US20070162067A1 - Method and inflatable chamber apparatus for separating layers of tissue - Google Patents

Abstract

An apparatus for tissue dissection and instrument anchoring and methods for using such apparatus are disclosed. The apparatus includes a cannula, a dissection balloon releasably attached to the cannula at the distal end, an anchoring balloon disposed on the cannula, and a means for inflating both balloons.

Description

• This application is a continuation of co-pending application Ser. No. 10/392,465, filed Mar. 19, 2003, which is a continuation of application Ser. No. 09/023,134, filed Feb. 12, 1998, now abandoned, which is a continuation of application Ser. No. 08/583,563, filed Jan. 5, 1996, now U.S. Pat. No. 5,779,728 which is a continuation-in-part (C.I.P.) of Ser. No. 08/542,666, filed Oct. 13, 1995, now U.S. Pat. No. 5,728,119 of inventors Jeffrey A. Smith, Daniel T. Wallace, Edwin J. Hlavka, Charles Gresl, John P. Lunsford, and Albert K. Chin, which is a C.I.P. of U.S. application Ser. No. 08/405,284, filed Mar. 16, 1995, now U.S. Pat. No. 5,632,761 of inventors Jeffrey A. Smith, Albert K. Chin, and Frederic H. Moll, which is a C.I.P. of Ser. No. 08/365,096, filed Dec. 28, 1994, now abandoned, of inventors Albert K. Chin and Todd Thompson, which is a C.I.P. of Ser. No. 08/319,552, filed Oct. 7, 1994, now abandoned, of inventors Albert K. Chin, Jeffrey A. Smith, John P. Lunsford and Frederic H. Moll, which is a C.I.P. of Ser. No. 08/282,287, filed Jul. 29, 1994, now U.S. Pat. No. 5,704,372 of inventors Frederic H. Moll, Jeffrey A. Smith, John P. Lunsford and Albert K. Chin, which is a C.I.P. of Ser. No. 07/911,714, filed Jul. 10, 1992, now abandoned, of inventors Albert K. Chin and John P. Lunsford, which is a C.I.P. of Ser. No. 07/794,590, filed Nov. 19, 1991, now issued as U.S. Pat. No. 5,309,896, of inventors Frederic H. Moll, Charles Gresl, Jr., Albert K. Chin, and Philip K. Hopper, which is a C.I.P. of Ser. No. 07/706,781, filed May 29, 1991, now abandoned, of inventors Frederic H. Moll, Albert K. Chin, Diane E. Caramore, and Frank T. Watkins III. The specifications of the above-referenced applications, which are commonly owned with present application, are incorporated by reference into the specification of the present application.
FIELD OF THE INVENTION
• The invention pertains to inflatable tissue separation and retraction devices and methods of using such devices. The apparatus and methods of the invention are useful in any procedure requiring dissection and/or retraction of tissue planes throughout the body including inguinal hernia repair, pelvic lymphadenectomy and bladder neck suspension in the preperitoneal space; renal, adrenal, aortic and anterior spinal access in the retroperitoneal space; penile prosthetic reservoir placement in the anterior abdominal wall; plastic surgery; and augmentation mammaplasty prosthetic placement. By way of example only, use of such devices and methods for hernia repair will be described.
BACKGROUND OF THE INVENTION
• A hernia is the protrusion of part of a body part or structure through a defect in the wall of a surrounding structure. Most commonly, a hernia is the protrusion of part of abdominal contents, including bowel, through a tear or weakness in the abdominal wall, or through the inguinal canal into the scrotum.
• An abdominal hernia is repaired by suturing or stapling a mesh patch over the site of the tear or weakness. The mesh patch has a rough surface that can irritate the bowel and cause adhesions. It is therefore preferred to install the patch properitoneally (the terms properitoneal and preperitoneal are used as synonyms). The mesh patch is preferably attached to the properitoneal fascia of the abdominal wall and covered by the peritoneum. To attach the mesh patch to the properitoneal fascia, the peritoneum must be dissected from the properitoneal fascia. This is a difficult process which involves the risk of puncturing the peritoneum. Moreover, strands of properitoneal fat interconnecting the peritoneum and the properitoneal fascia make it difficult to see the site of the hernia.
• The abdominal wall includes various layers of tissue. The peritoneum (P) is the innermost layer. Overlying the peritoneum are several layers of tissue, including the properitoneal fat layer (FL) and the properitoneal fascia (F). The properitoneal fascia is the layer to which a mesh patch is preferably attached in hernia repair. The properitoneal fat layer separates the peritoneum from the properitoneal fascia. The properitoneal fat layer is relatively weak, which enables the peritoneum to be separated relatively easily from the fascia.
• When the peritoneum is separated from the fascia, separation takes place at or in the properitoneal fat layer. The properitoneal fat layer can remain attached to the properitoneal fascia, or can come away with the peritoneum. Alternatively, part of the properitoneal fat layer can remain attached to the peritoneum and part of the fat layer can come away attached to the peritoneum. Because of the uncertainty in the point of separation, the layer which is detached will be called the peritoneum, and the layer from which the peritoneum is detached will sometimes be denoted as the overlying layer. Additional layers of tissue lie between the properitoneal fascia and the skin.
• An inguinal hernia occurs when the contents of the abdominal cavity break through the abdominal wall. As described above, a hernia is repaired by attaching a piece of mesh to the abdominal wall. To prevent the mesh from causing trauma to the bowel, either through irritation of the bowel by the rough surface of the mesh, or by adhesion of the bowel to the mesh, it is preferred to attach the mesh to the properitoneal fascia. With the mesh attached to the fascia, the peritoneum covers the mesh and isolates the bowel from the mesh.
• Conventional techniques of attaching the mesh patch to the properitoneal fascia, both laparoscopic and normal, involve blunt dissecting the peritoneum away from the properitoneal fascia, working from inside or outside the belly. The apparatus and methods according to the invention enable the peritoneum to be separated from the properitoneal fascia and the mesh patch attached to the fascia without entering the belly.
• Although the following description will describe apparatus and methods according to the invention with respect to hernia repair, the inventive apparatus and methods are not restricted to hernia repair. The apparatus and methods can also be used in other procedures in which one layer of tissue is separated from another to form a working space between the layers. These procedures include thoracoscopy in patients with pleural adhesions; pericardioscopy, or the introduction of an endoscope into the pericardial cavity, in patients with pericardial adhesions; retroperitoneal lymph node dissection, in which the peritoneum on the distal aspect of the abdominal cavity is separated from the underlying tissue which includes lymph nodes; and in separating a blood vessel from surrounding connective tissue in the course of, for example, a femoropopliteal arterial bypass graft procedure.
• Laparoscopic techniques to perform hernia repair are being used increasingly frequently. In the conventional procedure for carrying out a hernia repair laparoscopically, an endoscope and instruments are introduced into the belly through one or more incisions in the abdominal wall, and advanced through the belly to the site of the hernia. Then, working from inside the belly, a long incision is made in the peritoneum covering the site of the hernia. Part of the peritoneum is dissected from the properitoneal fat layer to provide access to the fat layer. This is conventionally done by blunt dissection, such as by sweeping a rigid probe under the peritoneum. In this procedure, it is difficult to dissect the peritoneum cleanly since patchy layers of properitoneal fat tend to adhere to the peritoneum.
• In an alternative known laparoscopic hernia repair procedure, the belly is insufflated. An incision is made in the abdominal wall close to the site of the hernia. The incision is made through the abdominal wall as far as the properitoneal fat layer. The peritoneum is then blunt dissected from the properitoneal fat layer by passing a finger or a rigid probe through the incision and sweeping the finger or rigid probe under the peritoneum. After the peritoneum is dissected from the properitoneal fat layer, the space between the peritoneum and the properitoneal fat layer is insufflated to provide a working space in which to apply the mesh patch to the properitoneal fascia.
• During the blunt dissection process, it is easy to puncture through the peritoneum, which is quite thin. Additionally, after initial dissection of the properitoneal space, known surgical procedures require introduction of various instruments in the space to conduct the surgery. These instruments can cause inadvertent puncture of the peritoneum wall after the initial dissection. A puncture destroys the ability of the space between the peritoneum and the fascia to hold insufflation gas; pressurized gas can travel through a puncture in the peritoneum to allow the fluid to migrate to the abdominal cavity and degrade the pressure differential maintaining the properitoneal cavity. Also, it is difficult to dissect the peritoneum cleanly since patchy layers of properitoneal fat tend to adhere to the peritoneum. Clearing difficult adhesions can sometimes result in a breach of the peritoneum itself.
• U.S. Pat. No. 5,309,896 (of which this application is a C.I.P.), discloses a laparoscopic hernia repair technique that enables a mesh patch to be attached to the properitoneal fascia without breaching the peritoneum. An incision is made through the abdominal wall as far as the properitoneal fat layer. A multi-chambered inflatable retraction device is pushed through the incision into contact with the peritoneum, and is used to separate the peritoneum from the overlying tissue layer. The main end chamber of the inflatable retraction device is then inflated to elongate the inflatable retraction device towards the site of the hernia. As it inflates, the inflatable retraction device gently separates more of the peritoneum from the overlying tissue layer. Once the main chamber of the inflatable retraction device is fully inflated, a second inflatable chamber is inflated. The second inflatable chamber enables the inflatable retraction device to continue to separate the peritoneum from the other tissue layers after the main inflatable chamber has been deflated.
• One or more apertures are then cut in the envelope of the main inflatable chamber to provide access to the site of the hernia for instruments passed into the main chamber. With such an arrangement, instruments pass through the main chamber while the main chamber remains between the peritoneum and the overlying layers. In this way, a patch can be attached to the properitoneal fascia without breaching the peritoneum.
• Until the present invention, it had not been known how to view a space between tissue layers while (or after) dissecting the layers with a balloon, without removing any portion of the dissecting apparatus including the balloon, but also without image degradation resulting from viewing through balloon wall. Nor, until the present invention, had it been known to design a balloon (suitable for tissue dissection, tissue retraction, and/or instrument anchoring) to have any of a wide range of inflated shape and pressure characteristics. For example, it had not been known to design a tissue dissection balloon to have inflated shape and pressure characteristics tailored for producing a working space (between dissected tissue layers) having a particular size and shape selected from a broad range of sizes and shapes.
SUMMARY OF THE INVENTION
• In a class of embodiments, the invention is an apparatus for tissue dissection and instrument anchoring, which includes a dissection balloon having a viewing window (preferably a rigid, transparent window) at its distal end. The window can but need not be a lens (such as a wide angle lens) having a desired focal length. The window of the dissection balloon is transparent, and either rigid or non-rigid but sufficiently strong to retain a desired optical shape while (and after) being pushed against tissue layers by a rigid obturator (or other rigid instrument) deployed within the balloon. In preferred embodiments, the window is cup-shaped, in the sense that it has a recessed base for receiving and capturing the distal end of a rigid obturator or endoscope.
• In preferred embodiments, the balloon is a long-necked balloon deployed through a cannula. The balloon has an open distal end, and a rigid, transparent window (made of polished, clear polycarbonate or acrylic material or the like) is glued over its open distal end. When the distal end of the balloon has been inserted between tissue layers, an endoscope extending through the cannula within the balloon can view the tissue layers through the window (whether or not the balloon is inflated).
• In other embodiments, the invention is a dissection balloon having a viewing window at its distal end, for use in an apparatus for tissue dissection, tissue retraction, and instrument anchoring. The window can but need not be a lens (such as a wide angle lens). In other embodiments, the invention is a dissection balloon assembly including a long-necked dissection balloon having a viewing window at its distal end, and a housing to which the dissection balloon's mouth is attached. The housing is shaped for removable attachment to a tissue retraction and instrument anchoring apparatus including a cannula (with the dissection balloon's neck deployed through the cannula and the window extending beyond the cannula's distal end).
• In other, simplified, embodiments, the invention is a dissection balloon, useful for separating tissue layers, attached to the distal end of a trocar or obturator. A viewing window which may or may not be a lens (such as a wide angle lens) is provided at the distal end of the dissection balloon. A longitudinal bore in the trocar or endoscope allows inflation fluid and instruments to be introduced into the balloon. The window may be used to view the tissue layers, via an endoscope inserted through the bore and into the balloon, regardless of whether the balloon is inflated.
• In another class of embodiments, the invention is an apparatus for tissue dissection and instrument anchoring, which includes a dissection balloon having nonuniform elasticity selected to achieve desired inflated shape and pressure characteristics. In a preferred embodiment, the dissection balloon comprises a sheet of relatively inelastic material bonded to another sheet of relatively elastic material. In another preferred embodiment, the dissection balloon consists of a first large sheet bonded (such as by RF-welding) to a second large sheet, and a reinforcing sheet bonded to the central portion of each large sheet. The two large sheets are made of material having high elasticity (preferably polyurethane), and the reinforcing sheet can be made of material having high or relatively low elasticity.
• In other embodiments, the invention is a balloon (either an anchoring or dissection balloon) having nonuniform elasticity selected to achieve desired inflated shape and pressure characteristics, for use in an apparatus for tissue dissection, tissue retraction, and instrument anchoring.
• Other embodiments of the invention are methods for using an apparatus for tissue dissection and instrument anchoring, said apparatus including a long-necked dissection balloon deployed through a cannula. The dissection balloon has a window at its distal end, or nonuniform elasticity selected to achieve desired inflated shape and pressure characteristics, or both such a window and such nonuniform elasticity. The distal end of the dissection balloon is inserted between tissue layers and inflated to dissect the tissue layers. In some embodiments, after dissection using the dissection balloon, the dissection balloon is deflated and withdrawn through the cannula before a medical operation is performed in a working space between the dissected tissue layers. In other embodiments, after dissection using the dissection balloon, the dissection balloon is deflated but retained in the patient during performance of a medical operation. In other embodiments, where the dissection balloon has lobes of other portions shaped so that instruments can be positioned between them, the dissection balloon remains inflated in the patient after the tissue layers have been dissected, instruments are then positioned between the dissected tissue layers without being obstructed by the inflated dissection balloon (e.g., between lobes or other separated portions thereof), and the instruments are manipulated to perform a medical operation.
• Another embodiment of the invention is a technique for packing a balloon in a manner which provides a tunnel through the packaged balloon for insertion of a laparoscope or other instrument, and which eliminates the need for packaging the balloon with an obturator positioned within it.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIGS. 1A-1C and2A-2B show a two-component apparatus for separating tissue layers and insufflating the space between the separated layers, where:
• FIG. 1A is the separation component of the two-component apparatus;
• FIG. 1B is part of the distal part of the separation component of the two-component apparatus with the main envelope in its everted position;
• FIG. 1C is part of the distal part of the separation component of the two-component apparatus with the main envelope in its inverted position;
• FIG. 2A is the insufflation component of the two-component apparatus with the toroidal inflatable chamber in its collapsed state; and
• FIG. 2B is the insufflation component of the two-component apparatus with the toroidal inflatable chamber in its expanded state.
• FIGS. 3A-3I are longitudinal cross sections of the abdomen illustrating a method of using a two-component apparatus to separate the peritoneum from the overlying layer, where:
• FIG. 3A shows an incision made through the abdominal wall, including the properitoneal fat layer, excluding the peritoneum;
• FIG. 3B shows the distal part of the separation component of a two-component apparatus inserted into the incision (the separation component includes the main envelope in its collapsed state);
• FIG. 3C shows the main envelope inflated to its expanded state to separate the peritoneum from the overlying layer;
• FIG. 3D shows the main envelope returned to its collapsed state;
• FIG. 3E shows the separation component removed from the incision;
• FIG. 3F shows the distal part of the insufflation component of the two-component apparatus inserted into the incision;
• FIG. 3G shows the toroidal inflatable chamber of the insufflation component inflated to its expanded state and the anchor flange slid into contact with the skin of the abdominal wall to provide a gas-tight seal;
• FIG. 3H shows the working space between the peritoneum and the overlying layer insufflated with a gas passed through the bore of the insufflation component; and
• FIG. 3I shows additional instruments passed through gas-tight trocar sheaths into the insufflated working space to repair the hernia by attaching a mesh patch to the properitoneal fascia.
• FIGS. 4A-4C show an embodiment of a first one-component apparatus for tissue dissection and instrument anchoring, where:
• FIG. 4A shows a main embodiment of the one-component apparatus with the main envelope in its expanded state;
• FIG. 4B shows details of the area marked “A” at the distal end of the tube assembly inFIG. 4A; and
• FIG. 4C shows the distal part of the tube assembly with the toroidal inflatable chamber in its expanded state.
• FIGS. 5A-5D show an alternative one-component apparatus for tissue dissection and instrument anchoring, where:
• FIG. 5A shows the alternative embodiment with the main envelope in its expanded state;
• FIG. 5B shows the elongated main envelope of the alternative one-component apparatus;
• FIG. 5C shows the distal part of the tube assembly of the alternative one-component apparatus with the main envelope in its everted state; and
• FIG. 5D shows the distal part of the tube assembly of the alternative one-component apparatus with the main envelope in its inverted state.
• FIGS. 6A-6H are longitudinal cross sections of the abdomen illustrating a method of using a one-component apparatus to separate the peritoneum from the overlying layer, wherein:
• FIG. 6A shows an incision made through the abdominal wall, including the overlying layer, excluding the peritoneum;
• FIG. 6B shows the distal part of the tube assembly of the one-component apparatus inserted into the incision. The tube assembly includes the main envelope in its collapsed state;
• FIG. 6C shows the main envelope inflated to its expanded state to separate the peritoneum from the overlying layer;
• FIG. 6D shows the main envelope returned to its fully collapsed state;
• FIG. 6E shows the apparatus advanced into the incision such that the envelope of the toroidal inflatable chamber clears the incision;
• FIG. 6F shows the toroidal inflatable chamber inflated to its expanded state;
• FIG. 6G shows the anchor flange slid into contact with the skin of the abdominal wall. The anchor flange together with the expanded toroidal inflatable chamber provides a gas-tight seal; and
