US20100174149A1 - Endoscopic inflatable retraction device, method of using, and method of making - Google Patents

Abstract

A method of providing access to tissue for a surgical instrument through a body wall is provided. The method includes providing an expandable retractor having a flexible sheath, the retractor being in a collapsed state; introducing the retractor into the body and placing the retractor adjacent the tissue; expanding the retractor; deploying the flexible sheath by engaging the flexible sheath with a tool and driving the flexible sheath through the body wall with the tool; and inserting the surgical instrument from outside the body through the flexible sheath to provide access to the tissue by the surgical instrument.

Description

• This application is a Continuation of application Ser. No. 10/638,854, filed Aug. 11, 2003, which is a Continuation of application Ser. No. 09/179,008, filed 26 Oct. 1998 (U.S. Pat. No. 6,605,037), which is a Continuation of application Ser. No. 08/561,160, filed 21 Nov. 1995 (U.S. Pat. No. 5,865,728), which is a Continuation-in-Part of application Ser. No. 08/106,231, filed 13 Aug. 1993 (now abandoned), which is a Divisional of application Ser. No. 07/794,590, filed 19 Nov. 1991 (U.S. Pat. No. 5,309,896), which is a Continuation-in-Part of application Ser. No. 706,781, filed 29 May 1991 (now abandoned), of inventors Frederic H. Moll, Albert K. Chin, Diane E. Caramore, and Frank T. Watkins III.
BACKGROUND OF THE INVENTION
• Laparoscopy dates back to the turn of the 20th Century. Early laparoscopic techniques were used primarily for diagnostic purposes to view the internal organs, without the necessity of conventional surgery. Since the 1930s, laparoscopy has been used for sterilization and, more recently, for the suturing of hernias. U.S. Pat. Nos. 4,919,152 and 4,944,443 are concerned with techniques for suturing hernias. Another very recent innovation is the use of laparoscopic surgery for removing the gallbladder.
• U.S. patent application Ser. No. 706,781, the application of which this application is a Continuation-in-Part, describes an apparatus and method wherein the abdominal wall is lifted away from the underlying abdominal organs by an inflatable device which is introduced laparoscopically and, once in place, inflated to engage and lift an extensive area of the abdominal wall.
• Even when such lifting techniques are used, it is still necessary to retract other organs to gain access to the organ or tissue to be treated or observed. In other procedures, to gain access to the organ or tissue to be treated or observed, it is necessary to separate the organ to be treated from tissue surrounding it. For example, to be able to observe the outer surface the heart, the outer surface of the heart has to be separated from the pericardium. To obtain the necessary retraction, current laparoscopic procedures use several small retractors inserted though a plurality of incisions. Because such retractors have a relatively small surface area, they tend to damage and/or cause trauma to the retracted organs or tissue. Moreover, the requirement for a plurality of incisions to heal may delay the patient's recovery.
• It is known to use a modified Foley catheter to retract organs and tissue with less damage. The modified Foley catheter comprises a small, substantially spherical balloon on the end of a catheter which is inserted through a small incision into the body. After insertion, the balloon is inflated. The modified Foley catheter is used in a similar manner to a conventional retractor, but the retracted organ or tissue is contacted by the relatively large surface area of the balloon. Such a retractor reduces damage to retracted organs or tissues, but is inconvenient to use because it has to be kept in place by means of an external clamping arrangement, and its relatively large balloon tends to obstruct access to the site to be treated.
SUMMARY OF THE INVENTION
• The present invention relates to an inflatable retraction device that mechanically retracts organs and tissues to provide access to treat or observe other organs or tissues. More specifically, the invention is concerned with a retraction device that retracts organs or tissues by means of an inflatable chamber. The retraction device is introduced laparoscopically in a collapsed state into the body and, once in place, inflated to engage an extensive area of the organ or tissue to be retracted, and to gently retract or displace the organ or tissue without damaging it. During laparoscopic treatment and observation procedures, a retraction device according to the invention retains its expanded condition, and hence its ability to provide retraction, while providing access for surgical instruments through itself to the organ or tissue being treated or observed, or allowing an organ or tissue to be brought inside itself for observation or treatment.
• In the following description, the word “organ” will be used to mean an organ or a tissue that is retracted by the retraction device. The word “treat” will be used to mean both treat and observe, and the word “treatment” will be used to mean both treatment and observation. The word “tissue” or the phrase “tissue to be treated” will both be used to mean the organ or the tissue that is treated through or inside the retraction device.
• To provide the large surface area required to retract organs gently, the inflatable retraction device according to the invention is relatively large. As a result, the retraction device is normally juxtaposed between the entry through which surgical instruments pass into the body and the tissue to be treated. An inflatable retraction device according to the invention avoids obstructing the access of surgical instruments to the tissue to be treated by providing one or more apertures in the envelope of the device. Such apertures allow instruments to pass into and out of the interior of the retraction device, or allow the tissue to be treated to enter the interior of the retraction device for treatment by instruments passed into the interior of the device. Treatment is thus carried out working through or inside the retraction device according to the invention.
• In those procedures in which the tissue to be treated enters the interior of retraction device through an aperture, the material of the retraction device surrounding the aperture may form a seal around the tissue, isolating it from the body outside the retraction device. Treatment of the tissue is carried out inside the retraction device.
• According to different aspects of the invention inflatable retraction devices according to the invention employ different ways to retain their ability to provide retraction while providing access for surgical instruments to the tissue to be treated or observed. An inflatable retraction device according to one aspect of the invention, such a retraction device being designated generally as a Type I retraction device, maintains its ability to provide retraction by means of an additional inflatable chamber, which forms a cage structure inside or outside the main inflatable chamber. The additional inflatable chamber is normally inflated after the main inflatable chamber of the retraction device has been inflated, and the retraction device has produced its desired retraction effect. Such an additional inflatable chamber is smaller and less powerful than the main inflatable chamber. Inflating the additional chamber alone would not always produce sufficient force to provide the desired retraction of the organ. However, the inflated additional chamber provides enough force to maintain an organ that has been retracted by the more powerful main inflatable chamber in its retracted position. The additional inflatable chamber is thus able to maintain the retraction effect of the retraction device after the retraction effect of the main inflatable chamber has been destroyed by piercing an aperture in the envelope of the main chamber to provide access to the tissue to be treated.
• The tube used to inflate the main chamber provides primary access for surgical instruments to the interior of the retraction device. If more instruments than can be accommodated by the inflation tube are needed, or if the inflation tube is not conveniently aligned with the tissue to be treated, instruments can additionally or alternatively be inserted through additional incisions. The instruments enter the retraction device through additional apertures in the envelope of the main chamber. The apertures are cut in the part of the envelope of the main chamber that does not form part of the additional inflatable chamber.
• In an alternative embodiment of a retraction device according to the invention, the ability of the retraction device to provide a retraction effect during the treatment or observation procedure is maintained by keeping the main chamber of the retraction device in an inflated state during the treatment procedure. Such a retraction device, designated generally as a Type II retraction device, does not require an additional inflation chamber to maintain its retraction effect. An elastomeric window is attached to the inside of the retraction device after the device has been inflated. The elastomeric window provides a gas-tight seal around instruments passed through it, and around a tissue brought into the interior of the retraction device through it.
• After the window has been installed, an instrument is passed through the window to pierce an aperture in the part of the envelope of the retraction device covered by the window to provide access to the organ to be treated. Surgical instruments are passed into the interior of the retraction device, primarily through the main inflation tube. The instruments can pass out of the retraction device to the tissue to be treated through the elastomeric window and the aperture in the envelope of the main chamber. Alternatively, the tissue to be treated enters the interior of the retraction device through the aperture and the elastomeric window. The elastomeric window provides a seal around the tissue to be treated enabling the retraction device to be maintained in its inflated state while treatment is carried out.
• A Type I or a Type II retraction device according to the invention may be provided, according to a further aspect of the invention, with tabs attached to the interior surface of the envelope of the device. The tabs are gripped with a suitable gripping tool to adjust the position and orientation of the inflated retraction device relative to the tissue to be treated. The retraction device may be partially deflated to enable adjustments to be more easily made.
• According to a further aspect of the invention, a Type I or a Type II retraction device may be provided, when in its collapsed state prior to inflation, with markings on its surface to aid proper orientation prior to inflation.
• According to a further aspect of the invention, a Type I or a Type II retraction device according to the invention may further be provided with a flexible sheath for providing a port to allow surgical instruments to pass from outside the body to the main chamber of the retraction device. The interior of the flexible sheath communicates with the main chamber of the retraction device. The flexible sheath is deployed after the retraction device has been inflated. According to one aspect of this invention, a flexible sheath attached to the envelope of the retraction device driven outward through the body wall. According to an alternative aspect of this invention, the flexible sheath is driven inward through the body wall to pierce, and to lock into engagement with, the envelope of the retraction device.
• According to a further aspect of the invention, in a retraction device according to the invention, the part of the envelope of the retraction device that is lower-most when the retraction device is deployed in the body is fitted with an integral tubular suction skirt. The suction skirt is connected to the operating room suction line and allows continuous or intermittent drainage of fluid that collects in the bottom of the cavity created by the retraction device during laparoscopic surgery.
• An inflatable retraction device according to the method of the invention is used according to the invention by forming a small opening in the wall of the body and laparoscopically inserting the retraction device into the body in a contracted state. After insertion and orientation, the retraction device is inflated. During the inflation process, the relatively large surface area of the retraction device gently retracts the organ obstructing access to the tissue to be treated.
• After the retraction device has been inflated, surgical instruments are passed from outside the body into the retraction device. One or more apertures are created by piercing, and possibly at least partially removing, the envelope of the retraction device adjacent to the tissue to be treated. The one or more apertures in the envelope of the retraction device provide access for the instruments to the tissue to be treated. Treatment is then carried out by working through the one or more apertures in the retraction device. The apertures may also provide access to the interior of the retraction device for surgical instruments passed from outside the body. Alternatively, the tissue to be treated can enter the main chamber of the retraction device through the one or more apertures and be treated inside the retraction device.
• After the treatment has been completed, the retraction device is deflated and evacuated prior to its removal from the body in a collapsed state.
• When a inflatable retraction device is used in the abdominal cavity, a inflatable retraction device according to the invention may be used alone to provide both retraction and lifting of the abdominal wall, or it may be used together with the abdominal lifting devices disclosed in the application Ser. No. 706,781, of which application this application is a Continuation-in-Part, or together with known insufflation techniques for lifting the abdomen.
• The invention is also concerned with methods of using inflatable retraction devices according to the invention in new procedures for suturing hernias without breaching the peritoneum, anterior resection of herniated intervertebral discs, resecting the lung, lung lobectomies, and for procedures for observing or treating the heart, the brain, the esophagus, and the prostate.
• The various procedures according to the invention involve placing an inflatable retraction device according to the invention inside a part of the body, such as the abdomen, the chest, or the skull via a small, limited incision or puncture site. The inflatable retraction device is placed adjacent to the organ to be displaced. Inflating the retraction device retracts the organ and exposes the tissue to be treated. Treatment of the tissue to be treated is then carried out using instruments passed into the interior of the retraction device. The tissue to be treated may remain outside the retraction device, or can enter the retraction device during treatment.
• In a procedure according to the invention to repair a hernia by placing a mesh over the site of the hernia, an inflatable retraction device is used to provide retraction and, additionally, to hold the mesh in place over the site of the hernia while the mesh is stapled in place.
• In a first method of construction according to the invention, a Type II polyhedral retraction device is made from suitably shaped pieces of flat plastic film connected together to form a polyhedral main envelope enclosing the main chamber. Such a construction can be used to approximate a spherical or spheroidal shape. A main inflation tube is attached to the main envelope such that the interior of the main inflation tube is in communication with the main chamber.
• In a first method for constructing a polyhedral Type I retraction device, a segmented additional envelope is formed from suitably shaped pieces of flat plastic film. The pieces are shaped to provide the required cage structure of the additional chamber. The additional chamber is formed by attaching the periphery of the additional envelope to the outside or the inside of the main envelope. The part of the surface of the main envelope that is not covered by the additional envelope provides a plurality of windows, which, after the additional chamber is inflated, may be at least partially removed to provide apertures through which treatment or observation can be carried out. An additional inflation tube is attached to the additional envelope such that the interior of the additional inflation tube is in communication with the additional chamber.
• In an alternative method of making an inflatable Type II retraction device according to the invention, two curved pieces of plastic film are attached to one another at their peripheries to form a main envelope enclosing a main chamber. A main inflation tube is attached to the main envelope such that the interior of the main inflation tube is in communication with the main chamber.
• In an alternative method for constructing a Type I retraction device, an additional envelope is formed from two more pieces of curved plastic film shaped to form the required cage structure of the additional chamber. The two pieces of the additional envelope are attached to one another either outside or inside the main envelope. The additional chamber is formed by attaching the periphery of the additional envelope to the outside or the inside of the main envelope. The part of the surface of the main envelope that is not covered by the additional envelop provides a plurality of windows which, after the additional chamber is inflated, may be at least partially removed to provide apertures through which treatment or observation can be carried out. An additional inflation tube is attached to the additional envelope such that the interior of the additional inflation tube is in communication with the additional chamber.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1 is a perspective view of a polyhedral Type IA inflatable retraction device according to a first embodiment of the invention;
