Abstract:
Devices and methods for stabilizing a portion of an organ or tissue in a closed or restricted space surgical site. Devices and methods for manipulating an organ or tissue in a closed or restricted space surgical site. Devices and methods for positioning and orienting stabilizers and manipulators I a closed or restricted space surgical site.

Description:
FIELD OF THE INVENTION  
       [0001]     The present invention pertains to the field of surgical instruments and techniques, and more particularly to surgical instruments and techniques for performance in reduced or restricted working spaces.  
       BACKGROUND OF THE INVENTION  
       [0002]     Certain surgical procedures require the surgeon to perform delicate surgical operations on tissues within the body that are moving or otherwise unstable. The ability to stabilize or immobilize a surgical site provides greatly improved surgical accuracy and precision and reduces the time required to complete a particular procedure. A large and growing number of surgeons are performing successful coronary artery bypass graft (CABG) surgery on the beating heart by temporarily stabilizing or immobilizing a localized area of the beating heart. Methods and apparatus for performing a CABG procedure on a beating heart are described in U.S. Pat. Nos. 5,894,843 and 5,727,569 to Benetti et al., the disclosures of which are herein incorporated by reference.  
         [0003]     In a typical CABG procedure, a blocked or restricted section of coronary artery, which normally supplies blood to some portion of the heart, is bypassed using a source vessel or graft vessel to re-establish blood flow to the artery downstream of the blockage. This procedure requires the surgeon to create a fluid connection, or anastomosis, between the source or graft vessel and an arteriotomy or incision in the coronary artery. Forming an anastomosis between two vessels in this manner is a particularly delicate procedure requiring the precise placement of tiny sutures in the tissue surrounding the arteriotomy in the coronary artery and the source or graft vessel.  
         [0004]     The rigors of creating a surgical anastomosis between a coronary artery and a source vessel or graft vessel demands that the target site for the anastomosis be substantially motionless. To this end, a number of devices have been developed which are directed to stabilizing a target site on the beating heart for the purpose of completing a cardiac surgical procedure, such as completing an anastomosis. Stabilization may be provided using a device that provides a mechanical or compression force to the tissue or by a device which applies a negative pressure or suction to the tissue. Representative devices useful for stabilizing a beating heart are described, for example, in U.S. Pat. Nos. 5,894,843; 5,727,569; 5,836,311 and 5,865,730.  
         [0005]     As beating heart procedures have evolved, regardless of whether compression or negative pressure has been used to stabilize or immobilize the heart, new challenges have arisen. For example, surgeons may gain access to the heart using a number of different approaches, both open and closed chest, such as through a sternotomy, mini-sternotomy, thoracotomy or mini-thoracotomy, or less invasively through a port provided within the chest cavity of the patient, e.g., between the ribs or in a subxyphoid area, with or without the visual assistance of a thoracoscope. Accordingly, the devices used to stabilize the heart must be configured to accommodate the particular approach chosen. For example, when a closed chest approach is used such as a port access approach wherein the device is introduced into the body cavity through a small access port or stab wound, the device must be designed to be advanced through such small openings without damaging the device or any internal body structures. A continuing need remains for new and better instruments that are capable of being delivered through small openings and still function satisfactorily in a closed-chest environment.  
         [0006]     Furthermore, in addition to addressing delivery problems of instruments though small access openings, the working space within a closed-chest surgical environment is extremely limited, allowing much less room to maneuver the instruments, as compared to the space provided in an open-chest surgical site, once they have been successfully delivered or placed in the operative site. Thus, new and better approaches, tools and techniques for controlling instruments in a closed chest environment are needed.  
         [0007]     As such, there is continued interest in the development of new devices and methods for easily and effectively stabilizing or immobilizing tissue, e.g., a beating heart, in a limited space environment, such as occurs during closed-chest procedures. Of particular interest would be the development of such devices and methods of use which may be used in a variety of surgical approaches, including a sternotomy, mini-sternotomy, thoracotomy, mini-thoracotomy, transabdominal, and particularly in less invasive techniques such as endoscopic or port access procedures (e.g., between the ribs or in a subxyphoid area), with or without the visual assistance of a thoracoscope.  
       SUMMARY OF THE INVENTION  
       [0008]     The present invention provides a stabilizer assembly for stabilizing a portion of an organ in a closed or restricted space surgical site, wherein the assembly includes: a stabilizer foot adapted to be delivered to a location of the organ through a first opening in a patient and adapted to contact a surface of the organ to provide stabilization thereto during a surgical procedure; and a support arm adapted to be delivered to the location of the organ through a second opening in the patient smaller than the first opening. The stabilizer foot includes at least one connecting member and the support arm includes a connecting feature at a distal end thereof, adapted to connect the support arm to the stabilizer foot via one of the connecting members. The connection may be accomplished in the closed or restricted space.  
         [0009]     In another aspect of the present invention, a stabilizer foot is provided for contacting an organ to stabilize a portion thereof in a closed or restricted space surgical site. The stabilizer foot includes at least one contact surface formed on an inferior side thereof which is adapted to contact a surface of the organ. At least one grab member is provided on a superior side of the stabilizer foot that is adapted to be grabbed by a grasping tool, wherein the stabilizer foot is configured to be inserted through an opening in a patient to contact the surface of the organ, and wherein the at least one grab member is adapted to be grasped by extending the grasping tool through the opening, while controlling the grasping tool from outside the opening.  
         [0010]     A stabilizer assembly is provided for stabilizing a portion of an organ in a closed or restricted space surgical site, the assembly including a stabilizer foot adapted to be delivered to a location of the organ through an opening in a patient and adapted to contact a surface of the organ to provide stabilization thereto during a surgical procedure. The stabilizer foot has at least one opening in a contact surface to apply negative pressure to a surface of the organ, and at least one vacuum line fluidly connected to the at least one contact surface opening and adapted to connect with a vacuum source external of the surgical site. Soft tissue retracting tapes are attached to the stabilizer foot and are adapted to be fixed externally of the opening in the patient after connection of the stabilizer foot to the organ via suction to stabilize a portion of the organ.  
         [0011]     A stabilizer foot and positioner assembly are provided for use in stabilizing a portion of an organ in a closed or restricted space surgical site. The assembly includes a stabilizer foot adapted to be delivered to a location of the organ through a first opening in a patient and adapted to contact a surface of the organ to provide stabilization thereto during a surgical procedure; and an elongated positioner extending from the stabilizer foot and having sufficient length to deliver the stabilizer foot to the surface of the organ by manipulating the positioner from outside the first opening.  
         [0012]     A support arm adapted to connect with a stabilizer foot in a closed or restricted space surgical site, wherein the stabilizer foot has been inserted through a first opening in a patient and the support arm is inserted through a second opening in the patient is provided. The support arm includes an elongated body adapted to pass through the second opening and having sufficient length to extend out of the second opening after connecting the support arm with the stabilizer foot; a connecting feature disposed at a distal end of the elongated body; and means for moving the connecting feature between a disconnected configuration in which the connecting feature may be readily disconnected from the stabilizer foot, and a connected configuration, in which the connecting feature securely connects with the stabilizer foot; wherein the means for moving is positioned for manipulation outside of the patient by a user.  
         [0013]     A manipulator assembly for moving or positioning an organ in a closed or restricted space surgical site is provided, including a low profile suction member adapted to be delivered to a location of the organ through a first opening in a patient and adapted to contact a surface of the organ and to attach to the organ using vacuum. The suction member further includes at least one grab member on a superior surface thereof. The said grab member(s) is/are configured to be engaged by a tool for applying force thereto to reposition the suction member on the organ. A suction line extends from the suction member and has sufficient length to extend out of the first opening, or a second opening in the patient for connection with an external vacuum source.  