• FIG. 6H shows the space between the peritoneum and the overlying layer insufflated with a gas passed through the bore of the apparatus.
• FIGS. 7A and 7B show a second embodiment of a one-component apparatus, wherein:
• FIG. 7A shows the second one-component apparatus with the main envelope in its expanded state; and
• FIG. 7B shows the second one-component apparatus with the main envelope in its collapsed state.
• FIG. 8A shows the second one-component apparatus with the main envelope in its expanded state and an endoscope passed through the bore of the outer tube into the main inflatable chamber.
• FIG. 8B shows the second one-component apparatus with the main inflatable chamber in its partially expanded state and an endoscope passed through the bore of the inner tube and through the bore of the main envelope.
• FIGS. 9A-9I show an alternative method of using either a one-component or two-component apparatus to separate the peritoneum from the overlying layer near the groin, with the apparatus inserted through an incision near the umbilicus.FIGS. 9A-9H are longitudinal cross sections of the abdomen, wherein:
• FIG. 9A shows an incision made through the abdominal wall, including the overlying layer, excluding the peritoneum;
• FIG. 9B shows the distal part of the apparatus inserted into the incision. A tube assembly of the apparatus includes a main envelope in its collapsed state;
• FIG. 9C shows the main envelope inflated to a partially-expanded state to separate part of the peritoneum from the overlying layer;
• FIG. 9D shows the main envelope returned to its collapsed state;
• FIG. 9E shows the apparatus advanced in the direction of the groin to bring the main envelope to the limit of the separated part of the peritoneum;
• FIG. 9F shows the main envelope re-inflated to a partially-expanded state to separate an additional part of the peritoneum from the overlying layer;
• FIG. 9G shows the main envelope advanced to close to the site of the hernia and re-inflated to its fully inflated state to create a working space; and
• FIG. 9H shows a component of the apparatus advanced through the tunnel into the working space, and the toroidal inflatable chamber inflated to form a gas-tight seal with the entrance of the tunnel.
• FIG. 9I is a plan view of the abdomen showing a component of the apparatus in position with its distal end in the working space and its toroidal inflatable chamber forming a gas-tight seal with the entrance of the tunnel.FIG. 9I shows the lesser extent to which the peritoneum is detached in the tunnel compared with in the working space.
• FIG. 10 is a perspective view of a preferred embodiment of the inventive one-component apparatus for tissue dissection, tissue retraction, and instrument anchoring.
• FIG. 11 is an exploded view ofobturator515, retainingring514, and the dissection balloon subassembly of theFIG. 10 apparatus.
• FIG. 12 is an exploded cross-sectional view of the dissection balloon subassembly of theFIG. 10 apparatus.
• FIG. 13 is a perspective view of the tissue retraction and instrument anchoring subassembly of theFIG. 10 apparatus.
• FIG. 14 is a partially side elevational, partially side cross-sectional view of theFIG. 10 apparatus (withballoon512 inflated andendoscope515′ substituted for obturator515).
• FIG. 15 is a perspective view of an alternative instrument anchoring subassembly, for use in theFIG. 10 apparatus as a substitute for theFIG. 13 subassembly.
• FIG. 16 is a plan view of a dissection balloon designed in accordance with the invention.
• FIG. 17 is a cross-sectional view of the balloon ofFIG. 16, taken along line A-A.
• FIG. 18 is a cross-sectional view of the balloon ofFIG. 16, taken along line B-B.
• FIG. 18A is an end view of an alternative implementation of the dissection balloon ofFIG. 16, when inflated, and with a window attached at its distal end.
• FIG. 18B is a side elevational view of the alternative implementation of the dissection balloon ofFIG. 16, when inflated, and with a window attached at its distal end.
• FIG. 18C is an end view of a preferred implementation of the dissection balloon ofFIG. 16, when inflated, and with a window attached at its distal end.
• FIG. 18D is a side elevational view of the preferred implementation of the dissection balloon ofFIG. 16, when inflated, and with a window attached at its distal end.
• FIG. 19 is a side elevational view of a balloon window for use aswindow508 of theFIG. 10 apparatus.
• FIG. 20 is a side elevational view of another balloon window for use aswindow508 of theFIG. 10 apparatus.
• FIG. 21 is a side elevational view of a third balloon window for use aswindow508 of theFIG. 10 apparatus.
• FIG. 21A is a perspective view of a fourth balloon window for use aswindow508 of theFIG. 10 apparatus.
• FIG. 21B is a side cross-sectional view of the window ofFIG. 21A.
• FIG. 21C is an embodiment of the inventive dissection balloon whose distal end portion is tapered to receive and capture an obturator (or endoscope).
• FIG. 22 is a plan view of another dissection balloon designed in accordance with the invention.
• FIG. 23 is a plan view of another dissection balloon designed in accordance with the invention.
• FIG. 24 is a plan view of yet another dissection balloon designed in accordance with the invention.
• FIG. 24A is a plan view of three component sheets of yet another dissection balloon designed in accordance with the invention
• FIG. 25 is a partially side elevational, partially side cross-sectional view of a portion of an alternative embodiment of the inventive apparatus for tissue dissection and instrument anchoring.
• FIGS. 26-35 show a method of using the inventive apparatus (such as that ofFIGS. 10-14) to separate the peritoneum from the overlying layer near the groin, with the apparatus inserted through an incision near the umbilicus.FIGS. 26-35 are longitudinal cross sections of the abdomen, wherein:
• FIG. 26 shows an incision made through the abdominal wall;
• FIG. 27 shows the distal end of the apparatus inserted into the incision;
• FIG. 28 showsdissection balloon512 inflated to separate part of the peritoneum from the overlying layer;
• FIG. 29 showsballoon512 returned to its collapsed state;
• FIG. 30 shows the apparatus advanced in the direction of the groin to bringballoon512 to the limit of the separated part of the peritoneum;
• FIG. 31 showsballoon512 re-inflated to separate an additional part of the peritoneum from the overlying layer;
• FIG. 32 showsballoon512 advanced to a position close to the site of a hernia and re-inflated to create a working space;
• FIG. 33 shows the dissection balloon assembly (512 and513) andring514 removed from the rest of the apparatus (i.e., the retraction and anchoring subassembly), andanchor balloon517 inflated;
• FIG. 34 showsfoam collar504 advanced into contact with the patient; and
• FIG. 35 shows the working space within the patient being insufflated (as a final step prior to performing a repair procedure within the working space).
• FIG. 36 is a perspective view of a balloon assembly for use in alternative embodiments of the invention.
• FIG. 37 is a plan view of theFIG. 36 assembly.
• FIG. 38 is a plan view of theFIG. 36 assembly with a portion of the balloon displaced inwardly.
• FIG. 39 shows theFIG. 38 assembly with a rolling device grasping an end of the first, inwardly-displaced balloon portion between two rods.
• FIG. 40 is an elevational view of the rolling device ofFIG. 39.
• FIG. 41 shows theFIG. 39 assembly during rolling of the first balloon portion.
• FIG. 42 is a cross-sectional view of theFIG. 36 assembly with first and second inwardly-displaced portions of the balloon rolled up into first and second rolls with an obturator positioned therebetween.
• FIG. 43 shows theFIG. 42 assembly, deployed between tissue layers and partially inflated.
• FIGS. 44 and 45 are cross-sectional views of theFIG. 36 assembly with the balloon in different stages of packing in accordance with an alternative method.
• FIGS. 46 and 47 are cross-sectional views of theFIG. 36 assembly with the balloon in different stages of packing in accordance with another alternative method.
• FIG. 48 is a cross-sectional view of a variation on theFIG. 36 assembly, with a balloon having accordion-folds.
• FIG. 49 is a cross-sectional view of theFIG. 48 assembly with the balloon having accordion-folds and packed in a compact state.
• FIG. 50A is an alternative embodiment of a tissue dissection apparatus in which the dissection balloon is mounted to the distal end of a trocar. The dissection balloon is shown in an inflated condition.
• FIG. 50B is an alternative embodiment of a tissue dissection apparatus in which the dissection balloon is mounted to the distal end of a semi-rigid obturator. The dissection balloon is shown in an inflated condition.
• FIG. 50C is an alternative embodiment of a tissue dissection apparatus in which the dissection balloon is mounted to the distal end of a rigid obturator. The dissection balloon is shown in an inflated condition.
• FIG. 51A is a top view of a tissue dissection apparatus illustrating an alternative embodiment of a technique for packing the balloon according to the present invention.
• FIG. 51B is a side view of the tissue dissection apparatus ofFIG. 51A further illustrating the inventive packing technique.
• FIG. 51C is a side view of the tissue dissection apparatus ofFIG. 51B illustrating the use of an obturator to extend the balloon in the distal direction.
• FIG. 51D is a cross-sectional side view of the proximal portion of the cannula of the tissue dissection apparatus ofFIG. 51A.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
• Throughout the disclosure, including in the claims, the term “balloon” is used in a broad sense to denote any inflatable structure, regardless of the elasticity of the material comprising it. For example, the term balloon is employed to denote both a thin-walled, inflatable structure consisting of material of low elasticity (which does not stretch significantly during inflation), and also a thin-walled, inflatable structure consisting of highly elastic material such as a sheet of urethane (which does stretch significantly during inflation). In preferred embodiments to be described, the invention employs a balloon having nonuniform elasticity (elasticity which varies from one place to another on the balloon's surface).
• Throughout the disclosure, the term “one-component” apparatus denotes, with reference to an apparatus for tissue dissection and instrument anchoring, an apparatus having a cannula, wherein after the cannula is inserted into a patient, it remains in the patient during tissue dissection using the apparatus and during anchoring of the apparatus in the patient to enable performance of medical procedures (subsequent to dissection) using the apparatus.
• Another device for separating tissue layers is disclosed in U.S. patent application Ser. No. 07/911,714, of which this application is a C.I.P. The device includes a main envelope that defines a main inflatable chamber. The apparatus also includes an introducing device for introducing the main envelope in a collapsed state between the first layer of tissue and the second layer of tissue. The introducing device inflates the main envelope into an expanded state to separate the first layer of tissue from the second layer of tissue, and to create a working space between the first layer of tissue and the second layer of tissue. Finally, the apparatus includes an insufflating device for introducing insufflation gas into the working space between the first layer of tissue and the second layer of tissue.
• In a method according to U.S. application Ser. No. 07/911,714, a first layer of tissue is separated from a second layer of tissue using a main envelope (defining a main inflatable chamber) and insufflation gas. The main envelope is introduced in a collapsed state between the first and second layers of tissue, and the main envelope is then inflated into an expanded state to create a working space between the first and second layers of tissue. Finally, insufflation gas is introduced into the working space between the first and second layers of tissue.
• U.S. Ser. No. 07/911,714 discloses a two-component apparatus including an inflatable main envelope and a device for introducing the main envelope (together constituting a first component which separates a first layer of tissue from a second layer of tissue to create a working space) and an insufflation device which insufflates the working space to maintain separation of the first layer of tissue from the second layer. The insufflation device is tubular, has an anchor flange slidably mounted on it, and has a toroidal inflatable chamber at its distal end. The anchor flange and toroidal inflatable chamber together form a gas-tight seal with the second layer of tissue.
• In a method disclosed in U.S. Ser. No. 07/911,714 for using the two-component apparatus, the introducing device pushes the main envelope in a collapsed state through an incision through the second layer of tissue to place the main envelope between the first and second layers of tissue. The main envelope is then inflated to gently separate the first and second tissue layers. An endoscope may be passed through the bore of the introducing device into the main chamber to observe the extent of separation of the layers of tissue. The main envelope is then returned to a collapsed state, and the main envelope and introducing device are removed through the incision. Next, the insufflating device is inserted into the incision so that its distal end projects into the working space between the two layers of tissue, and the toroidal inflatable chamber is inflated. The anchor flange is slid distally along the insufflating device to compress the second layer of tissue between it and the expanded toroidal inflatable chamber, and thus to form a gas-tight seal. Insufflating gas is then passed through the insufflating device into the working space to maintain the separation of the first layer of tissue from the second. An endoscope may be passed through the bore of the insufflating device into the working space to observe within the working space.
• A two-component apparatus (of the type disclosed in referenced U.S. Ser. No. 07/911,714) for separating tissue layers and insufflating the space between the separated layers is shown inFIGS. 1A-1C and2A-2B.FIG. 1A shows a partially cut-away view ofseparation component1 of the apparatus. Inseparation component1,introducer tube3 is a rigid tube having a bore with a circular cross section that can accommodate an endoscope.
• The proximal end ofintroducer tube3 is fitted with aport5, in theproximal end7 of which is mounted aflapper valve2.Shutter6 of flapper valve is operated bybutton9.Seat4 of the flapper valve additionally forms a gas-tight seal with an endoscope or other instrument inserted though the flapper valve into the bore ofintroducer tube3.Port5 is also fitted with avalve11 to which a supply of a suitable inflation fluid can be connected.
• Main envelope12 defines a maininflatable chamber13.Main envelope12 is fitted todistal end15 ofintroducer tube3.Main envelope12 is shown in a collapsed state inFIGS. 1B and 1C.Dotted line12X indicates the extent ofmain envelope12 withchamber13 in its expanded state. It should be noted that although themain envelope12 is illustrated as generally spherical, it can be formed as oblong, “hockey puck” or disc shaped, kidney bean shaped or in other shapes as suited for the particular dissection contemplated.
• Main envelope12 is preferably formed from an elastomeric material, such as latex, silicone rubber, or polyurethane. The main envelope can also be formed from a thin, inelastic material such as Mylar®, polyethylene, nylon, etc. If an inelastic material is used, it should be suitably packaged to fit inside the bore ofintroducer tube3 when in its collapsed state.
• The preferred elastomericmain envelope12 can be simply attached to thedistal end15 of theintroducer tube3 by stretching the main envelope over the distal end of the introducer tube, as shown inFIG. 1B. The main envelope is then kept in place by friction resulting from the tension caused by stretching. A suitable adhesive, such as an epoxy or cyanoacrylate adhesive, may additionally or alternatively be used. Other means of attaching the main envelope to the inside or the outside of the introducer tube can be used.
• After attachment,main envelope12 is inverted into the bore of the introducer tube, as shown inFIG. 1C. Inverting the main envelope into the bore of the introducer tube makes it easier to use the introducer tube to pass the main envelope through an incision and place it adjacent to the peritoneum, as will be described.
• The first part of a method (described in U.S. Ser. No. 07/911,714) usingseparation component1 of the two-component apparatus ofFIGS. 1A-1C and2A-2B to separate a first layer of tissue from a second layer of tissue will next be described with reference toFIGS. 3A-3E (the entire method, for repairing a hernia, will be described with reference toFIGS. 3A-3I).
• FIGS. 3A-3I show a longitudinal cross section of the lower abdomen. As indicated byFIG. 3A, an incision about 12-15 mm long is made in the abdominal wall (AW), and is carried through the abdominal wall as far as, and including, the properitoneal fat layer (FL).Distal end15 ofintroducer tube3 ofseparation component1 is then inserted into the incision to bring the distal end into contact with the peritoneum (P). Additional gentle pressure detaches the part of the peritoneum in the immediate vicinity of the incision from the overlying layer, as shown inFIG. 3B.FIG. 3B shows the peritoneum (P) detached from the properitoneal fat layer (FL). The deflated main envelope cannot be seen inFIG. 3B because it is inverted within the bore ofintroducer tube3.
• A source of a suitable inflation fluid (not shown) is connected tovalve11. A gas, preferably air, is the preferred inflation fluid, but other gases, such as carbon dioxide, can be used. A liquid, such as saline solution, can be used, but liquids are less preferable than gases because liquids change the optical properties of any endoscope inserted into maininflatable chamber13. The flow of inflation fluid is turned on, which ejects themain envelope12 of maininflatable chamber13 from the bore ofintroducer tube3.
• The inflation fluid progressively expands themain envelope12, and hence the maininflatable chamber13 defined by the main envelope, into an expanded state (as shown inFIG. 3C). The main envelope expands between the peritoneum and the properitoneal fascia, and gently and progressively detaches an increasing area of the peritoneum from the overlying layer as it expands. When the main envelope is in its expanded state, the main inflatable chamber is preferably about 4″-6″ (100-150 mm) in diameter.
• Early in the process of expanding themain envelope12, an endoscope E is inserted intoflapper valve2 inport5, as shown inFIG. 3C. Endoscope E is passed through the bore ofintroducer tube3 into the maininflatable chamber13. Once partially expanded,main envelope12 is sufficiently transparent for the extent of the detachment of the peritoneum to be observed through the endoscope.
• When a sufficient area of the peritoneum has been detached, the supply of inflation fluid is turned off. The inflation fluid is then vented from the main inflatable chamber, andmain envelope12 returns to its collapsed state. The peritoneum remains detached from the properitoneal fascia, however, as shown inFIG. 3D.Separation component1, including the collapsed main envelope, is then withdrawn from the incision1 (FIG. 3E).
• Insufflation component21 (shown inFIGS. 2A and 2B) of the two-component apparatus ofFIGS. 1A-1C and2A-2B will next be described.Insufflation component21 comprisesinner tube35 andouter tube37 mounted coaxially, with the outer tube covering the inner tube over most of the length of the inner tube. The inner tube is similar to the introducer tube3 (FIG. 1A), and is a rigid tube having a bore with a circular cross section that can accommodate a 10 mm endoscope.
• The proximal end ofinner tube35 is fitted with aport25, the proximal end27 of which has aflapper valve32.Shutter36 of the flapper valve is operated bybutton29.Seat34 of the flapper valve forms a gas-tight seal with an endoscope (not shown) or an obturator (such as obturator33) inserted though the flapper valve into the bore ofinner tube35.Port25 is also fitted with afirst valve31 to which a supply of a suitable insufflation fluid can be connected.
• Distal end41 ofouter tube37 stops short ofdistal end39 ofinner tube35.Insufflation component21 includes a toroidalinflatable chamber43.Envelope45 oftoroidal chamber43 is a cylindrical piece of a thin elastomeric material, such as latex, silicone rubber, or polyurethane.Envelope45 is placed over the distal ends of the inner tube and the outer tube.Proximal end47 ofenvelope45 is attached todistal end41 of the outer tube, anddistal end49 ofenvelope45 is attached todistal end39 of theinner tube35.
• The bore ofouter tube37 is spaced from the outer surface ofinner tube35.Annular space51 between the inner tube and the outer tube interconnectstoroidal chamber43 and asecond valve53.Second valve53 is connected to a source of a suitable inflation fluid (not shown). Thus,toroidal envelope45 can be inflated using an inflation fluid passing into toroidal inflatable chamber43 (the volume enclosed by envelope45) via thesecond valve53 and theannular space51. Toroidalinflatable envelope45 is shown in its collapsed state inFIG. 2A, and in its expanded state inFIG. 2B.