• FIG. 2 is vertical cross section, along the line2-2 inFIG. 1, of a polyhedral Type IA inflatable retraction device according to a first embodiment of the invention;
• FIG. 3 is horizontal cross section, along the line3-3 inFIG. 1, of a polyhedral Type IA inflatable retraction device according to a first embodiment of the invention;
• FIG. 4A is a longitudinal cross sectional elevational view of a body showing a packaged collapsed Type IA retraction device according to a first embodiment of the invention ready for insertion into the abdominal cavity;
• FIG. 4B is a longitudinal cross sectional elevational view of a body showing a packaged collapsed Type IA retraction device according to a first embodiment of the invention after it has been inserted into the abdominal cavity;
• FIG. 4C is a longitudinal cross sectional elevational view of a body showing a Type IA retraction device according to a first embodiment of the invention during the inflation of its main chamber in the abdominal cavity;
• FIG. 4D is a longitudinal cross sectional elevational view of a body showing a Type IA retraction device according to a first embodiment of the invention after the additional chamber has been inflated and the inflation pressure has been removed from the main chamber in the abdominal cavity;
• FIG. 5 is a longitudinal cross sectional elevational view of a body showing a Type IA retraction device according to a first embodiment of the invention used to retract the bowel and lift the liver to expose the gall bladder for observation by an endoscope inserted into the main chamber of the retraction device through the main inflation tube;
• FIG. 6 is a perspective view of a polyhedral Type II inflatable retraction device according to a second embodiment of the invention showing an elastomeric window attached to the inner surface of its main envelope;
• FIG. 7 is a perspective view of an elastomeric window suitable for attaching to the inner surface of the main envelope of a polyhedral Type II inflatable retraction device according to a second embodiment of the invention. The elastomeric window includes an electrical element for heating temperature sensitive adhesive applied to one of the surfaces of the elastomeric window.
• FIG. 8 is a perspective view of the elastomeric window ofFIG. 7 packaged prior to insertion into the retraction device.
• FIG. 9 is a perspective view of the outer surface of the main envelope of a polyhedral Type II inflatable retraction device according to a second embodiment of the invention. An elastomeric window has been attached to the inside of the main envelope and an aperture has been cut in the part of the main envelope covered by the elastomeric window.
• FIG. 10A is a longitudinal cross sectional elevational view of a body showing a packaged collapsed Type II retraction device according to a second embodiment of the invention ready for insertion into the abdominal cavity;
• FIG. 10B is a longitudinal cross sectional elevational view of a body showing a packaged collapsed Type II retraction device according to a second embodiment of the invention after it has been inserted into the abdominal cavity;
• FIG. 10C is a longitudinal cross sectional elevational view of a body showing a Type II retraction device according to a second embodiment of the invention during the inflation of its main chamber in the abdominal cavity;
• FIG. 10D is a longitudinal cross sectional elevational view of a body showing a Type II retraction device according to a second embodiment of the invention in its fully inflated condition in the abdominal cavity;
• FIG. 11A is a transverse cross sectional elevational view of the abdomen showing a Type IB retraction device according to a third embodiment of the invention during the inflation of its main chamber in the abdominal cavity;
• FIG. 11B is a transverse cross sectional elevational view of the abdomen showing a Type IB retraction device according to a third embodiment of the invention in its fully inflated condition in the abdominal cavity;
• FIG. 11C is a perspective view of a Type IS retraction device according to a third embodiment of the invention showing an alternative form of additional cavity having tacked sidewalls.
• FIG. 12A is a vertical cross sectional view of a polyhedral inflatable retraction device according to the invention fitted with a first embodiment of flexible sheath according to the invention installed in the abdominal cavity with the flexible sheath in its collapsed state.
• FIG. 12B is a vertical cross sectional view of a polyhedral inflatable retraction device according to the invention fitted with a first embodiment of flexible sheath according to the invention installed in the abdominal cavity showing the flexible sheath being driven through the abdominal wall.
• FIG. 12C is a vertical cross sectional view of a window of a polyhedral inflatable retraction device according to the invention showing a second embodiment of a flexible sheath according to the invention.
• FIG. 13A is a perspective view of a polyhedral Type IA inflatable retraction device fitted with a suction skirt according to the invention;
• FIG. 13B is vertical cross section, along the line2-2 inFIG. 1, of a polyhedral Type IA inflatable retraction device fitted with a suction skirt according to the invention;
• FIG. 14A is a longitudinal cross sectional elevational view of a body illustrating the use according to the invention of a retraction device according to the invention in the abdomen to retract the bowel to gain anterior access to the intravertebral discs, the aorta, or the kidneys for treatment or observation.
• FIG. 14B is a transverse cross sectional elevational view of a body illustrating the use according to the invention of a retraction device according to the invention in the abdomen to retract the bowel to gain anterior access to the intravertebral discs, the aorta, or the kidneys for treatment or observation.
• FIG. 15 is a transverse cross sectional plan view of the chest illustrating the use according to the invention of a retraction device according to the invention to retract the pericardium from the heart to gain access to the surface of the heart for treatment or observation.
• FIG. 16A is a transverse cross sectional elevational view of the chest illustrating the use according to the invention of a retraction device according to the invention to retract the lung away from the pleura to gain access to the surface of the lung for treatment or observation.
• FIG. 16B is a transverse cross sectional plan view of the chest illustrating the use according to the invention of a retraction device according to the invention to retract the lung away from the pleura, part of the lung entering the main chamber of the retraction device for treatment or observation.
• FIG. 17 is a longitudinal cross sectional elevational view of the chest illustrating the use according to the invention of a retraction device according to the invention to retract one lobe of the lung away from the rest of the lung to gain access to occlude part of the bronchial tree during a lobectomy.
• FIG. 18 is a longitudinal cross sectional elevational view of the abdomen illustrating the use according to the invention of a retraction device according to the invention to retract the liver to gain access to the gastroesophageal junction prior to sectioning the vagus nerve or to treating gastroesophageal reflux.
• FIG. 19 is a longitudinal cross sectional elevational view of the head illustrating the use according to the invention of a retraction device according to the invention to retract the brain away from the dura mater to gain access to the brain for treatment or observation.
• FIG. 20A is a transverse cross sectional elevational view of the lower abdomen illustrating the use according to the invention of a retraction device according to the invention between the abdominal wall and the peritoneum to retract the peritoneum to provide laparoscopic access to the site of a hernia without penetrating the peritoneum. A piece of mesh is shown being held in place over the site of the hernia by the retraction device.
• FIG. 20B is a transverse cross sectional elevational view of the lower abdomen showing a retraction device according to the invention in its fully inflated condition holding a piece of mesh in position on the inside of the peritoneum over the site of the hernia.
• FIG. 21 is a perspective view of a retraction device according to the invention with a piece of mesh attached to the outer surface of the main envelope.
• FIG. 22A is an exploded perspective view of the components of a polygonal Type IA retraction device illustrating the construction of such a device according to the invention.
• FIG. 22B is a plan view of the additional envelope blank of a polygonal Type IA retraction device.
• FIG. 23A is a perspective view of the additional envelope blank of a polygonal Type IA retraction device showing how a suction skirt according to the invention is formed from the additional envelope blank.
• FIG. 23B is a plan view of the additional envelope blank of a polygonal Type IA retraction device showing how a suction skirt according to the invention is formed from the additional envelope blank.
• FIG. 24A is an exploded perspective view of the components of a flat Type IA retraction device illustrating the construction of such a device according to the invention.
• FIG. 24B is a perspective view of the assembled and inflated flat Type IA retraction device.
• FIG. 25A is a perspective view of an inflated triangular prism-shaped Type IA retraction device according to the invention.
• FIG. 25B is a vertical cross sectional view of an inflated the assembled triangular prism-shaped Type IA retraction device according to the invention along theline25B-25B inFIG. 25A.
• FIG. 25C is an exploded perspective view of the components of a triangular prism-shaped Type IA retraction device illustrating the construction of such a device according to the invention.
• FIG. 25D is a plan view of the additional envelope blank of a triangular prism-shaped Type IA retraction device according to the invention.
• FIG. 26 is an exploded perspective view of the components of a polygonal Type II retraction device illustrating the construction of such a device according to the invention.
• FIG. 27 is an exploded perspective view of the components of a substantially hemispherical Type IA retraction device illustrating the construction of such device according to the invention.
• FIG. 28 is a cross sectional view of a substantially hemispherical Type IA retraction device.
DETAILED DESCRIPTION OF THE INVENTIONA.Inflatable Retraction Devices1. Type IA Retraction DeviceBasic Embodiment
• FIGS. 1,2, and3 show perspective, and vertical and horizontal cross sectional views, respectively, of afirst embodiment 1 of a retraction device according to the invention. This type of retraction device has an additional inflatable chamber and will be designated as a Type I retraction device. The Type I retraction device shown inFIGS. 1,2, and3 with a segmented additional chamber will be designated a Type IA retraction device. The retraction device is shown in its inflated condition. Theretraction device1 comprises amain envelope6 enclosing a maininflatable chamber11. Themain envelope6 is made of a relatively inelastic and tough film of a plastic such as Mylar®, polyethylene, or polyurethane. The preferred material for themain envelope6 is a polyethylene and nylon composite. The thickness of themain envelope6 is typically from 0.5 to 5 mils (13 to 130 microns). The proximal end of amain inflation tube16 is sealed into themain envelope6. Themain inflation tube16 allows an inflation gas to pass into and out of themain chamber11. The inflation gas is typically air, nitrogen or carbon dioxide, although other suitable gases may be used. Typical inflation gas pressures are in the range 0.3 to 0.7 pounds per square inch (psi) (0.21 to 0.48 kPa), the preferred pressure being 0.5 psi (0.35 kPa). Themain inflation tube16 is provided with aport51 on its distal end, through which endoscopes and/or surgical instruments can be passed into themain chamber11. Theport51 allows the inflation pressure of themain chamber11 to be maintained when surgical instruments are passed through the port.
• Themain envelope6 of the Type IA retraction device is a polyhedral structure constructed from two segmented, substantially flat pieces of plastic film, which gives the retraction device a substantially polyhedral shape. Alternatively, two non-segmented, substantially flat pieces of plastic film can be used to make a relatively flat Type IA retraction device. In a further alternative, the retraction device can be constructed from curved pieces of plastic film, which gives the retraction device a substantially spherical, spheroidal, or ellipsoidal shape.
• The size of retraction devices according to the invention can range from about 2″ (50 mm) wide by about 0.5″ (12 mm) high, for use inside the pericardium, to 10″-14″ (250-350 mm) wide by 4″-8″ (100-200 mm) high, for use in the abdominal cavity. The size of retraction device required for a given application depends on the application and the size of the patient.
• In the preferred embodiment, theadditional envelope21 is made from a film of the same thickness of the same plastic as themain envelope6. However, in some applications it may be advantageous make theadditional envelope21 from a film of a different thickness of the same plastic, or the same or a different thickness of a different plastic.
• Theperiphery26 of theadditional envelope21 is attached to the surface of themain envelope6. Theadditional envelope21 has a segmented shape such that, when itsperiphery26 is attached to themain envelope6, and theadditional chamber31 formed between the outside of themain envelope6 and the inside of theadditional envelope21 is inflated, theadditional chamber31 forms a cage structure inside or outside themain chamber11, as shown in the figures. When themain envelope6 is a polyhedral structure, the cage structure is preferably formed on the faces of the polyhedron. The parts of themain envelope6 that do not form part of the wall of theadditional chamber31 provide a plurality ofwindows46 that can be punctured to provide access for surgical instruments into and out of themain chamber11.
• Theadditional envelope21 is attached, preferably to the outer surface of themain envelope6, by welding along theperiphery26 of the additional envelope; alternatively, an adhesive may be applied to theperiphery26 of theadditional envelope21, and theadditional envelope21 brought into contact with themain envelope6. Other methods that produce a flexible, gas-tight seal between theperiphery26 of theadditional envelope21 and themain envelope6 may also be used.
• One end of anadditional inflation tube41 is sealed into theadditional envelope21. Theadditional inflation tube41 allows an inflation gas to pass into and out of theadditional chamber31. The inflation gas is typically air, nitrogen or carbon dioxide, although other suitable gases may be used. Typical inflation gas pressures are in the range 4 to 6 psi (2.8 to 4.1 kPa), the preferred pressure being 5 psi (3.5 kPa). The inflation gas pressure in the additional chamber is considerably higher than that in the main chamber to enable the additional chamber to exert sufficient force to keep already retracted organs in their retracted state despite the much smaller surface area of the additional chamber. Themain inflation tube16 is sealed through theadditional envelope21.
• In an embodiment of the Type I retraction device designed for use in an insufflated body cavity, themain inflation tube16 and theadditional inflation tube41 are contained within aninflation tube shield61, which forms a gas-tight seal with the retraction device. The outer wall of theinflation tube shield61 forms a gas-tight seal with the trocar or sheath through which it passes into the body cavity. Theinflation tube shield61 can be a separate component. Preferably, an extrusion can provide theinflation tube shield61, themain inflation tube16 and theadditional inflation tube41 in a unitary structure.
2. Type IA Retraction DeviceAlternative Embodiments
• The basic embodiment of a Type I retraction device has a singleadditional chamber31. In alternative embodiments,additional chamber31 is divided into a plurality of sub-chambers (not shown). The sub-chambers are isolated from one another, so that if one or more of them is accidentally punctured while the retraction device is in use, deflation of all of the retraction device can be avoided. Each sub-chamber can be equipped with its own additional inflation tube. Alternatively, each sub-chamber can be connected to an inflation manifold (not shown) through a non-return valve (not shown). This arrangement requires that each sub-chamber be deliberately punctured to deflate the retraction device in preparation for withdrawing the retraction device from the body at the end of the treatment procedure.
• In a further alternative embodiment of the Type IA retraction device, theadditional envelope21 may be attached to the inner surface of themain envelope6. In this embodiment, themain inflation tube16 passes through the additional chamber and forms a gas-tight seal with theadditional envelope21 in addition to themain envelope6.
• In a further alternative embodiment of the Type IA retraction device, theadditional envelope21 need not be segmented. Theadditional chamber31 is formed by attaching theadditional envelope21 to themain envelope6, the line of attachment forming the periphery of the cage structure of theadditional chamber31. With this arrangement, eachwindow46 comprises a double thickness of film. This makes it somewhat more difficult to cut an aperture in a window.
• In a further alternative embodiment providing a relatively flat Type IA retraction device shown inFIG. 248, neither themain envelope6 nor theadditional envelope21 are segmented. Theadditional envelope21 has a number of holes cut in it. Theadditional chamber31 is formed by attaching the periphery of each hole in theadditional envelope21 to themain envelope6.