         [0014]     A manipulator assembly for moving or positioning an organ in a closed or restricted space surgical site is provided to include a suction member adapted to be delivered to a location of the organ through a first opening in a patient and adapted to contact a surface of the organ and to attach to the organ using vacuum; and a positioner connected to the suction member. The positioner is flexible in bending and torsionally stiff, and is adapted to be drawn through the first opening and rerouted through a second opening in a patient. The positioner has sufficient length to extend proximally out of the second opening when the suction member is attached to a surface of the organ at the desired location.  
         [0015]     A manipulator assembly for moving or positioning an organ in a closed or restricted space surgical site is provided, including a suction member adapted to be delivered to a location of the organ through a first opening in a patient and adapted to contact a surface of the organ and to attach to the organ using vacuum; and a positioner connected to the suction member. The positioner is flexible in bending and torsionally stiff, and has sufficient length to extend proximally out of the patient when the suction member is attached to a surface of the organ at a desired location.  
         [0016]     A manipulator assembly for moving or positioning an organ in a closed or restricted space surgical site is provided that includes a low-profile suction member adapted to be delivered to a location of the organ through a first opening in a patient and adapted to contact a surface of the organ and to attach to the organ using vacuum; and a rigid positioner connected to the suction member. The positioner has sufficient length to extend proximally out of the patient when the suction member is attached to a surface of the organ at a desired location.  
         [0017]     A suction manipulator is provided, including a suction member adapted to be delivered to a location of an organ through a first opening in a patient and adapted to contact a surface of the organ and to attach to the organ using vacuum. The suction member includes at least one grab member on a superior surface thereof. Each grab member is configured to be engaged by a tool for applying force thereto to reposition the suction member on the organ.  
         [0018]     An extremely low profile manipulator is provided to include a main body formed of a flexible membrane; at least one grab member on a superior surface of the main body, configured to be engaged by a tool for applying force thereto to reposition the main body on an organ; and means for attaching the main body to the organ.  
         [0019]     A method of stabilizing a portion of an organ in a closed or restricted space surgical site includes the steps of: delivering a stabilizer foot through a first opening in a patient and contacting a surface of the organ with the stabilizer foot; inserting a distal end of a support arm through a second opening in the patient while controlling the distal end from a proximal end portion of the support arm outside the patient; and connecting the distal end of the support arm to the stabilizer foot.  
         [0020]     In another aspect of the invention, a method of stabilizing a portion of an organ in a closed or restricted space surgical site includes the steps of: delivering a stabilizer foot through a first opening in a patient and contacting a surface of the organ with the stabilizer foot; applying negative pressure between the stabilizer foot and the organ to fix the stabilizer foot to the organ; applying tension to soft tissue retractor tapes attached to the stabilizer foot, from a location outside of the first opening, to stabilize a portion of the organ; and fixing the soft tissue retractor tapes to a relatively stationary object to maintain the applied tension and stabilization.  
         [0021]     A method of positioning a stabilizer on a portion of an organ of a patient in a closed or restricted space surgical site is provided, including the steps of: delivering a stabilizer foot through a first opening in a patient and contacting a surface of the organ with the stabilizer foot; grasping a portion of the stabilizer foot using at least one grasper operated from outside the patient and applying force to the stabilizer foot via the grasper to perform at least one of relocating and reorienting the stabilizer foot; and removing all graspers from the restricted space surgical site when a desired orientation and location of the stabilizer foot has been achieved.  
         [0022]     A method of manipulating an organ or tissue in a closed or restricted space surgical site is provided, including the steps of: delivering a suction member through a first opening in a patient and contacting a surface of the organ or tissue with the suction member; positioning the suction member in a desired location on the organ or tissue by applying force to the suction member via at least one element extending out of the patient, from a location outside of the patient; delivering vacuum to the suction member when the suction member has been positioned in the desired location, to establish negative pressure between the suction member and the surface of the organ or tissue such that the suction member attaches to the organ or tissue; and exerting force on the suction member, via at least one element extending out of the patient, sufficient to move the suction member and the attached organ or tissue.  
         [0023]     A method of positioning a manipulator on a portion of an organ or tissue of a patient in a closed or restricted space surgical site is disclosed to include the steps of: delivering a manipulator head through a first opening in a patient and contacting a surface of the organ or tissue with the manipulator head; grasping a portion of the manipulator head using at least one grasper operated from outside the patient and applying force to the manipulator head via the grasper to perform at least one of relocating and reorienting the manipulator head; removing all graspers from the restricted space surgical site when a desired orientation and location of the manipulator head has been achieved; and attaching the manipulator head to the surface of the organ or tissue.  
         [0024]     A method of manipulating an organ or tissue of a patient in a closed or restricted space surgical site as disclosed includes the steps of: delivering a manipulator head through a first opening in a patient and contacting a surface of the organ or tissue with the manipulator head; positioning the manipulator head in a desired location on the organ or tissue by grasping a portion of the manipulator head using at least one grasper operated from outside the patient and applying force to the manipulator head via the grasper to perform at least one of relocating and reorienting the manipulator head; attaching the manipulator head to the surface of the organ or tissue; and moving the organ or tissue or maintaining the organ or tissue in a displaced location by applying force to at least one portion of the manipulation head via at least one grasper, from at least one location outside of the patient.  
         [0025]     These and other advantages and features of the invention will become apparent to those persons skilled in the art upon reading the details of the devices, assemblies and methods as more fully described below. 
     
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0026]      FIG. 1  shows a cutaway view showing use of a stabilizer in the performance of a closed-chest, beating heart, coronary artery bypass graft (CABG) procedure according to the present invention.  
         [0027]      FIG. 2A  shows a partial view of support arm including jaws for attachment according to the present invention.  
         [0028]      2 B shows a partial, sectional view illustrating one example of a mechanism for operating the jaws shown in  FIG. 2A  for locking them to a ball member.  
         [0029]      FIG. 2C  shows an example of jaws provided with features that assist the lead in of a ball member within the confines of the open jaws.  
         [0030]      FIG. 2D  shows an example of jaws which are joined at their proximal ends.  
         [0031]      FIG. 2E  shows an example of jaws which are separate.  
         [0032]      FIGS. 2F, 2G  and  2 H show other examples of jaw arrangements.  
         [0033]      FIG. 3A  shows another example of stabilizer foot configured with a removable positioning member.  
         [0034]      FIG. 3B  shows the stabilizer foot of  FIG. 3A  after contacting the positioning member therewith.  
         [0035]      FIG. 3C  shows an example of a mechanism for securing the position of the positioning member relative to the stabilizer foot.  
         [0036]      FIG. 3D  shows an example of a positioning member that is directly connected to a stabilizer foot, without the use of an intermediate joint such as a ball joint.  
         [0037]      FIG. 4  shows a stabilizer assembly having alternative examples of locking mechanisms for both the support arm and the positioning member.  
         [0038]      FIG. 5  shows an example of a stabilizer foot that is configured for positioning without the use of a positioning member.  
         [0039]      FIG. 6  shows a variation in a manner in which a support arm may be connected with a stabilizer foot.  
         [0040]      FIG. 7  shows another variation for connecting a support arm with a stabilizer foot  12 .  
         [0041]      FIG. 8A  shows still another variation for connecting a support arm with a stabilizer foot.  
         [0042]      FIG. 8B  illustrates a locking mechanism that may be employed with the variation of  FIG. 8A .  
         [0043]      FIG. 9A  shows a variation of an arrangement at the distal end of a support arm for making a connection with a ball member.  
         [0044]      FIG. 9B  shows the support arm of  FIG. 9A  and associated driver assembly for locking the support arm to a stabilizer foot.  
         [0045]      FIG. 10  illustrates a principle for design of ball and socket type connections that are provided in connections, particularly between a support arm and a stabilizer foot, or between a positioning member and a stabilizer foot.  
         [0046]      FIG. 11A  shows a modified arrangement of a support arm employing jaws for connecting with a stabilizer foot.  
         [0047]      FIG. 11B  is a partial view showing a mechanism for operating the jaws of the arrangement shown in  FIG. 11A .  
         [0048]      FIG. 12A  shows an example of a stabilizer foot having at least a stem formed from a malleable material.  