• Anchor flange55 is slidably mounted on theouter tube37, and can be locked in a desired position along the length of the outer tube with a simple over-center action locking lever (not shown). As will be described in detail below, the anchor flange and the toroidal inflatable chamber, in its expanded condition, enable theinsufflator component21 to form a gas-tight seal to prevent insufflation gas passed through the insufflator component from escaping.
• The use ofinsufflation component21 in the second part of the method ofFIGS. 3A-3I using the two-component apparatus ofFIGS. 1A-1C and2A-2B will next be described. It is preferred to useseparation component1 in conjunction with the first part of the method (described with referenced toFIGS. 3A-3E) and for dissecting the first and second tissue layers, but the second part of the method (using insufflation component21) may be used in following any other dissection operation including manual dissection with an endoscope, graspers, operating scope or any blunt instrument which may be used to dissect the tissue layers by sweeping the area between the layers.
• With reference toFIG. 3F,obturator33 ofcomponent21, havingblunt tip57, is inserted past flapper valve32 (shown inFIG. 2B) into the bore ofinner tube35.Tip57 ofobturator33 projects beyond the distal end of the inner tube to provideinsufflation component21 with a blunt nose. The blunt nose enables the distal end ofinsufflation component21 to be atraumatically inserted into the properitoneal space through incision I. The insufflation component is advanced through the incision until the proximal end of thecylindrical envelope45 is in the properitoneal space, clear of the incision, as shown inFIG. 3F.
• A suitable source (not shown) of an inflation fluid is attached tosecond valve53. A gas, such as air or carbon dioxide, can be used for the inflation fluid; alternatively, a liquid, such as saline can be used. Since the volume of inflation fluid required to inflate the toroidal inflatable chamber is small, about 15 ml in the preferred embodiment, the inflation fluid can be forced into the toroidal inflatable chamber from a large syringe. Inflation fluid is fed into toroidalinflatable chamber43 to expand the toroidal inflatable chamber to its expanded condition, as shown inFIG. 3G.
• Anchor flange55 is then advanced in the direction ofarrow59 alongouter tube37 to bringanchor flange55 into contact with the skin of the abdominal wall (as shown inFIGS. 3G and 3H).Insufflation component21 is then gripped, and the anchor flange is further advanced slightly. This forces the expanded toroidalinflatable chamber43 into contact with the overlying layer, and slightly compresses the abdominal wall (including the overlying layer but excluding the peritoneum) between the toroidal inflatable chamber and the anchor flange. Once adjusted, the anchor flange is locked in position on the outer tube. The expanded toroidal inflatable chamber is held against the overlying layer, and forms a gas-tight seal between the insufflation component and the abdominal wall (including the overlying layer but excluding the peritoneum). A suitable source (not shown) of an insufflation gas is attached tofirst valve31, and insufflation gas is passed through the bore ofinner tube35 into the working space between the peritoneum and the overlying layer created by separating by the peritoneum from the overlying layer using the separation component of the apparatus in the first part of the method described above. The pressure of the insufflation gas re-separates the peritoneum from the overlying layer, as shown inFIG. 3H, and provides a working space in which repair of the hernia can be carried out. The obturator is removed from the bore ofinner tube35. The bore ofinner tube35 can then be used to pass instruments, such as the endoscope, into the working space to perform the repair procedure. Insufflation pressure is maintained byflapper valve32.
• As part of the hernia repair procedure, additional gas-tight trocar sheaths are inserted through the abdominal wall into the working space, as shown inFIG. 3I. An endoscope (not shown) can be passed into the working space through the bore ofinner tube35, or through one of the additional trocar sleeves for observation. If the properitoneal fat layer remains attached to the properitoneal fascia, it is scraped off the fascia around the site of the hernia so that the patch can be attached directly to the fascia.
• A patch, preferably a Dacron® or Teflon® mesh, shown gripped by grippers, is passed through the sleeve of one trocar into the working space. Using the grippers, the patch is manipulated to place it in contact with the properitoneal fascia over the site of the hernia. The patch is attached to the properitoneal fascia by staples inserted using a stapler passed through the trocar sleeve into the working space. Sutures can alternatively be used to attach the patch to the properitoneal fascia.
• After the treatment procedure is completed,first valve31 is operated to release the insufflation gas from the working space.Second valve53 is operated to release the inflation fluid from toroidalinflatable chamber43.Envelope45 of the toroidal inflatable chamber returns to its collapsed state, flush with the outer surfaces of the inner tube andouter tube37.Insufflating component21 is then withdrawn from the incision, and the incision is closed using sutures or clips. The pressure of the viscera against the peritoneum returns the peritoneum into contact with the overlying layer. Over time, the peritoneum reattaches to the overlying layer.
• Several embodiments of a one-component apparatus are disclosed in U.S. Ser. No. 07/911,714. Each such one-component apparatus includes assemblies for performing multiple functions, including: introducing and inflating a main envelope to dissect tissue layers within a patient; anchoring the apparatus to the patient and insufflating the working space; and returning the inflated main envelope to a collapsed state. In some of these embodiments, the main envelope is deployed through an elongated tube, and the anchoring means includes an anchor flange slidably mounted on the elongated tube and a toroidal inflatable chamber at the distal end of the elongated tube. The anchor flange and toroidal inflatable chamber can be controlled to form, together, a gas-tight seal with the second layer of tissue.
• One-component apparatus121 (one of the one-component apparatus embodiments disclosed in U.S. Ser. No. 07/911,714) is shown inFIG. 4A.Apparatus121 is similar toinsufflation device21 ofFIGS. 2A-2B, and components ofapparatus121 corresponding to those ofdevice21 are identified by the same reference numbers as inFIGS. 2A-2B with “100” added thereto.Apparatus121 comprisestube assembly160, including aninner tube135 coaxially mounted inside anouter tube137.Outer tube137 coversinner tube135 over most of the length of the inner tube. The inner tube is a rigid tube having a bore with a circular cross section that can accommodate an endoscope (not shown).
• The proximal end of theinner tube135 is fitted with aport125, the proximal end127 of which includes aflapper valve132. Theshutter136 of the flapper valve is operated by thebutton129. Additionally, theseat134 of the flapper valve forms a gas-tight seal with an endoscope (not shown), or other instrument, inserted though the flapper valve into the bore of theinner tube135. Theport125 is also fitted with afirst valve131 to which a supply of a suitable insufflation fluid can be connected.
• Unlikeinsufflator device21 ofFIGS. 2A and 2B, the distal end ofouter tube137 extends as far as the distal end ofinner tube135.Tubes135 and137 are connected together over adistal portion167 of their lengths (see detail inFIG. 4B).Circumferential groove169 is formed in the inner wall ofdistal portion167.Groove169 is shown with a wedge-shaped cross section, but can have other cross sections, such as square, or semi-circular.Circumferential groove169 retainsmain envelope112, which defines maininflatable chamber113, in the bore ofinner tube135.
• Envelope145 of toroidalinflatable chamber143 covers the distal part oftube assembly160.Envelope145 is a cylindrical piece of thin elastomeric material, such a latex, silicone rubber, or polyurethane. Theproximal end147 and thedistal end149 of the envelope are attached to theouter surface163 of the tube assembly using a circumferential line of adhesive applied at each end of the envelope. An epoxy or cyanoacrylate adhesive is preferably used. Whenchamber143 is in its collapsed state,envelope145 lies almost flush with the outer surface oftube assembly160.
• Outer tube137 is spaced frominner tube135 over at least part of its circumference.Space151 between the inner tube and the outer tube, andradial passage161 through the wall of the outertube interconnect chamber143 andsecond valve153.Second valve153 is connected to a source of suitable inflation fluid (not shown).Chamber143 is shown in its collapsed state inFIGS. 4A and 4B, and in its expanded state inFIG. 4C.
• Anchor flange155 is slidably mounted ontube assembly160, and can be locked in a desired position along the length of the tube assembly with a simple over-center action locking lever (not shown). As will be described below,anchor flange155 and toroidalinflatable chamber143 in its expanded condition form a gas-tight seal to prevent insufflation gas from escaping.
• The apparatus ofFIGS. 4A-4C also includesmain envelope112 detachably attached to the bore ofinner tube135. The main envelope defines maininflatable chamber113.Main envelope112 is preferably formed of an elastomeric material such as latex, silicone rubber, or polyurethane (but can also be formed from a thin, inelastic material such as Mylar®, polyethylene, nylon, etc.). If an inelastic material is used forenvelope112, it should be suitably packaged to fit inside the bore of the inner tube when in its collapsed state.
• Main envelope112 is formed such that it has a substantially spherical shape when in its expanded state, and is also formed with aneck165.Neck165 has an outside diameter substantially equal to the diameter of the bore ofinner tube135.Neck165 can be rolled outward a number of times, as in the neck of a common toy balloon, or the neck can be attached to a suitable O-ring171 as shown inFIG. 4B. The rolled neck, or the O-ring attached to the neck, engages with thecircumferential groove169 in the inner wall in the inner tube to attachmain envelope112 to the inner tube.Main envelope112 is housed in the bore of the inner tube when the main inflatable chamber is in its collapsed state.
• Rip cord173, attached toneck165 ofmain envelope112, runs proximally up the bore ofinner tube135 and emerges fromport125 throughflapper valve132. The part of therip cord173 emerging from the flapper valve can be gripped and pulled in a proximal direction to release the rolledneck165 or the O-ring171 from thecircumferential groove169. By pulling further on the rip cord, the entire main envelope can be pulled proximally through the bore of the inner tube.
• FIG. 5A shows a one-component apparatus (which is a variation on the apparatus ofFIGS. 4A-4C) having an elongatedmain envelope112A. As shown inFIG. 5A (and described in referenced U.S. application Ser. No. 07/911,714),tube assembly160A includesinner tube135A mounted coaxially insideouter tube137A, with the proximal and distal ends of the tubes interconnected.Space151A between the inner tube and the outer tube communicates with the toroidal inflatable chamber through a radial passage in the wall of the outer tube. The space between the inner tube and the outer tube also communicates with the toroidalchamber inflation valve153A. The bore of theinner tube135A communicates with theport125A, fitted with theinsufflation valve185. Theport125A is also fitted with aflapper valve132A, including theflapper valve seat134A, which maintains gas pressure when the apparatus is used for insufflation.Flapper valve seat134A also provides a gas-tight seal around any instrument, such as endoscope E, passed through the flapper valve.
• Elongatedmain envelope112A is shown inFIG. 5B. The main envelope is an elongated cylinder with a closeddistal end177. The main envelope is preferably formed from an elastomeric material, such as latex, silicon rubber, or polyurethane. Attached to the proximal end of the main envelope is a manifold175 which mates with theproximal face127A of theport125A. The manifold175 is fitted with an O-ring seal187, which forms a gas-tight seal with any instrument passed through it. The manifold175 is also fitted with the mainchamber inflation valve131A to which a supply (not shown) of a suitable inflation fluid can be attached to inflate the maininflatable chamber112A.
• Elongatedmain envelope112A is passed throughflapper valve132A into the bore ofinner tube135A. The manifold175 is engaged with theproximal face127A of theport125A. When the manifold is engaged, thedistal end177 of the main envelope projects beyond the distal end of thetube assembly160A, as shown inFIG. 5C. The distal end of the main envelope is then inverted into the bore of theinner tube135A, as shown inFIG. 5D.
• An endoscope, or other suitable instrument, is inserted through O-ring seal187 to seal the manifold before inflation fluid is passed through mainchamber inflation valve131A to inflate maininflatable chamber113A.
• Alternatively, seal187 can be replaced by an additional flapper valve (not shown) so that the main inflatable chamber can be inflated without the need to use an instrument to seal the manifold.
• When inflation fluid is passed into maininflatable chamber113A throughvalve131A,distal end177 ofmain envelope112A is ejected frominner tube135A. The inflation fluid then progressively expands themain envelope112A, and hence maininflatable chamber113A defined by the main envelope, into an expanded state as shown inFIG. 5A. The part of the main envelope inside the inner tube is subject to the same inflation pressure as thedistal end177 of the main envelope, but is constrained by the inner tube and so does not inflate.
• After usingmain envelope112A to separate (dissect) the peritoneum from an adjacent tissue layer, as will be described below, the inflation pressure fluid is vented from maininflatable chamber113A, andmain envelope112A returns to its collapsed state. When the main envelope is in its collapsed state, it can move freely in the bore ofinner tube135. The main envelope is removed from the inner tube by disengaging manifold175 from theproximal face127A ofport125A, and usingmanifold175 to pull the main envelope proximally through the bore of the inner tube.
• Inflation fluid for the toroidal inflatable chamber (envelope145A of which is shown inFIG. 5A), is passed through toroidalchamber inflation valve153A. Insufflation gas is passed throughinsufflation valve185.
• The toroidal inflatable chamber andanchor flange155A of the embodiment ofFIGS. 5A-5D are the same as in the embodiment ofFIGS. 4A-4C, and will not be described again.
• In a method according to U.S. Ser. No. 07/911,714 of using a one-component apparatus to separate a first layer of tissue from a second layer of tissue, the elongated tube pushes the main envelope in a collapsed state through an incision through the second layer of tissue to place the main envelope between the first layer of tissue and the second layer of tissue. The main envelope is then inflated to gently separate the first layer of tissue from the second layer of tissue, thereby creating a working space between the two layers of tissue. An endoscope may be passed through the bore of the single elongated tube into the main chamber to observe the extent of separation of the layers of tissue. The main envelope is then returned to a collapsed state, detached from the elongated tube, and removed from the working space between the layers of tissue through the bore of the elongated tube. The toroidal inflatable chamber at the distal end of the elongated tube is then inflated into an expanded state. The anchor flange is slid distally along the elongated tube to compress the second layer of tissue between it and the expanded toroidal inflatable chamber to form a gas-tight seal. Insufflating gas is passed through the elongated tube into the working space to maintain the separation of the first and second tissue layers. An endoscope may be passed through the bore of the single elongated tube into the working space to observe within the working space.
• Such a method (described in U.S. Ser. No. 07/911,714) of using either the apparatus ofFIGS. 4A-4C or that ofFIGS. 5A-5D to separate a first layer of tissue from a second layer of tissue will next be described with reference toFIGS. 6A-6H. For specificity,FIGS. 6A-6H will be described with reference to separation of the peritoneum from the properitoneal fascia in the course of repairing a hernia using the apparatus ofFIGS. 4A-4C.
• FIGS. 6A-6H show a longitudinal cross section of the lower abdomen.Incision1 about 12-15 mm long is made in the abdominal wall, and carried through the abdominal wall as far as, and including the properitoneal fat layer as shown inFIG. 6A.Distal end115 oftube assembly160 ofapparatus121 is then inserted into the incision to bring the distal end into contact with the peritoneum. Additional gentle pressure detaches the part of the peritoneum in the immediate vicinity of the incision from the overlying layer, as shown inFIG. 6B.FIG. 6B shows the peritoneum detached from the properitoneal fat layer. The main envelope cannot be seen inFIGS. 6A and 6B because it is inverted within the bore of the tube assembly.
• A source of inflation fluid (not shown) is connected tovalve131. A gas, preferably air, is the preferred inflation fluid, but other gases, such a carbon dioxide can be used. A liquid, such as saline solution can be used, but liquids are less preferable because they change the optical properties of any endoscope inserted into maininflatable chamber113. The flow of inflation fluid is turned on, which ejectsmain envelope112 from the bore oftube assembly160.
• The inflation fluid progressively expandsmain envelope112, and hence maininflatable chamber113 defined by the main envelope, into an expanded state as shown inFIG. 6C. The main envelope expands between the peritoneum and the properitoneal fat layer, and gently and progressively detaches an increasing area of the peritoneum from the overlying layer as it expands. When the main envelope is in its expanded state, the main inflatable chamber is preferably about 4″-6″ (100-150 mm) in diameter.
• Early in the process of expandingmain envelope112, an endoscope E is inserted intoflapper valve132 inport125 as shown inFIG. 6C. Endoscope E is passed through the bore oftube assembly160 into maininflatable chamber113. Once the main envelope is partially expanded, the main envelope is sufficiently transparent for the extent of the detachment of the peritoneum to be observed using the endoscope.
• When a sufficient area of the peritoneum is detached, the supply of inflation fluid is turned off. The inflation fluid is then vented from maininflatable chamber113, and the main envelope progressively returns to its collapsed state. The peritoneum remains detached from the overlying layer, however, as shown inFIG. 6D. The main envelope is then removed from the bore oftube assembly160. The different methods of removing the main envelope from the bore of the tube assembly for the different forms of the one-component apparatus (that ofFIGS. 4A-4C and that ofFIGS. 5A-5D) are described above.
• Aftermain envelope112 has been removed from the bore of the tube assembly, the tube assembly is advanced into the incision in the direction ofarrow162 until the proximal end ofenvelope145 of the toroidal inflatable chamber is in the properitoneal space, clear of the incision, as shown inFIG. 6E.
• A suitable source (not shown) of an inflation fluid is attached tovalve153. A gas, such as air or carbon dioxide, can be used for the inflation fluid; alternatively, a liquid, such as saline can be used. Since the volume of inflation fluid required to inflate the toroidal inflatable chamber is small, about 15 ml in the preferred embodiment, the inflation fluid can be contained in a large syringe. Inflation fluid is fed into toroidalinflatable chamber43 to expand the toroidal inflatable chamber to its expanded condition, as shown inFIG. 6F.
• Anchor flange155 is then advanced in the direction ofarrow159 alongtube assembly160 to bring the anchor flange into contact with the skin S of abdominal wall AW.Tube assembly160 is then gripped, and the anchor flange is further advanced slightly. This forces the expanded toroidalinflatable chamber143 into contact with the overlying layer, and slightly compresses abdominal wall AW, including the overlying layer but excluding the peritoneum P, between the expanded toroidal inflatable chamber and the anchor flange, as shown inFIG. 6G. Once adjusted, the anchor flange is locked in position on the tube assembly. The expanded toroidal inflatable chamber is held against the overlying layer and forms a gas-tight seal with the abdominal wall, excluding the peritoneum.