• In a further alternative embodiment,FIGS. 25A,25B,25C, and25D show a Type IA retraction device in the shape of a triangular prism particularly suitable for use in the upper abdomen.
• In this embodiment, themain envelope6 and theadditional envelope21 are serrated rectangles, as shown inFIGS. 25C and 25D. The additional envelope has three large holes cut in it. Theadditional chamber31 is formed by attaching the periphery of each hole in theadditional envelope21 to themain envelope6. Opposite ends of the long axis of the rectangle and the serrations are joined together to form the triangular structure.
• All embodiments of the Type IA retraction device may be provided withtabs56 on the inside the main envelope in accordance with a further aspect of the invention, as shown inFIGS. 2 and 3. Thetabs56 may be separate components attached to the inside of themain envelope6 by welding, an adhesive, or some other suitable method. Alternatively, thetabs56 can be an integral part of themain envelope6 suitably extended into themain chamber11.Tabs56 provide points inside themain chamber11 that can be gripped by a suitable gripping tool (not shown) inserted intomain chamber11 through themain inflation tube16. The gripping tool allows the inflated retraction device to be manipulated to change its position so that, for instance, one of its windows can be aligned with the organ or tissue to be treated or observed. Partially deflating the inflated retraction device makes repositioning easier.
3. Type IA Retraction DeviceBasic Method of Use
• In the following description, the word “organ” will be used to mean an organ or a tissue that is retracted by the retraction device. The word “treat” will be used to mean both treat and observe, and the word “treatment” will be used to mean both treatment and observation. The word “tissue” or the phrase “tissue to be treated” will both be used to mean the organ or the tissue that is treated through or inside the retraction device.
• FIGS. 4A through 4D show a cross sectional elevational view of the abdomen A to illustrate the method by which a Type IA retraction device according to the invention is inserted into the body and used to retract an organ within the body to gain access to treat a tissue. In the method illustrated inFIGS. 354A through 4D, the retraction device is inserted into the abdomen A and is used to retract an organ, the bowel B, to gain access to treat a tissue, the gall bladder GB. Similar methods are used to insert a retraction device according to the invention into other parts of the body.
• Inflatable retraction device1 is supplied in a collapsed state, as shown inFIG. 4A, in which it is tightly packaged in a configuration that makes it essentially a linear extension of theinflation tube shield61. Theretraction device1 is packed so that when pressure is applied to themain inflation tube16, theretraction device1 deploys without tangling. Depending on the size of theretraction device1, the packaged retraction device will fit through an insertion tube (usually a trocar tube) of between 3 and 20 mm (0.12″-0.8″) in diameter, a typical diameter being 14 mm (0.55″). Theretraction device1 is retained in its collapsed state by thesleeve100 which, in turn, is held together by one-pull lacing105. Alternatively, thesleeve100 can be fitted with a tear-off strip (not shown). Pulling on thethread125 detaches the one-pull lacing105 or the tear-off strip from thesleeve100, releasing thecollapsed retraction device1.
• Thesleeve100 can be provided withsuitable markings115 to enable its orientation to be determined and, if necessary, adjusted, after insertion into the body and before inflation.
• Prior to starting the procedure, the abdomen A may be lifted to provide additional working space by gas insufflation, or by one of the mechanical devices disclosed in U.S. patent application Ser. No. 706,781, of which application this application is a Continuation-in-Part. The insufflated condition of the abdomen A is indicated by the broken line A′.
• A small incision is made in the skin of the abdomen A and a trocar (not shown) andtrocar tube120 are inserted into the incision and are driven through the wall of the abdomen A. The trocar is withdrawn. A second small incision is made in the skin of the abdomen A and a trocar (not shown) andtrocar tube122 are inserted into the incision and driven through the wall of the abdomen. The trocar is withdrawn and anendoscope110 is inserted into thetrocar tube122. The second incision is located so that theendoscope110 can observe the intended placement site of theretraction device1. Alternatively, a small endoscope (not shown), preferably about 2 mm (0.1″) in diameter, may be attached to the collapsed retraction device so that the location of the retraction device inside the abdomen may be determined. With this approach, theendoscope110 is not used, and the second incision need not be made.
• Thecollapsed retraction device1 is threaded, with the aid of itsinflation tube shield61, through thetrocar tube120 into the abdominal cavity AC, as shown inFIG. 4B, and manipulated into its correct position. The position ofcollapsed retraction device1 in the abdominal cavity AC is observed through the endoscope110: themarkings115 enable the orientation ofretraction device1 to be determined and adjusted if necessary. Alternatively, the position of the collapsed retraction device is determined by means of the small endoscope (not shown) attached to the retraction device.
• Thethread125 is then pulled to release thesleeve100 from around collapsedretraction device1, and the sleeve101 is withdrawn from the abdominal cavity AC through thetrocar tube120 by means of thethread125.
• Once theretraction device1 is correctly positioned, and released from itssleeve100, themain inflation tube16 is connected to a source of inflation gas (not shown) and the gas supply is slowly turned on to inflate themain chamber11. Theretraction device1 slowly expands, as shown inFIG. 4C, progressively displacing the bowel B as its size increases. Throughout the expansion process, theretraction device1 presents a relatively large surface area to the bowel B, and thus displaces the bowel B gently, progressively, and without trauma. Although theretraction device1 retracts the bowel B gently, the main chamber of the retraction device is capable of exerting the force necessary to effect the displacement the bowel B.
• Once theretraction device1 has reached its fully-inflated condition, its position is checked by viewing it through theendoscope110 and/or an endoscope (not shown) inserted into itsmain chamber11 via themain inflation tube16 and theport51. The tissue to be treated must be covered by one of thewindows46 ofretraction device1.
• If theretraction device1 is not correctly positioned, the inflation gas pressure is reduced slightly to partially deflateretraction device1. A suitable gripping tool is passed through theport51 and themain inflation tube16 into the interior of theretraction device1, to grip one of the tabs56 (FIGS. 2 and 3). The gripping tool is manipulated to correct the positioning error while the position of theretraction device1 is observed through theendoscope110 or the endoscope (not shown) in themain chamber11. Once the error is corrected, themain chamber11 of theretraction device1 is reinflated by means of themain inflation tube16.
• Once theretraction device1 is correctly positioned, theadditional inflation tube41 is connected to a source of inflation gas (not shown) and theadditional chamber31 is inflated to the required pressure, as shown inFIG. 4D. After theadditional chamber31 is fully inflated, the source of inflation pressure can be removed from themain chamber11 and themain inflation tube16. Theport51 can be removed from themain inflation tube16 since a gas-tight seal is no longer required around instruments inserted into themain inflation tube16, themain chamber11 now being at atmospheric pressure.
• A cuttinginstrument52 is then passed through themain inflation tube16 into themain chamber11 to cut asuitable aperture54 in thewindow46 that covers of the tissue to be treated, as shown inFIG. 5. Alternatively, an additional puncture may be made in the abdominal wall and a cuttinginstrument62 passed through this puncture to cut anaperture54A in awindow58 to gain access to themain cavity11, and thence to cut asuitable aperture54 in thewindow46. Theaperture54 provides an access to the tissue to be treated; for example, the gall bladder GB. Theaperture54 may simply be a cut in thewindow46, or all or part of thewindow46 may be removed to provide theaperture54. Those procedures that are carried out using instruments passed through theaperture54 in thewindow46 require that more of thewindow46 be removed than those procedures in which the tissue to be treated is pulled inside the retraction device. When the tissue to be treated is treated inside the retraction device, the periphery of theaperture54 through which the tissue is pulled may form a seal around the tissue and isolate it from the body outside the retraction device.
• If the main inflation tube is not conveniently placed relative to the tissue to be treated, or if more surgical instruments than can be accommodated by themain inflation tube16 are needed to perform the treatment, an alternative way of passing instruments into themain chamber11 is to make at least one further incision in the body wall, the further incision being made in a location adjacent afurther window58 of the retraction device, as shown inFIG. 5. A trocar (not shown) with tube60 is inserted into the further incision and is driven through the body wall to pierce thefurther window58. The trocar is withdrawn leaving the trocar tube60 in place. Instruments, e.g.,instrument62 are then inserted into the retraction device as required through the trocar tube60 and thefurther window58.
• FIG. 5 additionally shows theretraction device1 in place in the abdominal cavity AC in its fully inflated form. Themain chamber11 is not pressurized; the shape of the retraction device is maintained by the inflatedadditional chamber31. InFIG. 5,retraction device1 was placed before inflation such that when themain chamber11 was inflated, the expansion of theretraction device1 displaced the bowel B to the right of the drawing and lifted the liver L upwards to expose the tissue to be treated, i.e., the gall bladder GB.
• After the treatment is completed, theadditional chamber31 is disconnected from the source of inflation pressure and the pressure in theadditional chamber31 is released to collapse the retraction device. Collapsing the retraction device is assisted by connecting theadditional inflation tube41 to a vacuum line (not shown) to evacuate theadditional chamber31. Once theretraction device1 is fully collapsed, thetrocar tube120 is withdrawn from the abdominal cavity, theretraction device1 is withdrawn through the small abdominal opening, and the openings in the abdominal wall are closed in the normal way.
4. Type II Retraction DeviceBasic Embodiment
• FIG. 6 shows analternative embodiment201 of a retraction device that maintains its shape while allowing treatment to be carried out working through or inside it. The alternative embodiment lacks the second inflatable chamber of the Type I embodiment shown inFIGS. 1 through 5, and has only amain envelope206 enclosing amain chamber211. The single chamber embodiment of the retraction device will be designated as a Type II retraction device. Themain chamber211 remains inflated throughout the treatment process, access to the tissue to be treated being provided by anelastomeric window261 attached to themain envelope206. Theelastomeric window261 is self-sealing and maintains inflation pressure in themain chamber211 by forming a substantially gas-tight seal around instruments passed through it. Theelastomeric window261 also forms a substantially gas-tight seal around the tissue to be treated if the tissue to be treated is pulled through theelastomeric window261 into themain chamber211 for treatment.
• Themain envelope206 is made of a relatively inelastic and tough film of a plastic such as Mylar®, polyethylene, or polyurethane. The preferred material for the main envelope is a polyethylene and nylon composite. The thickness of themain envelope206 is typically from 0.5 to 5 mils (13 to 130 microns). The proximal end of amain inflation tub216 is sealed into themain envelope206. Themain inflation tube216 allows an inflation gas to pass into and out of themain chamber211. The inflation gas is typically air, nitrogen or carbon dioxide, although other suitable gases may be used. Typical inflation gas pressures are in the range 0.3 to 0.7 psi (0.21 to 0.48 Pa), the preferred pressure being 0.5 psi (0.35 kPa). Once themain chamber211 is fully inflated, the inflation gas pressure can be reduced to about 0.3 psi (0.21 kPa). Themain inflation tube216 is provided with aport251 on its distal end, through which endoscopes and other surgical instruments can be passed into themain chamber211. Theport251 provides a gas-tight seal around instruments passed through it and allows inflation pressure to be maintained in themain chamber211 with instruments present.
• Themain envelope206 of the Type II retraction device shown inFIG. 6 is a polyhedral structure constructed from two segmented, substantially flat pieces of plastic film, which gives the retraction device a substantially polyhedral shape. Alternatively, two non-segmented substantially flat pieces of plastic film can be used to make a relatively flat Type II retraction device. In a further alternative, the retraction device can be constructed from curved pieces of plastic film, which gives the retraction device a substantially spherical or spheroidal shape.
• The size of Type II retraction devices according to the invention can range from about 2″ (50 mm) wide by about 0.5″ (12 mm) high, for instance for use inside the pericardium, to 10″-14″ (250-350 mm) wide by 4″-8″ (100-200 mm) high, for use in the abdominal cavity. The size of retraction device required for a given application depends on the application and the size of the patient.
• The lack of a additional chamber in theretraction device201 shown inFIG. 6 makes orientation less critical. If themain envelope206 is constructed from one or two curved pieces of film, orientation is particularly uncritical. If themain envelope206 is a polyhedral structure having a number of faces, some orientation is required because the tissue to be treated must be substantially centered on one of the faces. Theretraction device201 can be provided withtabs256 on the inside themain envelope206.Tabs256 may be separate components attached to the inside of themain envelope206 by welding, an adhesive, or some other suitable method. Alternatively,tabs256 can be an integral part of themain envelope206 suitably extended into themain chamber211.Tabs256 provide points on the inside of themain chamber211 that can be gripped by a suitable gripping tool (not shown) inserted intomain chamber211 through theinflation tube216 andport251. The gripping tool allows theinflated retraction device201 to be manipulated to change its position so that the desired point on the tissue to be treated can be substantially centered on one of its faces. Partially deflating the inflated retraction device makes repositioning easier.
• Theelastomeric window261 is installed on the inside of themain envelope206 aft theretraction device201 has been placed in the body and inflated. Theelastomeric window261 is shown inFIG. 7 and comprises aflat piece266 of a film of an elastomeric material such as latex or silicone rubber about 0.5″ to 1.5″ (12 to 37 mm) in diameter. The periphery of theelastomeric film266 is attached by means of a suitable adhesive, such as an acrylic cement or a silicone adhesive to one of the flat faces of aring271 having a square or rectangular cross section. Thering271 is circular or elliptical in shape and is of a springy material such as polyethylene or stainless steel, so that will regain its circular or elliptical shape after being compressed across one of its diameters to enable it to be passed through theinflation tube216. The otherflat face276 of thering271 is coated with an adhesive. A pressure-sensitive adhesive such as a contact rubber adhesive may be used. In the preferred embodiment a hot-melt adhesive of the type used in woodworking glue guns is used. If a hot-melt adhesive is used, aheating element281, made of a suitable resistance wire, such as Nichrome, is inserted into a narrow groove in theface276 of thering271 to which the adhesive is applied. Suitableelectrical leads291 are connected to theheating element281.
• Before it can be inserted into theretraction device201, the elastomeric window must be wrapped across one of its diameters to reduce its width so that it can pass through themain inflation tube216, as shown inFIG. 8. A one-pull lacing arrangement205, or a sleeve with a tear strip (not shown) can be used. Wrappedelastomeric window261 is attached to amanipulation rod286 for insertion into the retraction device. Also attached to the manipulation rod is the thread225 to release the one-pull lacing205 or the tear strip (not shown) and, if a temperature-sensitive adhesive is used, theelectrical leads291 for the heating element281 (FIG. 7).
• The wrappedelastomeric window261 on the end of the manipulatingrod286 is passed through theport251 and themain inflation tube216 into themain chamber211. The lacing205 or tear-strip is released, which allows theelastomeric window261 to resume its circular shape. Theelastomeric window261 is then manipulated to bring it into contact with themain envelope206 such that theelastomeric window261 covers the tissue to be treated. If a pressure-sensitive adhesive is used, theface276 of the elastomeric window is pushed against themain envelope206 to affix theelastomeric window261 in place. If a hot-melt adhesive is used, theface276 of the elastomeric window is placed against themain envelope206 and a suitable source of electric current (not shown) is applied to theelectrical leads291 for the time required to melt the adhesive and affix theelastomeric window261 to themain envelope206.
