US20100324375A1 - Laparoscopic instrument and trocar system and related surgical method - Google Patents

Abstract

Laparoscopic instruments and cannulas are provided for performing laparoscopic procedures entirely through the umbilicus. Generally S-shaped laparoscopic instruments placed through the C-shaped trocar sleeves or through the cannula and instrument holder unit provide markedly improved degrees of instruments' freedom during trans-umbilical laparoscopic procedures.

Description

FIELD OF THE INVENTION
• The present invention relates to surgical instruments, and particularly to laparoscopic instruments, which facilitate the performance of laparoscopic procedures entirely through the umbilicus.
BACKGROUND
• Abdominal laparoscopic surgery gained popularity in the late 1980's, when benefits of laparoscopic removal of the gallbladder over traditional (open) operation became evident. Reduced postoperative recovery time, markedly decreased post-operative pain and wound infection, and improved cosmetic outcome are well established benefits of laparoscopic surgery, derived mainly from the ability of laparoscopic surgeons to perform an operation utilizing smaller incisions of the body cavity wall.
• Laparoscopic procedures generally involve insufflation of the abdominal cavity with CO2 gas to a pressure of around 15 mm Hg. The abdominal wall is pierced and a 5-10 mm in diameter straight tubular cannula or trocar sleeve is then inserted into the abdominal cavity. A laparoscopic telescope connected to an operating room monitor is used to visualize the operative field, and is placed through (one of) the trocar sleeve(s). Laparoscopic instruments (graspers, dissectors, scissors, retractors, etc.) are placed through two or more additional trocar sleeves for the manipulations by the surgeon and surgical assistant(s).
• Recently, so-called “mini-laparoscopy” has been introduced utilizing 2-3 mm diameter straight trocar sleeves and laparoscopic instruments. When successful, mini-laparoscopy allows further reduction of abdominal wall trauma and improved cosmesis. However, instruments used for mini-laparoscopic procedures are generally more expensive and fragile. Because of their performance limitations, due to their smaller diameter (weak suction-irrigation system, poor durability, decreased video quality), mini-laparoscopic instruments can generally be used only on selected patients with favorable anatomy (thin cavity wall, few adhesions, minimal inflammation, etc.). These patients represent a small percentage of patients requiring laparoscopic procedure. In addition, smaller, 2-3 mm, incisions may still cause undesirable cosmetic outcomes and wound complications (bleeding, infection, pain, keloid formation, etc.).
• Since the benefits of smaller and fewer body cavity incisions are proven, it would be attractive to perform an operation utilizing only a single incision in the navel. An umbilicus is the thinnest and least vascularized, and a well-hidden, area of the abdominal wall. The umbilicus is generally a preferred choice of abdominal cavity entry in laparoscopic procedures. An umbilical incision can be easily enlarged (in order to eviscerate a larger specimen) without significantly compromising cosmesis and without increasing the chances of wound complications. The placement of two or more standard (straight) cannulas and laparoscopic instruments in the umbilicus, next to each other, creates a so-called “chopstick” effect, which describes interference between the surgeon's hands, between the surgeon's hands and the instruments, and between the instruments. This interference greatly reduces the surgeon's ability to perform a described procedure.
• Thus, there is a need for instruments and trocar systems, which allow laparoscopic procedures to be performed entirely through the umbilicus while at the same time reducing or eliminating the “chopstick effect”. A laparoscopic procedure performed entirely through the umbilicus, using the laparoscopic instruments and trocar system according to an embodiment of the present invention, allows one to accomplish the necessary diagnostic and therapeutic tasks while further minimizing abdominal wall trauma and improving cosmesis.
SUMMARY OF THE INVENTION
• A general object of the present invention is to provide a laparoscopic instrument and an instrument or cannula holder for use in the performance of laparoscopic procedures, for instance, entirely through the umbilicus.
• A more specific object of the present invention is to provide a laparoscopic instrument, which may markedly increase the workspace between the laparoscopic instruments and between the hands of the surgeon where more than one instrument shaft is inserted through the same opening in the patient's abdominal wall.
• A more general object of the present invention is to provide a laparoscopic instrument that has enhanced operational flexibility to facilitate the performance of laparoscopic surgical procedures.
• A related object of the present invention is to provide a cannula or instrument holder utilizable in combination with such a laparoscopic instrument to facilitate the performance of a laparoscopic procedure through a single opening in the patient's abdominal wall, for instance, in the patient's umbilicus.
• Another object of the present invention is to provide generally S-shaped laparoscopic instruments.
• In one embodiment of the present invention, a stand-alone laparoscopic medical instrument insertable through a laparoscopic trocar sleeve comprises an elongate shaft, an operative tip disposed at one end of the shaft, and an actuator disposed at an opposite end of the shaft, the actuator being operatively connected to the operative tip via the shaft for controlling the operation of the operative tip. The shaft has a proximal end portion and middle portion and a distal end portion, at least the distal end portion being independently bendable to form a C shape. The distal segments of the shaft are rotatable about a longitudinal axis at least at one location along the instrument's shaft, preferably at the operative tip or proximal to the operative tip.
• Pursuant to additional features of the present invention, the distal end portion of the instrument shaft is continuously bendable into a smoothly curved C-shaped configuration, while a lock is operatively connected to the shaft for releasably maintaining the C-shaped curved configuration. Moreover, the distal end portion may be provided with an articulated joint, whereby the distal end portion is swingable relative to the middle portion of the shaft. The proximal end portion may also independently bendable to form a C shape.
• In a further embodiment of the present invention, a stand-alone laparoscopic medical instrument insertable through a laparoscopic trocar sleeve comprises an elongate shaft, an operative tip disposed at one end of the shaft, and an actuator disposed at an opposite end of the shaft. The actuator is operatively connected to the operative tip via the shaft for controlling the operation of the operative tip. The shaft has a proximal end portion and a distal end portion, the distal end portion being continuously bendable to form a smoothly curved C shape. The distal end portion is connected to the proximal end portion via an articulated joint, whereby the distal end portion may be laterally swung with reference to the proximal end portion.
