US20090112059A1 - Apparatus and methods for closing a gastrotomy - Google Patents

Abstract

A surgical instrument for forming a gastrotomy. In various embodiments, the surgical instrument may comprise a hollow tip for attachment to a distal end of a tubular member such as an endoscope. In other embodiments, the hollow tip is integrally formed on the distal end of the endoscope. The hollow tip is configured such that when it is brought into contact with the inner layer of tissue in the stomach, the tissue is caused to stretch. A hole-forming device may be passed through the hollow tip to pierce through the stretched inner layer and adjacent outer layers of tissue to form a passageway therethrough for permitting surgical procedures to be performed therethrough. After the surgical procedures are performed through the passageway, the hollow tip is removed from contact with the inner layer of tissue to permit the inner layer of tissue to relax and to cause the holes formed through the inner layer and outer layers of tissue to be offset from each other.

Description

FIELD OF THE INVENTION
• The present invention relates, in general, to surgical devices and methods of use and, more particularly, to devices and methods relating to closing an opening made through the abdominal wall utilizing laparoscopic surgical instruments and procedures.
BACKGROUND OF THE INVENTION
• Access to the abdominal cavity may, from time to time, be required for diagnostic and therapeutic endeavors for a variety of medical and surgical diseases. Historically, abdominal access has required a formal laparotomy to provide adequate exposure. Such procedures which require incisions to be made in the abdomen are not particularly well-suited for patients that may have extensive abdominal scarring from previous procedures, those persons who are morbidly obese, those individuals with abdominal wall infection, and those patients with diminished abdominal wall integrity, such as patients with burns and skin grafting. Other patients simply do not want to have a scar if it can be avoided.
• Minimally invasive procedures are desirable because such procedures can reduce pain and provide relatively quick recovery times as compared with conventional open medical procedures. Many minimally invasive procedures are performed with an endoscope (including without limitation laparoscopes). Such procedures permit a physician to position, manipulate, and view medical instruments and accessories inside the patient through a small access opening in the patient's body. Laparoscopy is a term used to describe such an “endosurgical” approach using an endoscope (often a rigid laparoscope). In this type of procedure, accessory devices are often inserted into a patient through trocars placed through the body wall. The trocar must pass through several layers of overlapping tissue/muscle before reaching the abdominal cavity. One of the most significant problems associated with such surgical procedures is the need to provide a secure closure of the gastrotomy site that is required for endoscope passage and, for example, specimen removal. Prior methods required the surgeon to close each of the muscle layers after the procedure is completed.
• Still less invasive treatments include those that are performed through insertion of an endoscope through a natural body orifice to a treatment region. Examples of this approach include, but are not limited to, cystoscopy, hysteroscopy, esophagogastroduodenoscopy, and colonoscopy. Many of these procedures employ the use of a flexible endoscope during the procedure. Flexible endoscopes often have a flexible, steerable articulating section near the distal end that can be controlled by the user by utilizing controls at the proximal end. Minimally invasive therapeutic procedures to treat diseased tissue by introducing medical instruments to a tissue treatment region through a natural opening of the patient are known as Natural Orifice Translumenal Endoscopic Surgery (NOTES)™. In the past, however, those instruments suited for insertion through a natural orifice lacked means for performing a gastrotomy that avoids the need for the surgeon to separately close each tissue and muscle layer after the operation is completed.
• Consequently a need exists for devices and methods that can be employed through a patient's natural orifice for closing a gastrotomy while avoiding the need to separately close the hole in each muscle and tissue layer in the abdominal wall.
• The foregoing discussion is intended only to illustrate some of the shortcomings present in the field of the invention at the time, and should not be taken as a disavowal of claim scope.
SUMMARY
• In one aspect of the invention, there is provided a surgical instrument for forming a gastrotomy. In various embodiments, the instrument comprises a tubular member that has a proximal end and a distal end. A hollow tip is provided on the distal end of the tubular member. The hollow tip has a tip axis and a distal end that extends at an acute angle relative to the tip axis.
