member is at least one blade or cutting surface. An adjustment mechanism moves the blade between retracted and extended positions to engage the cutting surface with the endocardial lead to cut the lead. Once severed, the cut portion of the lead remains within an inner channel of the tubular member and the apparatus and cut portion of the lead are removed from within the patient. Various embodiments include the blade pivotally connected to the distal end of the tubular member and activated by a wire adjustment mechanism. Others include a metallic wire for slicing through the lead. Still others include a pneumatically actuated adjustment mechanism that inflates to move the blade and engage the cutting surface with the lead.

Abstract: Various medical devices and methods for cutting and/or evacuating tissue are provided. The devices and methods may utilize a reciprocating mechanism or motor powered by suction from a vacuum source. The medical devices and methods may be used on tissue in various regions of a patient's body and for treating various conditions, e.g., for performing a polypectomy or discectomy.

Abstract: Disclosed herein is an endoscopic surgical assembly having improved cutting efficiency. In particular, the present invention provides an endoscopic shaver assembly configured for automated axial as well as rotational motion so as to enhance tissue resection.

Abstract: An electrosurgical working end and method for sealing and transecting tissue. An exemplary working end provides curved jaw members that are positioned on opposing sides of the targeted anatomic structure. The working end carries a slidable extension member having flange portions with inner surfaces that slide over the jaw members to clamp tissue therebetween. The working end carries an independent slidable cutting member that is flexible to follow the curved axis of the jaws. The electrosurgical surfaces of the jaws include partially-resistive bodies for carrying a current or load which modulates ohmic heating in the engaged tissue to prevent charring and desiccation of tissue to create a high strength thermal seal.

Abstract: A method for treating a brain tumor includes providing a surgical instrument having an inner member and an outer member. The outer member has a distal region forming a cutting window. The inner member is rotatably received within the outer member, and has a cutting tip that is exposed at the window. The cutting tip and the distal region of the outer member combine to define a cutting implement. An opening is created through the patient's skull to provide access to a brain tumor target site. The cutting implement is delivered through the opening to the target site. The cutting tip is placed into contact with the tumor and operated to cut the tumor. The target site is selectively aspirated to remove cut tumor tissue.

Abstract: A vitrectomy probe having a variable duty cycle cutting mechanism is disclosed. The probe includes a motor and a cam driver rotationally driven by the motor. The cam driver has a non-planar driver surface having surface features that vary at different radii. A follower mechanism is arranged to selectively interface with the driver surface at different radii on the driver surface in a manner to selectively interface with the varied surface features at the different radii. The follower is arranged to transfer rotational movement of the cam driver into linear movement of the follower mechanism.

Abstract: An ablative apparatus that can be used to treat atrial fibrillation and other cardiac arrhythmias by ablating cardiac tissue is disclosed. When the distal end of the apparatus reaches the tissue to be ablated, an ablation probe driven by a transducer is vibrated. Scratching the tissue with abrasive members, the vibrating ablation probe is capable of mechanically ablating tissues. This mechanical ablation may be utilized to penetrate epicardial fat, thereby exposing the underlying myocardium. The ablative apparatus may then be used subject the exposed myocardium to mechanical ablation, cryoablation, ultrasonic ablation, and/or any combination thereof.

Abstract: A rotating cutting head catheter for passage through chronic total occlusions or other refractory atherosclerotic plaque from diseased arteries is disclosed. The catheter's rotating cutting head is designed to reside safely within an outer protective sheath when not in use. The outer protective sheath contains one or more helical grooves or slots, and the cutting head contains protruding blades or projections that fit into these helical grooves or slots. Application of torque to an inner catheter or wire attached to the cutting head applies spin to the cutting head, and the force of the sheath's helical grooves or slots against the cutting head's protruding blades or projections advances the cutting head outward from the protective sheath. Once extended, the cutting head may now rotate freely. The device may use a guidewire to direct the cutting head to the desired position.