• In this further embodiment of the invention, the proximal end portion of the instrument shaft may includes a rigid segment connected to the distal end portion via the articulated joint. The proximal end portion may additionally include a flexible segment connected to the rigid segment on a side thereof opposite the distal end portion, the actuator being connected to a free end of the flexible segment, opposite the rigid segment.
• A stand-alone laparoscopic medical instrument insertable through a laparoscopic trocar sleeve comprises, in accordance with another embodiment of the present invention, an elongate shaft, an operative tip disposed at one end of the shaft, and a manual actuator disposed at an opposite end of the shaft, the manual actuator being operatively coupled to the operative tip via the shaft. A first mechanism is operatively connected to the shaft for bending a proximal portion of the shaft in a first direction, while a second mechanism is operatively connected to the shaft for bending a distal portion of the shaft in a second direction different from the first direction, whereby the shaft assumes a shape with a plurality of differently shaped segments.
• The shaft has a longitudinal axis at the one end, and the instrument further comprises a rotation mechanism operatively connected to the shaft for rotating the operative tip about the axis.
• Pursuant to another feature of this other embodiment of the invention, first locking element is operatively connected to the first mechanism and a second locking element is operatively connected to the second mechanism, whereby the proximal portion and the distal portion may be maintained as the differently shaped segments. Where the proximal portion and the distal portion are bendable by the first mechanism and the second mechanism in a common plane, the instrument may further comprise an additional mechanism operatively connected to the shaft for bending the distal portion of the shaft in an additional direction out of the plane.
• Where the proximal portion of the shaft assumes a first C-shaped configuration in response to operation of the first mechanism and the distal portion of the shaft assumes a second C-shaped configuration in response to operation of the second mechanism, the C-shaped configurations may face opposite sides of the shaft.
• A laparoscopic medical instrument comprises, in accordance with an additional embodiment of the present invention, an elongate flexible shaft, an operative tip disposed at one end of the shaft, and a manual actuator disposed at an opposite end of the shaft, the manual actuator being operatively coupled to the operative tip via the shaft, a first bending mechanism being operatively connected to the shaft for curving a proximal portion of the shaft in a first direction, and a second bending mechanism being operatively connected to the shaft for curving a distal portion of the shaft in a second direction different from the first direction, whereby the shaft assumes a shape with a plurality of arcuate segments.
• The instrument of this additional embodiment of the invention may additionally comprise a rotation mechanism operatively connected to the shaft for rotating the operative tip about the axis, a first locking element operatively connected to the first bending mechanism and a second locking element operatively connected to the second bending mechanism. The bending mechanisms each include a manual actuator mounted to the shaft at the other end thereof.
• A holder for cannulas and instruments in laparoscopic surgical operations comprises, in accordance with the present invention, a plate member having a surrounding edge and a wall surrounding the plate member, the wall being connected to the plate member all along the edge. The wall has a longitudinal axis, while the plate member extends substantially transversely to the axis. The plate member may be provided with a plurality of apertures for receiving respective elongate laparoscopic surgical members.
• The height dimension of the wall of the cannula and instrument holder is at least as great as, and preferably substantially greater than, the height dimension of the plate member. The wall may have at least one end portion extending as a flange to the plate member. In at least one embodiment of the cannula and instrument holder, the wall has two end portions extending as endless flanges to the plate, with the plate member being located at one end of the wall and with the plate member and the wall forming a cup shape.
• The inner diameter of the wall of the cannula and instrument holder at an end opposite the plate member is preferably larger than the inner diameter of the wall at the plate member, so that the cannula and instrument holder has a flared or tapered profile.
• Pursuant to further features of the present invention, the plate member and/or the wall of the cannula and instrument holder is inflatable, while the plate member is provided at the apertures with extensions elongating the apertures. The height of the plate member, in a direction parallel to the axis of the cannula and instrument holder, is at least as great as the height of the extensions. Preferably, the plate member is flexible.
• Pursuant to another feature of the present invention, where the apertures in the plate member of the cannula and instrument holder have a longitudinal dimension extending generally parallel to the axis, at least one of the apertures has a curvilinear or arced shape along the longitudinal dimension of the one of the apertures.
• The wall of the cannula and instrument holder may be flexible and at least partially curved in a direction parallel to the axis of the holder.
• At least one of the plate member and the wall of the cannula and instrument holder is provided with a gas channel for the introduction of an insufflation gas into a patient. In addition, the wall is advantageously provided with an anchoring element for securing the holder to a patient. The anchoring element is preferably taken from the group consisting of a hook and an eyelet.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1 is a schematic view of a conventional laparoscopic instrument inserted through a conventional straight trocar sleeve or cannula.
• FIG. 2A is a side view andFIG. 2B is an end view of an exemplary embodiment of a flexible C-shaped trocar sleeve or cannula.FIG. 2C is an exemplary embodiment of an S-shaped instrument.
• FIG. 3 is a schematic view of an exemplary embodiment of an S-shaped laparoscopic instrument inserted through a C-shaped flexible trocar sleeve or cannula.
• FIG. 4A is a lateral view andFIG. 4B is a perspective view of an exemplary inflatable unit with multiple C-shaped trocar sleeve or cannulas incorporated within the unit.
• FIG. 5A is a non-inflated lateral view andFIG. 5B is an inflated lateral view of an exemplary inflatable C-shaped trocar sleeve or cannula having a balloon-like structure within the hollow body of the cannula.
• FIG. 6 is a lateral view of an exemplary angulated needle with two sharp ends and a thread attached at the angle of the needle.
• FIG. 7 is a lateral view of an exemplary angulated needle having a long segment with a pointed end on one side of the angle and a short segment having attached thread on the other side of the angle.
• FIG. 8 is a cross-sectional view of an exemplary embodiment of an inflatable unit having multiple cannulas incorporated within the unit.
• FIG. 9 is a schematic side elevational view of a laparoscopic instrument in accordance with the present invention.
