US20160317184A1 - Access Device - Google Patents

Abstract

Various devices and methods are provided with respect to inserting multiple surgical instruments through a single surgical access device. A medical device including a flexible tissue retractor a releasable insert having multiple instrument openings, and a member such as a sleeve is disclosed. The insert can be in the form of an insert assembly including multiple components. The sleeve can support the insert with respect to the retractor such that the insert and sleeve can be removed together with the retractor remaining in the incision. A method of using the insert is also described.

Description

• This patent application incorporates by reference and claims priority to as a continuation in part of Devices and Methods for Providing Access Into a Body Cavity, U.S. Ser. No. 12/479,418, filed Jun. 5, 2009; and this patent application also incorporates by reference and claims priority to Provisional Patent Application Ser. No. 61/165,080 filed Mar. 31, 2009.
CROSS REFERENCE
• The present application cross references and incorporates by reference the following commonly assigned US patent applications: U.S. Ser. No. 11/398,985 filed Apr. 5, 2006 and published as US20060247673; U.S. Ser. No. 11/399,181 filed Apr. 5, 2006; U.S. Ser. No. 11/399,145 filed Apr. 5, 2006; U.S. Ser. No. 11/399,149 filed Apr. 5, 2006; U.S. Ser. No. 11/399,044 filed Apr. 5, 2006; U.S. Ser. No. 11/399,172 filed Apr. 5, 2006; U.S. Ser. No. 11/399,045 filed Apr. 5, 2006; U.S. Ser. No. 12/242,765 filed Sep. 30, 2008; U.S. Ser. No. 12/242,711 filed Sep. 30, 2008; U.S. Ser. No. 12/242,721 filed Sep. 30, 2008; U.S. Ser. No. 12/242,383 filed Sep. 30, 3008; U.S. Ser. No. 12/242,333 filed Sep. 30, 2008; U.S. Ser. No. 12/242,353 filed Sep. 30, 2008; U.S. Ser. No. 12/242,381 filed Sep. 30, 2008; U.S. Ser. No. 12/399,625 filed Mar. 6, 2009; U.S. Ser. No. 12/399,633 filed Mar. 6, 2009; U.S. Ser. No. 12/399,547 filed Mar. 6, 2009; U.S. Ser. No. 12/399,656 filed Mar. 6, 2009; U.S. Ser. No. 12/399,482 filed Mar. 6, 2009; U.S. Ser. No. 12/399,473; U.S. Ser. No. 12/110,724 filed Apr. 28, 2008; U.S. Ser. No. 12/109,881 filed Apr. 25, 2008; U.S. Ser. No. 12/425 filed Apr. 29, 2008; and U.S. Ser. No. 12/172,349 filed Jul. 14, 2008.
FIELD OF THE INVENTION
• The present invention relates to access devices, such as for providing surgical access into a body cavity.
BACKGROUND OF THE INVENTION
• 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 a the trocar sleeve. 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. Instruments used for mini-laparoscopic procedures are, however, 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 procedures. 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 desirable to perform an operation utilizing only a single incision in the navel. An umbilicus is well-hidden and the thinnest and least vascularized 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 or a surgical port located elsewhere while at the same time reducing or eliminating the “chopstick effect.”
SUMMARY OF THE INVENTION
• The present invention generally provides devices for allowing surgical access to an interior of a patient's body.
• In one embodiment, the medical device comprises a tissue retractor and an insert releasably supported within a passageway associated with the tissue retractor. The insert may have an outer surface sized and shaped to deform a flexible member of the tissue retractor to provide at least a portion of the passageway with a predetermined size and shape.
• The insert can be in the form of an insert assembly having a generally cylindrical outer surface sized to radially stretch a portion of the tissue retractor to have a generally circular or other suitable cross-section of predetermined diameter or width upon insertion of the insert within the passageway.
• The tissue retractor may be a flexible tissue retractor which includes a flexible member, such as a flexible membrane, having a first end and a second end, and the insert may be releasably supported or otherwise releasably insertable within the passageway of the flexible tissue retractor.
• In one embodiment, the insert comprises an assembly having an inner portion and an outer portion. The outer portion can have a generally cylindrical outer surface adapted to engage the inner surface of the passageway of the tissue retractor, and the inner portion may include a plurality of instrument openings aligned with instrument passageways rotatable with respect to the outer portion of the insert and the flexible tissue retractor,
• The insert may comprise an assembly which includes an outer body portion sized and shaped to engage and deform a portion of the inner surface of a flexible tissue retractor, a housing disposed at least partially within the outer sleeve, at least one instrument opening in an upper surface of the housing, and at least one seal operatively associated with each instrument opening. The insert assembly may also include an instrument channel member in the form of a unitary, flexible structure defining a plurality of tubular instrument channels. Each tubular instrument channel may be independently deformable with respect to the housing and the other tubular instrument channels. The instrument channels and instrument openings may be rotatably supported with respect to the outer sleeve and the tissue retractor, such as by a bearing member
• In one embodiment the flexible tissue retractor comprises first and second deformable rings, and the insert is sized and shaped to pass through at least one of the rings without deforming the ring. The insert may be sized and shaped to deform a portion of a flexible member extending intermediate the first and second rings
• In one embodiment, an assembly comprising a flexible tissue retractor, an insert, and a sleeve is provided. The sleeve may be positioned in the flexible tissue retractor, and the insert may be pressed into the sleeve. The sleeve and insert may be removed together from the retractor without removing the retractor from the incision. The sleeve may be provided to assist in inserting and removing the insert, and the sleeve may he formed of a material having a relatively low coefficient of friction, and a relatively high puncture resistance and/or high toughness
• In one embodiment, a method for accessing a body cavity through in incision is provided. The method includes the steps of positioning a tissue refractor in the incision; and releasably positioning an insert having multiple instrument openings into the tissue retractor. The step of positioning the insert may be by pressing the insert into the tissue retractor, and may include deforming and/or stretching at least a portion of the tissue retractor. The method may include forming an incision, positioning a tissue retractor in the incision, positioning a sleeve to extend at least partially within the tissue retractor, and postioning an insert having one or more instrument openings into the sleeve