• A suitable source (not shown) of insufflation gas is attached tofirst valve131, and insufflation gas is passed through the bore ofinner tube135 into working space WS between the peritoneum P and the overlying layer created by separating the peritoneum from the overlying layer. The pressure of the insufflation gas re-separates the peritoneum from the overlying layer, as shown inFIG. 6H, and provides a working space in which repair of the hernia can be carried out. The bore oftube assembly160 can be used to pass instruments, such as endoscope E, into the working space to perform the repair procedure. When no instrument is inserted into the bore of the tube assembly, insufflation pressure is maintained by the flapper valve.
• As part of a hernia repair procedure, additional gas-tight trocar sleeves (not shown) are inserted through the abdominal wall into the working space. The same procedure described above in connection withFIG. 31 is used to attach a mesh patch to the properitoneal fascia over the site of the hernia. The process can be observed using an endoscope passed through the bore oftube assembly160, or through one of the additional trocar sleeves.
• After the treatment procedure is completed,valve131 is operated to release the insufflation gas from the working space WS.Valve153 is operated to release the inflation fluid from toroidalinflatable chamber143, which releases compression of the abdominal wall AW, excluding the peritoneum. Toroidalinflatable chamber143 returns to its collapsed state, with itsenvelope145 flush with the outersurface tube assembly160. The tube assembly is then withdrawn from the incision, and the incision is closed using sutures or clips. The pressure of the viscera against the peritoneum returns the peritoneum into contact with the overlying layer. Over time, the peritoneum reattaches to the overlying layer.
• In a second embodiment of a one-component apparatus according to U.S. Ser. No. 07/911,714, the introducing device is an outer elongated tube, and the insufflating device comprises an inner elongated tube mounted in the bore of the outer tube. The proximal ends of the tubes are flexibly coupled together. One end of the main envelope is everted with respect to the other, and is attached to the distal end of the outer elongated tube. The other end of the main envelope is attached to the distal end of the inner elongated tube. The main inflatable chamber defined by the main envelope is thus substantially toroidal. The outer elongated tube has an anchor flange slidably mounted on it. The anchor flange and the main inflatable chamber together form a gas-tight seal with the second layer of tissue.
• Such second embodiment of a one-component apparatus is shown inFIGS. 7A-7B and8A-8B. In this embodiment, a substantially toroidal shape of the main chamber avoids the need to detach and remove the main envelope at the end of the separation process, and the toroidal main chamber provides both the separating function of the main chamber and the sealing function of the toroidal chamber of the embodiment ofFIGS. 4A-4C.
• The apparatus ofFIGS. 7A and 7B comprisestube assembly260, includingouter tube237 to which is attached atwin port assembly225 comprisingfirst port226 andsecond port228. The first port is provided with afirst flapper valve202, includingflapper valve seat204. The second port is provided with asecond flapper valve206, includingflapper valve seat208. Each flapper valve seat forms a gas-tight seal with an instrument passed through it.
• Tube assembly260 also includesinner tube235.Inner tube235 is shorter thanouter tube237. Theproximal end210 of the inner tube is flexibly attached to theproximal end222 ofouter tube237 and tofirst port226. The flexible attachment enables thedistal end214 of the inner tube to move in the direction shown by thearrow216. The first port communicates with the bore ofinner tube235, and the second port communicates with the bore ofouter tube237.
• Insufflation valve285 communicates withfirst port226, and the bore ofinner tube235. Mainchamber inflation valve231 communicates withsecond port228, and the bore ofouter tube237.
• Main envelope212 defines the maininflatable chamber213 and comprises a cylindrical piece of an elastomeric material such a latex, silicone rubber, or polyurethane. The apparatus is shown with its main envelope in its collapsed state inFIG. 7B, in which the structure of the main envelope can also be seen. The main envelope preferably has a diameter smaller than the outside diameter of the inner tube. Oneend230 of the main envelope is attached todistal end214 ofinner tube235 by means of a suitable adhesive, such as an epoxy or cyanoacrylate adhesive. Theother end232 of the main envelope is everted (i.e., turned back on itself to bring theinside surface234 of the main envelope to the outside) and attached to thedistal end236 of the outer tube using the same type of adhesive. The main envelope is preferably attached to the outer surfaces of the inner tube and the outer tube.
• FIG. 7A showsmain envelope212 in its expanded state. To reach this state, a source of inflation gas is connected tovalve231 and the gas flows into the main inflatable chamber through the bore ofouter tube237. The pressure acting onsurface238 of themain envelope212 causes the main envelope to assume the toroidal shape shown inFIG. 7A to define toroidalmain chamber213, withsurface234 defining the “hole” or “bore” through the toroidal main envelope.FIGS. 7A and 7B show the correspondence between thesurfaces234 and238 of the main envelope when the main envelope is in a collapsed state (FIG. 7B) and in an expanded state (FIG. 7A).
• Anchor flange255 is slidably mounted ontube assembly260, and can be locked in a desired position along the length of the tube assembly.Anchor flange255 is identical or similar to anchor flange55 (ofFIG. 2A) and thus will not be described further.
• FIG. 8A shows an endoscope E passed throughsecond flapper valve206,second port228, and the bore ofouter tube237 into maininflatable chamber213. The flexible mounting ofinner tube235 in the outer tube enables the endoscope to displaceinner tube235 in direction of thearrow216 to gain access to the main inflatable chamber. The endoscope is inserted through the second port into the main inflatable chamber during tissue separation using the apparatus to observe the extent of the separation.
• FIG. 8B shows an endoscope E passed throughfirst flapper valve202,first port226, the bore ofinner tube235, and bore234 ofmain envelope212. The distal part of the endoscope emerges from the bore of themain envelope212, and can be advanced beyond the maininflatable chamber213 to observe tissue such as the site of the hernia more closely. The endoscope is inserted through the first port, the inner tube, and the bore of the main envelope during insufflation using the apparatus. Instruments other than endoscopes can also be passed to the site of the hernia through the first flapper valve, the first port, the inner tube, and the bore of the main envelope if desired.
• As shown inFIG. 8B,main envelope212 is in a partially collapsed state that it preferably assumes during the insufflation phase of the procedure. During this part of the procedure, the partially collapsed main inflatable chamber andanchor flange255 together provide a gas-tight seal to prevent the leakage of insufflation gas. Alternatively, insufflation can be carried out with the main inflatable chamber in a fully expanded state.
• In a method described in U.S. Ser. No. 07/911,714 of using the embodiment ofFIGS. 7A, 7B,8A, and8B to separate a first layer of tissue from a second layer of tissue, the outer elongated tube pushes the main envelope in a collapsed state through an incision through the second layer of tissue to place the main envelope between the first layer of tissue and the second layer of tissue. The main envelope is then inflated to gently separate the first layer of tissue from the second layer of tissue, and to create a working space between the layers of tissue. An endoscope may be passed through the outer elongated tube into the main chamber to observe the extent of separation of the layers of tissue. The anchor flange is slid distally along the introducing device tube to compress the second layer of tissue between it and the main inflatable chamber, to form a gas-tight seal. Insufflating gas is then passed through the bore of the inner elongated tube and the bore of the main envelope into the working space to maintain the separation of the first layer of tissue from the second. An endoscope may be passed through the bore of the inner elongated tube and the bore of the main envelope into the working space to observe within the working space.
• More specifically, in performing this method, an incision about 12-15 mm long is made in the abdominal wall, and carried through the abdominal wall as far as, and including, the properitoneal fat layer. The distal end oftube assembly260 is then inserted into the incision into contact with the peritoneum. Additional gentle pressure detaches the part of the peritoneum in the immediate vicinity of the incision from the overlying layer (at this time,main envelope212 is inverted within the bore of the tube assembly). A source of inflation fluid is then connected tovalve231. A gas, preferably air, is the preferred inflation fluid, but other gases, such a carbon dioxide can be used. A liquid such as saline solution can be used, but a gas is preferred to a liquid because liquids change the optical properties of any endoscope inserted into the inflatable chamber. The flow of inflation fluid is turned on, which ejects themain envelope212 from the bore oftube assembly260.
• The inflation fluid progressively expandsmain envelope212, and hence maininflatable chamber213 defined by the main envelope, into an expanded state. The main envelope expands between the peritoneum and the properitoneal fat layer, and gently and progressively separates an increasing area of the peritoneum from the overlying layer as it expands. When the main envelope is in its expanded state, the main inflatable chamber is preferably about 4″-6″ (100-150 mm) in diameter.
• Early in the process of expandingmain envelope212, an endoscope is inserted intofirst flapper valve202. The endoscope is passed through the bore ofouter tube237 into maininflatable chamber213. Once partially expanded,main envelope212 is sufficiently transparent for the extent of the separation of the peritoneum to be observed using the endoscope.
• When a sufficient area of the peritoneum is separated, the supply of inflation fluid is turned off and the endoscope is removed from maininflatable chamber213.Valve231 is then opened to allow inflation fluid to vent partially from main inflatable chamber213 (allowingmain envelope212 to return at least partially to its collapsed state). Alternatively,main envelope212 may be kept fully expanded.
• Anchor flange255 is then advanced alongtube assembly260 to bring the anchor flange into contact with the skin of the abdominal wall.Tube assembly260 is then gripped, and the anchor flange is further advanced slightly. This forces themain envelope212 into contact with the overlying layer, and slightly compresses the abdominal wall, including the overlying layer but excluding the peritoneum, between the main envelope and the anchor flange. Once adjusted,anchor flange255 is locked in position on the tube assembly, andmain envelope212 forms a gas-tight seal with the abdominal wall and the peritoneum.
• A suitable source of insufflation gas is attached tosecond valve285, and insufflation gas is passed through the bore ofinner tube235, and bore234 ofmain envelope212, into the working space between the peritoneum and the overlying layer. The pressure of the insufflation gas re-separates the peritoneum from the overlying layer, and provides a larger working space in which repair of the hernia can be carried out.
• An instrument such as an endoscope can be passed throughsecond flapper valve206, the bore ofinner tube235, and bore234 ofmain envelope212, into the working space to perform a repair procedure. When no instrument is so inserted, insufflation pressure is maintained bysecond flapper valve206.
• After the treatment procedure is completed,valve285 is operated to release the insufflation gas from the working space.Valve231 is operated to release the inflation fluid from maininflatable chamber213, which releases compression from the abdominal wall, excluding the peritoneum.Main envelope212 returns to its collapsed state inside the bore ofouter tube237.
• The tube assembly is then withdrawn from the incision, and the incision is closed using sutures or clips. The pressure of the viscera against the peritoneum returns the peritoneum into contact with the overlying layer. Over time, the peritoneum reattaches to the overlying layer.
• In another method described in U.S. Ser. No. 07/911,714, access is provided through the abdominal wall from near the umbilicus to repair a hernia. This method will be described with reference toFIGS. 9A-9I. This method is often preferable to the hernia repair methods described above in which the incision is placed close to the site of the hernia, since in practice, it is preferred to make the incision at or near the umbilicus because the boundary between the peritoneum and the properitoneal fat layer can be more directly accessed near the umbilicus. The midline location of the umbilicus is devoid of muscle layers that would otherwise need to be traversed to reach the properitoneal fat layer.
• In the method ofFIGS. 9A-9I, the main envelope is partially expanded, collapsed, and advanced toward the site of the hernia. This sequence is repeated to progressively separate the peritoneum from the overlying layer and form the tunnel from the umbilicus to the site of the hernia. Then, at or near the site of the hernia, the main envelope is fully expanded to provide the working space at the site of the hernia. The working space is then insufflated to maintain the separation of the peritoneum from the overlying layer. The method ofFIGS. 9A-9I can be practiced using any of the two-component or one-component apparatuses described above. For specificity, the method will be described with reference to a two-component apparatus.
• An incision about 12-15 mm long is made in the abdominal wall AW, and is carried through the abdominal wall as far as, and including, the properitoneal fat layer FL. The incision is made at the umbilicus U, as shown inFIG. 9A.
• Distal end15 ofintroducer tube3 ofseparation component1 is then inserted into the incision to bring the distal end into contact with the peritoneum P. Additional gentle pressure detaches the part of the peritoneum in the immediate vicinity of the incision from the overlying layer, as shown inFIG. 9B. InFIG. 9B, the peritoneum is shown detached from the properitoneal fat layer FL.Main envelope12 cannot be seen inFIGS. 9A and 9B because it is inverted within the bore ofintroducer tube3.
• A source of a suitable inflation fluid (not shown), as previously described, is connected tovalve11. The flow of inflation fluid is turned on, which ejectsmain envelope12 of maininflatable chamber13 from the bore ofintroducer tube3. The inflation fluid progressively expandsmain envelope12, and hence maininflatable chamber13 defined by the main envelope, into a partially-expanded state, as shown inFIG. 9C. The main envelope expands between the peritoneum and the properitoneal fat layer FL, and gently and progressively detaches an increasing area of the peritoneum P from the overlying layer near the umbilicus as it expands.
• An endoscope (not shown) can be inserted into maininflatable chamber13 throughflapper valve2 and the bore ofintroducer tube3. The endoscope can be used to observe the extent of the separation of the peritoneum, as described above.
• Whenmain envelope12 expanded such that the maininflatable chamber13 is about one-fourth of its fully-expanded diameter, i.e., about 1.0″-1.5″ (25-37 mm) in diameter, the supply of inflation fluid is turned off.Valve11 is then operated to vent inflation fluid from the maininflatable chamber13. The main envelope progressively returns to its collapsed state, as shown inFIG. 9D. The peritoneum portion DP that was separated by the main inflatable chamber remains detached from the overlying layer, as shown. Alternatively, the main envelope can be inflated to a fully-expanded state.
• Separation component1, including the collapsedmain envelope12, is then manipulated in the direction indicated byarrow14, and then in the direction indicated byarrow16, to advancedistal part15 ofintroducer tube3 to the limit of the detached part DP of the peritoneum in the direction of the groin, as shown inFIG. 9E. An endoscope E inserted throughflapper valve2 into the bore ofintroducer tube3 enables the position of thedistal part15 relative to the detached part DP of the peritoneum to be observed.
• Oncedistal part15 of the introducer tube has been positioned, theseparation component1 is clamped in position, or is gripped, and inflation fluid is once more passed through thevalve11 and the bore ofintroducer tube3 into maininflatable chamber13. Themain envelope12 expands once more, increasing the extent of the detached part of the peritoneum towards the groin, as shown inFIG. 9F. The increased extent of the detached part of the peritoneum is indicated by line DP′ inFIG. 9F. The extent of the detached part of the peritoneum is increased in the direction from the umbilicus to the groin, but not in the direction transverse to this direction. Endoscope E is used to observe the extent of the separation.
• The process of collapsing themain envelope12, advancing thedistal part15 of the introducer tube to the limit of the detached part DP′ of the peritoneum in the direction of the groin, holding the introducer tube in position, and partially re-inflatingmain envelope12, is repeated until the detached part of the peritoneum includes the peritoneum over the site of the hernia. This process provides a tunnel T between the incision at the umbilicus and the site of the hernia (as shown inFIGS. 9G, 9H, and9I).
• When the main envelope is in the vicinity of the site of the hernia H,main envelope12 is fully inflated to form a working space WS including the site of the hernia. This is shown inFIG. 9G.
• The working space at the site of the hernia is then insufflated. With the two-component apparatus, inflation fluid is vented from the maininflatable chamber13 to collapsemain envelope12, and theseparation component1 is withdrawn from tunnel T through incisionI. Insufflation component21 is introduced into the incision, and advanced through the tunnel untilenvelope45 of toroidalinflatable chamber43 lies within the working space WS, clear of the tunnel. Toroidalinflatable chamber43 is inflated, the anchor flange is clamped in position, and insufflation gas is passed into the working space, as shown inFIG. 9H. Toroidalinflatable chamber43 provides a gas-tight seal with the entrance of the tunnel.
• FIG. 9I is a plan view of the abdomen withinsufflation component21 in place. The anchor flange has been omitted for clarity. Toroidalinflatable chamber43 provides a gas-tight seal with the entrance of tunnel T. The extent of the separated peritoneum is indicated by dotted line DP. It can be seen that the lateral extent of the separated peritoneum is considerably greater in working space WS than in tunnel T.
• At this stage, if a one-component apparatus had been used (with the main inflatable chamber remaining in the working space), inflation fluid would be vented from the main inflatable chamber to collapse the main envelope, and the main envelope would be withdrawn from the working space through the bore of the tube assembly. The tube assembly would be partially withdrawn until the envelope of a toroidalinflatable chamber43 lies within the working space, clear of the entrance to the tunnel. The toroidalinflatable chamber43 would then be inflated, the anchor flange clamped in position, and insufflation gas passed into the working space, as already described. The toroidalinflatable chamber43 would seal against the entrance from the tunnel into the working space.
• Alternatively, if another type of one-component apparatus had been used (with the main inflatable chamber remaining in the working space), the main envelope would preferably be returned to a partially collapsed state, and the tube assembly partially withdrawn until the main inflatable chamber lies within the working space, adjacent to the entrance of the tunnel. The anchor flange would be clamped in position, and insufflation gas is passed into the working space as already described. The partially-collapsed main chamber would seal against the entrance from the tunnel into the working space.
• Regardless of the embodiment of the apparatus used to create the insufflated working space WS shown inFIG. 9I, the hernia is then repaired using a procedure such as that described in connection withFIG. 31.
• Before eithercomponent1 or component21 (or a one-component apparatus that performs the functions of bothcomponents1 and21) is inserted into the patient, its inflatable envelopes and chambers are deflated and packed into a sheath. One method of packing an inflatable chamber in its deflated, compact state is to roll the chamber inwardly from opposing lateral sides.