• FIG. 10 is a schematic side elevational view of another laparoscopic instrument in accordance with the present invention.
• FIG. 11A-11F are diagrams of the instrument ofFIG. 10, showing different possible operational configurations of the instrument.
• FIG. 12 is a schematic cross-sectional view of a laparoscopic instrument or cannula holder in accordance with the present invention.
• FIG. 13 is a partial view similar toFIG. 12 of the laparoscopic instrument or cannula holder of that drawing figure.
• FIG. 14 is a partial cross-sectional view of another laparoscopic instrument or cannula holder in accordance with the present invention.
• FIG. 15 is a schematic perspective view of a laparoscopic instrument or cannula holder in a collapsed configuration between jaws of a deployment instrument.
• FIG. 16 is a schematic perspective view of another laparoscopic instrument or cannula holder in accordance with the invention.
DETAILED DESCRIPTION
• The present invention provides laparoscopic instruments and trocar sleeves or cannulas for the performance of laparoscopic procedures entirely through the umbilicus. The instruments may, however, be used to perform laparoscopic procedures at locations on a patient other than the umbilicus. Referring now in specific detail to the drawings, in which like reference numerals identify similar or identical elements, there is shown inFIG. 1 a conventional, prior art laparoscopic instrument—trocar assembly.
• As illustrated inFIG. 1, a conventional trocar sleeve or cannula1 is an essentially straight, hollow instrument, which allows conventionallaparoscopic instruments3 such as an endoscope of suitable diameter to be inserted through the conventional cannula1 and into theabdominal cavity5 of a patient. Conventional cannulas1 have a diameter of a round 2-15 mm. Once the conventionallaparoscopic instruments3 are in place, standard laparoscopic procedures may be performed, such as cholecystectomy, appendectomy, or simple diagnostic laparoscopy.
• As shown inFIG. 1, when conventional trocar sleeves or cannulas I and conventionallaparoscopic instruments3 are inserted only through the umbilicus of the patient, the close proximity of the instruments to each other results in the so-called chopstick effect, which is a significant limitation to the manipulation of conventionallaparoscopic instruments3 through conventional trocars1.
• As shown inFIG. 2A andFIG. 2B, an exemplary C-shaped trocar sleeve orcannula7 is generally an elongated tube having aproximal end15 and adistal end17. In one exemplary embodiment the C-shape curve through ends15,17 is bent so that each end portion forms an angle of approximately 30° with respect to a tangent to the center of the trocar sleeve orcannula7. However, any angle, which sufficiently reduces the chopstick effect, may be used. Thus, exemplary embodiments with angles from 5-45° may be used. A C-shaped trocar sleeve orcannula7 may be made of conventional material as is known in the art. The interior diameter of a C-shapedcannula7 is preferably around 5 mm. However, in alternate embodiments the interior diameter of the C-shapedcannula7 may range from 2-15 mm. In one exemplary embodiment, the C-shape is relatively fixed and does not vary, for example when thecannula7 has a rigid composition. In an alternate exemplary embodiment, the C-shapedcannula7 is more flexible allowing the surgeon or surgical assistant to bend thecannula7 changing the angle of the C-shape, for example, via insertion of an instrument into the cannula.
• In an alternative design, trocar sleeve orcannula7 is made of a flexible material with a memory.Trocar sleeve7 orcannula7 may have a straight or linear cylindrical configuration in a relaxed state, i.e., in the absence of externally applied forces. Sleeve orcannula7 assumes the curved or arcuate configuration shown inFIG. 2A upon the insertion through the cannula of a laparoscopic instrument shaft with a curved or arcuate section of sufficiently greater rigidity than the cannula.Cannula7 then bends through the application of external forces to take the arcuate form shown inFIG. 2A.
• FIG. 2C illustrates an exemplary S-shapedlaparoscopic instrument10. The S-shapedlaparoscopic instrument10 has, for example, a shaft10awith a preformed inherently S-shaped configuration including aproximal curve20 and adistal curve21. Examples oflaparoscopic instruments10 which can be formed generally into an S-shape include but are not limited to scissors, clamps, dissectors, staplers, clip appliers, retrieval bags, and electrocautery instruments.Instruments10 include a manual actuator10bat a proximal end and an operative tip10cat a distal end. The S-shaped shaft10amay be substantially rigid throughout. Alternatively, shaft10aor a portion thereof, for example,distal curve21, may be semi-rigid and flexible so that the shaft may be deformed from the S-shaped configuration to an at least partially straightened configuration upon application of deformation forces to the shaft. In the latter case, the shaft is made of a material with a memory so that the shaft automatically returns to the S-shaped configuration after relaxation of deformation forces. In another alternative,proximal shaft portion20 is rigid whiledistal shaft portion21 is flexible.Distal portion21 is flexed into substantially rigid C-shape by a locking mechanism (not separately shown), controlled by actuator10b, so the instrument assumes a rigid S-form when needed by the surgeon. In any event, the S-shape for these instruments can be achieved, for example, by using conventional manufacturing techniques modified to accommodate the S-shape contour of the instrument.
• As illustrated inFIG. 3, a generally S-shapedlaparoscopic instrument10 may be inserted through a C-shaped trocar sleeve orcannula7. For example, theproximal curve20 of the S-shapedinstrument10 corresponds to the curve of the C-shapedcannula7. Thedistal curve21 of the S-shapedinstrument10 also corresponds to the curve of the C-shapedcannula7 and when inserted through the. C shapedcannula7 will be, for example, entirely within theabdominal cavity5 of the patient. A C-shapedcannula7 and S-shapedlaparoscopic instrument10 allows the surgeon to perform the laparoscopic procedure without making incisions outside of the umbilicus. In accordance with the present invention, the size and curvature of a C-shapedcannula7 will correspond to the size and curvature of an S-shapedinstrument10 and can include any desired size.
• This arrangement of C-shapedcannula7 and S-shapedinstrument10 eliminates the “chopstick effect” which results from the insertion of conventionallaparoscopic instruments3 through the umbilicus. For example, the proximal curves of the S-shapedinstruments10 and the C-shapedcannula7 allows the surgeon's hands and the proximal portions of theinstruments20, including the instruments' handles, to be placed as far apart as is convenient for the surgeon. For example,workspace9ais created. Movement of the proximal portion of oneinstrument20 away from theproximal portion20 of the other also markedly separates the exposed (e.g. outside the body cavity) shafts of each instrument. The distal curve of the S-shapedinstrument21 createsworkspace9bbetween the portions of the instruments in the abdominal cavity and redirects the distal end of thelaparoscopic instrument10 back toward atarget site8, such as an abdominal organ or other abdominal structure or site.