• In one embodiment, a medical device is provided including a tissue retractor, at least one insert having at least one instrument opening, where the insert is positionable, such as by pressing, at different insertion depths within a passageway of the tissue retractor.
• In one embodiment, a method for accessing a body cavity includes the steps of positioning a flexible tissue retractor in the incision, wherein the tissue retractor provides a passageway extending through the incision; releasably positioning a first insert having at least one instrument opening in the passageway provided by the flexible tissue retractor; removing the first insert from the passageway provided by the tissue retractor; and positioning a second insert having at least one instrument opening in the passageway. The second insert can have a different number of instrument openings and/or a different size and/or a different shape than that of the first insert. The method can also include repositioning an insert to a second depth in the passageway of the retractor.
BRIEF DESCRIPTION OF THE DRAWINGS
• The invention will be more fully understood from the following detailed description taken in conjunction with the accompanying drawings, in which:
• FIG. 1 is a perspective, proximal view showing an access device comprising an insert having at least one instrument opening releasably supported within a flexible tissue retractor, with the proximal end of the insert shown inserted to be positioned below an upper, proximal end of the flexible tissue retractor;
• FIG. 2 is a perspective, distal view of the insert and flexible tissue retractor shown inFIG. 1, with a distal, bottom end of the insert shown visible from a lower, distal opening of the flexible tissue retractor;
• FIG. 3 is a cross-sectional view of a device of the type shown inFIG. 1;
• FIG. 4 is an exploded view of an insert of the type shown inFIG. 1;
• FIG. 5 is a perspective, proximal view showing an alternative access device comprising an assembly of an insert, a flexible tissue retractor, and a sleeve, the sleeve shown as including a generally annular portion disposed over the proximal end of the flexible tissue retractor, and the sleeve shown as including a generally cylindrical portion extending distally from the annular portion, at least a portion of the generally cylindrical portion of the sleeve disposed between the insert and the flexible tissue retractor.
• FIG. 6 is a cross-sectional view of the device of the type shown inFIG. 5, and showing the generally cylindrical portion extending distally beyond the distal end of the tissue retractor and the insert, the distal end of the cylindrical portion shown having a member in the form of a generally circumferentially extending rib or ledge for preventing the insert from being pressed into the body cavity and to assist in withdrawing the insert from the tissue retractor.
• FIG. 7 is an schematic exploded view of an insert similar to that shown inFIG. 4, but having three versus four instrument openings, including one relatively larger instrument opening (such as to receive a laparascope or other relatively larger diameter device), and two relatively smaller instrument openings (such as to receive relatively smaller devices, such as 5 mm graspers, clip appliers, or the like).
• FIG. 8 is a schematic depiction of how the insert ofFIG. 7 can be inserted into a sleeve (shown in half section), and the insert and sleeve can, in turn, be inserted into a flexible tissue retractor (also shown in half section).
• FIG. 9 illustrate the insert, sleeve, and tissue retractor positioned in tissue, with the insert shown inserted into and supported by the sleeve, and the sleeve, in turn, supported in the tissue retractor, with the sleeve and retractor shown in half section, andFIG. 9 illustrating the sleeve having a length longer than the axial length of the retractor, such that the sleeve can be positioned at various depths within the retractor, and such that inFIG. 9 the distal portion of the insert is shown positioned below the abdominal wall, and the distal portion of the insert abutting a retention feature in the form of an internal lip at the distal end of the sleeve, the retention feature preventing the insert from being pushed through the sleeve and into the abdominal cavity, and the lip facilitating removal of the insert with the sleeve when the sleeve is withdrawn from the flexible retractor.
• FIG. 10 is a perspective view illustrating how the sleeve and insert can be removed by fingers of a single hand grasping the edges of the sleeve and lining the sleeve proximally (upward inFIG. 10), with the insert retained by the sleeve and the insert being removed along with the sleeve when the sleeve is withdrawn from the retractor, and with the retractor left in place in the incision.
• FIG. 11 is a perspective view showing how, once the sleeve and insert have been removed from the flexible retractor, a specimen and/or specimen bag can be removed from the body through the flexible retractor.
• FIG. 12 is a cross-sectional schematic illustration of an embodiment where an insert is disposed within a flexible retractor, where the flexible retractor has an internal retention feature in the faint of an internal rib for retaining the insert at a desired depth within the retractor, andFIG. 12 illustrating how the insert's flexible support within the retractor allows an instrument extending through the insert to pivot the insert itself, such as to provide an improved range of motion of the instrument over seals mounted above or below the retractor.
• FIG. 13 provides a schematic cross-sectional illustration of an insert, sleeve, and retractor, where the insert includes zero closure seals in the form of duckbill seals at the proximal end of the insert for sealing instrument access channels when no instrument is inserted through the channel, and instrument seals in the form of septum seals for sealing about instruments inserted into the instrument channels.
DETAILED DESCRIPTION OF THE INVENTION
• Certain exemplary embodiments will now be described to provide an overall understanding of the principles of the structure, function, manufacture, and use of the devices and methods disclosed herein. One or more examples of these embodiments are illustrated in the accompanying drawings. Those of ordinary skill in the art will understand that the devices and methods specifically described herein and illustrated in the accompanying drawings are non-limiting exemplary embodiments and that the scope of the present invention is defined solely by the claims. The features illustrated or described in connection with one exemplary embodiment may be combined with the features of other embodiments. Such modifications and variations are intended to be included within the scope of the present invention.