         [0049]      FIG. 12B  shows an example of a stabilizer foot provided with multiple connection members attached to a sheet metal layer which is malleable.  
         [0050]      FIG. 12C  shows an example of a stabilizer foot having multiple connection members interconnected by wire form which may be of the same malleable material that the connection members are made of.  
         [0051]      FIG. 12D  shows a variation of the arrangement of  FIG. 12B  in which sheet metal appendages or extensions extend from the sheet metal layer to provide malleability for re-orienting the connection members.  
         [0052]      FIG. 13A  illustrates another arrangement for connecting a support arm to a stabilizer foot, in which a socket member is affixed to the stabilizer foot and the distal end of the support arm includes a connection member comprising a ball member and stem.  
         [0053]      FIG. 13B  shows a variation of the ball expansion mechanism in  FIG. 13A , in which the ball member is a solid, split ball that is expandable by drawing a wedge or cam member to further split and expand the ball.  
         [0054]      FIG. 14  is a partial view of a stabilizer assembly which includes a mechanism for magnetically coupling a support arm to a stabilizer foot.  
         [0055]      FIG. 15  shows an example of a stabilizer assembly in which one or more vacuum lines that are used to supply negative pressure to a vacuum-type stabilizer foot are also used to guide and align the connecting mechanism for joining a support arm with a stabilizer foot.  
         [0056]      FIG. 16  shows a stabilizer assembly that does not require a support arm in order to stabilize a portion of the organ to which it is attached.  
         [0057]      FIG. 17A  shows an organ manipulator for use in closed-chest or limited space surgical sites according to the present invention.  
         [0058]      FIG. 17B  is a side view of a suction member that may be employed in a manipulator assembly according to the present invention.  
         [0059]      FIG. 17C  is a partial, bottom view of the manipulator assembly of  FIG. 17A .  
         [0060]      FIG. 17D  shows a manipulator assembly in which grab members comprise nubs extending from locations distributed over the superior surface of a suction member.  
         [0061]      FIG. 17E  is a side view of a suction member showing a variation of grab members.  
         [0062]      FIG. 17F  is a partial top view of a manipulator assembly showing another variation of grab member.  
         [0063]      FIG. 17G  shows another example of a manipulator assembly provided with grab members.  
         [0064]      FIG. 17H  shows still another example of a manipulator assembly provided with grab members.  
         [0065]      FIG. 18  shows a manipulator assembly in which a positioning member is used to engage grab members on a suction member to position and reorient it.  
         [0066]      FIG. 19A  shows another example of a manipulator assembly according to the present invention.  
         [0067]      FIG. 19B  shows a malleable stylet that is used to define curvature in the tubular shaft of the assembly of  FIG. 19A .  
         [0068]      FIG. 19C  shows an assembly formed by the manipulator of  FIG. 19A  and the stylet of  FIG. 19B  in performing manipulation of an organ.  
         [0069]      FIG. 19D  is a partially cutaway view of an example of a tubular shaft component that may be employed in the manipulator of  FIG. 19C .  
         [0070]      FIG. 19E  is a partially cutaway view of another example of a tubular shaft component that may be employed in the manipulator of  FIG. 19C   
         [0071]      FIG. 19F  is an exploded view illustrating components use in operating the manipulator of  FIG. 19C .  
         [0072]      FIG. 20A  shows another example of a manipulator that employs a rigid positioner.  
         [0073]      FIG. 20B  shows a variation of the manipulator shown in  FIG. 20A .  
         [0074]      FIG. 20C  shows a sectional view of another manipulator that includes a suction member similar to the manipulator of  FIG. 20A , but which does not include an integrated rigid positioner.  
         [0075]      FIG. 20D  shows a manipulator with a sectional view of a low profile suction member.  
         [0076]      FIG. 20E  is a perspective view of another low profile manipulator in accordance with the present invention.  
         [0077]      FIG. 20F  shows a planar view and  FIG. 20G  shows a side view of an extremely low profile manipulator according to the present invention. 
     
    
     DETAILED DESCRIPTION OF THE INVENTION  
       [0078]     Before the present devices and methods are described, it is to be understood that this invention is not limited to particular embodiments described, as such may, of course, vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting, since the scope of the present invention will be limited only by the appended claims.  
         [0079]     Where a range of values is provided, it is understood that each intervening value, to the tenth of the unit of the lower limit unless the context clearly dictates otherwise, between the upper and lower limits of that range is also specifically disclosed. Each smaller range between any stated value or intervening value in a stated range and any other stated or intervening value in that stated range is encompassed within the invention. The upper and lower limits of these smaller ranges may independently be included or excluded in the range, and each range where either, neither or both limits are included in the smaller ranges is also encompassed within the invention, subject to any specifically excluded limit in the stated range. Where the stated range includes one or both of the limits, ranges excluding either or both of those included limits are also included in the invention.  
         [0080]     Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Although any methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, the preferred methods and materials are now described. All publications mentioned herein are incorporated herein by reference to disclose and describe the methods and/or materials in connection with which the publications are cited.  
         [0081]     It must be noted that as used herein and in the appended claims, the singular forms “a”, “and”, and “the” include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to “a ball” or “a ball joint” includes a plurality of such balls or ball joints and reference to “the contact member” includes reference to one or more contact members and equivalents thereof known to those skilled in the art, and so forth.  
         [0082]     The publications discussed herein are provided solely for their disclosure prior to the filing date of the present application. Nothing herein is to be construed as an admission that the present invention is not entitled to antedate such publication by virtue of prior invention. Further, the dates of publication provided may be different from the actual publication dates which may need to be independently confirmed.  
         [0000]     Definitions  
         [0083]     The term “open-chest procedure” refers to a surgical procedure wherein access for performing the procedure is provided by a full sternotomy, wherein the sternum is incised and the patient&#39;s ribs are separated using a sternal retractor to open the chest cavity for access thereto.  
         [0084]     The term “closed-chest procedure” refers to a surgical procedure wherein access for performing the procedure is provided by one or more openings which are much smaller than the opening provided by an open-chest procedure, and wherein a traditional sternotomy is not performed. Closed-chest procedures may include those where access is provided by any of a number of different approaches, including mini-sternotomy, thoracotomy or mini-thoracotomy, or less invasively through a port provided within the chest cavity of the patient, e.g., between the ribs or in a subxyphoid area, with or without the visual assistance of a thoracoscope.  
         [0085]     As alluded to above, surgical procedures carried out on a patient by “closed-chest” procedures allow much less free space for the surgeon to work in than do more conventional “open-chest” procedures such as those where access is gained through a sternotomy, for example. As such, the instruments used during closed-chest procedures must be as non-obstructive as possible and require only minimal amounts of space for their use. The present invention provides devices and methods that are useful for performing surgical procedures where working space is limited.  
         [0086]      FIG. 1  shows a cutaway view  100  showing use of a stabilizer  10  in the performance of a closed-chest, beating heart, coronary artery bypass graft (CABG) procedure. In this procedure, a primary thoracotomy  102  has been formed in the patient&#39;s chest  104 , of a size large enough to pass stabilizer foot  12  therethrough, and to allow sufficient space for the surgeon to work through in performance of dissection and anastomosis procedures. However, a primary opening other than a thoracotomy may alternatively be employed, such as a mini-sternotomy, sub-sternal opening, or the like. To assist in providing as much working space as possible through primary opening/thoracotomy  102 , positioning member  14  is made relatively slender and preferably has a tapering cross-section size from where it connects with stabilizer foot  12 , as it extends away from stabilizer foot  12 . Although positioning member  14  is shown integral with stabilizer foot  12  in  FIG. 1 , it may also be configured to be removable from stabilizer foot  12 , once the desired positioning of stabilizer foot  12  has been accomplished, thereby increasing the working space available through thoracotomy  102 .  