• In another general aspect of various embodiments of the present invention, there is provided a surgical instrument for forming a gastrotomy. In various embodiments, the surgical instrument comprises a hollow tip that is configured for attachment to a distal end of an endoscope. The hollow tip has a tip axis extending therethrough and a distal end that extends at an acute angle relative to the tip axis.
• In still another general aspect of various embodiments of the present invention, there is provided a surgical method for forming a gastrotomy through an organ wall that has an inner layer of tissue and at least one outer layer of tissue that is adjacent to the inner layer of tissue, wherein the inner layer of tissue is stretchable from a first relaxed condition to a stretched condition. The method may comprise stretching the inner layer of tissue to a stretched condition relative to the at least one outer layer of tissue and forming a first hole through the stretched inner layer of tissue and a second hole through the at least one outer layer of adjacent tissue such that the first and second holes are aligned with each other to permit passage of a surgical instrument therethrough. The method may further comprise performing a surgical procedure through the aligned first and second holes and thereafter permitting the inner layer to return to the first relaxed condition such that said first and second holes are no longer aligned with each other.
BRIEF DESCRIPTION OF THE FIGURES
• The accompanying drawings, which are incorporated in and constitute a part of this specification, illustrate embodiments of the invention, and, together with the general description of the invention given above, and the detailed description of the embodiments given below, serve to explain various principles of the present invention.
• FIG. 1 is a diagrammatical view illustrating the use of one embodiment of a surgical instrument of the present invention inserted through a patient's mouth and esophagus to perform a gastrotomy through the stomach wall;
• FIG. 2 is partial perspective view of a portion of an endoscope having a hollow tip of one embodiment of the present invention thereon with the hollow tip shown in cross-section for clarity;
• FIG. 3 is another view of the endoscope and hollow tip ofFIG. 2 in confronting spaced relationship with a portion of the stomach wall;
• FIG. 4 is another view of the endoscope and hollow tip ofFIGS. 2 and 3 in contact with a portion of the inner layer of tissue of the stomach wall;
• FIG. 5 is another view of the endoscope and hollow tip ofFIG. 4 with a hole-forming instrument inserted through a working channel in the endoscope and piercing through the inner and outer layers of tissue;
• FIG. 6 is another view of the endoscope and hollow tip ofFIG. 5 with the hole-forming instrument withdrawn from the inner and outer layers of tissue; and
• FIG. 7 is a cross-sectional view of a portion of the stomach wall after the endoscope and hollow tip have been removed from contact therewith.
DETAILED DESCRIPTION
• Certain exemplary embodiments will now be described to provide an overall understanding of the principles of the structure, function, manufacture, and use of the devices and methods disclosed herein. One or more examples of these embodiments are illustrated in the accompanying drawings. Those of ordinary skill in the art will understand that the devices and methods specifically described herein and illustrated in the accompanying drawings are non-limiting exemplary embodiments and that the scope of the various embodiments of the present invention is defined solely by the claims. The features illustrated or described in connection with one exemplary embodiment may be combined with the features of other embodiments. Such modifications and variations are intended to be included within the scope of the present invention.
• It will be appreciated that the terms “proximal” and “distal” are used herein with reference to a clinician manipulating an end of theinstrument20 that protrudes out of the natural orifice. The term “proximal” referring to the portion closest to the clinician and the term “distal” referring to the portion located away from the clinician. It will be further appreciated that, for convenience and clarity, spatial terms such as “vertical”, “horizontal”, “up” and “down” may be used herein with respect to the drawings. However, surgical instruments are used in many orientations and positions, and these terms are not intended to be limiting and/or absolute.
• The present invention generally relates to devices and methods that may be used in connection with endoscopes to perform a gastrotomy through the stomach wall and thereafter have the gastrotomy site be closed without the need for the surgeon to separately close the opening formed in each layer of muscle and tissue. While the various Figures illustrate one form of endoscope with which the various embodiments of the present invention may be advantageously employed, those of ordinary skill in the art will readily appreciate that the unique and novel features of the present invention may be employed with a variety of other forms of endoscopes without departing from the spirit and scope of the present invention.