• The present invention generally provides a medical device, such as a surgical access assembly, that allows one or more surgical instruments to be inserted through a single incision surgical access device, such as at various depths of insertion, thereby allowing for ease of manipulation of instruments within a patient's body while maintaining insufflation.
• FIG. 1 is a perspective view of the top, or proximal portion of the access assembly, andFIG. 2 is a perspective view of the bottom, or distal portion of the access assembly. Referring toFIGS. 1 and 2, in one embodiment the medical device is in the form of an access assembly comprising aflexible tissue retractor1000 and aninsert2000 having at least one instrument opening2014 (fourinstrument openings2014 shown inFIG. 1, and fourinstrument exits2016 shown inFIG. 2). Theinstrument openings2014 may extend through atop surface2702 of a portion of the insert, and theopenings2014 may be closed or otherwise obstructed by amembrane seal2600, as described in more detail below.
• Theinsert2000 is shown releasably supported within apassageway1104 defined by aflexible member1100 of theretractor1000. The phrase “releasably supported” in this context means the insert can be inserted and removed from the tissue retractor multiple times, including during a surgical procedure, without damaging or otherwise impairing the function of the retractor or the insert. In one illustrative example, theinsert2000 is releasably inserted by pressing (such as with a thumb or finger) the insert into the passageway of the retractor.
• Theflexible member1100 can include a first generally annular shaped, outer or top portion1120 (oriented generally horizontally inFIG. 1), a second generally annular shaped, inner portion1160 (oriented generally horizontally and generally parallel toportion1120 inFIG. 1), and a generally cylindrically shapedportion1140 extending axially in a distal direction fromportion1120 toportion1160.
• Theouter portion1120 can be associated with a first,proximal end1101 of theflexible member1100, and theinner portion1160 can be associated with a second,distal end1103 of the flexible member110. Theouter portion1120 is disposed outside the patient's body when the flexible retractor is positioned during surgery, and theinner portion1160 is disposed within the patient, such as within a body cavity, during a surgical procedure. An inner surface of the generallycylindrical portion1140 may provide most or substantially all of thepassageway1104, while an outer surface of the generallycylindrical portion1140 may contact the walls of an incision when theflexible retractor1000 is positioned during surgery, such as is shown in.FIG. 3.
• Theflexible member1100 may comprise a unitary, flexible membrane forming theportions1120,1140, and1160, and having afirst surface1102 and asecond surface1106. Thepassageway1104 oftissue retractor1000 may be defined at least in part by a portion of thefirst surface1102 facing radially inwardly in generallycylindrical portion1140. The portion of thesecond surface1106 associated with the generallycylindrical portion1140 may face radially outwardly so as to contact or otherwise engage the tissue at the incision site.
• Theflexible tissue retractor1000 may also comprise proximal and distal members for providing engagement of outer and inner portions of the retractor with outer and inner portions of the patient. For instance, thetissue retractor1000 may include a resilient, outer (proximal)deformable ring1200 and a resilient, inner (distal)deformable ring1400.Rings1200 and1400 are shown in phantom inFIGS. 1 and 2, and in cross-section inFIG. 3. Theflexible member1100 is shown extending intermediate therings1200 and1400, such thatmember1100 extends fromring1200 toring1400.
• FIG. 3 shows the access assembly offlexible refractor1000 and insert2000 positioned in an incision such that thedistal portion1160 of theretractor1000 and thering1400 are disposed in theabdominal cavity40, and the such that tissue60 (including a portion of the abdominal wall) engages thesurface1106 of the flexible retractor.
• Therings1200 and1400 can have any suitable closed or substantially closed configuration, including without limitation circular, oval, and elliptical configurations. By “resilient deformable ring” it is meant that the ring may be relatively easily deformed, such as by pressing opposite sides of the ring together with the fingers (and without any additional tools or aids), so that the ring may be inserted through a narrow incision in a body wall (e.g. the abdominal wall). For instance, theinner ring1400 may be deformed, such as by pressing opposite sides of the ring together with the fingers, and inserted through an incision in the patient, such as an incision through the abdominal wall. Once the ring is fully inserted, theinner ring1400 is able to resiliently return to its undeformed shape. The ring assists in securing theretractor1000 within the incision by engaging the inside surface of the abdominal wall of the abdominal cavity.
• The flexible member can comprise a flexible membrane of a resiliently deformable material, such as natural rubber, silicone, or a suitable deformable elastomer or elastomeric material. The deformable rings can be attached to the flexible membrane, or enclosed within rolled ends of the membrane. One suitable flexible tissue retractor comprising a flexible member with inner and outer deformable rings is a tissue retractor available from Hakko as Hakko FF0707.
• The flexible tissue retractor can be provided in one or more sizes, and in one example has a length, or height (measured in the direction ofaxis70 inFIG. 3) of between about 15 mm and about 30 mm, a maximum diameter corresponding to the diameter of therings1200/1400 of about 40 mm to about 80 mm, and an inner passageway diameter of between about 20 mm to about 40 mm. In the figures, the rings are shown having generally the same diameter, but it will be understood that the diameter of thering1200 may selected to be greater than that ofring1400, or the diameter ofring1200 may be less than that ofring1400. In one embodiment, a flexible tissue retractor having an inner passageway diameter smaller than that required to permit passage of a user's hand and generally less than about 50 mm can be desirable, so as to provide a access for multiple instruments but without requiring a relatively large incision.
• Theflexible tissue retractor1000 may be formed to have a self supporting predefined shape, such as the shape shown inFIG. 1. By “self supporting” it is meant that when theretractor1000 is placed on a substantially horizontal surface (e.g. flat table top), the retractor is able to maintain its shape without collapsing, with thepassageway1104 extending substantially vertically and with theportions1120 and1140 separated a predetermined distance from each other byportion1160.