         [0087]     Stabilizer foot  12  is adapted to contact the heart or other organ or tissue to provide stabilization thereto during a surgical procedure. Stabilizer foot  12  may include a pair of foot members or contact members as shown in  FIG. 1 , which may be connected to form a substantial U-shape, and which may be substantially planar, or slightly curved to conform to the shape of the heart or other organ or tissue, or one or more contact members may have a non-conforming curve to establish a contact between only a portion thereof and the beating heart or other organ and tissue. Stabilizer foot  12  may be malleable such that the shape of the contact members may be varied depending on the clinical assessment by the surgeon, the design of the remainder of the stabilizer  10 , and/or the design of other instruments to be used to complete the anastomosis.  
         [0088]     Stabilizer foot  12  may effect stabilization by application of negative pressure to the surface to be stabilized, which draws the surface against the contact members of stabilizer foot  12  when the negative pressure is applied. Alternatively, stabilizer foot  12  may be a mechanical stabilizer that effects stabilization through the application of physical pressure against the surface contacted. Further, a combination of negative pressure (suction) and physical (mechanical) pressure against the surface to be stabilized is possible. Thus, alternative stabilizer feet  12  may be utilized to offer a choice of a different design or configuration, or even principle of operation. For example a change from a mechanical stabilizer foot  12 , which operates by applying physical pressure against the beating heart tissue, may be replaced with a negative pressure stabilizer foot  12 , which engages the heart by vacuum. In this regard, any of the stabilizer feet  12  described herein could be exchanged for operation in the stabilizer  10  described.  
         [0089]     Additionally, other known contact members/stabilizer feet could be used or adapted to be used by those of ordinary skill in the art. The contact members of stabilizer foot  12  may have frictional surfaces on the underside thereof to more securely engage the tissue that they contact. The tips or ends of the contact members may be bent upward in the forms of “ski tips” to prevent edge effects (e.g., stress concentration, cutting, chafing, etc.) against the tissue which might otherwise be caused by straight tips. The contact members may also be modified to include apertures, openings or attachments to facilitate connection with sutures or other devices used to achieve the stabilization and/or anastomosis. Examples of alternative contact members/stabilizer feet that may also be modified for use with the present stabilizer can be found, for example, in U.S. Pat. Nos. 6,036,641; 6,283,912; or in copending U.S. application Ser. No. 09/769,964, filed Jan. 24, 2001, and titled “Surgical Instruments for Stabilizing a Localized Portion of a Beating Heart”. U.S. Pat. Nos. 6,036,641 and 6,283,912, and U.S. application Ser. No. 09/769,964 are each hereby incorporated herein, in their entireties, by reference thereto.  
         [0090]     At least a second, smaller thoracotomy, stab wound or other opening  106  may be formed in a location removed from primary opening or thoracotomy  102 , and is made only large enough to allow support arm  16  to be passed therethrough. The positioning of thoracotomy  106  may be separated far enough from thoracotomy  102  to allow support arm  16  to be inserted obliquely into the working space, as shown, so that support arm does not require much working space for the insertion, i.e. to form a very low profile instrument upon connection with stabilizer foot  12 . For example, support arm  16  and stabilizer foot  12  may form an angle ranging from about 90 degrees to about −20 degrees, based on the angle between support arm  16  and the plane of stabilizer foot  12  when contacted to or parallel with the portion of the surface of the heart that is being stabilized.  
         [0091]     Stabilizer foot  12  may be provided with multiple connecting members  18  to increase the probability of a connecting member  18  being positioned where support arm  16  can make contact and connect with it, regardless of the orientation of stabilizer  12  after positioning the same. As shown, connecting members  18  each include a ball member  20  that is connected to the stabilizer foot  12  via a stem or connecting element  22  having a reduced cross-sectional area relative to that of ball member  20 . In this example, connecting members  18  are rigidly connected to stabilizer foot  12 . As shown, connecting members  18  may be oriented so that they extend away from stabilizer foot  12 , in orientations approximately aligned with the oblique orientation of support arm  16  as it is inserted through opening/thoracotomy  106 , thereby facilitating the connection between support arm  16  and stabilizer foot  12  via a connecting member  18 . Connecting members  18  are rigid in the example shown in  FIG. 1 , but may be made malleable to the extent that they can be reshaped by a user, but requiring a substantial force for reshaping which is greater than any force that will be experienced during stabilization. Thus, even malleable connecting members  18  are rigid during a stabilizing procedure, i.e., are not deformed by stabilization forces or forces applied by the beating heart. Additionally, once it is ascertained which connecting member  18  is to be joined with support arm  16 , the other connecting members  18  may be deformed so as to be less obstructive to the surgical site.  
         [0092]      FIGS. 12A-12D  illustrate stabilizer feet  12  provided with various examples of malleable connecting members  18 . In  FIG. 12A , at least stem  22  is formed from a malleable material, such as annealed stainless steel or other malleable metal for example, having the characteristics described above, such that the orientation of connecting member  18  may be changed prior to use, but where connecting member  18  has sufficient stiffness so that it will not be deformed during the stabilization process. The example of  FIG. 12B  shows stabilizer foot  12  provided with multiple connection members  18  attached to a sheet metal layer  12   s  which is malleable. Connection members  18  may or may not be malleable. If they are not malleable, reconfiguration is still possible by grasping a connection member and applying a bending moment sufficient to plastically deform sheet meal layer  12   s  in the vicinity where the connection member  18  connects. If the connection members are malleable, then bending as mentioned above may deform both sheet metal  12   s  and connection member  18 . In  FIG. 12C  multiple connection members  18  are interconnected by wire form  12   w  which may be of the same malleable material that connection member  18  are made of for example.  FIG. 12D  shows a variation of the arrangement of  FIG. 12B  in which sheet metal appendages or extensions  12   a  extend from sheet metal  12   s  to provide malleability for re-orienting connection members  18 .  
         [0093]     Referring again to  FIG. 1 , jaws  24  or other grasping/gripping or connecting feature are provided at the end of support arm  16  and adapted to lock onto ball member  20  of any of connecting members  18 .  FIG. 2A  shows a partial view of support arm  16  including jaws  24  and  FIG. 2B  shows a partial, sectional view illustrating one example of a mechanism for operating jaws  24  to lock to ball member  20 . In this example, jaws  24  are made up of a pair of half chucks that open to easily pass over ball member  20 . The proximal end portions of jaws  24  each have a shoulder  28  formed therein, and together, shoulders  28  receive anchor  32  formed in the end of tension member  30 . An outer tube  34  is provided over tension member  30  and is slidable with respect thereto. In an open position, when outer tube  34  is drawn away, does not apply significant force to or is removed from contact with half chucks  24 , half chucks  24  are allowed to spread apart or open to form a distal opening sufficiently large to receive ball member  20 . Jaws/half chucks  24  may optionally be spring-loaded or otherwise biased to the open position. Jaws  24  may be further provided with features that assist the lead-in of ball member within the confines of the open jaws  24 .  FIG. 2C  shows one example, where the features in this example are chamfered leading surfaces  24   c.  Half chucks  24  may be separate pieces, as shown in  FIGS. 2B and 2D , or may be joined at their proximal ends  24   e  as shown in  FIG. 2D . The choice between whether to from half chucks  24  as separate pieces or as joined may be based upon manufacturing cost and/or ease of manufacturing. If joined, as in  FIG. 2D , then tensioning member may be bolted, welded or otherwise fixed to the proximal end  24   e  of the joined jaws  24 , or may be made integral therewith.  
         [0094]     Further, split chucks  24  may be provided, where each half chuck  24  includes two or more split components, such as  24   a  and  24   b  in  FIG. 2F , or  24   a , 24   b , 24   c  in  FIG. 2G . One or more grooves  25  may be maintained between chucks  24 , as shown in  FIGS. 2G and 2H , when chucks  24  are in the closed position (e.g. when chucks  24  have captured ball member  20 ) to allow an increased range of angular movement therethrough by stem  22  with respect to the longitudinal axis of support arm  16 . Still further, chucks  24  may be mounted to the tensioning member via a rotational joint to allow rotational positioning of the chucks during alignment with and capture of ball member  20 . By rotating the chucks, this allows positioning of the slots or grooves  25  between chucks to provide maximum angular positioning of support arm  16  with respect to stabilizer foot  12  in the desired direction. Such a rotational joint may be fixed upon locking jaws/chucks  24  in fixation with the stabilizer foot  12 , to maintain stability about the longitudinal axis of support arm  16  for carrying out stabilization.  