• Thus, an S-shapedlaparoscopic instrument10 may be thought of as having four segments or sections to allow an abdominal procedure to be performed entirely through the umbilicus and yet overcome the “chopstick effect” encountered with conventionallaparoscopic instruments3 and cannulas1. First, the portion outside of the patient'sabdominal cavity5 allows sufficient space between the surgeon's hands when manipulating the proximal portion of thelaparoscopic instruments10. Second, the portion at or near the umbilicus, which allows alaparoscopic instrument10 to enter theabdominal cavity5 is in close proximity to one or more additionallaparoscopic instruments10 so that allinstruments10 enter the abdomen through the umbilicus. Third, the portion beyond the second portion, which creates separation between laparoscopic,instruments10 within theabdominal cavity5. Fourth, the distal end of alaparoscopic instrument10 is shaped to point back toward the target abdominal organ, tissue, or other site.
• Examples of procedures which can be facilitated by the use of C-shaped trocar sleeves orcannulas7 and S-shapedlaparoscopic instruments10 include, but are not limited to diagnostic laparoscopy, cholecystectomy, appendectomy, salpingectomy, oophorectomy, treatment of infertility and extrauterine pregnancy, hysterectomy, removal of a section of bowel, a variety of gastric procedures, biopsy of various abdominal organs, including liver, and hernia repair.
• The following discussion describes, as an example, a cholecystectomy procedure as described inFIGS. 2A-C andFIG. 3. It should be noted, however, that many other laparoscopic procedures may be performed using various embodiments disclosed herein. The following description, therefore, is merely illustrative and is not intended to limit the present invention to the description given in this example.
• A laparoscopic procedure, such as a cholecystectomy, using a curved C-shaped flexible or rigid trocar sleeve orcannula7 and S-shapedlaparoscopic instruments10 is performed with the patient under general anesthesia. Carbon dioxide gas is insufflated intra-abdominally to 15 mm Hg through a 5 mm lateral umbilical incision using, for example, a VERESS™ needle. For example, two curved C-shaped 5 mmcannulas7 are then inserted through an incision in the umbilicus. The surgeon operates, for example, a 5 mm endoscope with one hand and a 5 mm S-shapedlaparoscopic instrument10 with the other, each of which is passed through arespective cannula7.
• The cannula for the endoscope could be straight so that a conventional straight endoscope could be used, the othercurved cannula7 providing separation between the instruments and the surgeon's hands. Pericholecystic adhesions, if present, are removed by blunt or sharp dissection using an S-shaped dissector to expose the dome of the gallbladder. A 2-0 nylon (or other suitable material) stay suture on a needle is placed through the abdominal wall immediately below the right costal margin at the right anterior axillary line, allowing for superior retraction of the gall bladder dome. The removal of the adhesions from around the gallbladder infundibulum is then continued as necessary. A second stay suture is placed through the right flank and then through the neck of the gallbladder allowing for lateral retraction to expose the cystic structures. The cystic duct and cystic artery are dissected, then ligated with clips, utilizing a 5 mm S-shaped clip applier, and then finally transected with an S-shaped scissors. With continued retraction from stay sutures, the gallbladder is removed from the liver bed utilizing an S-shaped electrocautery device equipped with a hook, dissecting the gallbladder from medial to lateral and inferior to superior direction. The perihepatic area is then irrigated using an S-shaped irrigation/suction device.
• The above-described procedure is greatly facilitated by the use of S-shapedlaparoscopic instruments10 and C-shapedcannulas7, allowing the procedure to be performed entirely through the umbilicus while at the same time reducing or eliminating the “chopstick effect”. For example, each of the S-shaped laparoscopic instruments is inserted and removed from the activecurved cannula7 as needed during the procedure and conflict with the endoscope is avoided. Thus, as a result, improved cosmesis, reduced operative and post-operative complications, and a less complicated surgical technique are achieved.
• FIG. 4A andFIG. 4B illustrate aninflatable cannula holder30 having, for example, multiple C-shaped trocar sleeves or cannulas incorporated within theunit30. Thelateral wall34 of the inflatablecannula holder unit30 may vary from extremely flexible and stretchable when deflated, thus facilitating insertion into the umbilical incision, to somewhat rigid when inflated during the surgical procedure. Theinflatable unit30 has, for example, a horizontalupper plate31 and a horizontallower plate32. Curved or arcuate trocar sleeves orcannulas33a,33b, and33cwill extend through the horizontalupper plate31 and horizontallower plate32 and may be incorporated within thelateral wall34. Cannulas33a,33b,33cmay be rigid or flexible members. One or more straight trocar sleeves or cannulas33d may also be provided whichtraverse holder unit30 and particularlyupper surface31 andlower surface32 thereof. Any given straight cannula33dmay be rigid or flexible. In the latter case, the cannula33dmay be sufficiently flexible to bend in conformation to a generally C-shapedsection20 or21 (FIG. 2C) oflaparoscopic instrument10. Shaft10aorsection20,21 thereof is either rigid or has a sufficient rigidity to force the bending of cannula33d. One of more ofcannulas33a,33b, and33cmay similarly be flexible members with a memory tending to return the cannulas to a straight or arcuate configuration.
• Rigid sections may be inserted or attached around the periphery of the horizontal upper31 or lower32 plate to add stability. The horizontalupper plate31 and horizontallower plate32 may be, for example concave or straight. At least one and possibly two or more C-shaped trocar sleeves orcannulas33a,33b,33c, (described previously) can be incorporated within thelateral wall34 of theinflatable unit30 and are distributed, for example, evenly around thewall34 of theunit30. The upper31 andlower plate32 are preferably made of a flexible plastic material or other suitable surgical quality material.
• In an alternate embodiment, theinflatable unit30 has one or more C-shaped trocar sleeves orcannulas7 incorporated within itslateral wall34, and one or more straight cannula1, also incorporated within the inflatable unit'slateral wall34. The straight cannula may accommodate, for example, a straight endoscopic or laparoscopic instrument, while the C-shapedcannulas7 can accommodate an S-shapedinstrument10 as described above. Thus, even where one of the instruments is relatively straight and passes through a relatively straight cannula1, the chopstick effect is still reduced as a result of the remaining C-shapedcannulas7 and S-shapedinstruments10, which provide space between the surgeons hands, the proximal portions of laparoscopic instruments (which includes the straight laparoscope), and the distal ends of the laparoscopic instruments (which also includes the straight laparoscope).