• InFIGS. 1-3, theinsert2000 is shown pressed into or otherwise positioned within apassageway1104 such thatinsert2000 and theinstrument openings2014 are disposed below thering1200 and theannular portion1120 of the flexible tissue retractor. As shown inFIG. 3, a member such as a retention feature in the form of aninternal rib1108 may be formed with or otherwise provide on the internal surface of the retractor. Therib1108 can be positioned to prevent theinsert2000 from being pushed through theretractor1000 and into thebody cavity40.
• InFIGS. 2 and 3, the distal end of theinsert2000 and the instrument exits2016 are shown extending generally at or below thedistal ring1400 and thedistal portion1160 of the flexible retractor. Accordingly, theinsert2000 is positioned within theretractor1000 to provide a low profile, such that the instruments inserted into theopenings2014 and out of theexits2016 can be pivoted with respect to theinsert2000 and/or each other at pivot points positioned distally of the upper,proximal ring1200, such as at pivot points positioned within the incision. Such a low profile configuration allows seals associated with the instrument passageways in theinsert2000 to reside belowring1200, and in particular, within the incision or within the abdominal cavity. Without being limited by theory, it is believed that positioning seals in the abdominal space may assist in preventing the seals from being collapsed or otherwise affected by tissue pressure, and may prevent tissue from closing instrument passageways or otherwise blocking or reducing visibility through the instrument passageways.
• Referring toFIGS. 3 and 4, theinsert2000 shown comprises an insert assembly. The insert assembly is shown comprising anouter body portion2100, a bearingmember2200, aninversion constraint member2300, aspacer2400, an elastomericinstrument channel member2500, amembrane seal2600, and aninner housing2700, as described more filly below.
• Outer body portion2100 is shown in the form of a generally cylindrical shell having a generally cylindricalouter surface2110, aninner surface2112, adistal ledge2120 extending radially inwardly fromsurface2112, and an internal surface feature, such as acircumferentially extending protrusions2114.
• Theouter body portion2100 may be a generally rigid, hard shell formed of a suitable material, such as polyethylene or other suitable medical grade materials, so that when theinsert2000 is inserted into theflexible retractor1000, theouter body portion2100 does not deform to any significant degree, but instead acts to stretch or otherwise expand the flexible retractor to maintain thepassageway1104 in a desired shape and size, or to provide the passageway with a predetermined size and shape.
• Theouter body portion2100 shown may inserted into the retractor to deform the portion of the retractor spaced from and intermediate therings1200 and1400. Theouter body portion2100 can be sized and shaped to pass through one or bothrings1200 and1400 without deforming the rings. For instance,outer body portion2100 may have a generally cylindrical outer surface having an outer diameter smaller than the inner diameter ofring1200, and the outer surface can be sized to radially and circumferentially stretch the portion of the retractor associated withpassageway1104. Accordingly, theinsert2000 may provide thepassageway1104 extending through the incision with a generally circular cross-section of predetermined diameter. The advantages of ease of insertion of a flexible retractor are retained, while preventing thepassageway1104 from being narrowed or constricted by the incision. In addition, an insert having a generally cylindrical configuration provides a generally circular opening through the retractor, with a circle providing the maximum area per unit of perimeter length. A generally circular cross-section of the insert also allows for ease in providing for rotation of a portion of the insert, such as with respect to the outer surface of the insert and/or the retractor.
• In one embodiment, the outer diameter of thebody portion2100 may be sized to be slightly larger than the inner diameter ofpassageway1104 when retractor is free standing, without theinsert2000 disposed in thepassageway1104. After therefractor1000 has been inserted into an incision, theinsert2000 may be inserted intoretractor1000. Theinsert2000 may be sized to stretch the retractor, to at least slightly enlarge thepassageway1104, and theinsert2000 can frictionally engage the internal surface ofpassageway1104. Theinsert2000 can act to hold open thepassageway1104 against the compressive forces of the incision acting on theretractor1000.
• Theouter body portion2100 is shown having a generally cylindrical outer surface, but it will be understood that other outer surface shapes may be employed, including generally smooth or faceted outer surfaces. Suitable surface include, but are not necessarily limited to oval, elliptical, ovoid, oblong, and combinations thereof. For instance, it may be desirable to provide various inserts having different outer surface shapes and sizes to provide or assist in providing apassageway1104 having a certain size and shape, depending on for instance the procedure being performed and/or the size of the incision. The size and shape of the outer surface ofbody portion2100 may serve to deform the flexible member to provide at least a portion of the passageway with a predetermined size and shape. Additionally, the size and shape of the outer body portion may serve to provide frictional engagement of theouter body portion2100 with the inner surface of thepassageway1104 in the flexible retractor.
• Still referring toFIGS. 3 and 4, theinner housing2700 includes an outer proximally facingtop surface2702 through whichinstrument openings2014 may extend. Theinner housing2700 shown also has a generally cylindricalouter side surface2710 extending distally from thetop surface2702. Theinstrument channel member2500 is shown supported withininner body portion2700. Theinstrument channel member2500 defines a plurality ofinstrument channels2550, eachchannel2550 generally aligned with and extending from aproximal opening2014 to adistal exit2016. Themembrane seal2600 is shown captured between theinner housing2700 and a proximal end of theinstrument channel member2500. Themembrane seal2600 provides a seal for preventing loss of insufflation through aninstrument opening2014 prior to insertion of an instrument through the opening. Themembrane seal2600 may be in the form of a thin membrane formed of a flexible material which can be punctured or otherwise pierced by a surgical instrument. In one embodiment, theseal2600 comprises a membrane formed of polyurethane having thickness of less than about 0.010 inch, and in particular the membrane can have a thickness of about 0.006 inch. Alternatively, zero closure seals such as a duck bill seal or other suitable seals for sealing in the absence of instrument may be employed in association with theopenings2014.