         [0095]     Upon sliding the distal end of outer tube  34  into jaws  24  and applying force, this causes jaws  24  to move to the closed position (shown in  FIG. 2 ). This action may be precipitated by manually sliding outer tube  34  toward and against jaws  24  while at the same time preventing tension member  30  from traveling in the same direction, or even applying tension to tension member  30  in the direction shown by arrow  31 . Alternatively, the proximal end portion of tension member  30  may be threaded, and a mating, threaded drive member  36  may be threaded thereover. Upon advancing drive member (in the direction opposite to arrow  31 ) along tension member  30  by turning it, this drives outer tube  34  against jaws  24 , driving jaws  24  to the closed position shown in  FIG. 2 . Reverse translation of drive member along tension member  30  (in the direction of arrow  31 ) releases force on jaws  24  by outer tube  34 , thereby returning jaws to the open position so that support arm  16  can be disconnected from stabilizer foot  12 .  
         [0096]     Further, a light source  26  ( FIG. 1 ) may be provided anywhere in the vicinity of the distal end of support arm  16  to provide light to the user (as viewed through thoracotomy/opening  102  to aid in connecting support arm  16  to stabilizer foot  12 , as well as to provide light for performing a surgical procedure, such as an anastomosis with artery  108 , for example.  
         [0097]      FIG. 3A  shows another example of stabilizer foot  12  configured with removable positioning member  14 . In this example, tensioning member  42 , such as a steel cable, steel fiber or high strength suture, is fixed to foot  12  and threaded through removable positioning member  14 . A small enlargement or anchor  44  is fixed on tensioning member  42 , against which tensioning forces may be applied to exert tension in tensioning member  42 , since anchor  44  cannot pass through slot  44   s.  An annular space or opening  44   a  is provided through positioning member  14 , and anchor  44  is dimensioned so that it may easily pass through the annulus. After relieving tension in tensioning member  42 , anchor  44  may be slid from slot  44   s  to be passed through space  44   a , allowing positioning member  14  to be slid over anchor  44  and removed from thoracotomy/opening  102  after positioning of stabilizer foot  12  has been completed in a manner described hereafter. A large enlargement or stop member  46  is provided at the proximal end of tensioning member  42 , which is of a size that cannot pass through the annulus of positioning member  14 . Thus, stop member  46  prevents tensioning member  14  from becoming completely separated from the apparatus, as a safety precaution, so that this piece is not misplaced or lost track of. Additionally, if repositioning is desired, stop member  46  maintains positioning member  14  threaded on tensioning member  42 , so that positioning member  14  can be readily reattached to stabilizer foot  12 .  
         [0098]     The process of positioning stabilizer foot  12  includes manually sliding positioning member  14  into contact with stabilizer foot  12  (if it is not already so positioned at the time of inserting stabilizer foot  12  through thoracotomy/opening  102 ), as shown in  FIG. 3B . Anchor  44  is oriented along tensioning member  42  in a position that allows it to be locked against slot  48  on positioning member  14  when positioning member  14  is placed in contact with stabilizer foot  12 . By sliding tensioning member  42  through slot  48  so that anchor  44  is on the outside surface of tensioning member  14 , slot  48 , due to its dimensions, prevents anchor  44  from sliding therethrough. This permits application of tension in tensioning member  42  to lock the position of positioning member  14  relative to stabilizer foot  12 . An example of a tension applicator is tensioning nut  50  which may be formed in the proximal portion of tensioning member  14 . Mating threads  52  may be provided on the distal portion of tensioning member  14  to mate with threads in tensioning nut  50  (see  FIG. 3C ). Thus, upon rotation of tensioning nut  50  with respect to the distal portion of positioning member  14  (as indicated by the arrow in  FIG. 3B ), tension is applied through tensioning member  42  as the length of positioning member increases while anchor  44  maintains a relatively fixed position. With sufficient tension, a rigid connection between position member  14  and stabilizer foot  12  is formed, so that stabilizer foot  12  can be accurately and positively positioned through movements of positioning member  14 .  
         [0099]     Once stabilizer foot  12  has been positioned where desired, and optionally, a support member  16  has been fixed to stabilizer foot  12  (which will be described below), positioning member  14  may be removed from thoracotomy/opening  102  to increase the working space. Reverse rotation of tensioning nut with respect to the distal portion of positioning member  14  relieves the tension in tensioning member  42 , so that tensioning member  42  can be slid back out of slot  48 . This allows positing member  14  to be removed from contact with stabilizer foot  12  and slide over anchor  44 , removing it from thoracotomy/opening  102 .  
         [0100]     As shown in  FIGS. 3A-3B , the interface between positioning member  14  and stabilizer foot  12  form a ball joint  54 , which allows angular positioning/orientation of positioning member  14  relative to stabilizer foot  12 , prior to locking the connection. Further, after a certain amount of positioning the user may find it desirable to re-orient the position/angulation of positioning member  14  relative to stabilizer foot  12  to provide an increased or different range of positions that the positioning member  14  is capable of moving stabilizer foot  12  to, given the constraints imposed by the dimensions of thoracotomy/opening  102 . This is easily accomplished by relieving sufficient tension, via use of tensioning nut  50 , on tensioning member  42  to allow the reorientation of positioning member, after which tension is re-applied to lock the new orientation of positioning member  14  with respect to stabilizer foot  12 . As shown, a ball-shaped member  54   a  is provided on stabilizer foot  12 , which receives a cup-shaped member  54   b  formed in the distal end of positioning member  14 . However, these components may be reversed, i.e., a cup-shaped member may be provided on stabilizer foot  12  and a ball-shaped member may be formed at the distal end of positioning member  14 .  
         [0101]     Alternatively, the assembly may forego the ball joint  54  configuration for use in situations where positioning member  14  may be directly aligned with stabilizer foot  12  through thoracotomy/opening  102  and perform the positioning required without angling the orientation of positioning member  14  with respect to stabilizer foot  12 , a joint assembly may be done away with altogether. An example of such an arrangement is illustrated in  FIG. 3D , where positioning member  14  is simply locked against stabilizer foot  12  through application of tension by tensioning member  42  as described above. Other alternatives may include other joint interfaces, such as a rotational joint, barrel joint, etc, provided between positioning member  14  and stabilizer foot  12 .  
         [0102]     Once stabilizer foot  12  has been positioned as desired, support arm  16  may be connected to stabilizer foot  12  via another thoracotomy or other opening  106  and positioning member may optionally be removed from thoracotomy/opening  102  to maximize the working space through thoracotomy/opening  102 . If removed, positioning member  14  is preferably not removed from stabilizer foot  12  until a secure connection between support arm  16  and stabilizer foot  12  has been made, such as by fixing jaws  24  to connecting member  18  (e.g., ball member  20 ) and additionally fixing support arm  16  to a relatively immovable object. Typically, support arm is fixed with respect to the operating table using a standard clamping arm (not shown) that clamps to the surgical table and is adjustable to be moved to the location of support arm  16  wherein it is clamped to support arm  16  and then fixed or locked so that it is relatively immovable. Other alternatives may be employed for fixing the support arm  16  to a relatively immovable object, however, including fixing by hand holding.  
         [0103]     Although support arm  16  is shown in  FIG. 1  to be a substantially straight and rigid component, alternative support arms  12  may be curved, malleable, or even multi-jointed, to provide a wider range of access to a stabilizer foot  12  to be joined with and/or a wider range of control over which stabilizer foot  12  may be controlled during stabilization.  