• Inflatable unit30 may include one or more passageways40aand40dformed by generally cylindrical webs of resilient material (not separately designated) connected at opposite ends toupper surface31 andlower surface32. Upon inflation ofunit30, the webs close the passageways and, upon insertion ofrespective cannulas33aand33d, form a sealed engagement therewith. In one possible mode of use,cannulas33aand33dare inserted through passageways40aand40donly after placement ofunit30 in an opening formed in a patient and upon inflation of the unit. Alternatively, allcannulas33a,33b,33c,33dmay be disposed within and coupled tounit30 prior to the positioning thereof in the patient.
• The surgeon may place theinflatable unit30 through an approximately 1.5 to 2.5 cm incision in the umbilicus. Theunit30 is inserted prior to inflation with the C-shapedcannulas33a,33b,33c, for example, parallel and in close proximity to each other. Theupper plate31 will remain outside of the umbilicus while thelower plate32 is located just inside theabdominal cavity5. Once theunit30 is properly positioned, the surgeon or assistant may inflate theunit30. Theunit30 may be inflated via, for example, a one-directional valve using a syringe or gas line inserted into a narrow hollow tube connected to theunit30 as is known in the art. The syringe or gas line may be alternatively inserted directly into an one-directional valve. Thus, means for inflating theunit30 can be similar to the means for inflating a conventional endotracheal tube.
• In an exemplary embodiment, the diameter of theinflatable unit30 increases upon inflation. The unit may be inflated to the extent needed for the particular laparoscopic procedure. By placing the trocar sleeves or cannulas in the lateral walls of the inflatable unit, the surgeon may position a trocar sleeves or cannula, and thus an instrument inserted through a cannula, as far away from the other cannulas and instruments as possible within the confines of a chosen space such as the umbilicus. In addition, the surgeon may change the position of the cannulas and instruments within the umbilicus by rotating theinflatable unit30 around its vertical axis. Moreover, theinflatable unit30 seals the opening of the patient'sabdominal cavity5 to prevent leakage of CO₂from the abdominal cavity.
• In an alternate embodiment as shown inFIG. 8, the distance between theupper plate31 and thelower plate32 may be reduced, thereby increasing the ability of the trocar sleeve orcannula7 to move in relation to the wall of theinflatable unit30. This design, where the distance between31 and32 is reduced to form the “plate member,” is preferred. The plate member is located perpendicular to the axis of the cannula holder and anywhere within its walls.
• Thus, as an example, the cholecystectomy procedure described above may be performed using theinflatable unit30 in conjunction with S-shapedlaparoscopic instruments10, rather than using separate cannula/instrument arrangements. Once the gallbladder is transected and removed from the liver bed, it is removed through the 1.5 to 2.5 mm incision along with theinflatable unit30. If necessary, the initial incision can be extended to remove the gallbladder. Alternatively, the gallbladder may be opened to remove or crush and remove gallstones, facilitating removal of the gallbladder through the umbilical incision.
• As shown inFIG. 5A andFIG. 5B, aninflatable unit70 includes a single C-shaped trocar sleeve or cannula (not separately designated) having a radially expandable and inflatable balloon-like structure75 incorporated within thehollow lumen73 of the cannula. A single laparoscopic instrument may be inserted within thisinflatable unit70.
• Unit70 may then be inflated to secure the cannula and laparoscopic instrument together as one movable unit. Theinflatable unit70 may be inflated via, for example, a one-directional valve using a syringe or gas line inserted into a narrowhollow tube74 connected to theunit70 as is known in the art. The syringe or gas line may be alternatively inserted directly into an one-directional valve. Thus, means for inflating theunit70 can be similar to the means for inflating a conventional endotracheal tube. Inflating theinflatable unit70 also serves to seal the abdomen preventing insufflated gas from escaping through the lumen of the cannula. Theinflatable unit70 then may be deflated, the laparoscopic instrument may be removed, and a different instrument may be inserted.
• While the above description of S-shapedinstruments10 and C-shapedcannulas7 has been directed to procedures performed entirely through the umbilicus, it is to be understood that embodiments of the present invention may be adapted for use in other entry sites. Therefore, when it is desirable to have entry of multiple instruments in a relatively localized area, embodiments of the present invention may be used for such entry, while reducing or eliminating the so-called “chopstick effect”. Thus, existing scars or hidden areas such as the pubic hair line or the axillary region may be used as a localized entry site.
• As illustrated inFIG. 6, an angulatedbi-directional needle50 is provided with a firstsharp end51, a secondsharp end52, and asurgical thread55 attached to theangle57 of theneedle50. Theneedle50 has, for example, a total length of around 5-10 cm. The length of each segment from angle to sharp end is roughly equivalent, but need not be. An acute angle of around 160° is formed by the angulatedneedle50, however angles57 ranging from a straight needle, i.e. 180°, to anacute angle57 of around 90° may be used. The needle is formed out of steel or other suitable material. Thesurgical thread55, such as 2-0 nylon, is attached at theangle57 of theneedle50.
• The angulatedneedle50 simplifies suture delivery through the gall bladder or other abdominal structure. For example, the firstsharp end51 of theneedle50 is inserted through the body wall by the surgeon. Theneedle50 is then grasped within theabdominal cavity5 by a laparoscopic instrument under endoscopic guidance and is pulled toward the organ of interest. With the secondsharp end52 leading, a stitch is placed through the abdominal structure of interest. The secondsharp end52 is then delivered through the abdominal wall.
• The angulatedbi-directional needle50 allows delivery of a stitch without changing the orientation of the sharp end as would be necessary if a needle with only one sharp end is used. Changing the direction of the needle with one sharp end to 180 degree laparoscopically might be technically challenging.
• An alternative exemplary embodiment of an angulated needle is shown inFIG. 7. In this embodiment the angulated needle60 has, for example, along segment61 with onesharp end62 on one side of theangle65. The needle60 has a bluntshort segment67 on the other side of theangle65.Thread68 is attached to the end of the bluntshort segment67.
• The angulated needle60 allows penetration through the body wall as a straight needle. The needle60 is inserted into and through the wall of the gallbladder. The needle is then flipped 180° and delivered back through the abdominal wall. The angulated needle60, can be used to reposition a gall bladder or other structure during a laparoscopic procedure by, for example, pulling or relaxing the suture, which eliminates or reduces the need for the insertion of one or more additional cannulas and laparoscopic instruments for that purpose. The angulation of the angulated needle60 also reduces the chance of iatrogenic injury to surrounding structures by allowing the needle60 to be flipped and then delivered back through the abdominal wall prior to contacting surrounding abdominal structures.