• Once theelastomeric window261 is firmly affixed to themain envelope206, the manipulatingrod286 is detached from it and withdrawn from themain chamber211. Asuitable cutting instrument252 is passed through theport251 and themain inflation tube216 into themain chamber211 and through theelastomeric window261, as shown inFIG. 6. Theelastomeric window261 forms a gas-tight seal around the cuttinginstrument252, and re-seals itself after thecutting instrument252 is withdrawn. The cuttinginstrument252 is used to cut an aperture in thepart296 of themain envelope206 that is covered by theelastomeric window261. Thepart296 of themain envelope206 is shown by shading inFIG. 9. Theaperture254 may simply be a cut in thepart296 of theenvelope206, or all or part of thepart296 of theenvelope206 may be removed to provide theaperture254. Procedures that are carried out using instruments passed through theelastomeric window261 require removing more of thepart296 of theenvelope206 than procedures in which the tissue to be treated enters the retraction device through theaperture254 and theelastomeric window261. When the tissue to be treated is treated inside theretraction device201, theelastomeric window261 forms a seal around the tissue and isolates it from the body outside the retraction device. The treatment procedure is then carried out by inserting instruments through theport251 and themain inflation tube216 into themain chamber211 and either working through theelastomeric window261 or working on the tissue to be treated inside thecavity211.
5. Type II Retraction DeviceBasic Method of Use
• Theretraction device201 is inserted into the abdomen using a procedure similar to that used to insert a Type IA retraction device.Inflatable retraction device201 is supplied in a collapsed state, as shown inFIG. 10A, in which it is tightly packaged in a configuration that makes it essentially a linear extension of themain inflation tube216. Theretraction device201 is packed so that when inflation pressure is applied to themain inflation tube216,retraction device201 deploys without tangling. Depending on the size of theretraction device201, the packaged retraction device will fit through an insertion tube of between 3 and 20 mm (0.12″-0.8″) in diameter, a typical diameter being 14 mm (0.55″). Theretraction device201 is retained in its collapsed state by asleeve100 which, in turn, is held together by one-pull lacing105 or a tear strip (not shown).
• Thesleeve100 can be provided withsuitable markings115 to enable its orientation to be determined and, if necessary, adjusted, after insertion into the abdomen and before inflation.
• Prior to inserting the retraction device, the abdomen A may be lifted to provide additional working space by gas insufflation, or by one of the mechanical devices disclosed in U.S. patent application Ser. No. 706,781, of which application this application is a Continuation-in-Part. The insufflated state of the abdomen A is indicated by the broken line A′.
• A small incision is made in the skin of the abdomen A and a trocar (not shown) andtrocar tube120 are inserted into the incision and are driven through the wall of the abdomen A. The trocar is withdrawn. A second small incision is made in the skin of the abdomen A and a trocar (not shown) andtrocar tube122 are inserted into the incision and driven through the wall of the abdomen. The trocar is withdrawn and anendoscope110 is inserted into thetrocar tube122. The second incision is located so that theendoscope110 can observe the intended placement site of theretraction device1. Alternatively, a small endoscope (not shown), preferably about 2 mm (0.1″) in diameter, may be attached to the collapsed retraction device so that the location of the retraction device inside the abdomen may be determined. With this approach, theendoscope110 is not used, and the second incision need not be made.
• Thecollapsed retraction device201 is threaded, with the aid of itsmain inflation tube216, through thetrocar tube120 into the abdomen A, and manipulated into its correct position. The position ofcollapsed retraction device201 is observed through the endoscope110: themarkings115 enable the orientation of the retraction device to be determined and adjusted if necessary. Alternatively, the position of the collapsed retraction device is determined by means of the small endoscope (not shown) attached to the retraction device.
• Thethread125 is then pulled to release thesleeve100 from around thecollapsed retraction device201, as shown inFIG. 10B, and thesleeve100 is withdrawn from the abdominal cavity AC through thetrocar tube120 by means of thethread125. Themain inflation tube216 is connected to a source of inflation gas (not shown). The inflation gas pressure is slowly increased to inflate themain chamber211. Theretraction device201 slowly expands, progressively displacing the bowel B as its size increases, as shown inFIG. 10C. Throughout the expansion process, theretraction device201 presents a relatively large surface area to the bowel B, and thus displaces the bowel gently, progressively, and without trauma. Although theretraction device201 retracts the bowel B gently, the main chamber of theretraction device201 is capable of exerting the force necessary to effect the displacement of the bowel.
• Onceretraction device201 has reached its fully-inflated condition, its position is checked by viewing it through either theendoscope110 and/or an endoscope (not shown) inserted into themain chamber211 of theretraction device201 via theport251 and themain inflation tube216. The tissue to be treated should be in contact with themain envelope206 and lie substantially directly in line with themain inflation tube216. Further, if the retraction device is a polyhedron, the tissue to be treated should be substantially centered in one of its faces. The position of theretraction device201 can be adjusted by gripping one or more of thetabs256 with a suitable gripping tool (not shown), as described above. Once theretraction device201 is correctly positioned, theelastomeric window261 may be installed as described above.FIG. 10D shows theretraction device201 in its fully inflated state with theelastomeric window261 installed, and theinstrument252 passed through theelastomeric window261 and theaperture254 in themain envelope206 to treat the tissue to be treated, the gall bladder, GB.
• After the treatment is completed, themain chamber211 is disconnected from the source of inflation pressure and the pressure in themain chamber211 is released to collapse the retraction device. Collapsing the retraction device is assisted by connecting themain inflation tube216 to a vacuum line (not shown) to evacuate themain chamber211. Once fully collapsed, theretraction device201 is withdrawn from the abdominal cavity through the opening in the abdominal wall that remains after withdrawing thetrocar tube120. Theelastomeric window261 is sufficiently flexible to be withdrawn through the opening in the abdominal wall along with theretraction device201. The openings in the abdominal wall are then closed in the normal way.
6. Type IB Retraction Device
• A further embodiment of the invention, which is a variation on the Type I retraction device, designated Type IB, is shown inFIGS. 11A,11B, and11C. This variation has the advantage of providing two large, flat windows, but has the disadvantage that it does not allow any access to tissues lying to the side of the retraction device. Theretraction device301 shown inFIGS. 11A and 11B is substantially cylindrical in shape. A stack of one or more toroidal chambers forms the additional chamber331. The example shown inFIGS. 11A and 11B has 3toroidal chambers325,327 and329. Alternatively, as shown inFIG. 11C, a singlechamber having sidewalls333 that are tacked together can be used for the additional chamber331. In this alternative embodiment, the tacked sidewalls form an enclosure having a height that is considerably greater than its width. InFIGS. 11A,11B, and11C, thediaphragms307 and309 cover the top and bottom, respectively, of theretraction device301. Thediaphragms307 and309, together the inner walls of thetoroidal chambers325,327, and329, form themain chamber311.
• Themain inflation tube316 is sealed into themain chamber311 and allows the main chamber to be inflated. Theadditional inflation tube341 is sealed into the additional chamber331. If more than one toroidal chamber is used to provide the additional chamber, the toroidal chambers may be interconnected and a singleadditional inflation tube341 used, or each toroidal chamber may be provided with its own additional inflation tube (not shown). The latter approach prevents theretraction device301 from collapsing completely if one of thetoroidal chambers325,327, or329 is accidentally punctured, and also allows the height of the retraction device to be adjusted by selectively inflating thetoroidal chambers325,327, or329.
• The Type IB retraction device shown inFIGS. 12 and 13 is constructed from similar materials to the Type IA retraction device, and may be fitted withtabs356, similar totabs56 in the Type IA retraction device, to enable it to be properly positioned after inflation. A similar procedure is used to deploy the Type IB retraction device in the body as is used to deploy the Type IA retraction device, and will not be described in detail. A similar inflation procedure is used, except that the additional chamber may be inflated at least partially at the same time as the first cavity is inflated. The Type IB retraction device depends more for its shape on the additional chamber than the Type IA retraction device. Hence, at least partial inflation of the additional chamber is necessary to enable the retraction device to displace organs to the side of the retraction device. Inflation pressures similar to those used for the Type IA retraction device are used.
• Treatment procedures using the Type IB retraction device are similar to those using the Type IA retraction device, except that the Type IB retraction device does not provide access to tissues to the side of the device. Thediaphragms307 and309 are analogous to the windows46 (FIG. 1) of the Type IA retraction device. Either or both of the windows provided by thediaphragms307 and309 may be pierced to provide apertures though which treatment may be carried out, or through which the tissue to be treated may be brought into the retraction device for treatment, or through which instruments may be passed into and out of themain chamber311.
7. Flexible Sheaths
• A further aspect of the invention is the provision in a retraction device according to the invention, of one or more flexible sheaths to interconnect the main chamber of the retraction device and the outside of the body into which the retraction device is inserted. The flexible sheath provides a tract through the body wall that allows additional surgical instruments or endoscopes to be introduced into the main chamber of the retraction device, and/or allows tissue and the like to be removed. In one embodiment of this aspect of the invention, the flexible sheath is attached to a window of a Type I retraction device or to the main envelope of a Type II retraction device.FIG. 12A shows a flexible sheath according to the invention attached to awindow46 of a TypeIA retraction device1, which is shown as an example. A flexible sheath according to this aspect of the invention can also be used with Type IB and Type II retraction devices. Theflexible sheath3 is substantially cylindrical in shape with a closeddistal end8. Theproximal end13 of the flexible sheath is attached to the outer surface of thewindow46. The sidewall18 of theflexible sheath3 is folded concertina-style when the retraction device is packaged, and remains folded after the retraction device has been inflated. After theretraction device1 has been deployed in the body, as shown inFIG. 12B, a suitablepointed tool23 is fed into themain chamber11 to pierce ahole28 in the part of thewindow46 that is covered by theflexible sheath3. Thepointed tool23 is pushed through thehole28 to engage with thedistal end8 of theflexible sheath3. Thedistal end8 is first pressed against the inner surface of the body wall W using the pointedtool23. The resulting bulge in the skin S on the outside of the body indicates where theflexible sheath3 will emerge. Asmall incision33 is made in the skin S at that point. Theflexible sheath3 is then driven by the pointedtool23 through the body wall W to emerge through theincision33.
• With a Type I retraction device, thedistal end8 of theflexible sheath3 is then opened to provide access to themain chamber11. The flexible sheath does not have to be gas-tight in the manner of conventional trocar sheaths, and permits ordinary surgical instruments to be used.
• With a Type II retraction device, the flexible sheath is fitted with a gas-tight port similar to the port251 (FIG. 6) before thedistal end8 is opened.
• The alternative embodiment of aflexible sheath43 according to the invention, shown inFIG. 12C, is not initially attached to the retraction device. A TypeIA retraction device1 is shown inFIG. 12C as an example. A flexible sheath according to this aspect of the invention can also be used with Type IB and Type II retraction devices. Theflexible sheath43 comprises a cylindrical piece of flexible plastic48 with acoaxial locking device53 on its proximal end. The distal end of the flexible sheath for a Type II retraction device must be closed by a port (not shown) similar to the port251 (FIG. 6) so that pressurization of the main cavity can be maintained after theflexible sheath43 has been installed.
• Theflexible sheath43 is installed after theretraction device1 has been deployed in the body. Asmall incision58 is made in the skin S of the body. Theflexible sheath43 is then driven through the body wall W by a sharp trocar point (not shown). The trocar point pierces ahole63 in thewindow46 of theretraction device1, and pushes thelocking device53 of theflexible sheath43 through thehole63 to engage thelocking device53 with thewindow46. When used with a Type II retraction device, the lockingdevice53 forms a gas-tight seal with thewindow46.
8. Suction Skirt
• According to a further aspect of the invention, a retraction device according to the invention may be fitted with a tubular suction skirt on the part of the retraction device that is lower-most when the retraction device is deployed in the body.FIGS. 13A and 13B show, as an example, a polygonal Type 1A retraction device of the type used in the abdominal cavity. The suction skirt of this aspect of the invention can be used with other type I and type II retraction devices.
• Irrigation is often used during surgery to clear away bleeding or blood clots. This fluid collects in the bottom of the cavity in the body created by the retraction device and needs to be cleared away. Thesuction skirt12 on the bottom of the retraction device is connected to a suction line and removes such fluid during the treatment procedure, keeping the cavity clear of accumulated fluids. In the example shown, the suction skirt is a tubular appendage attached to the lower-most extremity of the retraction device. In the retraction device shown inFIGS. 13A and 13B, the suction skirt is formed from part of theadditional envelope21 around thebottom window46. The bottom or sides of the suction skirt is pierced with between six and twelveholes17. In the embodiment shown, the suction skirt is about ¼″ (6.2 mm) in diameter, and theholes17 are about ⅛″ (3.1 mm) in diameter.
• The suction skirt is made of the polyethylene-nylon composite that is the preferred material for themain envelope6 of the retraction device. This material is sufficiently resilient that a tubular structure made from it can retain its open cross section under a low vacuum. One end of the suction skirt is closed; the other is connected to a thin-wall polyethylene tube22 that runs up the side of the retraction device to exit the body through the same incision as is used for the inflation tubes. If, as is shown inFIGS. 13A and 13B, the retraction device is used in an insufflated body cavity, thesuction skirt tube22 passes inside theinflation tube sheath61. The distal end of thesuction skirt tube22 has attached to it a connector suitable for attaching to an operating room suction line.
B. Surgical Procedures Using Inflatable Retraction Devices
• 1. Retracting the Bowel to Provide Anterior Access to the Spine, the Aorta, the Kidneys, Etc.
• The method according to the invention of using a retraction device according to the invention in a procedure to perform an anterior resection of a herniated intervertebral disc is illustrated inFIG. 14. A method can be adapted to gain anterior access to the aorta, the kidneys, and other tissues that lie outside the peritoneum.FIG. 14A shows a longitudinal cross section of the body; andFIG. 14B shows a transverse cross section along theline14B-14B inFIG. 14A. Anterior access to the spine is normally difficult due to the difficulty of retracting the overlying bowel using conventional laparoscopic retractors. A Type I or a Type II retraction device according to the invention is used according to the invention to retract the bowel by forming asmall incision420 in the abdominal wall W and inserting a trocar (not shown) withtrocar tube430 into theincision420 and driving the trocar into the abdominal cavity AC. The trocar is removed and theretraction device401 is passed through thetrocar tube430 into the abdominal cavity AC in its contracted state with the aid of its inflation tube or inflation tube shield (theinflation tube shield461 of a Type IA retraction device is shown). After insertion and orientation, themain chamber411 of theretraction device401 is inflated with a suitable inflation gas passed thoughinflation tube416. During the inflation process, the relatively large surface area of themain chamber411 of the retraction device gently retracts thebowel431, either upwards or downwards, depending on the position of the disc to be treated. The positioning of the retraction device is checked and adjusted, if necessary, as previously described.
• If a Type I retraction device is used, it must be positioned such that the disc that it is desired to treat is centered in one of its windows. Theadditional chamber431 is inflated, and the inflation gas pressure in the411 main chamber is released. The inflated additional chamber maintains the shape of the retraction device.