         [0104]      FIG. 4  shows alternative examples of components of a stabilizer assembly  10  which includes alternative locking mechanisms for both support arm  16  and positioning member  14 . Also, in this example, stabilizer foot is shown having only two connecting members  18 , which may be rigid or malleable, as described above. Jaws  24  may be connected to tensioning member  30  in the same manner as described above with regard to the example of  FIG. 2 . An adjustment screw or nut  36  is provided at the proximal end of tensioning member  30  which can be rotated to provide fine adjustment of the degree to which jaws close, i.e., the amount of distance left between the jaws may be finely adjusted. Additionally, gross-adjustment mechanism  35  is provided to quickly lock jaws  24  to ball member  20  with a simple action. In the example shown, a pair of handles  35   h  (like scissor handles) are provided which can be hand-squeezed together by an operator to actuate and lock locking mechanism, which operates in the same manner as the locking mechanism on a VISE-GRIP™ tool. By separating the handles  35   h,  locking mechanism  35  is quickly released, thereby quickly releasing jaws  24  from ball member  20 . Thus locking mechanism is effective in situations where support arm  16  needs to be quickly fixed to stabilizer foot  12 , where support arm  16  needs to be quickly released from stabilizer foot  12  and then quickly reaffixed to stabilizer foot  12  (such as if the stabilizer foot  12  needs to be repositioned, for example), or just in general to expedite this part of the procedure. Alternatively, any other “over-center” type locking linkage may be provided for quick locking and releasing of jaws  24  to and from ball member  20 .  
         [0105]     Positioning member  14  in  FIG. 4  is also provided with an over-center type locking mechanism  51  for securely fixing positioning member  14  against stabilizer foot  12 . The proximal end of locking mechanism  51  is provided with slot  48  which functions in the same manner as slot  48  in the example described with respect to  FIG. 3B . Once tensioning member is positioned in slot  48  to secure anchor  44 , linkage components  51   a , 51   b  may be squeezed together by hand or with a squeezing tool, such as forceps of the like, effecting a quick locking action of the linkage to place tensioning member  42  under a predetermined amount of tension to lock position member  14  in place against stabilizer foot  12 . Although not shown, locking mechanism  51  may also be provided with a fine adjustment mechanism to adjust the amount of final tension that is exerted by locking linkage components  51   a , 51   b . By pulling apart components  51   a , 51   b,  this quickly unlocks the assembly, allowing for subsequent removal of tensioning member  42  from slot  48  and withdrawal of positioning member  14  away from stabilizer foot  12  and out of thoracotomy/opening  102 .  
         [0106]      FIG. 5  shows an example of a stabilizer foot  12  configured for positioning without the use of positioning member  14 . In this configuration, a plurality of grab points or grab members  62  are provided around the periphery of stabilizer foot  12  and extend therefrom so that they can be readily grasped by a tool such as grasper  64 . Grasper  64  may be a conventional surgical tool and operated by a simple scissor-type actuator, for example, or other conventional, readily available grasping tool dimensioned to be useable through thoracotomy  102 . Grab points  62 , as shown are partial loops of wire extending from stabilizer foot  12  and fixed thereto at both ends, but may have other configurations, such as tabs extending from stabilizer foot  12 , molded configurations that are integral with stabilizer foot  12  but shaped to be easily grasped by grasper  64 , other shapes of extensions, or the like. Further, stabilizer foot  12  may be provided with a deformable upper surface, such as by forming it of a viscoelastic material or the like, for example, so that grasper  62  may grasp anywhere on the upper surface of stabilizer foot in order to reposition stabilizer foot  12 . A viscoelastic material is advantageous in that after being released by the grasper, the upper surface will relax back to its initial shape.  
         [0107]     In use, the stabilizer foot  12  shown in  FIG. 5  may be inserted through thoracotomy/opening  102  using grasper  64  and positioned approximately in the desired location on the tissue surface where stabilization is desired. Further adjustment is then carried out by grasping the appropriate grab point  62 , moving stabilizer foot  12 , releasing the grasp, and grasping another grab point  62 , if needed to further reposition stabilizer foot  12 . This process can be repeated until the position of stabilizer foot  12  has been finally manipulated into the desired position and orientation.  
         [0108]     Further, multiple graspers  64  may be used through multiple thoracotomies to position stabilizer foot using more than one grasper  64 , which may provide better and/or faster positioning and control over the positioning of stabilizer foot  12 . A third incision, thoracotomy or opening, as well as further additional openings (not shown in  FIG. 1 ) may be provided for access by a second grasper  64  and stabilizer foot  12  may be securely held in position via two graspers through thoracotomy/opening  102  and the third or other additional opening, while support arm  16  is passed through opening/thoracotomy  106  and connected to stabilizer foot  12 . When using multiple graspers, one of the grab members may be is grasped by a second grasping tool before releasing a grasp of the same or another grab member by a first grasping tool. Alternatively, grab members may be simultaneously grasped by at least first and second grasping tools to triangulate forces on the stabilizer foot to move the stabilizer foot. Such first and second grasping members may simultaneously engage the same grab member, or, more typically, different grab members.  
         [0109]     Due to the large degree of position and orientation control provided by grab points  62 , stabilizer foot may only require one connecting member  18 , as shown. However, multiple connecting members  18  may be provided, just as in the examples described previously.  
         [0110]      FIG. 6  shows a variation in the manner in which support arm  16  may be connected with stabilizer foot  12 . It is advantageous to provide a connection which may be easily and rapidly established between support arm  16  and stabilizer foot  12  because closed-chest techniques may necessitate assembly of support arm  16  and stabilizer foot  12  inside the chest, where working space is limited, as has been already described above. In this example, stabilizer foot  12  is provided with a slot  68  with a recess (e.g., a spherical recess or other recess configured large enough to easily receive ball member  72 )  70  into which ball member  72  at the distal end of support arm  16  may be inserted to make the connection. Recess  70  functions as a socket forming a ball and socket joint with ball member  72  upon connection of support arm  16  to stabilizer foot  12  as described below. Ball member  72  is contacted to recess  70  on the underside of stabilizer foot  12  as shown. A slot  68  extends from recess  70  to the periphery of stabilizer foot  12  and is wide enough to allow post/shaft  74  to pass therethrough, but narrow enough to prevent ball member  72  from entering or passing therethrough. Upon contacting recess  70  with ball member  72 , support arm is then rotated to pass shaft  74  through slot  68  so that support arm is oriented to extend from the top side of support arm  16 . After orienting support arm  16  to the desired angle relative to stabilizer foot  12 , outer tube  34  is advanced relative to shaft/post  74  and ball member  72 , to clamp against the top surface of stabilizer foot  12 , thereby locking the relative positions of ball member  72  and recess  70  against one another. Outer tube  34  may be driven using any of the mechanism disclosed herein, see, e.g., the descriptions with regard to  FIGS. 2B and 4 . Further, outer member is drivable away from stabilizer foot to allow repositioning of support arm  16  relative to stabilizer foot  12 , after which the ball joint may be locked again in the manner described above, or, upon further retraction of outer tube  34  away from stabilizer foot  12 , support arm  16  may be disconnected from stabilizer foot  12  by reversing the connecting steps described above.  
         [0111]     As shown, recess  70  is provided on the bottom or contact surface side of stabilization foot  12 . Stabilization foot  12 , as shown, is a vacuum- or negative pressure-type stabilizer foot  12 , as apparent from the presence of ports  13 . However, this same connection arrangement may be applied to other types of stabilizer feet  12 , including mechanical-type stabilizer feet  12 . Further, although only one slot/recess  68 , 70  is shown, stabilizer foot  12  may be provided with multiple slots/recesses  68 , 70  around the periphery thereof, to provide more versatility as to where support arm  16  may be connected.  