• Thedistal ledge2120 of theouter body portion2100 provides an axial thrust support surface on which bearingmember2200 may be rotatably supported (see for instanceFIG. 3).Bearing member2200 may serve to provide rotational support for an assembly comprising theinner body portion2700 andinstrument channel member2500, such that the assembly is able to rotate relative to theouter body portion2100 about anaxis70 extending generally longitudinally through thepassageway1104 in the retractor1000 (seeFIG. 3).Bearing member2200 may be formed of any suitable material, such as high density polyethylene.
• Accordingly, bearingmember2200 may be provided so that when theinsert2000 is pressed into place withinflexible retractor1000, theouter body portion2100 may remain generally stationary with respect to theretractor1000, while theinstrument channel member2500 is rotatable within the retractor. Rotation of themember2500 permits rotational positioning of theinstrument openings2014 andpassageways2550 to provide desired positioning of one or more instruments extending throughinsert2000.
• Theinstrument channel member2500 is shown comprising a plurality ofinstrument channels2540, each instrument channel comprising aninstrument passageway2550. Theinstrument channel member2500 may be advantageously formed as a one piece, unitary structure formed from a deformable, resilient material such as polyisoprene, Kraton, or Sanoprene, so that eachinstrument channel2540 is independently deformable with respect to thehousing2700 and to the other instrument channels. Accordingly, instruments inserted into theinstrument passageways2550 may be angled and/or pivoted with respect to each other, allowing for increased freedom of motion of each instrument relative to the others. If desired, aseal member2544 or other constriction may be provided at the distal end of eachinstrument channel2540 for providing sealing about an instrument positioned within theinstrument channel2540.
• In the figures, theinstrument channels2540 are shown to be generally cylindrical in shape, and extending distally from aproximal base2510.Openings2514 in thebase2510 correspond to and are generally aligned with theinstrument openings2014 byrecesses2520 formed in the upper surface of thebase2510. Therecesses2520 may be positioned to mate with features on the underside (distal side) of theinner housing2700.
• Theprotrusions2114 formed in the inner surface ofouter body portion2100 may operatively engage a feature, such as acircumferentially extending groove2714 formed in an outercylindrical surface2710 of theinner housing2700. Theprotrusions2114 engagegroove2714 to restrain theinner housing2700 axially (i.e. in the proximal and distal directions) with respect to theouter body portion2100, while permitting rotation of theinner body portion2700 with respect to theouter body portion2100. Alternatively, thebody portion2100 could include a groove, and theinner housing2700 could include a protrusion for engaging such a groove.
• Inversion constraint member2300 may be provided to preventinstrument channels2540 from becoming “inverted” (e.g. in the manner of a shirt sleeve being pulled inside out) when an instrument is withdrawn from thechannel2540. Themember2300 is shown having a generally disc shapedbody2320 havingapertures2340 extending therethrough. Eachaperture2340 can be sized to fit over the distal end of acorresponding instrument channel2540. Themember2300 may be formed of any suitable material, including for instance polyisoprene, Sanoprene, or Kraton. The flexibility of themember2300 may be tailored with respect to the flexibility of more proximal portions of theinsert2000. For instance, ifmember2300 is made relatively more flexible than a proximal portion of the insert2000 (such as for instance the top surface of the housing2700), then instruments inserted in the instrument channels will tend to pivot about a fulcrum associated with the more proximal portion of the insert. Alternatively, if themember2300 is made relatively more rigid with respect to the more proximal portions of theinsert2000, then the instruments will tend to pivot about a fulcrum associated with themember2300. As shown inFIG. 3, themember2300 may he positioned axially between bearingmember2200 andspacer2400, and themember2300 may be positioned radially inward of the distal portion of theinner housing2700.
• FIGS. 5 and 6 and illustrate an alternative embodiment of an access device according to the present invention. The access device shown comprises an assembly of aflexible tissue retractor1000, aninsert2000, and asleeve3000. Theflexible tissue retractor1000 and theinsert2000 can be of any suitable form, including as described above with respect toFIG. 1-4.
• Sleeve3000 may be provided to assist in preventing theinsert2000 from being pressed through theretractor1000 and into a body cavity, and to assist in removing theinsert2000 from theretractor1000. For instance, during a surgical procedure it may be desirable to interchange one or more inserts in atissue retractor1000 without removing thetissue retractor1000 from the incision.Sleeve3000 may also be provided to protect theretractor1000 from being torn or otherwise damaged by instruments inserted throughinsert2000. In one embodiment,multiple inserts2000 may be provided for a specific procedure, each insert having a different shape, a different size, a different number of instrument openings, and/or different instrument opening sizes. Or, it may be desirable to remove aninsert2000 from the retractor positioned in the incision, such as to withdraw an instrument, apparatus, tissue, or body organ through the passageway of thetissue retractor1000.
• Referring toFIGS. 5 and 6, thesleeve3000 may comprise a generallyannular portion3100 and a generallycylindrical portion3200. The generallyannular portion3100 is shown having a generally flat proximal. (upper)surface3110, and an opposite, generally flat distal (downward)surface3120. Sleevedistal surface3120 may abut or otherwise contact or face the proximal portion offlexible tissue retractor1000 when thesleeve3000 is fully positioned with respect toretractor3000 andinsert1000.
• The generallycylindrical portion3200 is shown extending distally from, and at substantially a right angle to, theannular portion3100. The generallycylindrical portion3200 is shown including a radially outwardly facingsurface3210 and an inwardly facingsurface3220. The inwardly facingsurface3220 provides apassageway3104. The generallycylindrical portion3200 extends at least partially through theflexible tissue retractor1000, and inFIGS. 5 and 6 the generallycylindrical portion3200 extends through theretractor1000 to extend distally beyond the distal end of theretractor1000.