• Above-referenced U.S. Ser. No. 08/405,284 discloses a device which performs both dissection and retraction of tissue layers while at least a part of the device remains in the patient throughout the dissection and retraction procedure, so that the user need not remove one assembly from the patient and then insert a second assembly into the patient (searching for the dissected spatial plane in order to deploy the second assembly in the proper position) between the dissection and retraction steps. In a preferred implementation, the distal end of the device is moved to a position between tissue layers in the patient. A first balloon is then inflated between the tissue layers to dissect the tissue layers. A second balloon, which is used to retract the tissue layers, is then inflated between the tissue layers. The distal end of the device for introducing and inflating first balloon remains in the patient until the second balloon has been inflated, so that the tissue layers remain at least partially separated at all times after initial introduction of the device between such layers. After retracting the tissue layers with the second balloon, the first balloon is deflated, e.g., by a puncturing step which creates an opening in the first balloon. Instruments are then introduced into a working space through the opening in the first balloon. The second balloon, which can be positioned in the interior of the first balloon, is inflated to seal the working space so that insufflating fluid is impeded from escaping.
• A preferred embodiment of the inventive one-component apparatus (identified by reference numeral600) for tissue dissection and instrument anchoring, and also tissue retraction, will be described with reference toFIGS. 10, 11,12,13, and14.
• FIG. 10 is a perspective view ofapparatus600.FIG. 14 is a partially side elevational, partially side cross-sectional view ofapparatus600.FIGS. 11, 12,13,16,17,18,19,20, and21 are views of portions (or substitutes for portions) ofapparatus600.FIG. 11 is an exploded view ofobturator515, retainingring514, and the dissection balloon subassembly ofapparatus600.FIG. 12 is an exploded cross-sectional view of the dissection balloon subassembly ofapparatus600. Each ofFIGS. 19, 20, and21 is a side elevational view of a balloon window for use aswindow508 ofapparatus600.FIG. 13 is a perspective view of the tissue retraction and instrument anchoring subassembly ofapparatus600.
• The assembly ofFIG. 15 is an alternative anchor balloon assembly which can be substituted for that ofFIG. 13 inapparatus600 ofFIGS. 10, 11,12, and14.
• With reference toFIG. 10,apparatus600 includeshousing509, cannula505 (connected tohousing509 and extending out fromdistal face509A of housing509), retaining ring514 (around housing509), clamp503 (around cannula505), foam collar504 (aroundcannula505, and attached to clamp503 so thatclamp503 andcollar504 can slide together as a unit alongcannula505 untilclamp503 locked in a fixed position along cannula505),housing513,dissection balloon512 having along neck512A (shown inFIG. 11) whose free end is attached tohousing513 and which extends throughcannula505,anchor balloon517 attached to cannula505 (near distal end505A ofcannula505 as shown inFIG. 14),sheath506 which enclosesballoons517 and512, and obturator515 (extending throughhousing513,housing509, andcannula505 into the interior of balloon512).
• Flapper valve521 is mounted withinhousing509, and a biasing spring (not shown) biases valve521 in a closed position (not shown inFIG. 14) in which valve521 rests against an elastomeric seal around an end port in the proximal face of housing509 (the face at the right end ofhousing509 inFIG. 14) thus sealing the port. Whenbutton520 is depressed (such as byring514 fitted around housing509), mechanical linkage522 (connected betweenbutton520 and valve521) holds valve521 in the open position shown inFIG. 14, in which obturator515 (or a similarly shaped endoscope or other instrument) is free to pass into the port through the proximal face ofhousing509, and through the central channel extending throughhousing509. Whenbutton520 is released (such as whenring514 is removed),linkage522 allows spring-biased valve521 to return to its normally closed position sealing the port in the proximal face ofhousing509. The seat of flapper valve521 (around the end port in the proximal face of housing509) preferably forms a gas-tight seal with obturator515 (or an endoscope or other instrument) inserted though the end port and intocannula505.
• During use of the apparatus, afterballoon512 has been inflated (withobturator515 or another instrument inserted through the end port in the proximal face ofhousing509 and into cannula505),balloon512 can be deflated as follows. The obturator (or other instrument) is withdrawn through the end port in the proximal face ofhousing509 whilebutton520 remains depressed (e.g., whilering514 remains in place over button520), thus allowing the inflating fluid to escape past the open flapper valve521 out the end port in the proximal face ofhousing509. Any remaining inflating fluid withinballoon512 can be pumped out using a deflation bulb (or other pump) positioned against port531 (port531 can include a valve, or it can simply be an open port which accepts a hand bulb or syringe), or any such remaining inflating fluid can be forced out by compressingballoon512.
• Withhousing513 detached from the proximal face ofhousing509, it is sometimes useful to mount a converter in the end port in the proximal face ofhousing509, to maintain a fluid seal when an instrument is inserted through the converter (and through the end port) intocannula505. By using differently sized and shaped converters, instruments of different sizes and shapes can be introduced intocannula505. When performing a procedure in an insufflated working space in the patient using such an instrument, use of a converter of an appropriate size and shape may be needed to prevent undesired deflation of the working space due to undesired leakage of insufflation gas through the end port in the proximal face ofhousing509 around the instrument (if the outer diameter of the instrument is less than the diameter of the end port).
• Mouth512B ofdissection balloon512 is attached (preferably by glue) totube portion564 ofhousing513, as shown inFIGS. 14 and 12. With reference toFIG. 14, the apparatus is preferably assembled by removably attaching the distal face of housing513 (the left face inFIG. 14) to the proximal face of housing509 (such as by snap fitting or bayonet fitting means).Elongated neck512A ofballoon512 is extended throughtube portion564 ofhousing513, through the central channel ofhousing509, and throughcannula505.Endoscope515′ is inserted throughseal560 ofhousing513, and (within balloon512) throughtube portion564 ofhousing513, the central channel ofhousing509, andcannula505 until thedistal end515A ofendoscope515′ abutswindow member508 at the distal end of balloon512 (as shown inFIG. 14).
• In a class of preferred embodiments (to be discussed below),balloon512 comprises a first sheet of thin elastomeric material (such as polyurethane, latex, or silicone rubber) bonded (e.g., RF-welded) to a second sheet of thin, inelastic (or having relatively low elasticity) material such as polyester, polyethylene, or nylon film.Balloon512 is preferably formed to have a wide profile when expanded, in the sense that its width (dimension W shown inFIG. 11) when expanded is much greater than its expanded height (dimension H shown inFIG. 14). Another dissection balloon having a different expanded shape can be substituted forballoon512 in alternative embodiments.
• Before the apparatus is first used,balloon512 is packed againstobturator515 so as to occupy a small volume (as shown inFIG. 10), so that the packedballoon512 does not significantly impede insertion ofobturator515 into the patient. At an appropriate time during use of the apparatus (e.g., before or during inflation of balloon512),balloon512 is expanded (inflated as shown inFIG. 14) to occupy a larger volume.Obturator515 is withdrawn and replaced by an endoscope (e.g.,endoscope515′ ofFIG. 14) for viewing the patient throughwindow508 ofballoon512. Alternatively, before the apparatus is first used,balloon512 is packed against an endoscope (e.g.,endoscope515′) so as to occupy a small volume, so that the packedballoon512 does not significantly impede insertion of the endoscope into the patient, and allows visualization of anatomy during insertion of the device.
• Anchor balloon517 is attached tocannula505, near distal end505A ofcannula505 as shown inFIG. 14. Before the apparatus is first used,balloon512 is packed against cannula505 (as shown inFIG. 14) so as to occupy a small volume, so that the packedballoon517 does not significantly impede insertion ofcannula505 into the patient. Before the apparatus is first inserted into a patient, both packedballoons512 and517 are preferably packed into sheath506 (sheath506 is shown inFIG. 10, but not inFIG. 14). At an appropriate time during use of the apparatus,balloon517 is expanded (inflated) to occupy a larger volume (as shown inFIG. 13). Preferably,balloon517 has a rounded triangular shape when expanded as shown inFIG. 13. In alternative embodiments, another anchor balloon having a different expanded shape (such astoroidal balloon519 ofFIG. 15) can be substituted forballoon517. As will be described below,balloon517 is used for retracting tissue layers and for maintaining insufflation fluid in a working space.
• Whenclamp503 is locked in a position alongcannula505pressing foam collar504 against the patient,foam collar504 helps to immobilize the entire apparatus (includinghousing509 and cannula505) andcollar504 applies a modest compressive force to the tissue betweenclamp503 andinflated balloon517, thereby helpingballoon517 form a seal to limit the escape of insufflation gas during laparoscopic procedures.
• Sheath506 (shown inFIG. 10) is preferably perforated but may be formed in any other manner permitting easy opening. Inflation ofballoon512 tears aperforated sheath506 along the perforation and releases bothballoon512 andballoon517. Alternatively,sheath506 may include an independent opening mechanism, such as a removable thread which binds the sheath together, and which can be opened by the operator at a desired time.
• Inflation port531 ofhousing513 is used for inflating and deflatingballoon512.Port531 is opened by inserting an inflation device, such asbulb500 ofFIG. 10, into it. When opened,port531 provides a path for inflatingballoon512 by pumping gas (or other fluid) throughmouth512B ofballoon512 into the interior ofballoon512, and for deflatingballoon512 by allowing inflation fluid to escape fromballoon512 out throughport531. Aconventional hand bulb500 or a syringe can be used to inject the fluid through port531 (or throughvalves510 and511 to be discussed below). Alternatively,port531 can be a continually open port that accepts a hand bulb or syringe.
• Inflation valve510 ofhousing513 is used for inflating and deflatinganchor balloon517.Valve510 is opened by inserting an inflation device, such asbulb500 ofFIG. 10, into it. When opened,valve510 provides a path for inflatingballoon517 by pumping gas (or other fluid) throughcannula505 throughmouth517M ofballoon517 into the interior ofballoon517, and for deflatingballoon517 by allowing inflation fluid to escape out frommouth517M ofballoon517 and then out throughvalve510.
• Insufflation valve511 is used to supply insufflation gas or liquid into a working space within the patient.Valve511 is typically used when obturator515 (orendoscope515′), the dissection balloonassembly comprising balloon512 andhousing513, andring514 have been removed from the remaining portion (the tissue retraction and instrument anchoring subassembly) of theFIG. 10 apparatus (and valve521 has been closed, and the anchoringassembly comprising collar504 and clamp503 has been locked to anchor the remaining portion of the apparatus to the patient).Valve511 is opened by inserting an inflation device into it. When opened,valve511 provides a path for insufflation fluid to flow through the channel surrounded bycannula505 into the working space (sealed by expandedballoon517 and theclamp assembly503,504) and provides a path for allowing insufflation fluid to escape out from the working space throughvalve511.
• We next describe a preferred structure of the dissection balloon assembly in more detail with reference toFIG. 12. To assemble this assembly,mouth512B ofballoon512 is glued to a cylindrical rim on the left face of base562 (as shown inFIG. 12) ofhousing513.Tube564 is glued to a cylindrical rim on the opposite face ofbase562, and theneck512A ofballoon512 is pulled to the right throughbase562 andtube564 into the configuration shown inFIG. 12. Then, cover566 is glued to base562 to formhousing513. Thus, wheninflation port531 ofcover566 is opened, inflation fluid can be pumped throughport531 and the volume enclosed byhousing513 intomouth512B ofballoon512.Main seal560 is glued around the central orifice throughcover566, to provide a fluid seal preventing fluid from escaping out through this orifice when an obturator or other rod-shaped instrument is inserted through the orifice into the interior ofballoon512. Typically, the assembledFIG. 10 apparatus is packaged with an obturator such asobturator515 extending throughseal560 into the interior ofballoon512. At various times during use of the apparatus, the obturator is removed and replaced by an endoscope (e.g.,endoscope515′ ofFIG. 14) having the same or similar outer dimensions.Seal560 is preferably made of rubber or another elastomer.
• Next, with reference toFIGS. 13 and 14, we describe a preferred structure of the anchoring and tissue retractionassembly including housing509 andballoon517. In some implementations, a converter door516 (made of rigid plastic) is slidably mounted to the outside ofhousing509. In the position shown inFIG. 13,door516 covers a port (not shown) through the side wall ofhousing509.Door516 can be slid proximally (away from balloon517) to uncover this port. The port is normally sealed by a closed second flapper valve (similar to valve521 ofFIG. 14) withinhousing509. In response to depression ofbutton520, a second mechanical linkage (similar tolinkage522 ofFIG. 14) moves the second flapper valve to open the port, so that (whendoor516 is open) an instrument can be inserted through the opened port intohousing509 and then throughcannula505 into the working space within the patient. In some implementations,door516, the port (through the side wall of housing509) which can be covered bydoor516, and the associated valve means for opening and closing the port, are omitted.
• In a preferred implementation of theFIG. 10 apparatus,port531, housing513 (includingcover566 and base562), andhousing509 are made of hard plastic (such as that known as ABS plastic),obturator515 andring514 are made of hard plastic (such as polypropylene or ABS plastic),clamp503,cannula505, and dissection balloon window508 (which can be shaped as a lens) are made of polycarbonate,foam collar504 is made of polyurethane foam,sheath506 is made of polyurethane,valves510 and511 are made of stainless steel and plastic, the flapper valveassembly comprising button520, link522, valve521, and the seat against which valve521 rests when closed is made of stainless steel, ABS plastic, and silicone rubber, and the converter doorassembly comprising door516 is mode of silicone rubber and polyetherimide.
• Any of the balloon cannula systems of referenced U.S. Ser. No. 08/365,096 can be employed in alternative implementation of the present invention, e.g., to provide a supporting portion which extends into the interior of the dissection balloon to provide support for the dissection balloon during inflation.
• With reference again toFIG. 13,anchor balloon517 is substantially bell-shaped, and composed of two sheets (517A and517B) bonded together (e.g., by RF-welding) atseams518A,518B, and518C.Outer seam518A defines the outline of a bell-shape,semi-circular seam518B reduces pressure induced stresses at the periphery of balloon517 (and eliminates the need to provide baffles), andseam518C defines a circular throughhole (through which the longitudinal axis ofcannula505 extends, and through which an instrument such as an endoscope can be extended).Outer seam518A has a semi-circular upper portion which is substantially concentric with a throughhole defined byseam518C.Sheet517A has amouth portion517M (shown inFIG. 14), andballoon517 is attached atmouth portion517M tocannula505, so thatballoon517 can be inflated and deflated usingvalve510. The shape ofballoon517 and the strength and elasticity of its component sheets (and thus the inflating fluid pressure within it during use) are chosen so that inflated balloon517 (positioned between two dissected tissue layers) not only anchorscannula505 to the patient but also retracts the dissected tissue layers by a desired amount and alternatively-shaped and structured anchor balloons will be used for alternative uses. Preferably,sheet517A is an inelastic plastic sheet (e.g., made of polyester) which does not stretch significantly during inflation of balloon517 (to define the desired inflated structure of the balloon even with inflating fluid pressure within the balloon that is adequate for retracting the tissue layers by the desired amount). Also preferably,sheet517B is a highly elastic sheet (e.g., made of polyurethane) which does stretch significantly during inflation. In alternative embodiments (to be described),anchor balloon517 is replaced by another balloon having nonuniform elasticity tailored for the particular intended use in any of the ways discussed below (e.g., the anchor balloon of the invention can comprise two large sheets of relatively low elasticity as does the balloon ofFIG. 23, with relatively elastic insert sheets bonded to the large sheets as inFIG. 23).
• FIG. 15 is a perspective view of an alternative anchoring subassembly for use in theFIG. 10 apparatus as a substitute for theFIG. 13 subassembly. TheFIG. 15 subassembly differs from that ofFIG. 13 only in that the former includestoroidal anchor balloon519 mounted aroundcannula505 while the latter includes above-describedanchor balloon517 mounted aroundcannula505. Preferably,anchor balloon519 ofFIG. 15 is made of a thin, highly elastic material such as polyurethane or silicon coated latex, and has a mouth portion at whichballoon519 is mounted to cannula505 (so thatballoon519 can be inflated or deflated using valve510). When inflated,balloon519 functions to anchorcannula505 to the patient, but typically does not retract dissected tissue layers to the degree that inflatedballoon517 would retract the same layers.
• We next describe preferred implementations of dissection balloon512 (and variations thereon) in more detail.FIGS. 16-18 show a first preferred embodiment ofballoon512.
• In the embodiment ofFIGS. 16-18,balloon512 includes: first andsecond sheets513A and513B attached together atseam512C such as by RF (radio frequency) welding; andneck reinforcing sheet513C attached tosheet513A (such as by RF welding) atneck512A ofballoon512. Preferably,sheets513A and513B are polyurethane sheets of 0.002 inch thickness (each having high elasticity so that it stretches substantially during inflation) andsheet513C is made of material having low elasticity (e.g., polyester film, or a multilayer film commercially available from Rexham comprising polyurethane and polyester layers) so that it does not stretch significantly during inflation. This preferred embodiment (withwindow508 attached to its distal end), when inflated, has the appearance shown inFIGS. 18C and 18D, whereFIG. 18C is an elevational view of the distal end of the inflated balloon andFIG. 18D is a side elevational view of the distal end of the inflated balloon.
• In an alternative embodiment, reinforcingsheet513C is omitted,sheet513A is made of thin, highly elastic material such as polyurethane or silicon coated latex (having high elasticity so that it stretches substantially during inflation) andsheet513B is made of material (e.g., a multilayer film commercially available from Rexham comprising polyurethane and polyester layers) having low elasticity so that it does not stretch significantly during inflation. This alternative embodiment (withwindow508 attached to its distal end), when inflated, has the appearance shown inFIGS. 18A and 18B, whereFIG. 18A is an elevational view of the distal end of the inflated balloon andFIG. 18B is a side elevational view of the distal end of the inflated balloon. If bothsheets513A and513B were inelastic, there would be relatively high localized stress (and wrinkles) atseam512C whenballoon512 were inflated. By constructingballoon512 from twosheets513A and513B having substantially different elasticities in accordance with the invention, puckering and wrinkling atseam512C is reduced whenballoon512 is inflated, and the balloon's inflation characteristics can be tuned for desired results, including but not limited to increased lateral dissection, reduced incidence of epigastric (vein) stripping, and preferential, controlled dissection.
• With reference toFIG. 16,distal end portion512E of balloon512 (opposite theneck512A) is shaped to accept the end of an obturator or endoscope for control and manipulation of the balloon, and to receive awindow508 having a groove around a generally cylindrical side wall (best shown inFIGS. 10, 11, and14).
• A preferred technique for manufacturingballoon512 ofFIG. 16 is to bond togethersheets513A and513B with a weld (indicated by the dashed line around the periphery ofFIG. 16) of width X around the sheets' peripheries, and then tobond sheets513A and513C together with a weld of width X around their peripheries. Then, the weld is trimmed to a width Y (inFIG. 16), the trimmed weld's outer periphery is the solid line around the periphery ofseam512C. Then,end portion512E is formed by cutting bondedsheets513A and513B alongline512F (shown inFIG. 16). The latter cut givesend portion512E a cylindrical shape to which a suitable window508 (made of rigid material) can be glued.