• If a Type II device is used, an elastomeric window (not shown) is installed, as previously described, on the inside of the main envelope in a position that will provide access to the disc to be treated.
• Themain envelope406 of both types of retraction device can then be pierced, and partially removed, if necessary. An incision is made in the peritoneum exposed by the retraction device to gain access to and to resect the disc to be treated.
• One or more flexible sheaths may be inserted through the abdominal wall to provide access to the interior of the retraction device for surgical instruments. If a Type I retraction device is used, normal surgical instruments may be used, and such tools may be freely manipulated in the space created by the retraction device. Because the main chamber of the retraction device is not under pressure, there is no need to use laparoscopic instruments through rigid trocar tubes.FIGS. 14A and14B show instrument452 passed from outside the body through themain inflation tube416 into themain chamber411. Theinstrument452 passes out of themain chamber411 through an aperture (not shown) pierced in the window446.
• Once treatment has been completed, the retraction device is deflated and removed from the body, and the small incisions in the abdominal wall repaired, as already described.
• 2. Retracting the Pericardium
• A procedure according to the invention in which a small, oblate version of a Type I or Type II retraction device according to the invention is used to displace thepericardium403 from theheart408 is shown inFIG. 15, which shows a transverse cross section of the chest. Displacement of the pericardium allows theouter surface413 of theheart408 to be observed, and such procedures as endocardial mapping, ablation, transmyocardial revascularization, and defibrillation to be carried out. These procedures have until now been difficult to do laparoscopically because access to the surface of theheart408 is obstructed by thepericardium403.
• In the procedure according to the invention, asmall puncture418 is made in thechest wall423 and through thepuncture418, asmall incision428 is made in thepericardium403. An introducer tube (not shown) is inserted to connect thepericardial cavity453 to outside the patient. Aretraction device401 according to the invention is inserted using its inflation tubes (themain inflation tube416 is shown) through the introducer tube into thepericardial cavity453 so that it rests between thesurface413 of the heart and thepericardium403. Theretraction device401 is then released from its packing (not shown), as described above, and itsmain chamber411 is inflated. During the inflation process, themain envelope406 of the retraction device gently displaces theheart408 from thepericardium403. The position of the retraction device is checked and, if necessary, adjusted.
• If a Type I retraction device is used, it must be positioned such that the part of the heart that it is desired to treat is centered in one of its windows. Theadditional chamber431 is then inflated and the inflation pressure removed from the main chamber.
• If a Type II device is used, an elastomeric window is installed, as previously described, on the inside of the main envelope in a position that will provide access to the part of the heart to be treated.
• Once the retraction device is in position, the introducer tube (not shown) can be withdrawn and themain inflation tube416 used as a path for endoscopes and instruments to pass in to the main chamber of the retraction device.
• 3. Retracting the Pleura
• FIG. 15 shows anendoscope433 passed through themain inflation tube416 to observe theouter surface413 of the heart.FIG. 15 also shows aninstrument probe438 that has been passed through thechest wall423 to contact thesurface413 of the heart. Theinstrument probe438 is passed through thepericardium403 and themain chamber411 of theretraction device401, piercing afirst window443 and asecond window448 of the retraction device. After the treatment is completed, the retraction device is withdrawn from the pericardial cavity, as already described, and the small incisions in the pericardium and the chest wall are repaired.
• FIG. 16 shows a further procedure according to the invention in which a retraction device according to the invention is used in the pleural cavity to retract the lung from the pleura to allow observation and manipulation.FIG. 16A shows a vertical cross sectional view of the chest andFIG. 16B shows a transverse cross section along the line168-16B inFIG. 16A. A small, oblate version of a Type I or TypeII retraction device401 according to the invention is used to displace thelung402 from thepleura407 to allow resection of alobe412 of thelung402.
• In the procedure, asmall incision417 is made in thechest wall423 and, through theincision417, a trocar (not shown) is inserted to connect thepleural cavity432 to outside the patient. The trocar point (not shown) is removed leaving the trocar tube (not shown) connecting thepleural cavity432 to outside the patient. Aretraction device401 according to the invention is inserted using its inflation tubes (inflation tube416 is shown) through the trocar tube into the pleural cavity, so that it rests between the surface of thelung402 and thepleura407. Theretraction device401 is then released from its packing (not shown), as described above, and itsmain chamber411 is inflated. During the inflation process themain envelope406 of the retraction device gently displaces thelung402 from thepleura407. The position of the retraction device is checked and, if necessary, adjusted.
• If a Type I retraction device is used, it must be positioned such that the part of the lung that it is desired to treat is centered in one of its windows. Theadditional chamber431 is then inflated and the inflation pressure removed from themain chamber411.
• If a Type II device is used, an elastomeric window is installed, as previously described, on the inside of the main envelope in a position that will provide access to the part of the lung to be treated.
• Once the retraction device is in position, the trocar tube (not shown) can be withdrawn and themain inflation tube416 used as a path for endoscopes and instruments to pass to the inside of the retraction device.
• FIG. 16 shows anendoscope433 passed through themain inflation tube416 into the main chamber of theretraction device401. In the embodiment of theretraction device401 shown, themain inflation tube416 enters themain chamber411 through afirst window443. Part of asecond window448 has been removed, as already described, to allow apart437 of thelung402 to enter themain chamber411 of retraction device for treatment. Atrocar tube447 passes through thechest wall423 and enters the retraction device by piercing athird window452, and aninstrument442 is passed through thetrocar tube447 to section part of thelung437. The part of thewindow448 that has not been removed forms a seal around thepart437 of the lung inside the retraction device, and prevents sectioned tissue from entering the pleural cavity. After the treatment of the lung is completed, the retraction device is withdrawn from the pleural cavity, as already described, and the small incisions in the pleura and the chest wall are repaired.
• 4. Retracting a Lobe of the Lung
• In a further procedure according to the invention, a retraction device according to the invention is used to retract one lobe of a lung in a lobectomy. This is shown inFIG. 17, which shows a longitudinal cross section of the chest. The lobes of the lung overlay one another: in performing a lobectomy, access to the hilar portion of the bronchial tree is required so that the branches of the bronchial tree feeding the lobe to be sectioned can be occluded. A Type IA or TypeII retraction device401 according to the invention is used to displace thelobe404 away from the rest of thelung409 to provide access to the bronchial tree414.
• In the procedure, asmall incision419 is made in thechest wall423, and through theincision419, a trocar (not shown) is inserted through thechest wall423 andpleura429. The trocar (not shown) is removed and the trocar tube is maneuvered to place its distal end between thelobe404 and the rest of thelung409. Aretraction device401 according to the invention is inserted using its inflation tubes (inflation tube416 is shown) through the trocar tube into position between thelobe404 and the rest of thelung409. Theretraction device401 is then released from its packing (not shown), as described above, and itsmain chamber411 is inflated. During the inflation process, themain envelope406 of the retraction device gently displaces thelobe404 away from the rest of thelung409. The position of the retraction device is checked and, if necessary, adjusted.
• If a Type I retraction device is used, it must be positioned such that the part of the bronchial tree that it is desired to occlude is centered in one of its windows. Theadditional chamber431 is then inflated and the inflation pressure removed from the main chamber.
• If a Type II retraction device is used, a elastomeric window (not shown) is applied to the inside of themain chamber411 in a position such that the part of the bronchial tree that it is desired to occlude can accessed through the elastomeric window.
• With both types of retraction device, an aperture is cut in themain envelope406 through which the procedure for occluding a part of the bronchial tree can be carried out using instruments passed into themain chamber411 through theinflation tube416. Additional instruments can be inserted into the main chamber through flexible sheaths (not shown) and/or, in a Type I retraction device, through apertures pierced in other windows (not shown) of themain envelope406. After the bronchial tree has been occluded, the retraction device is deflated and withdrawn, as already described, from between thelobe404 and the rest of thelung409. The procedure for sectioning the lobe is carried out before the small incisions in the pleura and the chest wall are repaired.
• 5. Retracting the Liver to Gain Access to the Gastroesophageal Junction
• Another procedure according to the invention is shown inFIG. 18. It is necessary to gain access to the gastroesophageal junction between thestomach405 and theesophagus410 to be able to section the vagus nerve, or to treat gastroesophageal reflux. The gastroesophageal junction is normally obscured by the liver415, which must be retracted provide access for treating this area. A Type I or TypeII retraction device401 according to the invention is used to displace the liver415 away from theesophagus410. According to the procedure, asmall incision420 is made in theabdominal wall425. A trocar (not shown) and trocar tube440 is inserted through theincision420 and is driven through theabdominal wall425 into the abdominal cavity AC and the trocar is removed. The trocar tube is maneuvered to place its distal end between the liver415 and theesophagus410. Aretraction device401 according to the invention is inserted using its inflation tubes (inflation tube416 is shown) through the trocar tube into position between the liver415 and theesophagus410. Theretraction device401 is then released from its packing (not shown), as described above, and itsmain chamber411 is inflated. During the inflation process themain envelope406 of the retraction device gently displaces the liver415 away from theesophagus410. The position of the retraction device is checked and, if necessary, adjusted.
• If a Type I retraction device is used, it must be positioned such that the gastroesophageal junction is centered in one of its windows. Theadditional chamber431 is then inflated and the inflation pressure removed from the main chamber.
• If a Type II retraction device is used, a elastomeric window (not shown) is applied to the inside of themain chamber411 in a position such that the gastroesophageal junction can accessed through the elastomeric window.
• With both types of retraction device, an aperture is cut in themain envelope406 through which the treatment procedure can be carried out using instruments (e.g., instrument452) passed into themain chamber411 through at least theinflation tube416. Additionally or alternatively, instruments can be inserted into themain chamber411 through flexible sheaths (not shown) and/or, in a Type I retraction device, through apertures pierced in other windows (not shown) in themain envelope406. After the treatment procedure has been carried out, the retraction device is deflated and withdrawn, as already described, from between the liver415 and theesophagus410, the small incisions in abdominal wall are repaired.
• 6. Retracting the Dura Mater
• Another procedure according to the invention is shown inFIG. 19, which shows a vertical cross section of the head. To observe and treat thebrain450, it is necessary to separate the brain from theoverlying dura mater455. A small, very oblate version of a Type I or TypeII retraction device401 according to the invention is used in this procedure. According to the procedure, asmall incision460 is made in the skin of the head, and, working through the incision, asmall hole465 is drilled in the skull to provide access to thedura mater455. Anincision470 is made in the dura mater to expose the surface of thebrain450. Aretraction device401 according to the invention is inserted using forceps through theincision460, thehole465, and theincision470 into the skull between the surface of thebrain450 and thedura mater455. Theretraction device401 is then released, as described above, from its packing (not shown), and itsmain chamber411 is inflated. During the inflation process themain envelope406 of the retraction device gently displaces thebrain450 away from thedura mater455. The position of the retraction device is checked and, if necessary, adjusted.
• If a Type I retraction device is used, it must be positioned such that part of the brain that it is desired to treat is centered in one of its windows. The additional chamber (not shown) is then inflated and the inflation pressure removed from the main chamber.
• If a Type II retraction device is used, a elastomeric window (not shown) is applied to the inside of themain chamber411 in a position such that the part of the brain that it is desired to treat can be accessed through the elastomeric window.
• With both types of retraction device, an aperture is cut in themain envelope406 through which the treatment procedure can be carried out, using instruments passed into themain chamber411 through theinflation tube416. Additionally or alternatively, instruments can be inserted into the main chamber, in a Type I retraction device, through apertures pierced in other windows (465,470) of themain envelope406. After the treatment procedure has been carried out, the retraction device is deflated and withdrawn, as already described, from between thebrain450 and thedura mater455. Finally, the small incisions in the dura mater and the scalp and the hole in the skull are repaired.
• 7. Hernia Repair
• Laparoscopic techniques are already being used to repair hernias, but conventional techniques require that two incisions be made in the peritoneum, the second incision being a relatively large one, and the peritoneum around the second incision be retracted. These unnecessary incisions delay recovery and provide the opportunity for complications. A procedure according to the invention enables hernia repair to be carried out without having to breach the peritoneum.FIG. 20A shows a vertical cross section of the lower abdomen. A flat, substantially elliptical or rectangular Type IA or TypeII retraction device501 according to the invention is used to retract theperitoneum502 away from theabdominal wall517. In the procedure according to the invention, asmall incision522 is made in theabdominal wall517 near theumbilicus507, and the layers of tissue are cut through as far as the peritoneum. Aretraction device501 according to the invention is inserted using forceps through theincision522 into position between theabdominal wall517 and theperitoneum502. Theretraction device501 is then released, as described above, from its packing (not shown), and itsmain chamber511 is inflated. During the inflation process themain envelope506 of the retraction device spreads inferiorly towards the inguinal area, and gently displaces theperitoneum502 back from theabdominal wall517. The position of the retraction device is checked and, if necessary, adjusted.
• If a Type I retraction device is used, it must be positioned such that the site of the hernia is centered in one of its windows. Theadditional chamber531 is then inflated and the inflation pressure removed from the main chamber.
• If a Type II retraction device is used, a elastomeric window (not shown) is applied to the inside of themain chamber511 in a position such that the site of the hernia can be accessed through the elastomeric window.
• With both types of retraction device, an aperture is cut in themain envelope506 through which the treatment procedure can be carried out using instruments passed into themain chamber511 through theinflation tube516. Additionally or alternatively, instruments can be inserted into the main chamber through flexible sheaths (not shown) and/or, in a Type I retraction device, through apertures (not shown) pierced in other windows of themain envelope506. After the hernia has been repaired, the retraction device is deflated and withdrawn, as already described, from between theperitoneum502 and theabdominal wall517 and the small incision in theabdominal wall517 is repaired.
• One known technique for repairing a hernia is by suturing or stapling a fine mesh over the site of the hernia. The mesh is preferably installed on the abdominal wall outside the peritoneum to prevent the mesh and its sutures or staples from irritating the bowel. Using conventional laparoscopic techniques to hold the mesh in place while it is cut to size and stapled in position is a very difficult procedure. In a procedure according to the invention, a piece ofmesh527 is attached, for instance by a suitable adhesive applied to the perimeter of the piece of mesh, to substantially cover thewindow532 of theretraction device501, as shown inFIG. 21. Thewindow532 is the window that will contact the site of thehernia512 when the retraction device has been deployed. The retraction device with the mesh is then packaged as previously described, and the retraction device is inserted between theperitoneum502 and theabdominal cavity517 and inflated, also as previously described.