• FIG. 1 illustrates, in general form, asurgical instrument20 of the present invention that can be inserted through a natural orifice to form an opening through thestomach wall16. In the example depicted inFIG. 1, theinstrument20 is inserted through themouth10 andesophagus12 into thestomach14 to form an opening through thestomach wall16. In various embodiments, theinstrument20 may comprise a tubular member sized to receive a surgical instrument. In various embodiments, for example, the tubular member may comprise anendoscope30 that may be inserted through a substantiallyhollow overtube40 that is inserted into thestomach14 through the patient'smouth10. A variety of different types of endoscopes are known and, therefore, their specific construction and operation will not be discussed in great detail herein. In various embodiments, theendoscope30 has adistal end32 and aproximal end34 and may operably support avideo camera36 that communicates with avideo display unit40 that can be viewed by the surgeon during the operation. Theendoscope30 may further have one ormore working channels38 extending therethrough for receiving various types of surgical instruments. SeeFIG. 2.
• Also in various embodiments of the present invention, ahollow tip50 may be attached to, or integrally formed on, thedistal end32 of theendoscope30. In various embodiments, thehollow tip50 may be attached to theendoscope30 by, for example, an appropriate adhesive or be pressed onto thedistal end32 and be retained thereon by a “frictional fit”. Thehollow tip50 may be fabricated from, for example, a thermoplastic material and have a tip axis “A-A” that may be substantially coaxially aligned with the central axis of theendoscope30 when installed thereon. In addition, thehollow tip50 may be formed with an angleddistal end52 that is angled at an acute angle “α” relative to the tip axis A-A. In various embodiments, the angle α may be, for example, approximately forty-five degrees or from ten degrees to eighty degrees. As will become apparent as the present Detailed Description proceeds, thedistal end52 of the hollow tip is to be formed in such away so that, when pressed against theinner tissue layer17 of thestomach wall16, thattissue layer17 is stretched within thehollow tip50. In various embodiments, thedistal end52 of thehollow tip50 may be substantially non-piercing. “Non-piercing” as used herein means that when used as described herein, thetip50 will not pierce through the organ by itself; however, after the organ is pierced by other means, the hollow tip could be inserted through the opening, if so desired.
• FIGS. 3-6 illustrate use of theinstrument20.FIG. 3 depicts a portion of thestomach wall16 through which the gastrotomy will be performed. As can be seen in that Figure, thestomach wall16 may consist of, for example, a first inner layer oftissue17 known as mucosa or Rugae that lines thestomach wall16 and at least a second layer of tissue ormuscle18. The inner layer oftissue17 is stretchable from a relaxed condition (FIGS. 3 and 7) to a stretched condition (FIGS. 4-6). Thesecond layer18 of tissue may actually comprise more than one layer or amount of muscle and other tissue. It will be appreciated, however, that all of that tissue/muscle18 and theinner layer17 make up thestomach wall16.
• As shown inFIG. 3, the surgeon initially manipulates theendoscope30 to bring thehollow tip50 into spaced confronting relationship with the portion of thestomach wall16 through which the gastrotomy is to be performed. Thereafter, theendoscope30 is manipulated in such a manner to cause thedistal end52 of thehollow tip50 to be pressed against theinner layer17 of thestomach wall16. Because of the differences between theinside layers17 and outside layers oftissue18, the tissue layers17,18 stretch at different rates. SeeFIG. 4. In some embodiments, a vacuum instrument60 may be passed through a workingchannel38 in theendoscope30 to apply a suction or vacuum within thehollow tip50 from a source of vacuum62 (FIG. 1) to draw theinner layer17 of thestomach wall16 into stretched sealing engagement with thedistal end52 of thehollow tip50. SeeFIG. 5.
• Once thehollow tip50 is pressed against theinner layer17 of thestomach wall16 in the above-described manner, a conventional hole-formingdevice70 such as, for example, a conventional Sphinctorotome, a needle knife or other incisor-type instrument is inserted through a workingchannel38 to form a continuous hole orpassageway19 through thelayers17 and18 of thestomach wall16. SeeFIG. 5. As can be seen inFIGS. 6 and 7, thecontinuous hole19 actually consists ofhole segment19A andhole segment19B that are aligned with each other. After thehole19 has been formed through thestomach wall16, the hole-forminginstrument17 may be withdrawn back through the workingchannel38 in theendoscope30 and other surgical instruments such as, for example, guide wires, dilating balloons, etc. (not shown) may be inserted through the workingchannels38 and through thehole19.
• After the desired surgical procedures such as, for example, Diagnostic Peritonoscopy or Transgastric Cholecystectomy have been performed through thehole19, theentire instrument20 may be removed from the site. After theinstrument20 is removed, theinner tissue layer17 is once again permitted to move to a relaxed state which causes an offset between thehole segments19A and19B as represented by the distance “OS” inFIG. 7. Thehole segments19A and19B are then permitted to naturally seal through the body's normal healing process.