• The width W ofballoon512 ofFIG. 16 is longer than the length (the distance from line B-B toline512F) ofballoon512, in order to increase the lateral extent of the tissue layers dissected by this balloon when it is inflated. In a typical implementation ofballoon512 ofFIG. 16, width W is 6.8 inches, length L ofsheet513C is 5.875 inches, width Z of reinforcingsheet513C is 0.82 inch, width X of the original (untrimmed) weld around the periphery ofballoon512 is 0.125 inch, and width Y of the trimmed weld around the periphery ofballoon512 is 0.06 inch.
• Each ofFIGS. 19, 20, and21 is a side elevational view of a balloon window for attachment to the distal end of the inventive dissection balloon, aswindow508 is attached to the distal end ofballoon512 ofapparatus600 of the embodiment ofFIGS. 10-14. The window shown in each ofFIGS. 19-21 is preferably composed of transparent, rigid material such as polished, clear polycarbonate or acrylic material. The window of each ofFIGS. 19-21 (andwindow508 ofFIGS. 10 and 14) functions mechanically to separate tissue layers when pushed against the tissue layers by a rigid obturator (or a rigid endoscope such asendoscope515′ ofFIG. 14 whosedistal end515A is pushed againstwindow508 as shown inFIG. 14). In alternative embodiments, the window of the inventive balloon is transparent and either rigid or non-rigid, but sufficiently strong to retain a desired optical shape while (and after) being pushed against tissue layers by a rigid obturator (or other rigid instrument) deployed within the dissection balloon.
• The window of each ofFIGS. 19-21 has acircular groove508A around its generally cylindrical side wall, so thatend portion512E ofdissection balloon512 shown inFIG. 16 (or a corresponding end portion of alternative embodiment of the inventive dissection balloon) can be conveniently glued to groove508A. Alternatively, it can be stepped or formed in another fashion with a surface conducive to gluing or mechanical fastening, and can have a hollow base for accepting the distal end of an endoscope or obturator (as does the window ofFIGS. 21A and 21B to be discussed below).
• The window ofFIG. 19 is a wide angle lens, and each of itsfront surface508B and itsrear surface508C (shown in phantom view inFIG. 19) has a curvature chosen to achieve desired wide angle lens optical properties.
• The window ofFIG. 20 is a lens (but not a magnifying lens), and each of itsfront surface508D (having greater curvature thansurface508B ofFIG. 19) and itsrear surface508C (shown in phantom view inFIG. 20) has a curvature chosen to achieve the desired lens optical properties.
• The window ofFIG. 21 is a magnifying lens, having a flatrear surface508E (not a curved rear surface such ascurved surface508C ofFIG. 20). Itsfront surface508D has a curvature chosen to achieve the desired lens optical properties.
• The window ofFIGS. 21A and 21B is a lens, which has a flat rearoptical surface508F and a curved frontoptical surface508G.Surface508G has a curvature chosen to achieve the desired lens optical properties. The window ofFIGS. 21A and 21B has acylindrical skirt508H which extends in the proximal direction (away fromfront surface508G) from the periphery ofsurface508F.Skirt508H has multiple functions: to provide a surface conducive to gluing or mechanical fastening of a dissection balloon to the window; and (after the balloon has been attached to the window) to guide the distal end of an endoscope or obturator within the balloon into engagement withsurface508F and allow for positive control and manipulation of the balloon in response to movement of the endoscope or obturator (without tearing the balloon).
• As an alternative (or in addition) to employing a cup-shaped window (such as the skirted window ofFIGS. 21A and 21B), the balloon itself is shaped so that when the window is attached to the balloon's distal end, the balloon defines a channel that guides the distal end of an endoscope or obturator within the balloon into engagement with the window. Such a channel also allows for positive control and manipulation of the balloon in response to movement of the endoscope or obturator (without tearing the balloon). An example of a dissection balloon having such a shape isdissection balloon912 ofFIG. 21C, whosedistal end portion912A is tapered to define a channel for receiving and capturing an obturator (or endoscope)515. When obturator (or endoscope)515 is moved, the force (e.g., frictional force) it exerts ondistal end portion912A allows for positive control and manipulation ofballoon912 in response to such movement.
• The dissection balloon of the invention can have the alternative shape shown inFIG. 22.Dissection balloon512′ ofFIG. 22 is identical todissection balloon512 ofFIG. 16 except in that it has a circular cross-section (having radius R in the plane ofFIG. 22 as shown) rather than an oblong cross-section (as does balloon512 in the plane ofFIG. 16). As shown inFIG. 22,balloon512′ includes rectangularneck reinforcing sheet513C′, but some alternative versions ofballoon512′ do not include such a neck reinforcing sheet. The same materials can be used to manufactureballoon512′ (and each variation onballoon512′) as are used to manufacture each corresponding version ofballoon512. In a typical implementation ofballoon512′ includingneck reinforcing sheet513C′ as shown inFIG. 22, radius R is 2.125 inches, width Z of the neck reinforcing sheet is 0.82 inch, and length L of the neck reinforcing sheet is 5.875 inches.
• It is within the scope of the invention to employ a dissection balloon (and/or an anchoring balloon) having nonuniform elasticity selected to achieve desired inflated shape and pressure characteristics. For example,dissection balloon512 ofFIG. 16 has been described in an embodiment comprising one sheet of relatively inelastic material bonded to another sheet of relatively elastic material (with or without a third sheet of material for reinforcing the balloon neck).
• Numerous other implementations of dissection balloons (and/or anchoring balloons) having nonuniform elasticity are contemplated. For example, dissection balloon712 ofFIG. 23 has nonuniform elasticity selected to achieve desired inflated shape and pressure. Dissection balloon712 includes a firstlarge sheet700 bonded (such as by RF-welding around the periphery ofFIG. 23) to a second large sheet (identical tosheet700 but not visible inFIG. 23). The two large sheets are made of material having low elasticity (preferably a multilayer film-commercially available from Rexham comprising polyurethane and polyester layers, but alternatively a film of other material such as polyester). Two disk-shapedsheets704 of material having high elasticity (preferably, polyurethane) are bonded to each large sheet. For example, two disk-shapedsheets704 are bonded (such as by RF-welding) tosheet700, each atannular weld region702 as shown inFIG. 23. Each disk-shapedsheet704 bonded tolarge sheet700 is RF-welded to the corresponding disk-shaped sheet (the disk-shaped sheet below it, and thus not visible inFIG. 23) atannular weld region708 shown inFIG. 23. Thus, when balloon712 is inflated, its inelastic large sheets do not stretch significantly, but the elastic annularregions surrounding welds708 do stretch significantly (and thus function as elastic baffles). As a result, balloon712 has a very flat profile (in the sense that its inflated height in a direction perpendicular to the plane ofFIG. 23 is very small relative to its maximum dimension in the plane ofFIG. 23), it can be inflated to a greater pressure (when compared to a balloon made entirely of the inelastic material), and the stresses at its welds are more evenly distributed (when compared to a balloon made of two inelastic sheets bonded together at a single long weld).
• As another example,dissection balloon812 ofFIG. 24 has nonuniform elasticity selected to achieve desired inflated shape and pressure.Dissection balloon812 consists of a firstlarge sheet722 bonded (such as by RF-welding around the periphery ofFIG. 24) to a second large sheet (identical tosheet722 but not visible inFIG. 24), and a reinforcing sheet bonded to the central portion of each large sheet. The two large sheets are made of material having high elasticity (preferably, polyurethane) having a first thickness. A reinforcing sheet720 (which can be of the same material and can have the same thickness as sheet722) is bonded to the central region of each large sheet (one such reinforcingsheet720 is shown inFIG. 24 RF-welded tosheet722 at weld regions721). Unreinforced portions ofsheet722 are visible inFIG. 24 atneck portion812A ofballoon812 and at the lateral end regions ofballoon812. Thus, in theFIG. 24 embodiment, at least part ofneck portion812A and the lateral end regions ofballoon812 have greater elasticity than the central portion to whichsheet720 is bonded. So, whenballoon812 is inflated, it has an hourglass profile (in the sense that its inflated lateral end portions stretch substantially more than its reinforced center portion). This structure is useful for certain tissue dissection applications where it is desired to increase the lateral extent of the tissue layers dissected.
• In a variation on theFIG. 24 embodiment to be described with reference toFIG. 24A, the dissection balloon also has nonuniform elasticity selected to achieve desired inflated shape and pressure. This dissection balloon consists of a six sheets (three of which are shown inFIG. 24A, and the other three of which are identical to those shown inFIG. 24A). The six sheets are bonded together (such as by RF-welding). Four of the sheets arelateral end sheets722′ made of material having high elasticity (preferably, polyurethane). The twoother sheets720′ are central sheets made of material having lower elasticity (or lower heat deflection temperature sensitivity) thansheets722′. To construct the balloon, twoend sheets722′ are bonded to the lateral edges of eachcentral sheet720′ to make a composite sheet, one composite sheet is placed on the other (with the peripheries of the two composite sheets matched), and the two composite sheets are then bonded together around their matched peripheries.
• In another variation on theFIG. 24 embodiment, a dissection balloon consists of two large sheets (having identical shape) bonded together at their peripheries, but at least one of the sheets (and preferably each of the sheets) has greater thickness (and hence lower elasticity) at its central portion and lesser thickness (and hence greater elasticity) at its lateral end portions. For example, each large sheet is made of polyurethane, its central portion has the same size and shape as doessheet720 ofFIG. 24 with 0.004 inch thickness, and its lateral end portions have 0.002 inch thickness.
• In other embodiments, the desired nonuniform elasticity of the inventive balloon (either an anchoring balloon or a dissection balloon) is achieved by any one (or combinations of two or more) of the following:
• 1. at least one portion of the balloon is a sheet having a first thickness and at least one other portion is a sheet having a second thickness different than the first thickness;
• 2. at least one portion of the balloon is made of multilayer material comprising a first number of layers and at least one other portion is made of multilayer material comprising a second number of layers, where the second number is different than the first number (in such embodiments, all the layers typically have the same thickness, but alternatively some of the layers are thicker than others); and
• 3. the balloon is made of materials whose elasticity varies with temperature, and at least two different portions of the balloon are made of different materials with different heat deflection temperatures so that these portions have different elasticities (e.g., because the elasticity of each material depends on exposure to heat, and one portion of the balloon stretches more than another portion when both portions are subjected to the same temperature and pressure).
• With reference again toFIGS. 10-14, the apparatus ofFIGS. 10 and 14 is designed so that insufflation can be performed after obturator515 (orendoscope515′), the dissection balloon assembly (comprisingballoon512 and housing513), andring514 have been removed from the anchoring and tissue retraction assembly (comprisingelements509,503,504,505, and517), and after valve521 has been closed,balloon517 has been inflated, andcollar504 and clamp503 have been locked to anchor the tissue retraction assembly to the patient. After removal ofobturator515,ring514, and the dissection balloon assembly, an endoscope (or other instrument) can be inserted through the end port of housing509 (thereby displacing flapper valve521), and throughcannula505 into the working space within the patient (in order to view the working space or perform some medical procedure therein). However, alternative embodiments of the invention enable such a viewing operation (or medical procedure) to be performed (unimpeded by the dissection balloon) in other ways.
• For example, theFIG. 25 embodiment enables such a viewing operation (or medical procedure) to be performed in the following manner. TheFIG. 25 embodiment is intended to replace the dissection balloon assembly ofFIG. 11 (which compriseshousing513 and balloon512). TheFIG. 25 apparatus includescontrol lever670 having two ports therethrough:cannula access port672; and dissectionballoon access port674.Control lever670 is slidably mounted betweenhousing members666 and664.Mouth512B ofdissection balloon512 is attached around the circular rim ofport674, andballoon512 is pulled throughcentral channel664A throughmember664 so thatelongated neck512A ofballoon512 extends throughchannel664A as shown inFIG. 25. Thus, whenlever670 is moved to its upper position (shown inFIG. 25), withport674 aligned withchannel664, an endoscope (or obturator) can be inserted throughcentral channel666A ofmember666, throughport674, into the interior of balloon512 (such as during a tissue dissection and tunneling operation).
• To inflate the dissection balloon with the endoscope or obturator in place as described, inflation gas is pumped through port631 (i.e., through an opened valve, not shown, in port631) intomouth512B of the balloon. O-ring seal675 betweenlever670 andmember666, and O-ring seal676 betweenlever670 andmember664, prevent the inflation gas from escaping out from betweenmembers664 and666. O-ring seal678 mounted to lever670 aroundport674 is compressed against the endoscope, thus preventing the inflation gas from escaping out throughchannel666A around the endoscope. Thus, a tunneling operation can be viewed using the endoscope (with imaging light entering the endoscope through a window such aswindow508 mounted at the distal end of balloon512).
• To implement a viewing operation or medical procedure (in a manner unimpeded bydissection balloon512, such as where it is not desired to view through a window mounted at the balloon's distal end),balloon512 is deflated (the inflation gas escapes out through the opened valve in port631), the endoscope or obturator is removed from withinballoon512 andport674, andlever670 is then pushed down to alignport672 with alignedchannels664A and666A. This translation oflever670 causeslever670 to movemouth512B of the balloon downward, so that the portion ofballoon neck512A adjacent tomouth512B moves againsttapered section665 ofmember664, away from the aligned longitudinal axes ofchannels664A and666A. In this configuration, an endoscope (or other instrument) can be inserted thoughcentral channel666A ofmember666, throughport672, and through channel664 (but not into the interior of balloon512) into the working space within the patient (to enable viewing of the working space, or performance of a medical procedure therein, in a manner unobstructed by the dissection balloon).
• As an alternative to implementing theFIG. 25 embodiment (but with use of a long-necked dissection balloon deployed through a cannula such ascannula505 ofFIG. 10, with a rigid window such aswindow508 ofFIG. 10 attached to the balloon's distal end), it may be desirable to attach the window to the distal end of the dissection balloon non-permanently, such as by a tether or hinge (e.g., a living hinge), rather than permanently (e.g., by glue). Then, at the end of tunneling using the inflated balloon, the balloon is deflated, the obturator or endoscope employed for tunneling is removed from within the balloon, the non-permanently attached window is moved away (e.g., rotated on its hinge, or pushed away but retained on a tether) from the longitudinal axis of the cannula. Then, a surgical instrument or endoscope can be inserted through the cannula into the working space within the patient in a manner unimpeded by the window but without removing the balloon from the cannula. Where the window is tethered, it can be pushed out the distal end of the cannula after tunneling (so as to dangle on the tether in the balloon or between the dissected tissue layers), or the tether can be pulled out through the proximal end of the cannula (to remove the tethered window from the working space within the patient).
• Alternative embodiments of the invention employ an alternative means (other than that embodied in the dissection balloon assembly ofFIG. 25 or that ofFIG. 10) for mounting a long-necked dissection balloon so that the balloon can be deployed through a cannula during dissection, and then positioned (after dissection) so as not to impede or obstruct viewing of a working space or performance of a surgical procedure. For example, some embodiments employ a mechanism to disconnect the mouth of the deflated dissection balloon (after dissection) from a housing to which the balloon mouth is attached during dissection. With the balloon mouth so disconnected from the housing (but with the deflated balloon remaining in the working space), an endoscope or other instrument is inserted through the housing (without entering the mouth or interior of the balloon) and into a working space between the dissected tissue layers.
• In other embodiments, the deflated dissection balloon is pulled out of the cannula (through the cannula's proximal end) after dissection. In one of these embodiments, the mouth of the dissection balloon is attached to a sliding element in a housing and the body of the balloon extends through a cannula attached to the housing. The balloon is introduced into a patient and inflated to perform tissue dissection. After dissection, the balloon is deflated, inverted, and pulled back through the cannula. The sliding element is then slid out of the way (e.g., away from the cannula's central longitudinal axis) and an endoscope or other instrument is inserted through the housing and the cannula (without entering the mouth or interior of the balloon) into a working space between the dissected tissue layers.
• With reference toFIGS. 26-35, we next describe an embodiment of the inventive method for using an apparatus (such as that ofFIGS. 10-14) having a long-necked dissection balloon deployed through a cannula and having a window at its distal end. For specificity,FIGS. 26-35 are described with reference to the embodiment ofFIGS. 10-14 which includesdissection balloon512, deployed throughcannula505, which has a rigid window508 (which can be a lens) mounted at its distal end, and which also has anendoscope515′ deployed throughcannula505 and balloon512 (with the distal end of the endoscope abutting window508). For the purpose of illustration only, the method is described in the context of separating the peritoneum from the properitoneal fascia in the course of repairing a hernia. Variations on the described embodiment (and in the apparatus employed to perform it) are useful for performing other medical procedures throughout the body.
• As shown inFIG. 26, an incision about 12-15 mm long is made in the abdominal wall AW, and is carried through the abdominal wall as far as, and including, the properitoneal fat layer FL. The incision is made at the umbilicus U. The distal end of the apparatus (i.e.,window508 and the distal portion ofballoon512 to whichwindow508 is attached) is lubricated and then inserted into the incision to bring the distal end into contact with the peritoneum. Additional gentle pressure is exerted on the proximal end ofendoscope515′, which presseswindow508 against the peritoneum, thereby detaching the part of the peritoneum in the immediate vicinity of the incision from the overlying layer (as shown inFIG. 27). In subsequent steps, the apparatus is advanced along the posterior surface of the peritoneum (toward the right inFIG. 26) until the distal end of the device is located at or near the groin.
• Alternatively, in any of the dissection steps of the method, an obturator or other instrument (having substantially the same shape asendoscope515′) can be substituted forendoscope515′. Such other instrument can be removed and replaced by an endoscope at any time to enable viewing of the space within the dissected tissue using the endoscope.