• The position of theretraction device501 is then adjusted, usingtabs556 and a suitable gripping tool (not shown) to position the mesh-covered window so that themesh527 covers the site of thehernia512. Once the retraction device is properly positioned, theadditional chamber531 is inflated and the inflation pressure removed from the main chamber. Theretraction device501 holds themesh527 in place over the site of the hernia while the mesh is stapled in place and excess mesh is cut off. Part of thewindow532 is cut away, using a suitable tool inserted into themain chamber511 through theinflation tube516, to expose the area of the mesh into which staples will be placed. The mesh is stapled to the site of thehernia512 using staples (not shown) inserted by means of a conventional laparoscopic stapler (not shown). More of thewindow532 is then cut away and a suitable laparoscopic cutting tool is inserted into themain chamber511 to cut the mesh around the stapled area. The excess mesh is removed when the retraction device is removed from the body, as previously described.
• In a variation on this procedure, a low irritation Dacron® mesh is installed on the inside of the peritoneum, the retraction device with a piece of mesh covering one of its windows being inserted into the peritoneal cavity before the retraction device is inflated, as shown inFIG. 20B.
• In a variation on both of the above procedures, the mesh is cut to the required size before it is attached to the window of the retraction device. The mesh is attached to the window of the retraction device by one-pull lacing, and the thread for the one-pull lacing is fed through the main inflation tube. After the mesh has been correctly positioned and stapled in place, as previously described, the thread is pulled to release the one-pull lacing, which releases the mesh from the window of the retraction device. The retraction device is then withdrawn as previously described. This variation does not require the mesh to be cut to size after it has been stapled in place.
C. Methods of Constructing Inflatable Retraction Devices
• 1. Polygonal Type IA Retraction Device
• The construction according to the invention of a polygonal Type IA retraction device is illustrated inFIGS. 22A and 22B. The construction of a dodecahedral retraction device is illustrated. A dodecahedral retraction device gives a good compromise between approximating a spherical or spheroidal shape, and complexity. Increasing the number of faces makes a shape that is more nearly spherical but is more complex to make. The additional chamber of a retraction device that is more nearly spherical provides more retraction force than the additional chamber of a polyhedral retraction device that is more nearly cubic.
• The main envelope and the additional envelope of the retraction device are both made of a relatively inelastic and tough film of a plastic such as Mylar®, polyethylene, or polyurethane. The preferred material is a polyethylene and nylon composite. The thickness of the main envelope is typically from 0.5 to 5 mils (13 to 130 microns). In the preferred embodiment, the additional envelope is made from a film of the same thickness of the same plastic as the main envelope. However, in some applications it may be advantageous make the additional envelope from a film of a different thickness of the same plastic, or from a film of the same or a different thickness of a different plastic.
• Two segmented circularmain envelope blanks600 and601 and two segmented circularadditional envelope blanks625 and626 are cut from a piece of film, preferably by die cutting.
• The main envelope blank600, the additional envelope blank625, and the formation of an envelope half from them will now be described. A similar explanation applies to the main envelope blank601, the additional envelope blank626, and the formation of an envelope half from them.
• The number of segments in the twomain envelope blanks600 and601, plus 2, determines the number of faces that the polyhedral retraction device will have. In the dodecahedral retraction device illustrated, the main envelope blank600 has fivesegments605. The width and depth of thesegments605 determines the shape of the retraction device: wide, shallow segments result is a relatively flat retraction device, whereas narrow, deep segments result in a relatively tall retraction device.
• The number ofsegments630 in the additional envelope blank625 is preferably equal to the number ofsegments605 of the main envelope blank600; thus, the additional envelope blank625 has fivesegments630 to match the fivesegments605 of themain envelope blank600. The shape of thesegments630 is substantially the same as that of thesegments605, except the parts of eachsegment630 indicated by shading and thereference numeral655 inFIG. 22B are cut away compared with thesegment605 in the main envelope blank. When the additional envelope blank625 is assembled with the main envelope blank600, the cut awayareas655 provide the windows46 (FIG. 1) in the side of the retraction device. Eacharea655 will therefore be called aside window area655. Anotherarea645 in the center of the additional envelope blank625 is cut away. When theadditional envelope625 is assembled with the main envelope blank600, the cut awayarea645 forms the window46 (FIG. 1) in the top end or the bottom end of the retraction device, and will thus be called theend window area645. The end window area is shown with a circular shape inFIG. 22B; alternatively, it could have a polygonal shape. The side and end window areas are preferably cut in the same die-cutting operation in which the additional envelope is die cut from the plastic film.
• An envelope half is made by laying the additional envelope blank625 on the main envelope blank600 such that thesegments630 coincide with thesegments605. Thebroken line650 inFIG. 22A indicates the position of eachside window area655 when the additional envelope blank625 is correctly positioned on themain envelope bank600. The periphery of eachside window area655 of the additional envelope blank625 is attached to the main envelope blank600, preferably by welding. Alternatively, a line of adhesive applied to the periphery of eachside window area655 can be used. The periphery of theend window area645 in the additional envelope blank625 is also attached to the main envelope blank600, preferably by welding. Alternatively, a line of adhesive applied to the periphery of theend window area645 can be used.
• The envelope half is then given a 3-dimensional form by joining theedge610 of eachsegment605 in the main envelope blank600 to theedge615 of the adjacent segment, and by joining theedge635 of eachsegment630 in the additional envelope blank625 to theedge640 of the adjacent segment. The preferred method of joining in this step and the following steps involving joining is overlap welding. Alternatively, butt welding or a line of a suitable adhesive can be used. The envelope half may be formed so that the additional envelope blank625 is inside or outside themain envelope blank600. In the preferred embodiment, the additional envelope blank is inside the main envelope blank.
• A second envelope half is made from the main envelope blank601 and the additional envelope blank626, as described above. One of the two envelope halves is then inverted relative to the other, and the two envelope halves are joined together with theperiphery620 in contact with the periphery621 (main envelope) and theperiphery660 in contact with the periphery661 (additional envelope). The peripheries of the envelope blanks on the inside are joined first. In the preferred embodiment, which has the additional envelope outside the main envelope, the envelope halves are joined as follows: theperipheries620 and621 of themain envelope blanks600 and601 are joined first. A small part of theperipheries620 and621 of the main envelope blanks is left unjoined. Themain inflation tube616 is a piece of polyethylene tubing with an outside diameter in the range of 2.5 to 19.5 mm (0.1″ to 0.77″) and of suitable length. The distal end of themain inflation tube616 is fitted with aport651 that allows surgical instruments to be passed into the main inflation tube while maintaining inflation pressure in the main chamber of the retraction device. Theport651 also includes a fitting (not shown) suitable for connecting the port to a source of inflation gas (not shown). The proximal end of themain inflation tube616 is inserted into the unjoined part of theperipheries620 and621 of theadditional envelope blanks600 and601 and joining theperiphery620 to theperiphery621 is completed. Where theperipheries620 and621 contact themain inflation tube616, they are joined to the outer wall of the main inflation tube to form a gas-tight seal.
• Theperipheries660 and661 of the outer envelope blanks, i.e., theadditional envelope blanks625 and626, are then joined to one another and, where they contact themain inflation tube616, to the outer wall of the main inflation tube to form a gas-tight seal. A small part of theperipheries660 and661 of theadditional envelope blanks625 and626 is left unjoined. Theadditional inflation tube641 is a piece of polyethylene tubing with an outside diameter in the range of 2.5 to 5 mm (0.1″ to 0.2″) and of suitable length. The distal end of theadditional inflation tube641 is fitted with a fitting (not shown) suitable for connecting it to a source of inflation gas (not shown). The proximal end of theadditional inflation tube641 is inserted into the unjoined part of theperipheries660 and661 of theadditional envelope blanks625 and626, and joining theperiphery660 to theperiphery661 is completed. Where theperipheries660 and661 contact theadditional inflation tube641, they are joined to the outer wall of the additional inflation tube to form a gas-tight seal.
• In the alternative embodiment, with the additional envelope inside the main envelope, theperipheries660 and661 of theadditional envelope blanks625 and626 are joined to one another and to the outer wall of themain inflation tube616. Theperipheries620 and621 of themain envelope blanks600 and601 are then joined together, and to the outer wall of themain inflation tube616 and to the outer wall of theadditional inflation tube641.
• If the retraction device is for use in an insufflated body cavity, the main and additional inflation tubes must be surrounded by an inflation tube shield. The additional envelope blanks for such a retraction device are cut to include aninflation tube seal680 and681. The inflation tube sheath (not shown) is pushed over the main and additional inflation tubes after they have been sealed into the retraction device and the inflation tube seals are joined to one another, preferably by welding. Alternatively, a suitable adhesive can be used. Where the inflation tube seals680 and681 contact the inflation tube sheath, they are joined to the outer wall of the inflation tube shield to form a gas-tight seal. The above method can be adapted for use if a single extrusion is used to provide the main and additional inflation tubes and the inflation tube sheath.
• An alternative method of making a polygonal type IA retraction device is the same as the method just described, except that theadditional envelope blanks625 and626 are cut with the same die as themain envelope blanks600 and601. A main envelope blank is attached to an additional envelope blank by welding along thebroken lines650 and665 (FIG. 22A). Alternatively, a main envelope blank can be attached to an additional envelope blank by a line of a suitable adhesive spread along thebroken lines650 and665. The envelope halves are then formed and attached to one another using the method described above.
• The additional chamber of a retraction device in which the additional envelope blank and the main envelope blank are cut using the same die is substantially the same shape as the additional chamber of a retraction device in which the additional envelope blank is cut using its own die. The alternative method of construction saves the tooling cost of the die to cut the additional envelope blank. A retraction device made according to this method has a double thickness of film on its windows46 (FIG. 1), which makes it somewhat more difficult to cut apertures in the windows prior to carrying out the treatment process.
• 2. Polygonal Type IA Retraction Device with Suction Skirt
• The construction according to the invention of a polygonal Type IA retraction device including a suction skirt according to the invention is illustrated inFIGS. 23A and 23B. A plurality ofholes608, preferably between 6 and 12, are cut around the periphery of theend window area646 of the additional envelope blank631. Eachhole608 is preferably about ⅛″ (3 mm) in diameter. When the retraction device is deployed in the body, it must be oriented such that the additional envelope blank631 is lower-most. Additionally, a short radial cut613 is made in the additional envelope blank631. Preferably, theholes608 and the radial cut613 are die cut, preferably by the same die used to cut the additional envelope blank631.
• The method of constructing the retraction device is the same as that described above, except that the step of attaching the periphery of theend window646 of the additional envelope blank631 to the main envelope blank601 is changed as follows: additional envelope blank631 is attached to the main envelope blank601 by welding along a circular line concentric with theend window area646 and displaced radially outward by about 0.5″ (12.5 mm) to lie outside the line of theholes608. The weld line is indicated inFIG. 23 by thebroken line618. The part of the additional envelope blank631 forming the periphery of theend window area646 is then displaced radially outwards by about ⅛″ (3 mm) and is attached to the main envelope blank601 by a circular weld, indicated by thebroken line623, inside the line of theholes608. Displacing the periphery of the end window area radially outward moves the part of the additional envelope blank631 between the two welds indicated by thebroken lines618 and623 away from the part of the main envelope blank that it overlays, and forms a flat tubular structure between the two envelope blanks. One end of the tubular structure is closed by a short radial weld indicated by the broken line633, close to the radial cut613.
• Construction of the retraction device is completed as described above. The proximal end of thesuction tube638, which is a piece of thin-wall polyethylene tubing about ¼″ (6 mm) in outside diameter is inserted into the open end of the tubular structure provided by the radial cut613. In a retraction device for use in an insufflated body cavity, thesuction tube638 is sealed into the inflation tube sheath.
• The method described above can be adapted to provide a suction skirt around one of the side windows of a polygonal Type IA retraction device. Such a suction skirt would be useful if the retraction device is oriented with a side window lower-most when in use. The method can also be adapted to make a flat retraction device with a suction skirt around one or more of its holes or around the junction between its envelope halves. The method can also be adapted to make a triangular prism-shaped Type IA retraction device with a suction skirt around one of its holes or along one or both of the sides of its lower-most face.
• 3. Relatively Flat Type IA Retraction Device
• The construction according to a further aspect of the invention of a simpler, relatively flat Type IA retraction device according to the invention is illustrated inFIGS. 24A and 24B. The main envelope and the additional envelope of the retraction device are both made of a relatively inelastic and tough film of a plastic such as Mylar®, polyethylene, or polyurethane. The preferred material is a polyethylene and nylon composite. The thickness of the main envelope is typically from 0.5 to 5 mils (13 to 130 microns). In the preferred embodiment, the additional envelope is made from a film of the same thickness of the same plastic as the main envelope. However, in some applications it may be advantageous make the additional envelope from a film of a different thickness of the same plastic, or from a film of the same or a different thickness of a different plastic.
• Two substantially circular or ellipticalmain envelope blanks600 and601, substantially equal in size, and two substantially circular or ellipticaladditional envelope blanks625 and626, substantially the same size as themain envelope blanks600 and601, are cut from a piece of film, preferably by die cutting. The die cutting process also cutsholes670 and671 in theadditional envelope blanks625 and626 respectively. The number, shape, and size ofholes670 and671 depends on the intended application of the retraction device. When theadditional envelope blanks625 and626 are assembled with themain envelope blanks600 and601 respectively, theholes670 and671 form the windows646 (FIG. 248) in the retraction device. Increasing the proportion of the additional envelope removed to formholes670 and671 increases the window area through which treatment procedures can be carried out, but reduces the ability of the additional cavity of the retraction device to maintain retraction after the main cavity has been punctured.
• An envelope half is made by laying the additional envelope blank625 on themain envelope blank600. The positions of the periphery of eachhole670 when the additional envelope blank625 is properly positioned on themain envelope bank600 is indicated by thebroken line650 inFIG. 24A. The periphery of eachhole670 of the additional envelope blank625 is attached to the main envelope blank600, preferably by welding. Alternatively, a line of adhesive applied to the periphery of eachhole670 can be used. A second envelope half is made from the main envelope blank601 and the additional envelope blank626, using the method described above.