• As illustrated inFIG. 9, a stand-alone laparoscopic medical instrument insertable through a laparoscopic trocar sleeve or cannula comprises anelongate shaft80 formed of a plurality of a plurality of rigid cylindrical segments including amiddle segment82, threeproximal end segments84,86, and88, and threedistal end segments90,92, and94. During a laparoscopic procedure utilizing the instrument ofFIG. 9,middle segment82 traverses a laparscopic cannula, trocar sleeve, or instrument holder as described herein, whileproximal end segments84,86, and88 are located outside the patient anddistal end segments90,92, and94 are located inside the patient. Anoperative tip96 is disposed at one end of theshaft80, more particularly at a free end ofdistal end segment94, and actuator handles or hand grips98 are disposed at an opposite end of the shaft, more particularly at a free end ofproximal end segment88. Actuator handles98 are operatively connected tooperative tip96 viashaft80 for controlling the operation of the tip.
• Proximal end segments84,86 and88 form aproximal shaft portion100 that is independently bendable to form, for example, a C shaped configuration.Proximal end segments84,86, and88 are connected to one another via joints orarticulations102 and104 and tomiddle segment82 via a joint orarticulation106.
• Distal end segments90,92 and94 form adistal shaft portion108 that is independently bendable to form, for example, a C shaped configuration.Distal end segments90,92, and94 are connected to one another via joints orarticulations110 and112 and tomiddle segment82 via a joint orarticulation114.
• Operative tip96 may be rotatable about alongitudinal axis115. Further rotational capability may be provided by including a joint116,118,120 alongdistal end segments90,92 ormiddle segment82, where relative rotation of proximal and distal parts is effectuated about a longitudinal axis of the respective segment.
• Proximal end portion88 is provided with rotary actuators orknobs122 for modifying the angles between adjacentdistal end segments90,92,94, for rotatingoperative tip96 relative todistal end segment94 aboutaxis114, and for implementing the longitudinal-axis rotation atjoints116,118, and/or120. Wing-nut-type clamps124 may be provided atknobs122 for releasably locking those actuators to maintain the angles between adjacentdistal end segments90,92,94, the rotary position ofoperative tip96, and the longitudinal-axis rotation atjoints116,118, and/or120.
• Clampingelements126,128,130 may be provided at the articulations orjoints102,104,106 for locking the relative positions ofmiddle segment82, andproximal end segments84,86,88. Alternatively, further knobs and wing-nut clamps (not shown) may be provided at the proximal end of the instrument for changing the angles between pairs ofadjacent segments82,84,86,88.
• During a laparoscopic surgical procedure, the axial position ofoperative tip96 may be adjust by sliding the laparoscopic instrument ofFIG. 9 into and out of the patient, for example, by modifying the position ofmiddle segment82 relative to the respective cannula or instrument holder aperture. In addition, the axial position ofoperative tip96 may be changed by adjusting the configuration ofdistal end portions90,92,94 relative to one another. Strongly arced configurations have a shorter axial extent than configurations with more shallow arcs. Further degrees of freedom in the positioning ofoperative tip96 relative to a surgical site are provided by the rotatability ofoperative tip96 aboutaxis114 and the rotatability atjoints116,118,120. The positional adjustability provided by articulations orjoints110,112,114 greatly enhances the practical capabilities of the instrument.
• FIG. 10 depicts another stand-alone laparoscopic medical instrument having ashaft132 insertable through a laparoscopic trocar sleeve or cannula.Shaft132 has a continuously flexible proximal end portion orsegment134, a rigid straight middle portion orsegment136, and adistal end portion138.Proximal end portion134 anddistal end portion136 are connected to opposite ends ofmiddle portion136 via respective articulations orjoints140 and142, so that the proximal end portion and the distal end portion are laterally swingable relative to the middle portion, as indicated by dual headedarrows144 and146.Middle portion136 constitutes about one-third of the total length ofshaft132.
• Shaft132 is provided at a proximal end, i.e., at the free end ofproximal end portion134, with a pair ofhand grip actuators148, and is further provided at a distal end, i.e., at the free end ofdistal end portion138 with anoperative tip150 such as a scissors, a forceps, a clamp, a cauterizing element, etc.Operative tip150 is rotatable about alongitudinal axis152 relative to the end ofdistal end portion138, as indicated by abidirectional arrow154. As indicated by anotherbidirectional arrow157,proximal end portion134 anddistal end portion138 may be rotable relative to one another about a longitudinal instrument axis156, owing to a rotable joint158 exemplarily provided alongmiddle portion136.
• Distal end portion138 includes two segments orsections160 and162 pivotably connected to one another via an articulation or joint164, as indicated by a dual headedarrow166.Distal-most section162 is continuously bendable along its length into an infinite number of smoothly curved generally C-shaped configurations, as indicated by anarrow168. The moreproximal section160 may be rigid and linear or, alternatively, also continuously flexible along substantially its entire length and formable into a multitude of smoothly arced generally C-shaped configurations.
• Proximal end portion134 is provided along a linear proximal section (not seaprately labeled) with a pluraluty ofactuator knobs170 and lockingelements172 for controllably modifying (a) the degree of curvature ofproximal end portion134 anddistal end portion138, particularlydistal-most section162, (b) the angles betweenportions134 and136 andportions136 and138, (c) the angle betweensections160 and162, (d) the degree and direction of rotation ofoperative tip150 aboutaxis152, and (e) the relative angular position ofproximal end portion134 anddistal end portion138, as determined by the operational status ofjoint158. By way of illustration, a modified position and curvature ofdistal-most section162 is indicated inFIG. 10 at174. A modified position ofproximal section160 and a corresponding modified curvature of distalmost section162 are indicated in phantom at176. An alternate position ofproximal end portion134 with respect tomiddle portion136 is shown in phantom at178.
• FIGS. 11A-11F depict additional possible positional and curvature configurations of the instrument ofFIG. 10, particularlydistal end portion138.
• During a laparoscopic surgical procedure, the axial position ofoperative tip150 may be adjust by sliding the laparoscopic instrument ofFIG. 10 into and out of the patient, for example, by modifying the position ofmiddle portion136 relative to the respective cannula or instrument holder aperture. In addition, the axial position ofoperative tip150 may be changed by adjusting the configuration ofdistal end portion138, as depicted inFIGS. 11A-11F. Strongly arced configurations (FIGS. 11B and 11C) have a shorter axial extent than configurations with more shallow arcs (FIGS. 11A,11E). Further degrees of freedom in the positioning ofoperative tip150 relative to a surgical site are provided by the rotatability ofoperative tip150 aboutaxis152 and the rotatability at joint158.