• At any time, including during inflation ofdissection balloon512 and during advancement ofwindow508 between layers of tissue in the patient, the patient can be viewed by light that has propagated throughwindow508 intoendoscope515′. To inflateballoon512, a source of a suitable inflation fluid (not shown, but as previously described), is connected to port531 which protrudes fromdissection balloon housing513, and the flow of inflation fluid is turned to inflatedissection balloon512 at least partially (as shown inFIG. 28).Balloon512 expands between the peritoneum P and the properitoneal fat layer FL and progressively detaches an increasing area of the peritoneum from the overlying tissue over the entire dissection area. When using the preferred embodiment of the apparatus in whichballoon512 has an oval profile when expanded (in the sense that its expanded width is much greater than its expanded height),balloon512 should be packed and the apparatus deployed so that expandedballoon512's largest cross-sectional area is parallel to the tissue layers being dissected (the largest cross-sectional area should be oriented in a plane perpendicular to the plane ofFIG. 28 to maximize the area of the tissue dissection while minimizing trauma to the patient).
• With reference toFIGS. 29-32,balloon512 may be inflated and deflated a number of times, rather than just once, to dissect progressively the tissue layers. After inflatingballoon512 the first time (thereby partially dissecting the tissue layers), the inflation fluid inballoon512 is vented andballoon512 returns to its collapsed state, as shown inFIG. 29. The peritoneum DP that was separated byballoon512 remains detached from the overlying layer. The apparatus, includingcollapsed dissection balloon512, is then manipulated to advance the distal end (window508) to the limit of detached peritoneum DP in the direction of the groin, as shown inFIG. 30.Endoscope515′ enables the position of the distal end relative to the detached part of the peritoneum to be observed.
• Balloon512 is then inflated again thereby increasing the extent of the detached part of the peritoneum towards the groin, as shown inFIG. 31. The extent of the detached part of the peritoneum is increased in the direction from the umbilicus to the groin, but is not significantly increased in the direction transverse to this direction.Endoscope515′ is again used to observe the extent of the separation (in the manner described above).
• The “tunneling” process of collapsingdissection balloon512, advancing the distal end of the apparatus to the limit of the detached part of the peritoneum in the direction of the groin, holding the distal end in position, and re-inflating the dissection balloon, is repeated until the detached part of the peritoneum includes the site of the hernia. Care should be exercised to avoid dissecting tissue below the pubic bone, and to avoid forcing the dissection balloon downward into the deep pelvis in a manner that would cause trauma to the bladder.
• Then,dissection balloon512 is deflated (by removingendoscope515′ from the proximal end of the apparatus whilering514 remains in place to hold the flapper valve withinhousing509 open). Then, the dissection balloon assembly (comprisinghousing513 and deflated balloon512) andring514 are removed from the retraction and anchoring assembly of the apparatus, leaving the retraction and anchoring assembly shown inFIG. 33 (with the flapper valve withinhousing509 closed as a result of removal of ring514). Then, a suitable source of inflation fluid is attached to anchorballoon inflation valve510, andanchor balloon517 is inflated, leaving the retraction and anchoring assembly in the configuration shown inFIG. 33. When fully inflated,anchor balloon517 should not be in direct contact with the bladder's surface.
• Then clamp503 is advanced alongcannula505 toward the incision in the patient (preferably also,housing509 is pulled back away from the incision in the patient), and clamp503 is locked in a position alongcannula505 in which clamp503 compressesfoam collar504 against the patient (as shown inFIG. 34). In this configuration,collar504 helps to immobilize the anchoring and retraction assembly (includinghousing509 and cannula505) to the patient, andcollar504 applies a modest compressive force to the tissue betweenclamp503 andinflated anchoring balloon517, thereby helpingballoon517 form a seal to limit the escape of insufflation gas from working space WS within the patient out through tunnel T (betweencollar504 andballoon517 in the patient) during subsequent medical procedures.Inflated anchor balloon517 itself preferably provides a substantially gas-tight seal with the entrance of the tunnel T. Of course, in alternative embodiments, anchor balloon519 (described with reference toFIG. 15) is employed rather thananchor balloon517 shown in various ones ofFIGS. 26-35.
• With reference toFIG. 35, the working space WS at the site of the hernia is then insufflated if necessary, by providing insufflation fluid (indicated by arrow F inFIG. 35) throughvalve511 andcannula505 into the working space WS. The hernia is then repaired using a known procedure. During such procedure, instruments can be removed from or inserted through the end port inhousing509 and cannula505 (and/or instruments can be introduced into the working space through other incisions in the abdominal wall of the patient). At the end of the procedure, the extraperitoneal cavity can be quickly deflated by pressingbutton511 to open the flapper valve withinhousing509.
• In other embodiments of the inventive method (also employing a long-necked dissection balloon deployed through a cannula), after dissection using the balloon, the balloon is deflated and retracted before a repair operation is performed in a working space between the dissected tissue layers. In alternative embodiments (also employing a long-necked dissection balloon deployed through a cannula), after dissection using the balloon, the balloon is deflated but retained in the patient during performance of a repair operation. In other embodiments employing a long-necked dissection balloon deployed through a cannula, where the balloon has lobes or other portions shaped so that instruments can be positioned between them, the balloon remains inflated in the patient after tissue is dissected using the balloon, instruments are then positioned between the dissected tissue layers without being obstructed by the inflated balloon (e.g., between lobes or other separated portions of the inflated balloon), and the instruments are manipulated to perform a repair operation.
• FIGS. 36 and 37 show apreferred dissection balloon901 for use in theFIG. 10 apparatus (for dissecting the preperitoneal space) as a substitute forballoon512 ofFIG. 10. When inflated,balloon901 has an oval profile, with an oblong cross-section (as shown inFIG. 37) in the plane containing its longest dimension. It is understood that the present invention may be practiced using a dissection balloon of any of a wide variety of shapes (suitable for deploying the balloon through a cannula) and that the shape ofballoon901 inFIG. 37 is merely an example. For example,balloon901 may be spherical, flat, kidney-shaped, cylindrical, or may have any other shape suited for the particular dissection and/or retraction contemplated.
• Balloon901 is preferably mounted to housing513 (of the type described with reference toFIGS. 11 and 12) as shown inFIGS. 36 and 37 but may alternatively be attached to any other housing.Elongated neck901A ofballoon901 has a circular cross-section that can accommodate an endoscope.
• As shown inFIG. 36,balloon901 is formed fromfirst sheet913 and second sheet915 (connected at seam943) in a manner described above with reference toFIGS. 16-18.Balloon901 is preferably made of the materials and fabricated in the manner described above in connection withFIGS. 16-24, and can be elastic, inelastic, or partially elastic and partially inelastic.
• A preferred method of packingballoon901 will be described with reference toFIGS. 38-42. As shown inFIG. 38, firstlateral portion917 ofballoon901 is initially displaced inwardly (i.e., pushed “inside-out” into the interior of the balloon). Although it is preferred to displacefirst portion917 in a direction perpendicular to the longitudinal axis of the balloon'sneck901A,first portion917 can alternatively be displaced inwardly in any other direction.
• Inwardly-displacedportion917 is then rolled up using arolling device921 inserted throughneck901A. Referring toFIGS. 39 and 40, rollingdevice921 includes two rollingrods923 for grasping first inwardly-displacedportion917, whenrods923 are disposed in the interior of the balloon. Eachrod923 has a diameter of about ⅛ inch androds923 are separated by a gap of preferably less than 1/16 inch. The gap size and diameter of therods923 may vary, depending on the thickness of the balloon material. Furthermore, the rollingdevice921 may include any other feature for grasping the inwardly displaced portion, such as a pair of jaws, a clamp or a pair of elastically deformable arms. The rolling device has aknurled handle925 which is gripped to manipulate it.
• Rolling device921 is rotated to roll theportion917 as shown inFIG. 41 into a roll931 (shown inFIG. 42). Afterportion917 has been rolled into a sufficientlycompact roll931, secondlateral portion927 of balloon901 (opposite first portion917) is displaced inwardly and rolled in the same manner asportion917 to form a roll929 (shown inFIG. 42). An obturator (or endoscope)935 is positioned throughneck901A ofballoon901 betweenrolls929 and931 to provide structural support forballoon901 during insertion into the patient.Rolls929,931 are positioned on opposite sides of obturator (or endoscope)935 with obturator (or endoscope)935 preferably includingconcave portions938 for receiving therolls929,931. The two rolls929,931 (and the portion ofelement935 between them) are then encased withinsheath933, which is similar or identical tosheath506 described above in conjunction with the apparatus ofFIGS. 10-14.
• The compact, deflated, sheathedballoon901 is introduced into the patient between two tissue layers to be separated and is then inflated.Balloon901 may be used for dissecting and/or retracting tissue planes throughout the body. Referring toFIG. 43 which showsballoon901 during inflation in the peritoneum, the inwardly-displaced portions evert during inflation so that differential motion betweenballoon901 and adjacent tissue layers937 is minimized thereby reducing trauma to the tissue layers.
• Although it is preferred to roll the first and second inwardly-displaced portions into first andsecond rolls929,931 within the interior of balloon901 (after pushing these portions inside-out into the balloon's interior),balloon901 may be packed in any other manner so long as an inwardly-displaced portion is provided which everts during inflation. For example, with reference toFIGS. 44 and 45, inwardly-displacedportions917,927 can be displaced to a side opposite the initial displacement and then rolled intorolls929,931 as previously described.
• First and second inwardly-displacedportions917,927 can alternatively be rolled in a conventional manner from opposing lateral sides afterportion917,927 have been displaced inward as shown inFIGS. 46 and 47. In this case, displaced first andsecond portions917,927divide balloon901 into anupper part939 and alower part941. Theupper part939,first portion917, andlower part941 are then rolled up in a conventional manner as shown inFIG. 47. Whenballoon901 is rolled in the manner shown inFIGS. 46-47, theballoon901 will suffer the problem of relatively high differential motion betweenballoon901 and the adjacent tissue layers during initial inflation and deployment, however, during the end of the inflation, the balloon will have relatively low differential motion relative to the tissue layers. This method of packing a balloon is useful when problematic internal structures are positioned laterally outward from the obturator. When the balloon is formed from first andsecond sheets913,915, the upper andlower parts939,941 are preferably formed by the first and second sheets, respectively. By configuringballoon901 in this manner, the first and second portions include a part ofseam943 between the first andsecond sheets913,915. When coupling the first andsecond sheets913,915 together with an RF weld,seam943 forms a relatively thin, rigid periphery which can cut or otherwise traumatize the tissue layers. Referring toFIG. 43,seam943 everts into aspace945 between the tissue layers along the lateral edges ofballoon901 thereby minimizing contact betweenseam943 and the tissue layers.
• Aballoon901′ having a number of inwardly-displaced portions in the form of accordion-folds947 (when inflated) as shown inFIG. 48 can be employed in place ofballoon901 ofFIGS. 36-37.FIG. 48 also shows obturator (or endoscope)935 withinballoon901′ (having been inserted throughneck902′ ofballoon901′).FIG. 49 showsballoon901′ ofFIG. 48 in a compact, deflated state.
• Although preferred balloon packing techniques have been described, the invention can be practiced using other packing techniques or combinations of features of the described techniques. For example, a small roll may be formed in the manner shown in theFIGS. 39 and 41 followed by the procedure described with reference toFIG. 47.
• FIG. 50A shows a simplified version of anapparatus1000 according to the present invention. Thisapparatus1000 comprises an introducer tube ortrocar1 which may be similar to theintroducer tube1 described in referenced application Ser. No. 07/911,714 and described herein with respect toFIGS. 1A-1B and2A-2C.Trocar1 includes acannula3 which has a rigid tube having a bore with a circular cross section that can accommodate an endoscope.
• The proximal end oftrocar1 is preferably fitted with aport5, in theproximal end7 of which is mounted aflapper valve2.Shutter6 of flapper valve is operated bybutton9.Seat4 of the flapper valve additionally forms a gas-tight seal with an endoscope or other instrument inserted though the flapper valve into the bore oftrocar1.Port5 is also fitted with avalve11 to which a supply of a suitable inflation fluid can be connected. Naturally,trocar1 may be provided with various other types of seals and ports without diverging from the scope of the present invention.
• Attached todistal end15 of thecannula3 is adissection balloon1512 preferably having the materials, features, and construction ofdissection balloon512 ofFIG. 10 (including any of the implementations ofballoon512 discussed above, such as those in whichballoon512 has nonuniform elasticity) but preferably having ashorter neck1512A than balloon512 (seeelongate neck512A ofFIG. 11).Balloon1512 can be attached to thedistal end15 ofcannula3 by stretchingneck1512A over the distal end of the trocar and held in place by friction resulting from the tension caused by stretching. A suitable adhesive, such as an epoxy or cyanoacrylate adhesive, may additionally or alternatively be used. Other means of attaching the balloon to the inside or the outside of the cannula can be used.
• Theballoon1512 is preferably packed inside or around the distal end of an obturator and covered with a sheath prior to insertion of theballoon1512 into the patient in a manner similar to that described with respect to the embodiment ofFIG. 10 (seeobturator515 andsheath506 described with respect to the embodiment ofFIG. 10; an obturator may be inserted throughcannula3 in a similar manner). Once the trocar is positioned within the patient, an inflation medium is supplied to the balloon via thevalve11 in thetrocar1. An endoscope may be inserted into the balloon before inflation for observation through the lens, or during and/or after inflation for viewing through the balloon wall, to permit observation of balloon position and surrounding tissue.
• Theapparatus1000 is simpler than the previously described embodiments in that it may be provided without a subassembly andanchor balloon517 such as those shown inFIG. 13. Moreover, because theballoon1512A is itself mounted on thetrocar1, rather than on a narrower tube such as thecannula505 which during use is normally inserted into and withdrawn from the body through a trocar,balloon1512 can be a larger and bulkier balloon thanballoon512 ofFIGS. 10-12 will typically be.
• From this example it should be apparent that the balloons described herein may be delivered to an anatomical site within a patient by a variety of cannulas or other means in addition to those described with respect to the assembly ofFIG. 10 and thetrocar1 ofFIG. 50A. For example, a balloon of the type described herein may be attached to the distal end of a semi-rigid obturator (designated3A inFIG. 50B) for insertion into a patient's body, or it may be attached to a flexible obturator (designated3B inFIG. 50C) and contained within a rigid sheath3C telescopically received over theflexible obturator3B and slidably withdrawn from the balloon prior to inflation (FIG. 50C). As with the previously described embodiments, an obturator having a cannula to which theballoon1512 is attached would preferably include a sealed port at its proximal end through which instruments and inflation fluid may be introduced for passage into the balloon. Moreover, although theballoon1512 shown inFIGS. 50A-50C is of the type having a lens1508 (which can be identical to above-describedlens508, or any of the above-described variations on lens508), it should be appreciated that the configuration of FIG.50A,50B, or50C can be used with any type of balloon, including those of various shapes and sizes, those formed of various materials, and those provided without viewing windows.
• An alternative balloon packing technique is illustrated inFIGS. 51A-51D. This technique is one which allows the balloon to be packaged in a manner in which the overall length of the package is decreased. Such a technique may be desirable for a number of reasons.
• For example, if a procedure is being carried out on a smaller patient using a dissecting balloon which is packaged in a manner which gives the packaged balloon substantial length, the distal end of the balloon may reach its destination within the body before essential features of the device (e.g., theanchor balloon517 ofFIG. 10) have passed into the fascia. Utilizing shorter balloons in such instances is not necessarily desirable because smaller balloons have less dissecting capacity than do larger balloons and thus may not provide effective dissection.
• Packing the balloon to have a shortened packaged length is also advantageous in that it decreases the amount of packaging materials needed for the device and it thereby reduces packaging costs.
• A new packing method according to the invention is one in which the overall packaged length of the device is shortened by packaging the device without including an obturator within the packaged device. Referring toFIG. 51A, as with several of the embodiments described above,dissection balloon512 is provided attached to a distal portion of a flexible or rigid tube such as the cannula designated3D (see, for example,trocar1 ofFIG. 50A, orobturators3A and3B ofFIGS. 50B and 50C, respectively). Thecannula3D may be formed of a single piece of molded flexible polymer having aport11A for delivering inflation fluid to the balloon and further having an integral self-sealingseal2A. Theseal2A permits passage of instruments (such asobturator515B shown inFIG. 51C) into the cannula and seals itself around such instruments to prevent loss of inflation pressure.
• Although theballoon512 shown in the drawings is of the type having alens508 as described above, it should be appreciated that this packing technique may be used for any type of balloon, including those of various shapes and sizes, those formed of various materials, and those provided without viewing windows.
• To pack theballoon512 according to the present embodiment, the balloon is flattened and then folded proximally against thecannula3D to the orientation shown inFIG. 51A (top view) and51B (side view), in a manner similar to that in which an umbrella closes around its shaft. Next, theballoon512 is folded into a sheath such assheath506 described above with respect to the embodiment ofFIG. 10.
• This packing technique differs from the techniques previously described herein in that with those techniques the balloon is folded tightly against an obturator (such asobturator515 ofFIG. 11) inserted through the balloon. In such embodiments, if the obturator is removed prior to deployment of the balloon, a “tunnel” remains within the packaged balloon and a laparoscope may subsequently be inserted into the “tunnel” if desired. However, if the apparatus is packaged and shipped without the obturator in place, portions of the balloon will migrate into the tunnel during shipping and will therefore impede insertion of a laparoscope through the balloon prior to inflation.
• When the balloon is folded over the flexible or rigid neck or cannula as described above, the neck maintains a tunnel through the folded and compressed balloon. This facilitates insertion of a laparoscope or other instrument (such as an obturator) through the tunnel and into the balloon to provide visualization and/or to provide stiffness which facilitates insertion of the balloon into the body cavity.
• In the present embodiment, anobturator515B may, but need not, be positioned within thecannula3D during packing. Referring toFIG. 51C, when the apparatus is to be used for large patients anobturator515B may be advanced through thecannula3D to push theballoon512 distally so as to increase the overall length of the apparatus. Doing so helps theballoon512 to reach the desired depth within the patient for dissection.
• It is contemplated that numerous modifications of and variations on the disclosed embodiments can be made without departing from the scope of the invention as defined by the following claims.