         [0112]      FIG. 7  shows another variation for connecting support arm  16  with stabilizer foot  12 . In this arrangement, stabilizer foot  12  is provided with a socket member  76  extending therefrom. Socket member  76  is preferably bifurcated, but may be configured otherwise as long as it is capable of expanding when the foot members  12   a , 12   b  of stabilizer foot  12  are squeezed together. For example, socket member may be segmented into four sections, or trifurcated. In use, stabilizer  12  is inserted through an incision (such as thoracotomy  102 ) and positioned using any of the techniques described above. Once in the proper position, foot members  12   a , 12   b  are then squeezed together in the direction indicated by arrows  77 , which causes socket member  76  to expand in the directions  78  shown. In the expanded configuration, ball member  72  can be readily placed within the confines of socket member  76 . Upon release of the squeezing forces on foot members  12   a , 12   b,  socket member returns to its relaxed, non-expanded state, which is dimensioned to form a secure friction fit with ball member  72 . One or more slots  79  are provided by the separations between the socket member components, allowing angulation of support arm  16  with respect to stabilizer foot  12 , if necessary, while socket member  76  is in the expanded state. The squeezing of foot members  12   a , 12   b  may be performed by forceps or other surgical instrument through thoracotomy  102 , for example.  
         [0113]     Although not shown in  FIG. 7 , stabilizer foot  12  may be provided with grab points  62  or other features to facilitate the positioning thereof, and or may be provided with an integral or removable positioning member  14 . To assist in the flexing/squeezing of foot members  12   a , 12   b , a cutout or weakened section  80  may be formed between foot members  12   a , 12   b  in stabilizer foot  12 .  
         [0114]      FIG. 8A  shows still another variation for connecting support arm  16  with stabilizer foot  12 . This arrangement is provided specifically for those stabilizer feet that employ vacuum during the stabilization process. In this arrangement, the need for an external vacuum line is eliminated by providing an airtight support arm through which a vacuum may be applied to stabilizer foot  12 . Alternatively, a vacuum line may be run through support arm  16  and connected in an airtight manner to stabilizer foot  12  though the connection arrangement shown. In this arrangement, stabilizer foot  12  includes a connection member  18  having a ball member  20  extending from a stem  22  which connects it with the stabilizer foot  12 . In this instance, however, ball member  20  and stem  22  have a central opening or port  82  therethrough which fluidly connect with the features on the contact members of stabilizer foot  12  that are adapted to apply vacuum to the surface of the organ/tissue to be stabilized.  
         [0115]     Support arm  16  is provided with a socket member  84  at its distal end, which may be cup-shaped and/or split to form at least one slot  86  to increase the range of angulation with which support arm  16  may be oriented with respect to stabilizer foot  12  and to facilitate spreading of socket member  84  to receive ball member  20  as described below. Preferably, socket member  84  is configured to form a friction fit with ball member  20  upon reducing the inside diameter of socket member  84 .  
         [0116]     The socket member portions are expandable upon sliding outer tube  34  away from socket member  84  (in the direction of arrow  8 B as shown in  FIG. 8A  to increase the space available for receiving ball member  20 , as shown in  FIG. 8B . The socket member portions may be biased toward the open position, such as by placement of a biasing member (e.g., coil spring or the like) therebetween (not shown) or may be biased apart as they are engaged against the sides of ball member  20 . Further alternatively, a mechanism for positively driving the socket member portions to the open position may be employed, as would be readily apparent to one of ordinary skill in the art. Upon positioning the socket member portions around ball member  20 , outer tube  34  may then be advanced in the direction of arrow  8 A (see  FIG. 8B ), wherein the distal end of outer tube  34  rides against ramped or cammed surfaces  85  extending proximally from socket member  84 , thereby forcing the portions of socket member toward one another and clamping against ball member  22 . Initially, outer tube  34  may be moved distally with respect to socket member only so far as to capture ball member  20  while still allowing relative movement between ball member  20  and socket member  84 . This allows the user to position support arm  16  with respect to stabilizer foot  12  into the orientation desired. Further distal movement of outer tube  34  with respect to socket member  84  may then be carried out to apply greater clamping force of socket member  84  on ball member  20  sufficient to lock these members together to prevent any further relative movement.  
         [0117]     The ramped proximal extensions may extend further proximally, within outer tube  34  (not shown) and merge into a single rod or shaft for providing driving leverage of outer tube  34  in a manner as shown in  FIG. 2B , for example. Other driving mechanisms may be provided for driving outer tube, as discussed herein, and further, as would be readily apparent to those of ordinary skill in the art.  
         [0118]     Support arm  16  is further provided with a seal  86  that is mounted at the distal end of outer tube  34  and, together with socket member  84 , forms an airtight seal with ball member  20  when socket member  84  is engaged and locked to ball member  20 . The connection is made following procedures already described above. Once the connection is made, stabilizer foot  12  is supported by support arm  16  and vacuum may also be applied to the surface against which the contact members make contact by applying a vacuum through support arm  16 . This simplifies the process of inserting stabilizer foot through thoracotomy/opening  102 , since there is no vacuum line extending from stabilizer foot  12 . Further, it eliminates a step which may be carried out with stabilizer feet which do have a vacuum line extending therefrom, where the vacuum line is first inserted through thoracotomy/opening  102  with the stabilizer foot  12  and then manipulated so as to pass out of another thoracotomy, opening or incision to free up space in thoracotomy/opening  102 .  
         [0119]     As in  FIG. 7 , and other Figs. in which grab points, a positioning member or other positioning features are not shown on stabilizer foot  12 , the stabilizer foot shown in  FIG. 8A  may be provided with grab points  62  or other features to facilitate the positioning thereof, and or may be provided with an integral or removable positioning member  14 . Further, although only one connecting member  18  is provided in the example shown in  FIG. 8A , multiple connecting members  18  may be provided extending from different locations on stabilizer foot  12 . In this example, when multiple connecting members  18  are provided, each connecting member  18  is provided with a valve in central opening  82  that permits vacuum to be drawn through the opening in a direction exiting stabilizer foot  12  and connecting member  18 , but does not allow flow in the opposite direction. In this way, connecting members  18  which are not connected with support arm  16  prevent inflow therethrough when a vacuum is drawn via support arm  16 .  
         [0120]      FIG. 9A  shows a variation of an arrangement at the distal end of support arm  16  for making a connection with a ball member  20  on connecting member  18 . In this arrangement, the distal end of outer tube  34  functions as a socket member  84 . As shown, socket member  84  is merely an end portion of the cylindrical outer tube  34 . Alternatively, the end portion of outer tube  34  may be flared or shaped to more closely resemble a portion of a spherical surface that is dimensioned to form a ball and socket joint with ball member  20 . The locking mechanism of this arrangement includes finger  92  that extends distally past the distal end of outer tube  34 . Finger  92  is externally mounted with respect to outer tube  34 , such as by mounting it in a fixed position relative to driver  95 , as shown in the cutaway view of  FIG. 9B . Driver  95  includes a locking lever  96  linked  97  to outer tube  34 , such that when locking lever  96  is rotated toward handle  98  of driver  95 , linkage  97  drives outer tube  34  distally, toward the distal end  92   t  of finger  92 . This is the action that is carried out for locking ball member  20  between finger tip  92   t  and socket  84 . Release of the locking connection is carried out by reverse rotation of locking lever  96  with respect to handle  98 . Alternative configurations may be provided to driving the locking mechanism, as will be apparent to those of ordinary skill in the art. Further alternatively, finger  92  may be configured to translate relative to outer tube  34 , while maintaining the position of tube  34  stationary relative to driver  95  or other driving mechanism. For example, finger  92  or outer tube  34  may extend beyond the proximal end of outer tube  34  or finger  92 , respectively and have threads on the proximally extending portion which mate with a drive nut  36  used to extend and retract finger  92  or outer tube  34 , by turning drive nut  36  while drive nut  36  remains in a fixed position along the longitudinal axis of outer tube  34  or finger  92 , similar to the concept shown in  FIG. 2 . Alternative driving arrangements may be used, including ratchet mechanisms, cam drives, and the like, which would be readily apparent to those of ordinary skill in the mechanical arts.  