• InFIGS. 5 and 6, theinsert2000 is shown diposed within thepassageway3104 provided by generallycylindrical portion3200 ofsleeve3000.Sleeve portion3200 is, in turn, shown disposed within theflexible tissue retractor1000. Theinsert2000,sleeve3000, and flexible tissue retractor may be assembled in any desired order, either before or after the tissue retractor is positioned in an incision. For instance,insert2000 may be pressed intosleeve3000, and the sleeve/insert subassembly may then be pressed intoretractor1000 either before or after the retractor is positioned in the incision. Alternatively, thesleeve3000 may be pressed or otherwise inserted into the retractor either before or after the retractor is positioned in the incision, and the insert may then be pressed into the sleeve.
• Generally, thetissue retractor1000 will first be inserted into an incision, such as by deforming one or bothrings1200/1400 to insert the retractor in the incision, or by using an insertion tool to insert the retractor in the incision. Thesleeve3000 may then be inserted into theretractor1000, such as by pressing the sleeve into the retractor. Theinsert2000 may then be inserted into thesleeve3000.
• Thesleeve3000 is shown having a member such as a retention feature for preventing the insert from being pressed completely through the sleeve/retractor into the body cavity, and to assist in removing theinsert2000 from the retractor. Referring toFIG. 6, a retention feature in the form of a generally circumferentially extending ledge orlip3300 is shown extending generally radially inwardly at a distal end of the generallycylindrical portion3200 ofsleeve3000. Thelip3300 may be circumferentially continuous, and may be sized and shaped to abuttingly engage a portion of the insert, such as the distal end of theouter body portion2100.
• In the embodiment shown inFIGS. 5 and 6, when theinsert2000 and thesleeve3000 are fully inserted withinretractor1000, theseals2544 are positioned below the distal end of theretractor1000. Such an arrangement can provide an instrument pivot point below the retractor, and within the body cavity.
• If desired, theinsert2000 and/orsleeve3000 may be partially withdrawn from the fully inserted configuration shown inFIGS. 5 and 6, in a proximal direction to reposition the distal end of theinsert2000 with respect to theretractor1000. Accordingly, the positions where the surgical instruments exit theinsert2000 can be varied in a generally continuous manner along theaxis70, and the point where instruments exit theinsert2000 can be located at a plurality of positions within the passageway provided by the retractor, or distally below the distal end of the retractor.
• If desired, a kit may be provided withdifferent inserts2000,different tissue retractors1000, and/ordifferent sleeves3000. For instance, the kit may include a plurality oftissue retractors1000, each sized and/or shaped for a different incision size. The kit may include a plurality ofinserts2000 having different instrument openings sizes and/or configurations. The kit may include sleeves with generally cylindrical portions having different lengths and/or diameters.
• In order to withdraw theinsert2000 from theretractor1000 and incision, a portion of thesleeve3000, such as theannular portion3100, may be gripped with one or both hands (such as at opposite sides of the annular portion3100), and the sleeve may be pulled proximally (upward inFIGS. 5 and 6) to withdrawn thesleeve3000 and insert2000 from thetissue retractor1000.
• Thesleeve3000 may be formed of a non-metallic plastic or elastomeric material. Thesleeve3000 may have a thickness of between about 0.004 inch and 0.025 inch, and may be formed of a relatively low friction, high puncture resistant material having a relatively high elongation before tearing, and be relatively resistant to silicone or other lubricants without breaking down or degrading. Onesuitable sleeve3000 can be formed of sheet or film having a thickness of about 0.005 inch to about 0.007 inch.Sleeve3000 may be formed to have a coefficient of friction less than that of theretractor1000, and the coefficient of friction of thesleeve3000 can be less than about 0.25, more particularly, less than about 0.20, and still more particularly, less than about 0.15.
• In one embodiment,sleeve3000 may be formed of a relatively stiff, non-metallic plastic or elastomeric material, having a hardness greater than the hardness of the tissue retractor, and a flexibility less than that of the tissue retractor. In another embodiment, the sleeve may be formed of a material, that is relatively soft and flexible. One suitable material from whichsleeve3000 may be formed is a thermoplastic polyurethane elastomer such as a Pellethane brand polyurethane available from Dow Chemical.
• Multiple inserts2000 may be provided, such as two, three, or more inserts may be provided in a kit form for use in a single surgical procedures. For example, a first insert may be provided having two or more instrument openings, and a second insert may also be provided having multiple instrument openings. The first and second inserts may have the same number of instrument openings, or a different number of instrument openings.
• FIG. 7 is an schematic exploded view of aninsert2000 similar to that shown inFIG. 4, but having threeinstrument openings2600, versus four instrument openings as shown inFIG. 1. InFIG. 7, the three instrument openings include one relatively larger instrument opening (such as to receive a laparascope or other relatively larger diameter device), and two relatively smaller instrument openings (such as to receive relatively smaller devices, such as5mm graspers, clip appliers, or the like). As shown inFIG. 7, theinstrument channel member2500 has three instrument channels corresponding to the three instrument openings, with one of the instrument channels shown being relatively larger in diameter than the other two instrument channels. Theinsert2000 ofFIG. 7 can have generally the same shape and diameter as that ofFIG. 1. Alternatively, if desired, the insert could have a different diameter and/or a different shape.
• FIG. 8 is a schematic depiction of how the insert ofFIG. 7 can be inserted into a sleeve3000 (shown in half section), and theinsert2000 andsleeve3000 can, in turn, be inserted into a flexible tissue retractor1000 (also shown in half section). As described above, thesleeve3000 can include a retention feature in the form of a generally circumferentially extending ledge orlip3300 is shown extending generally radially inwardly at a distal end of the generallycylindrical portion3200 ofsleeve3000. Thelip3300 may be circumferentially continuous, and may be sized and shaped to abuttingly engage a portion of the insert, such as the distal end of theouter body portion2100 of the insert. If desired, thesleeve3000 can be firmed of a relatively resilient material, and the inner diameter of theportion3200 of thesleeve3000 can be sized to engage the outer surface of the insert (such as by having a slightly smaller diameter than the insert2000) so that the insert can be releasable positioned at multiple insertion depths within theportion3200. In this way theinsert2000 can be positioned at multiple insertion depths with respect to the flexible tissue retractor, withfeature3300 being operable to prevent the insert from being inadvertently pushed into the body cavity.