• One or more of the actuatormechanisms including knobs170 and lockingelements172 may be operatively connected toshaft132 for bending distal section162 (and optionally section160) in a direction out of the plane of the drawing sheet.
• Whereproximal portion134 ofshaft132 assumes a first C-shaped configuration in response to operation of a respective one of theknobs170 and distal portion138 (or162) of the shaft assumes a second C-shaped configuration in response to operation of a second one of theknobs170, the C-shaped configurations may face opposite sides of the shaft, thus formingshaft132 into a generally S-shape.
• As depicted inFIG. 12, aholder180 for cannulas and laparoscopic surgical instruments such as those discussed above with reference toFIGS. 9-11F includes aplate member182 having a surrounding orperimetric edge184 and awall186 surrounding the plate member.Wall186 is provided with a plurality of anchoring elements such aseyelets187 or hooks189 for securing theholder180 to a patient via suture thread.
• Wall186 is connected toplate member182 all alongedge184. Wall has alongitudinal axis188, withplate member182 extending substantially transversely to that axis.Plate member182 is provided with a plurality of apertures orport members190,192 for receiving respective elongatelaparoscopic instruments194 and196.Instrument194 is configurable to have an S-shapedshaft198 and may specifically take the form of the instruments discussed with reference to FIGS.9 and10-11F.Instrument196 is a fiberoptic instrument including acamera200 in the form of a charge coupled device and abendable shaft202.Shaft202 has a proximal end portion260 and a distal end portion262 that may be independently flexed into continuous smooth C-shaped configurations as shown in the drawing. Alternatively,shaft202 may be substantially identical toshaft132 of the instrument shown inFIG. 10. The rotational capability discussed above with reference tooperative tip150 and joint158 may be omitted fromlaparoscope196.Laparoscope196 has an operative tip264 provided with the usual illumination aperture and imaging lens (neither shown). Actuators are omitted from the depiction inFIG. 12 ofinstruments194 and196 for purposes of simplicity. An actuator for controlling the operative tip264 oflaparoscope196 may take the form of conventional controls for illumination and CCD operation, where a CCD is located at the operative tip of the device.
• Holder180 is an inflatable unit, bothplate182 andwall186 being at least partially hollow for receiving a pressurizing fluid such as air. To that end, atube204 is connected toholder180 for the delivery of air from a pressure source such as a syringe (not illustrated). Avalve206 is provided ontube204. Asecond tube208 with avalve210 is connected toholder180 for providing a channel for the conveyance of an insufflation gas such as carbon dioxide from a reservoir thereof (not shown) to the patient. Anaperture212 is provided along aninner surface214 ofwall186 for enabling the delivery of the insufflation gas to the patient viatube208.
• Wall186 has a height dimension H1 at least as great as, and preferably substantially greater than, a height dimension H2 ofplate member182.Wall186 has twoend portions216 and218 extending as endless or annular flanges toplate member182.Plate member182 is located towards an upper end ofwall186,plate member182 forming a shallow cup shape and a deep cup shape withflanges216 and218, respectively.
• Wall186 has inner diameters D1 and D2 of the free ends offlanges216 and218, oppositeplate member182. These inner diameters D1 and D2 are larger than a diameter D3 ofplate member182, which is the inner diameter ofwall182 at the plate member. Consequently, cannula andinstrument holder180 has a flared or tapered profile on each side ofplate182. This flared or tapered shape may exhibit a curved or arced profile as shown in the drawing.
• FIG. 13 is a cross-sectional view ofholder180 similar toFIG. 12, withlaparoscopic instruments194 and196 removed to showpossible valves220 and222 included inport members190,192.Valves220 and222 are not a part of the present invention. Any known valve structure may be used inport members190,192.
• It is possible forport members190,192 to be disposed entirely withinplate member182. In that case, the port members incorporate flat valves in the form of flexible, horizontally located membrane with openings for the passage of laparoscopic instruments.
• As illustrated inFIG. 14, aflexible plate member224 of a cannula andinstrument holder226 similar to that ofFIGS. 12 and 13 hasapertures228 provided with rigid port members orcannulas230 serving in part to elongate the apertures. Port members orcannulas230 have a curvilinear or arced shape along their longitudinal dimensions and haveflanges232 and234 that extend outside ofplate member224.Plate member224 has a height H3 in a direction parallel to anaxis236 of the cannula and instrument holder, which is at least as great as heights H4 and H5 ofextension flanges232.
• Cannula andinstrument holder226 has asidewall237 that is substantially rigid in a region aboutplate member224 and flexible at least in a distal flange region (inside the patient) spaced fromplate member224. Such a design facilitates cannula insertion in the abdominal wall opening and overall structural integrity of the system while under deforming external pressure (rigid part), and provides an improved degree of freedom, particularly in the lateral planes, within the system (flexible part).
• Plate members182 and224, as well aswalls186 and238 ofholders180 and226 are flexible, but can acquire a semi-rigid form upon filling with inflation fluid. The flexibility of theholders180,226 means that these devices can be rolled or folded into a compact deflated configuration for insertion into the umbilicus or other abdominal aperture.FIG. 15 shows such a compacted insertion configuration of aninstrument holder240 havingport members242. For assisting in the deployment of theinstrument holder240,tongs244 may be used.Tongs244 have a pair ofhandles246 and a pair of substantiallycylindrical jaw elements248. The compactedinstrument holder240 is held betweenjaw elements248 for insertion into the umbilicus. The compacted holder is held by a finger or instrument in place, whiletongs244 are opened slightly (arrow247) and pulled (arrow249) toseparate jaw elements248 from theholder240. Theholder240 is then inflated in the umblicus to the use configuration.
• FIG. 16 depicts another instrument orcannula holder250 for the insertion of multiple laparoscopic instruments into a patient through a single aperture in the abdominal wall of the patient. Instrument orcannula holder250 includes a flaredannular body member252 provided at one end with a plurality of tapered or funnel-shapedintroduction ports254.Ports254 includeapertures256 for the introduction of laparoscopic instruments as discussed hereinabove.
• The term “laparoscopic medical instrument” is used herein to denote all instruments utilizable in the performance of a laparoscopic medical procedure, including surgical instruments and laparoscopes.
• While several exemplary embodiments of laparoscopic instruments and cannulas for the performance of laparoscopic procedures entirely through the umbilicus have been described herein, it is to be understood that variations may be made in the laparoscopic instruments and cannulas without departing from the spirit and scope of the present invention as defined by the appended claims.