• One of the two envelope halves is then inverted relative to the other, and the two envelope halves are joined together with theperiphery620 in contact with the periphery621 (main envelope) and theperiphery660 in contact with the periphery661 (additional envelope). The envelope halves may be joined such that theadditional envelope blanks625 and626 are inside or outside themain envelope blanks600 and601. In the preferred embodiment, the additional envelope blanks are inside the main envelope blanks. The method of joining the envelope halves is the same as the method for joining the envelope halves of a polygonal Type IA retraction device, so will not be further described. The completed retraction device is shown inFIG. 24B.
• In an alternative embodiment of the relatively flat Type IA retraction device, the main inflation tube may be connected to the main chamber by piercing a hole in one of thewindows646 and attaching the periphery of the hole to the outer wall of the inflation tube. This embodiment is more useful than the basic embodiment, in which the main inflation tube is connected between the perimeters of the two envelope halves, in procedures in which the convenient entry point in the body for instruments lies more or less directly across the short dimension of the retraction device from the tissue to be treated. Examples of such procedures are shown inFIGS. 15,16A,16B, and19.
• In the alternative embodiment with the additional envelope outside the main envelope, theperipheries620 and621 of the main envelope blanks are joined to one another and to the outer wall of the main inflation tube. Theperipheries660 and661 of the additional envelope blanks are then joined to one another, and to the outer walls of the main and the additional inflation tubes.
• The flat Type IA retraction device can also be made with its additional envelope blanks and its main envelope blanks cut using the same die, as described in connection with the polygonal Type IA retraction device. The main and additional envelope blanks are attached by welding or a line of adhesive along thebroken lines650.
• 4. Triangular Prism-Shaped Type IA Retraction Device
• The triangular prism Type IA retraction device is constructed according to the invention from two flat envelope blanks, as shown inFIG. 25C. The main envelope and the additional envelope of the retraction device are both made of a relatively inelastic and tough film of a plastic such as Mylar®, polyethylene, or polyurethane. The preferred material is a polyethylene and nylon composite. The thickness of the main envelope is typically from 0.5 to 5 mils (13 to 130 microns). In the preferred embodiment, the additional envelope is made from a film of the same thickness of the same plastic as the main envelope. However, in some applications it may be advantageous make the additional envelope from a film of a different thickness of the same plastic, or from a film of the same or a different thickness of a different plastic.
• A substantially rectangular main envelope blank700, and a substantially rectangular additional envelope blank725, substantially the same size as the main envelope blank700, are cut from a piece of film, preferably by die cutting. Each envelope blank700 and725 can be regarded as being divided lengthwise into three panels. At least the two outer panels have equal length. Each panel is serrated as shown inFIG. 25C. If the outer panels are larger than the inner panel, their serrations are truncated, as shown. The serrations are preferably die cut at the same time as the envelope panels are die cut. The die cutting process also cuts onehole770 in each panel of the additional envelope blank725, as shown inFIG. 25D. Substantially circular holes are shown inFIG. 25D: holes of a different shape, or more than one hole per panel can be cut, depending on the intended application of the retraction device. When the additional envelope blank725 is assembled with the main envelope blank700, theholes770 form the windows746 (FIG. 25A) in the retraction device. Increasing the proportion of the additional envelope removed to form theholes770 increases the window area through which treatment procedures can be carried out, but reduces the ability of the additional cavity of the retraction device to maintain retraction after the main cavity has been punctured.
• Assembly is begun by laying the additional envelope blank725 on the main envelope blank700 so that their peripheries overlap. The positions of the periphery of eachhole770 when the additional envelope blank725 is properly positioned on themain envelope bank700 is indicated by thebroken line750 inFIG. 25C. The periphery of eachhole770 of the additional envelope blank725 is joined to themain envelope blank700. The preferred method of joining in this step and the following steps involving joining is overlap welding. Alternatively, a line of adhesive applied to the periphery of the pieces being joined, for example, the periphery of eachhole770, can be used. The periphery760 of the additional envelope blank725 is joined to theperiphery720 of the main envelope blank700 by welding along thebroken line740. A small part of theperipheries720 and760 is left unjoined.
• Theadditional inflation tube741 is a piece of polyethylene tubing with an outside diameter in the range of 2.5 to 5 mm (0.1″ to 0.2″) and of suitable length. The distal end of theadditional inflation tube741 is fitted with a fitting (not shown) suitable for connecting it to a source of inflation gas (not shown). The proximal end of theadditional inflation tube741 is inserted into the unjoined part of theperiphery720 of the main envelope blank700 and the periphery760 of the additional envelope blank725, and joining theperiphery720 to the periphery760 is completed. Where theperipheries720 and760 contact theadditional inflation tube741, they are joined to the outer wall of the additional inflation tube to form a gas-tight seal.
• The retraction device is then folded, as shown by thearrows782 and787, along the boundaries between the panels, i.e., along thelines710 and715, to bringedge722 into contact withedge727 with the main envelope blank700 on the inside. The following parts of the periphery of the retraction device are then joined:736 to741,737 to742,746 to751,747 to752,756 to761,757 to762,766 to771,767 to772, and722 to727. A small part of theperipheries722 and727 is left unjoined.
• Themain inflation tube716 is a piece of polyethylene tubing with an outside diameter in the range of 2.5 to 19.5 mm (0.1″ to 0.77″) and of suitable length. The distal end of themain inflation tube716 is fitted with a port (not shown) that allows surgical instruments to be passed into the main inflation tube while maintaining inflation pressure in the main chamber of the retraction device. The port also includes a fitting (not shown) suitable for connecting the port to a source of inflation gas (not shown). The proximal end of themain inflation tube716 is inserted into the unjoined part of theperipheries722 and727 and joining theperiphery722 to theperiphery727 is completed. Where theperipheries722 and727 contact themain inflation tube716, they are joined to the outer wall of the main inflation tube to form a gas-tight seal.
• If the retraction device is for use in an insufflated body cavity, the main and additional inflation tubes must be surrounded by an inflation tube shield. The main and additional envelope blanks for such a retraction device are each cut to include aninflation tube seal780 and781. The inflation tube sheath (not shown) is pushed over the main and additional inflation tubes after they have been sealed into the retraction device and the peripheries of the inflation tube seals are joined to one another. Where the inflation tube seals780 and781 contact the inflation tube sheath, they are joined to the outer wall of the inflation tube shield to form a gas-tight seal. The above method can be adapted for use if a single extrusion is used to provide the main and additional inflation tubes and the inflation tube sheath.
• The triangular prism-shaped Type IA retraction device can also be made with its additional envelope blank and its main envelope blank cut using the same die, as described in connection with the polygonal Type IA retraction device. The additional envelope blank is attached to the main envelope blank by welding or a line of adhesive along thebroken lines750.
• 5. Polygonal Type II Retraction Device
• The construction according to the invention of a polygonal Type II retraction device is illustrated inFIG. 26. The construction of a dodecahedral retraction device is illustrated. A dodecahedral retraction device gives a good compromise between approximating a spherical or spheroidal shape, and providing windows of a useful size. Increasing the number of faces makes a shape that is more nearly spherical but has smaller faces, which limits the size of elastomeric window that can be used.
• The main (and only) envelope of the Type II retraction device is made of a relatively inelastic and tough film of a plastic such as Mylar®, polyethylene, or polyurethane. The preferred material for the main envelope is a polyethylene and nylon composite. The thickness of the main envelope is typically from 0.5 to 5 mils (13 to 130 microns). To form the main envelope, two segmented circularmain envelope blanks600 and601 are cut from a piece of film, preferably by die cutting. The number ofsegments605 in the twomain envelope blanks600 and601, plus 2, determines the number of faces that the polyhedral retraction device will have. In the dodecahedral retraction device illustrated, themain envelope blanks600 and601 each have fivesegments605. The width and depth of thesegments605 determines the shape of the retraction device: wide, shallow segments result is a relatively flat retraction device, whereas narrow, deep segments result in a relatively tall retraction device.
• An envelope half is formed by joining theedge610 of eachsegment605 in the main envelope blank600 to theedge615 of the adjacent segment. The preferred method of joining is overlap welding, but butt welding or a suitable adhesive can also be used. A second envelope half is made using themain envelope blank601. One of the two envelope halves is then inverted relative to the other, and the two envelope halves are joined together with theperiphery620 in contact with theperiphery621. Again, the preferred method of joining is overlap welding, but butt welding or a suitable adhesive can also be used. A small part of theperipheries620 and621 of the twomain envelope blanks600 and601 is left unjoined.
• Themain inflation tube616 is a piece of polyethylene tubing with an outside diameter in the range of 2.5 to 19.5 mm (0.1″ to 0.77″) and of suitable length. The distal end of themain inflation tube616 is fitted with aport651 that allows surgical instruments to be passed into the main inflation tube while maintaining inflation pressure in the main chamber of the retraction device. The proximal end of themain inflation tube616 is inserted into the unjoined part of theperipheries620 and621 and joining theperiphery620 to theperiphery621 is completed. Where theperipheries620 and621 contact theinflation tube616, they are joined to the outer wall of the inflation tube such that a gas-tight main envelope is formed in contact with the bore of the main inflation tube.
• The methods described above for making relatively flat and triangular prism-shaped Type IA retraction devices can easily be adapted to make relatively flat and triangular prism-shaped Type II retraction devices respectively.
• 6. Curved Type IA and Type II Retraction Devices
• Substantially full- or hemispherical, spheroidal, or ellipsoidal Type IA and Type II retraction devices can be made from curved pieces of plastic film. The construction according to the invention of a hemispherical Type IA retraction device from curved plastic film is illustrated inFIGS. 27 and 28. The method can easily be adapted to make a substantially spherical, spheroidal or ellipsoidal Type IA retraction device by interconnecting two envelope halves made according to the method to be described below using the method for joining envelope halves described above.
• Themain envelope602, theadditional envelope607, and the bottom diaphragm647 of the retraction device are all made of a relatively inelastic and tough film of a plastic such as Mylar®, polyethylene, or polyurethane. The preferred material is a polyethylene and nylon composite. The thickness of themain envelope602 is typically from 0.5 to 5 mils (13 to 130 microns). In the preferred embodiment, theadditional envelope607 and the bottom diaphragm647 are made from a film of the same thickness of the same plastic as the main envelope. However, in some applications it may be advantageous make the additional envelope and/or the bottom diaphragm from a film of a different thickness of the same plastic, or a film of the same or a different thickness of a different plastic.
• A main envelope blank602, an additional envelope blank607 and a bottom diaphragm647 are cut from a piece of film, preferably by die cutting. The envelope blanks are similar, except that holes612 are cut in the additional envelope blank607. Theholes612 are cut preferably by the same die that is used to cut the additional envelope blank607. When the additional envelope is assembled with the main envelope blank, theholes612 form the windows646 (FIG. 28). InFIG. 27, holes612 are shown as having a circular shape, but they could have other suitable shapes.
• According to one aspect of the method, the main envelope blank602 and the additional envelope blank607 are stretched over the surface of a former. The surface of the former is the hemispherical, hemispheroidal, hemiellipsoidal, or other shape that it is desired to impart on the envelope blank. The surface of the former is heated and its temperature sufficiently high, and the envelope blank remains in contact with the surface of the former for sufficiently long a time, for the plastic film of the envelope blank to soften, such that when the envelope blank cools, it adopts the shape of the surface of the former. The surface of the former is cooled, the periphery of the envelope blank is trimmed to the periphery of the surface, and the envelope blank is removed from the former. An envelope blank can also be curved by blowing the envelope blank into a suitably-shaped, heated concavity, or by pressing the envelope blank between suitably-shaped, heated male and female dies.
• An envelope half is made by laying the curved additional envelope blank607 on the curvedmain envelope blank602. The periphery of eachhole612 in the additional envelope blank607 is attached to the main envelope blank602, preferably by welding. Alternatively, a line of adhesive applied to the periphery eachhole612 can be used.
• In an alternative method, an envelope half is made by laying the additional envelope blank607 on themain envelope blank602. The periphery of eachhole612 in the additional envelope blank607 is attached to the main envelope blank602, preferably by welding. Alternatively, a line of adhesive applied to the periphery of eachhole612 can be used. The resulting flat envelope half is then curved and trimmed around its periphery using one of the methods described above.
• In either of the above methods, the main envelope blank and the additional envelope blank can cut using the same die, and the second chamber can be formed by attaching the additional envelope blank to the main envelope blank by welding or applying adhesive along thebroken lines627. This method produces a retraction device with a double layer of plastic film on the windows646 (FIG. 28), which makes it somewhat less convenient to use.
• A substantially hemispherical retraction device can be made by attaching theperiphery632 of the main envelope blank602 to theperiphery637 of the additional envelope blank607, and to theperiphery642 of the bottom diaphragm647, preferably by welding, as shown inFIG. 28. Alternatively, a line of adhesive applied to the periphery of one or both the envelope halves and to theperiphery642 of the bottom diaphragm647 can be used. A small part of theperipheries632 and637 is left unjoined. Theadditional inflation tube641 is a piece of polyethylene tubing with an outside diameter in the range of 2.5 to 5 mm (0.1″ to 0.2″) and of suitable length. The distal end of theadditional inflation tube641 is fitted with a fitting (not shown) suitable for connecting it to a source of inflation gas (not shown). The proximal end of theadditional inflation tube641 is inserted into the unjoined part of theperipheries632 and637, and joining theperiphery632 to theperiphery637 is completed. Where theperipheries632 and637 contact theadditional inflation tube641, they are joined to the outer wall of the additional inflation tube to form a gas-tight seal.
• A small part of the joint between theperiphery637 of the additional envelope blank607 and theperiphery642 of the bottom diaphragm647 is also left unjoined. Themain inflation tube616 is a piece of polyethylene tubing with an outside diameter in the range of 2.5 to 19.5 mm (0.1″ to 0.77″) and of suitable length. The distal end of themain inflation tube616 is fitted with aport651 that allows surgical instruments to be passed into the main inflation tube while maintaining inflation pressure in the main chamber of the retraction device. Theport651 also includes a fitting (not shown) suitable for connecting the port to a source of inflation gas (not shown). The proximal end of themain inflation tube616 is inserted into the unjoined part of theperipheries637 and642, and joining theperiphery637 of the additional envelope blank607 to theperiphery642 of the bottom diaphragm647 is completed. Where theperipheries637 and642 contact themain inflation tube616, they are joined to the outer wall of the main inflation tube such that a gas-tight seal is formed.
• The methods described above for making curved envelope halves can also be used to make the envelope halves used in constructing a Type II retraction device.