Abstract: A treatment system comprises an outer sheath and an end effector. The end effector has a plurality of cutting features, at least a portion of which are configured to debride a tissue surface when the end effector is actuated. The cutting features may also be configured to harvest tissue. A medical fluid reservoir is in fluid communication with the end effector, such that the end effector may deliver a medical fluid to a target site such as a fistula. The medical fluid may include harvested tissue cells and a scaffold material. A vacuum cannula may be positioned coaxially within the interior cavity of the end effector, and an RF probe may be positioned co-axially within the interior cavity of the vacuum cannula. The vacuum cannula and RF probe may be used together to seal a fistula in which medical fluid has been dispensed.

Abstract: A flexible biopsy needle assembly includes a flexible coring stylet that is slidably disposed within a flexible outer cannula. The stylet includes an elongated body, a tip, a sampling notch adjacent to the tip, and at least one ferrule along the length of the body. The cannula includes an elongated tubular body defining a lumen sized for sliding passage of the stylet, a cutting edge at the opening of the lumen, and an array of slits along the length of its body. The slits are sized to allow the diameter of the ferrule(s) to extend partially therein. The slits and ferrule(s) interact to limit or control the flexibility of the cannula at the location of the slits.

Abstract: A method and device for endoscopic harvesting of blood vessels from a patient for use in subsequent procedures. The device having a two piece headpiece. A vessel to be removed is inserted into the headpiece and the top and bottom portions of the headpiece are alternatively extended in reciprocating fashion to dissect above and below the vessel. The headpiece having electrodes for ligation of any side branch vessels which are uncovered in the dissection process.

Abstract: An ophthalmic surgical probe having a modular drive assembly and a skin that is removable from the drive assembly. This design simplifies probe manufacturing and provides greater manufacturing flexibility.

Abstract: A surgical instrument includes a cutting member with an implement for cutting tissue, and a drive coupled to the cutting member to simultaneously rotate and translate the cutting member in response to a force applied to the drive. A method of cutting tissue includes positioning an outer member such that tissue is located within the outer member, engaging the tissue with an inner member, and simultaneously rotating and translating the inner member to cut the tissue. A tangential cutting force is applied to the tissue with the inner member to mechanically cut the tissue. The inner member is mechanically driven to undergo simultaneous rotation and translation.

Abstract: Described herein are methods, systems and devices for cutting a ligament of a patient. In some embodiments, the method may include the steps of advancing a cannulated probe into a patient, advancing the distal end of the tissue modification device assembly posteriorly through the skin of the patient such that it exits the patient, exposing at least one tissue modification element of the tissue modification device assembly, and reciprocating at least a portion of the tissue modification device assembly by alternately pulling on proximal and distal portions of the tissue modification device assembly to draw the at least one tissue modification element across the ligament to cut the ligament, in some embodiments, the system may include a probe, a tissue modification device, and a sheath. The tissue modification device may include a proximal handle, at least one tissue modification element configured cut ligament, and a sharp distal tip.

Abstract: Described herein are methods, systems, and devices for performing a minimally invasive carpal tunnel release procedure to cut a target transverse carpal ligament. In some embodiments, the method may include the steps of advancing a probe percutaneously though a patient's skin from a first location, advancing a tissue modification device from the first location and between the target ligament and non-target tissue so that a proximal handle on the tissue modification device extends from the patient at the first location, attaching a distal handle in communication with the distal end of the tissue modification device. In some embodiments, a system may include a probe configured to be advanced percutaneously though a patient's skin from a first location, a tissue modification device comprising a proximal handle and a flexible distal region having uni-directional blades, and a distal handle configured to connect to the distal end of the tissue modification device.

Abstract: An auger is axially fixed to and positioned within a cutter. The auger and cutter advance at the same time relative to a contact structure placed against a vessel, penetrating the wall of the vessel and cutting a tissue plug. When the auger and the cutter are retracted from the vessel wall, the tissue plug is retained by the auger and cutter and removed from the vessel wall. The auger and the cutter thus create an opening in the vessel wall, without the need for a prior incision in that wall.