Claims (30)

1-16. (canceled)

17. An instrument holder assembly for laparoscopic surgical operations,

said instrument holder assembly having an insertion configuration for insertion of said instrument holder assembly through an incision in a patient for at least partial insertion of said instrument holder assembly into a patient cavity, and an in use configuration for use of said instrument holder assembly for access to said patient cavity, said instrument holder assembly comprising:

a flexible member having a surrounding edge;

an at least partially flexible wall surrounding said flexible member, said at least partially flexible wall being connected to said flexible member all along said edge, said at least partially flexible wall having a longitudinal axis, said flexible member extending substantially transversely to said axis, said at least partially flexible wall extending away from said flexible member at least in a direction away from a patient; and

a plurality of cannulas connected to and extending from said flexible member inside said at least partially flexible wall,

said cannulas defining a plurality of separate and mutually spaced apertures for receiving respective elongate laparoscopic surgical members,

wherein, for the insertion configuration, the flexible member and the at least partially flexible wall are folded into a compact configuration wherein the at least partially flexible wall has a compressible cross-sectional dimension, said compressible cross-sectional dimension along the longitudinal axis of said at least partially flexible wall being less than a dimension of the incision in a patient where said at least partially flexible wall extends at least partially through the incision in a patient.

18. The instrument holder assembly defined inclaim 17 wherein said flexible member and said at least partially flexible wall each have a height dimension extending parallel to said axis, the height dimension of said at least partially flexible wall being substantially greater than the height dimension of said flexible member.

19. (canceled)

20. The instrument holder assembly defined inclaim 17 wherein said at least partially flexible wall has at least one end portion extending as a flange to said flexible member on the side of said flexible member opposite the patient.

21. An instrument holder assembly for laparoscopic surgical operations,

said instrument holder assembly having an insertion configuration for insertion of said instrument holder assembly through an incision in a patient for at least partial insertion of said instrument holder assembly into a patient cavity, and an in use configuration for use of said instrument holder assembly for access to said patient cavity, said instrument holder assembly comprising:

a flexible member having a surrounding edge; and

an at least partially flexible wall surrounding said flexible member, said at least partially flexible wall being connected to said flexible member all along said edge, said at least partially flexible wall having a longitudinal axis, said flexible member extending substantially transversely to said axis,

said flexible member being provided with a plurality of cannulas connected to and extending from said flexible member inside said at least partially flexible wall, said cannulas defining a plurality of separate apertures for receiving respective elongate laparoscopic surgical members,

wherein, in the in use configuration, said at least partially flexible wall has two end portions extending as endless or perimetrical flanges to said flexible member, said end portions extending in opposite directions away from said flexible member, and

wherein, for the insertion configuration, the flexible member and the at least partially flexible wall are folded into a compact configuration wherein the at least partially flexible wall has a compressible cross-sectional dimension, said compressible cross-sectional dimension along the longitudinal axis of said at least partially flexible wall being less than a dimension of the incision in a patient where said at least partially flexible wall extends at least partially through the incision in a patient.

22. The instrument holder assembly defined inclaim 20 wherein said flexible member is located at one end of said at least partially flexible wall.

23. The instrument holder assembly defined inclaim 17 wherein said flexible member is located at one end of said at least partially flexible wall.

24. The instrument holder assembly defined inclaim 17 wherein said flexible member and said at least partially flexible wall form two cup shapes.

25. The instrument holder assembly defined inclaim 17 wherein said at least partially flexible wall has a first inner diameter at said flexible member and a second inner diameter at an end opposite said flexible member, said second inner diameter being larger than said first inner diameter.

26-28. (canceled)

29. The instrument holder assembly defined inclaim 17 wherein the cannula and instrument holder assembly consists of said flexible member and said at least partially flexible wall.

30-31. (canceled)

32. The instrument holder assembly defined inclaim 17 wherein said apertures have a longitudinal dimension extending generally parallel to said axis, at least one of said apertures having a curvilinear or arced shape along the longitudinal dimension of said one of said apertures.

33. (canceled)

34. The instrument holder assembly defined inclaim 17 wherein said at least partially flexible wall is at least partially curved in a direction parallel to said longitudinal axis.

35. (canceled)

36. The instrument holder assembly defined inclaim 17 wherein said at least partially flexible wall is provided with an anchoring element for securing the instrument holder assembly to a patient, said anchoring element being taken from the group consisting of a hook and an eyelet.

37-40. (canceled)

41. The instrument holder assembly defined inclaim 17 wherein said cannulas all extend in a common direction away from said flexible member so that said cannulas are all disposed on only one side of said flexible member.

42. The instrument holder assembly defined inclaim 17, wherein the instrument holder assembly is inflatable and deflatable.

43. The instrument holder assembly defined inclaim 42, wherein the instrument holder assembly is inflated when in the insertion configuration to assume the in use configuration.

44. The instrument holder assembly defined inclaim 20, wherein the at least partially flexible wall is substantially rigid in a region about the flexible member and flexible at least in a distal region of the at least partially flexible wall inside the patient cavity that is spaced from the flexible member.

45. The instrument holder assembly defined inclaim 44, configured wherein, when the instrument holder assembly is in the in use configuration, the distal region of the at least partially flexible wall is inside the patient cavity.

46. The instrument holder assembly defined inclaim 17, wherein said at least partially flexible wall extending away from said flexible member at least in a direction away from a patient thereby defines together with said flexible member, in the in use configuration, a cup shape on a side of said flexible member opposite the patient.

47. The instrument holder assembly defined inclaim 21, wherein the instrument holder assembly is inflatable and deflatable.

48. The instrument holder assembly defined inclaim 21, wherein the instrument holder assembly is inflated when in the insertion configuration to assume the in use configuration.

49. The instrument holder assembly defined inclaim 21, wherein the at least partially flexible wall is substantially rigid in a region about the flexible member and flexible at least in a distal region of the at least partially flexible wall that is spaced from the flexible member.

50. The instrument holder assembly defined inclaim 49, configured wherein, when the instrument holder assembly is in the in use configuration, the distal region of the at least partially flexible wall is inside the patient cavity.

51. An instrument holder assembly comprising:

an annular body member; and

a plurality of tapered funnel-shaped port elements each defining a plurality of cross-sectional diameters and each of said plurality of tapered funnel-shaped port elements connected to said body member and extending proximally in a common direction therefrom, the taper of each of said tapered funnel-shaped port elements decreasing the plurality of cross-sectional diameters in the proximal direction.

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