• As can be readily appreciated from the foregoing, the various embodiments of the present invention described above represent a vast improvement over prior devices and methods used to form and thereafter close a gastrotomy. The unique and novel features of the present invention enable the operation to be performed through a natural orifice in the patient and thereby avoid several disadvantages associated with other conventional surgical methods and procedures that require incisions to be made into the abdomen. The present invention may encompass tips that are configured for attachment to a distal end of a surgical instrument and, if desired, supplied and/or sold separately from that instrument. Such tips may be pressed onto or otherwise temporarily attached to the distal end of the instrument to complete the above-described procedure and thereafter removed from the instrument and discarded or reprocessed for future use. Other embodiments of the present invention contemplate permanent attachment of the tip to the distal end of the instrument and still other embodiments envision that the angled distal end of the tip be integrally formed on the distal end of the instrument.
• While several embodiments of the invention have been described, it should be apparent, however, that various modifications, alterations and adaptations to those embodiments may occur to persons skilled in the art with the attainment of some or all of the advantages of the invention. For example, according to various embodiments, a single component may be replaced by multiple components, and multiple components may be replaced by a single component, to perform a given function or functions. This application is therefore intended to cover all such modifications, alterations and adaptations without departing from the scope and spirit of the disclosed invention as defined by the appended claims.
• The devices disclosed herein can be designed to be disposed of after a single use, or they can be designed to be used multiple times. In either case, however, the device can be reconditioned for reuse after at least one use. Reconditioning can include an combination of the steps of disassembly of the device, followed by cleaning or replacement of particular pieces, and subsequent reassembly. In particular, the device can be disassembled, and any number of particular pieces or parts of the device can be selectively replaced or removed in any combination. Upon cleaning and/or replacement of particular parts, the device can be reassembled for subsequent use either at a reconditioning facility, or by a surgical team immediately prior to a surgical procedure. Those of ordinary skill in the art will appreciate that the reconditioning of a device can utilize a variety of different techniques for disassembly, cleaning/replacement, and reassembly. Use of such techniques, and the resulting reconditioned device, are all within the scope of the present application.
• Preferably, the invention described herein will be processed before surgery. First a new or used instrument is obtained and, if necessary, cleaned. The instrument can then be sterilized. In one sterilization technique, the instrument is placed in a closed and sealed container, such as a plastic or TYVEK® bag. The container and instrument are then placed in a field of radiation that can penetrate the container, such as gamma radiation, x-rays, or higher energy electrons. The radiation kills bacteria on the instrument and in the container. The sterilized instrument can then be stored in the sterile container. The sealed container keeps the instrument sterile until it is opened in the medical facility.
• Any patent, publication, or other disclosure material, in whole or in part, that is said to be incorporated by reference herein is incorporated herein only to the extent that the incorporated materials does not conflict with existing definitions, statements, or other disclosure material set forth in this disclosure. As such, and to the extent necessary, the disclosure as explicitly set forth herein supersedes any conflicting material incorporated herein by reference. Any material, or portion thereof, that is said to be incorporated by reference herein, but which conflicts with existing definitions, statements, or other disclosure material set forth herein will only be incorporated to the extent that no conflict arises between that incorporated material and the existing disclosure material.
• The invention which is intended to be protected is not to be construed as limited to the particular embodiments disclosed. The embodiments are therefore to be regarded as illustrative rather than restrictive. Variations and changes may be made by others without departing from the spirit of the present invention. Accordingly, it is expressly intended that all such equivalents, variations and changes which fall within the spirit and scope of the present invention as defined in the claims be embraced thereby.