• FIG. 9 illustrates atissue retractor1000 disposed in an incision intissue60, withinsert2000 releasably supported in thesleeve3000, andsleeve3000 in turn releasably supported within thetissue retractor1000. Theinsert2000 is shown disposed at the distal end ofsleeve3000, with the distal end of the insert abutting against member/retention lip3300 of the sleeve.
• FIG. 9 also illustrates thesleeve3000 can have an axial length longer than the axial length of theretractor1000. If desired, the sleeve can be positioned at various depths within the retractor, so that the distal end of the sleeve (e.g. the distal end of the cylindrical portion3200) can be positioned proximal or distal of the distal end of the retractor. InFIG. 9, the distal end of the sleeve is shown disposed distally (below) the distal end of thetissue retractor1000, so that the instrument exits2016 of theinsert2000 are positioned below the abdominal wall. The retention feature (e.g. lip member3300) prevents the insert from being unintentionally pushed into theabdominal cavity60A. Thefeature3300 also facilitates removal of theinsert2000 with thesleeve3000 when the sleeve is withdrawn proximally from theflexible retractor1000. Accordingly, the retractor can be left in the incision after removal of thesleeve3000 carrying the insert.
• FIG. 10 is a perspective view illustrating how thesleeve3000 and insert2000 can be removed by fingers of a single hand grasping the edges of theportion3100 ofsleeve3000 and titling the sleeve proximally (upward inFIG. 10), with the insert carried and retained by thesleeve3000. The insert is shown being removed along with the sleeve when the sleeve is withdrawn from theretractor1000, and with the retractor left in place in the incision intissue60.
• FIG. 11 is a perspective view showing how, once thesleeve3000 and insert2000 have been removed from the passageway provided byflexible retractor1000, a specimen and/orspecimen bag5000 can be removed proximally (upward inFIG. 11) from the body cavity (e.g.abdominal cavity60A) through the passageway of theflexible retractor1000, such as with angrasper instrument6000 inserted through the passageway of the retractor.
• FIG. 12 shows a cross-sectional schematic illustration of an embodiment where aninsert2000 is disposed within aflexible retractor1000, without the use of asleeve3000. Theflexible retractor1000 is shown having an internal retention feature in the form of an internal rib orlip1108 for retaining theinsert2000 at a desired depth within the retractor. InFIG. 12, thelip1108 is shown positioned about midway along the length of the passageway provided byretractor1000, so that the distal end of theinsert2000 is disposed about midway along the length of the passageway of the retractor.
• FIG. 12 illustrates how the flexible support of the insert within theflexible retractor1000 allows an instrument7000 (e.g. a laparascope or instrument for manipulating/grasping tissue) extending through an instrument channel of theinsert2000 can be employed to pivot theinsert2000 itself, such as to provide an improved range of motion of the instrument, as compared to the range of motion provided by instrument supports and seals mounted above or below a retractor.
• FIG. 13 provides a schematic cross-sectional illustration of an assembly comprising aninsert2000,sleeve3000, andretractor1000, where the insert includes zero closure seals in the form ofduckbill seals2630 associated with the proximal end of the instrument access channels (for sealing instrument access channels when no instrument is inserted through the channel), and instrument seals in the form ofseptum seals2640 operatively associated with the distal ends of the instrument access channels for sealing about instruments inserted into the instrument channels. Alternatively, theseals2640 could be provided at the proximal end of the insert, and theseals2630 could be provided at the distal end of the insert.
• The devices disclosed herein can be designed to be disposed of after a single use, or they can be designed to be used multiple times. In either case, however, the device can be reconditioned for reuse after at least one use. Reconditioning can include any combination of the steps of disassembly of the device, followed by cleaning or replacement of particular pieces, and subsequent reassembly. In particular, the device can be disassembled, and any number of the particular pieces or parts of the device can be selectively replaced or removed in any combination. Upon cleaning and/or replacement of particular parts, the device can be reassembled for subsequent use either at a reconditioning facility, or by a surgical team immediately prior to a surgical procedure. Those skilled in the art will appreciate that reconditioning of a device can utilize a variety of techniques for disassembly, cleaning/replacement, and reassembly. Use of such techniques, and the resulting reconditioned device, are all within the scope of the present application.
• Preferably, the invention described herein will be processed before surgery. First, a new or used instrument is obtained and if necessary cleaned. The instrument can then be sterilized. In one sterilization technique, the instrument is placed in a closed and seated container, such as a plastic or TYVEK bag. The container and instrument are then placed in a field of radiation that can penetrate the container, such as gamma radiation, x-rays, or high-energy electrons. The radiation kills bacteria on the instrument and in the container. The sterilized instrument can then be stored in the sterile container. The sealed container keeps the instrument sterile until it is opened in the medical facility.
• It is preferred that device is sterilized. This can be done by any number of ways known to those skilled in the art including beta or gamma radiation, ethylene oxide, steam, and a liquid bath (e.g., cold soak).
• One skilled in the art will appreciate further features and advantages of the invention based on the above-described embodiments. Accordingly, the invention is not to be limited by what has been particularly shown and described, except as indicated by the appended claims. All publications and references cited herein are expressly incorporated herein by reference in their entirety.