Claims (21)

1. (canceled)

2. A method of providing access to tissue for a surgical instrument through a body wall, comprising:

providing an expandable retractor having a flexible sheath, the retractor being in a collapsed state;

introducing the retractor into the body and placing the retractor adjacent the tissue;

expanding the retractor;

deploying the flexible sheath by engaging the flexible sheath with a tool and driving the flexible sheath through the body wall with the tool; and

inserting the surgical instrument from outside the body through the flexible sheath to provide access to the tissue by the surgical instrument.

3. The method ofclaim 2, wherein the retractor comprises an inflatable retractor and wherein expanding the retractor includes inflating the retractor.

4. The method ofclaim 3, wherein the inflatable retractor has a main envelope defining a main chamber and wherein the main chamber is inflated to an expanded state.

5. The method ofclaim 4, further comprising the step of piercing an aperture in the main envelope to provide access to the tissue by the further surgical instrument.

6. The method ofclaim 4, wherein the flexible sheath communicates with the main chamber and further comprising the step of inserting the surgical instrument into the main chamber through the flexible sheath.

7. The method ofclaim 4, wherein the flexible sheath is deployed after the retraction device has been inflated.

8. The method ofclaim 2, wherein the flexible sheath is attached to the retractor and the flexible sheath is deployed by being driven outward through the body wall.

9. The method ofclaim 2, wherein the flexible sheath is deployed by being driven inward through the body wall to pierce and to lock into engagement with, the retraction device.

10. The method ofclaim 2, wherein the flexible sheath has a sidewall, the sidewall being folded, and wherein deploying the flexible sheath includes unfolding the sidewall.

11. The method ofclaim 8, wherein the tool comprises a pointed tool and wherein the step of deploying includes piercing a hole in the retractor and pushing the pointed tool through the hole.

12. The method ofclaim 11, wherein the pointed tool is pressed against the inner surface of the body wall.

13. The method ofclaim 12, further comprising the step of making a skin incision at the location of the tool and then driving the flexible sheath through the body wall to emerge through the incision.

14. The method ofclaim 2, further comprising the step of opening a distal end of the flexible sheath, after the flexible sheath is driven through the body wall.

15. The method ofclaim 14, further comprising the step of fitting the flexible sheath with a gas-tight port.

16. The method ofclaim 2, wherein the flexible sheath has a locking device disposed on a proximal end thereof.

17. The method ofclaim 9, wherein, before the step of driving the flexible sheath, a skin incision is made in the body wall.

18. The method ofclaim 17, wherein the step of driving includes driving through the body wall with a sharp trocar point.

19. The method ofclaim 18, further comprising the step of piercing the retractor with the trocar point.

20. The method ofclaim 18, wherein the flexible sheath has a locking device and further comprising the step of pushing the locking device of the flexible sheath through the skin incision to engage the retractor.

21. The method ofclaim 20, wherein the locking device forms a gas-tight seal with the skin incision.

Images