Claims (22)

1. A surgical instrument for forming a gastrotomy, said surgical instrument comprising:

a tubular member sized to receive a surgical instrument, said tubular member having a proximal end and a distal end; and

a non-piercing hollow tip on said distal end of said tubular member, said hollow tip defining a tip axis and having a distal end extending at an acute angle relative to said tip axis.

2. The surgical instrument ofclaim 1 wherein said acute angle is approximately forty-five degrees.

3. The surgical instrument ofclaim 1 wherein said hollow tip is attached to said distal end of said tubular member by a frictional fit.

4. The surgical instrument ofclaim 1 wherein said hollow tip is attached to said tubular member by adhesive.

5. The surgical instrument ofclaim 1 wherein said hollow tip is integrally formed on said distal end of said tubular member.

6. The surgical instrument ofclaim 1 wherein said tubular member comprises an endoscope.

7. The surgical instrument ofclaim 5 wherein said endoscope has at least one working channel therethrough to receive a hole-forming device therethrough.

8. The surgical instrument ofclaim 7 wherein said endoscope has a working channel therethrough for receiving a vacuum forming instrument therethrough.

9. A method for processing an instrument for surgery, the method comprising:

obtaining the surgical instrument ofclaim 1;

sterilizing the instrument; and

storing the instrument in a sterile container.

10. A surgical instrument for forming a gastrotomy, said surgical instrument comprising a non-piercing hollow tip configured for attachment to a distal end of an endoscope, said hollow tip defining a tip axis and having a distal end extending at an acute angle relative to said tip axis.

11. The surgical instrument ofclaim 10 wherein said acute angle is approximately 45 degrees.

12. A method for processing an instrument for surgery, the method comprising:

obtaining the hollow tip ofclaim 10;

sterilizing the hollow tip; and

storing the hollow tip in a sterile container.

13. A surgical kit comprising:

an endoscope; and

a hollow tip ofclaim 11.

14. A surgical method for forming a gastrotomy through an organ wall having an inner layer of tissue and at least one outer layer of tissue adjacent to said inner layer of tissue, wherein the inner layer of tissue is stretchable from a first relaxed condition to a stretched condition, said method comprising:

stretching the inner layer of tissue to a stretched condition relative to the at least one outer layer of tissue;

forming a first hole through the stretched inner layer of tissue and a second hole through the at least one outer layer of adjacent tissue such that said first and second holes are aligned with each other to permit passage of a surgical instrument therethrough;

performing a surgical procedure through the aligned first and second holes; and

permitting the inner layer to return to the first relaxed condition such that the first and second holes are no longer aligned with each other.

15. The surgical method ofclaim 14 wherein said stretching comprises:

providing a surgical instrument having a hollow tip thereon, the hollow tip having a tip axis and a distal end that extends at an acute angle relative to the tip axis; and

pushing the angled distal end of the hollow tip into contact with the inner layer of tissue to cause a portion of the inner layer of tissue to move to the stretched condition.

16. The surgical method ofclaim 15 wherein said forming comprises:

inserting a hole-forming instrument through the surgical instrument and the hollow tip; and

piercing a portion of the hole forming instrument through the portion of stretched inner layer of tissue and the at least one outer layer of tissue adjacent to the portion of stretched inner layer of tissue.

17. The surgical method ofclaim 15 further comprising applying suction within the hollow tip.

18. The surgical method ofclaim 15 wherein the surgical instrument comprises an endoscope.

19. The surgical method ofclaim 18 wherein said pushing comprises:

inserting a portion of the endoscope having the hollow tip thereon through a natural orifice in a patient to bring the hollow tip into engagement with the inner layer of tissue;

an applying a pushing force to another portion of the endoscope protruding out of the natural orifice.

20. The surgical method ofclaim 15 wherein said permitting comprises removing the angled distal end of the hollow tip from contact with the inner layer of tissue.

21. The surgical method ofclaim 14 wherein said performing a surgical procedure comprises performing transgastric access.

22. The surgical method ofclaim 14 wherein said performing a surgical procedure comprises inserting one of a guide wire and a dilating balloon through the aligned first and second holes.

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