Claims (20)

What is claimed:

1. A medical device comprising:

a flexible tissue retractor having an outer surface for engaging a body incision and an inner surface defining a passageway;

a sleeve, at least a portion of the sleeve positionable within the passageway; and

an insert comprising at least one instrument opening, wherein the insert is adapted to be releasably supported in the passageway.

2. The medical device ofclaim 1 wherein at least a portion of the sleeve is disposed between a portion of inner surface of the flexible tissue retractor and a portion of the insert.

3. The medical device ofclaim 1 wherein the sleeve comprises a generally cylindrical portion sized to be positioned within the passageway between a portion of the flexible member and a portion of the insert.

4. The medical device ofclaim 1 wherein the insert and sleeve are removable together from the passageway of the flexible tissue retractor.

5. The medical device ofclaim 1 wherein sleeve is removably positionable in the passageway of the flexible tissue retractor, and wherein removal of the sleeve from the tissue retractor is operable to remove the insert from the passageway.

6. The medical device ofclaim 1 wherein the sleeve is positionable in the passageway between an outer surface of the insert and a portion of the inner surface of the flexible member, and wherein the sleeve comprises a material having a hardness less than the hardness of the outer surface of the insert.

7. The medical device ofclaim 1, wherein the sleeve comprises a first portion positionable within the passageway of the flexible tissue retractor, and second portion positionable outside the passageway.

8. The medical device ofclaim 1 wherein the second portion is adapted to be grasped by a user to withdraw the sleeve and insert together from the passageway.

9. The medical device ofclaim 1 wherein the sleeve comprises a first portion positionable within the passageway of the flexible tissue retractor, and a second portion extending radially from the first portion and positionable outside the passageway of the flexible tissue retractor.

10. The medical device ofclaim 1 wherein the sleeve comprises a ledge for restricting axial movement of the insert through the sleeve.

11. A medical device comprising:

a flexible tissue retractor having an outer surface for engaging a body incision and an inner surface for defining a body access passageway;

an insert releasably supported within the body access passageway, the insert comprising:

a plurality of instrument openings;

at least one seal associated with each instrument opening; and

a removable sleeve disposed intermediate the insert and at least a portion of the passageway of the flexible tissue retractor.

12. The device ofclaim 11 wherein the sleeve and insert are adapted to be removed together from the passageway.

13. The medical device ofclaim 11 wherein the sleeve and insert are adapted to be inserted together into the passageway.

14. The medical device ofclaim 11 wherein the sleeve has an axial length greater than an axial length of the insert.

15. The medical device ofclaim 11 wherein the sleeve has an axial length greater than an axial length of the passageway.

16. A medical device comprising:

a flexible tissue retractor having an outer surface for engaging a body incision and an inner surface defining a passageway;

a member having a portion releasably positionable within the passageway of the flexible tissue retractor; and

an insert comprising at least one instrument opening;

wherein the member is adapted to releasably support the insert with respect to the passageway of the flexible tissue retractor.

17. The medical device ofclaim 16 wherein the member comprises a sleeve.

18. The medical device ofclaim 16 wherein member and insert are configured to be removed together from the passageway of the flexible tissue retractor.

19. The medical device ofclaim 18 wherein the member and insert are configured to be removed together from the flexible tissue retractor without removing the tissue rectractor from a body incision.

20. The medical device ofclaim 16 wherein the member comprises a retention feature for preventing the insert from being pushed through the member and into a body cavity.

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