Claims (31)

1. A surgical device comprising:

an elongate tubular member having a bore, the bore configured for receiving a surgical instrument therethrough;

a first inflatable member disposed in a distal region of the elongate tubular member, the first inflatable member having an inflated state and a deflated state;

a collar disposed on the elongate tubular member, the collar being compressible and capable of engaging body tissue between the collar and the first inflatable member when the first inflatable member is in the inflated state;

a first port fluidly coupled to the first inflatable member; and

a second port in fluid communication with the the bore.

2. The device ofclaim 1, wherein the balloon has a toroidal configuration in the inflated state.

3. The device ofclaim 1, wherein the first port and the second port are located in a proximal region of the device.

4. The device ofclaim 1, further including a first housing located at a proximal end of the device.

5. The device ofclaim 4, wherein the first port and the second port are disposed on the first housing.

6. The device ofclaim 3, wherein the bore of the surgical instrument has an inner diameter of about 10 mm.

7. The device ofclaim 1 further including an obturator insertable through the bore.

8. The device ofclaim 1 further including a second inflatable member disposed at a distal end of a second housing.

9. The device ofclaim 8, wherein the second housing includes a third port that is fluidly coupled to an interior of the second inflatable member.

10. The device ofclaim 7, wherein the introduction of an inflation medium into the second port is communicated to the distal end of the device.

11. The device ofclaim 9, wherein the introduction of an inflation medium is communicated to the interior of the second inflatable member through the third port and causes the second inflatable member to transition from an uninflated state towards an inflated state.

12. The device ofclaim 8, wherein the second housing is releasably attached to a first housing, the first housing located at a proximal end of the device.

13. The device ofclaim 8 further including a first housing located at a proximal end of the device and the second housing being releasably attached to the first housing.

14. The device ofclaim 13 further including an obturator that is releasably attached to the second housing.

15. The device ofclaim 14, wherein a distal portion of the obturator extends into the interior of the second inflatable member.

16. The device ofclaim 1, further including a valve disposed in the bore.

17. The device ofclaim 1, wherein the collar includes a locking mechanism for securing a position of the collar relative to the elongate tubular member.

18. The device ofclaim 1, wherein the collar is formed from a foam material.

19. The device ofclaim 1, wherein the collar has a substantially planar distal face adapted for contacting tissue.

20. The device ofclaim 1, wherein the collar is slidable with respect to the elongate tubular member.

21. The device ofclaim 1, wherein a distal face of the collar conforms to a surface of body tissue located between the first inflatable member and the collar.

22. A method of accessing a space comprising the steps of:

making an incision through body tissue;

inserting a device through the incision, the device including:

an elongate tubular member having a bore, the bore configured for receiving a surgical instrument therethrough,

a first inflatable member disposed in a distal region of the elongate tubular member, the first inflatable member having an inflated state and a deflated state,

a collar disposed on the elongate tubular member, the collar being compressible and capable of engaging body tissue between the collar and the first inflatable member when the first inflatable member is in the inflated state,

a first port fluidly coupled to the first inflatable member, and

a second port in fluid communication with the bore; and

introducing an inflation medium to the first port such that the first inflatable member transitions from an uninflated state to an inflated state.

23. The method ofclaim 22, wherein the device further includes a valve disposed in the bore.

24. The method ofclaim 22, further comprising the step of:

inserting a surgical instrument through the bore of the device.

25. The method ofclaim 24, further comprising the step of:

performing a procedure using the surgical instrument.

26. The method ofclaim 22, further comprising the step of:

insufflating the space by introducing an inflation medium through the bore of the device.

27. The method ofclaim 22, wherein the collar of the device is formed from a foam material.

28. The method ofclaim 22, wherein the collar has a substantially planar distal face adapted for contacting tissue.

29. The method ofclaim 22, wherein the collar is slidable with respect to the elongate tubular member.

30. The method ofclaim 22, wherein a distal face of the collar conforms to a surface of body tissue located between the first inflatable member and the collar.

31. The method ofclaim 29, further comprising the step of:

sliding the collar distally towards the first inflatable member such that at least a portion of the collar contacts skin of the patient.

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