         [0121]     In operation, finger  92  and outer tube  34  facilitate support arm  16  to be quickly and easily connected with and disconnected from stabilizer foot  12 . After insertion of stabilizer foot  12  through a first incision and positioning of stabilizer foot on the surface of an organ/tissue to be stabilized, using one or more of the techniques described above, support arm  16 , having been inserted through a second incision (either before or after insertion of stabilizer foot  12 , described above) is maneuvered to approximate the distal end of support arm with connection member  18 . Support arm  16  is maneuvered to a position where ball member  20  resides between distal tip  92   t  of finger  92  and the distal end of outer tube  34  (i.e., socket member  84 ), preferably with distal tip contacting ball member  20 . Driver  95  is then actuated as described above, to drive socket member  84  into contact with ball member  20  on a surface opposite where distal tip  92   t  contacts ball member  20 , resulting in the ball member  20  being captured between distal tip  92   t  and socket member  84 .  
         [0122]     Continued driving by rotation of locking lever  96  may be carried out until a sufficient compression force is developed to lock the relative positions of ball member  20  and socket member  84 . As locking lever  96  passes over center of the linkage  97  it locks with respect to driver  95 . Lever  96  is pushed against handle  98  and the over-center action locks tube  34  in place against ball  20  and finger  92 . Reverse rotation of lever  96  with respect to driver unlocks the mechanism and separates tip  92   t  and socket member  84  for release of ball member  20 . Prior to locking, the user may wish to establish only a slight compression force, where ball member  20  and socket member  84  are in contact, but where the user may still manipulate support arm  16  to angulate its orientation with respect to stabilizer foot  12 . Such manipulation may be for purposes of orienting support arm optimally for fixing it to a relatively immovable object, such as the surgical table, for example, or to optimize the orientation of support arm to provide the maximum support to stabilizer foot  12 . Once the desired orientation is achieved, support arm is fixed to a relatively immovable object and the compression force is increased to lock the relative positions of ball member  20  and socket member  84 .  
         [0123]      FIG. 10  illustrates a principle for design of ball and socket type connections that are provided in connections, particularly between support arm  16  and stabilizer foot  12 , or between positioning member  14  and stabilizer foot  12 . This principle illustrates that the larger a ball member is with respect to the stem on which it is mounted, the smaller the encapsulation angle can be for the same joint strength, therefore, the larger the effective angle of rotation that is available to that stem (as well as a member connected to the stem, such as support arm  16 , positioning member  14 , or stabilizer foot  12 ). Thus, for example, the angle of rotation “a” that is available to stem  22   a  which is attached to relatively smaller ball member  20   a  is less than the angle of rotation “b” that is available to stem  22   b  that is attached to the larger ball member  20   b.  Accordingly, ball member  20  should be made as large as practically possible, relative to stem  22  to provide the greatest range of angulation available for orienting one component relative to another component, in which the components are connected by a ball and socket connection including ball member  20 . For example, a typical stem outside diameter used for such purposes is around 0.094″± about 0.010″, and a typical ball member outside diameter is about 0.200″± about 0.015″, although bal member  20  may be made even larger, given that the operating space allows, to take advantage of the above principle where allowed.  
         [0124]     Turning now to  FIG. 11A , a modified arrangement of a support arm  16  employing jaws  24  for connecting with a stabilizer foot  12  is shown. Jaws  24  are configured to engage with and lock with respect to ball member  20  of stabilizer foot  12 , similarly to that described with regard to the jaw members described above. Further, jaws  24  are provided with an additional degree of freedom (such as by the provision of pivot joint  96 , for example). Once jaws  24  have made contact with and have captured ball member  20 , but prior to locking the connection, support arm may be easily manipulated in both “pitch” and “yaw” axes, thereby improving the maneuverability of arm  16  for optimum orientation, without having to release the grasp of ball member  20 , reposition arm member  16  and re-grasp ball member in the new position/orientation of arm  16 . Upon locking jaws  24  relative to ball member  20 , pivot joint  92  is also locked.  
         [0125]      FIG. 11B  is a partial view of a mechanism that may be used to operate the pivoted jaws shown in  FIG. 11A . The mechanism is shown in an isolated view, with the outer tube of support arm  16  not shown. A pair of control rods  30   a , 30   b  are pivotally connected to respective ones of the pair of jaw members  24  at  101   a , 101   b,  in addition to the pivot member pivotally connecting the jaw members  24  together, as shown in  FIG. 11B . Control rods  30   a , 30   b  extend proximally through the outer tube of support arm  16  and may be translated by operator manipulation either distally or proximally with respect to the outer tube. For example, moving rods  30   a  and  30   b  both proximally causes jaws  24  to close and moving both rods  30   a , 30   b  proximally causes jaws  24  to open. However, by moving rod  30   b  proximally while moving rod  30  distally, for example, jaws  24  can be manipulated to maintain the same spacing while pivoting, or pitching (upward in  FIG. 11B ) about pivot  96 . Thus, greater control of the jaws  24  is provided, by providing more degrees of freedom about which jaws  24  may be controlled.  
         [0126]      FIG. 13A  illustrates another arrangement for connecting support arm  16  to stabilizer foot  12  in which socket member  84  is affixed to stabilizer foot  12  and the distal end of support arm  16  includes a connection member  18  comprising a ball member  20  and stem  22 . Ball member  20  is expandable, so that when in a contracted, or relatively non-expanded state, it is dimensioned to easily be positioned within the confines of socket member  84 , and once so positioned, is expandable to make contact with and then lock its position against socket member  84 , thereby fixing the relative positions of stabilizer foot  12  and support arm  16 . Socket member  84  preferably includes at least one slot to increase the range of angulation along which stem  22  may be moved therebetween relative to axis L shown in  FIG. 13A .  
         [0127]     As shown in  FIG. 13A , ball member  20  may be formed of a semi-rigid inflatable member such as a polymeric balloon or a thin-walled steel or other metal member that can be hydraulically expanded. Expansion fluid may be delivered through a channel through stem  22  and outer tube  34  or may be delivered through a separate tube that runs externally (not shown) of stem  22  and/or outer tube  34 . Alternatively, ball member  20  may be a solid metal or polymer that is a split ball which is expandable by drawing a wedge or cam member  21 , as shown in  FIG. 13B , to further split ball member  20  and thereby expand its outside diameter. In this arrangement, a cable or other tensioning member  23  is fixed to wedge or cam  21  and tension may be applied through tensioning member  23  (for example, from the proximal end of support arm  26  using a tensioning technique similar to one of those described above) to draw wedge or cam further into ball member  20 , thereby expanding it, since ball  20  does not move relative to stem  22  in the direction along the longitudinal axis of support arm  16 . Optionally, a biasing member  27  (such as a coil spring or other biasing member) may be placed over tensioning member  23  between the proximal end portion of ball  20  and wedge  21 , so that upon release of tension in tensioning member  23 , biasing member  27  drives wedge  21  in the opposite direction allowing a reduction of the size of ball member  20  so that ball member  20  can be easily removed from socket member  84 .  
         [0128]      FIG. 14  is a partial view of a stabilizer assembly  10  which includes a mechanism for magnetically coupling support arm  16  to stabilizer foot  12  or to help guide couplings provided on support arm  16  and stabilizer foot which can then be mechanically locked together, such as by any of the mechanical configurations described herein, or by VELCRO™ or adhesive. By providing powerful permanent magnets, such as rare earth magnets, at the distal end of support arm  16  and a portion of stabilizer foot  12  to connect with the distal portion of support arm  16 , these components are automatically drawn together and joined when placed in the vicinity of one another. As shown, magnetic posts  88  are provided at the distal end of support arm  16  and mating recesses such as alignment load bearing holes  90  are provided in stabilizer foot  12  to receive posts  88 . Posts  88  are provided with a magnetic polarity opposite that of the material immediately surrounding holes  90 , so that post  88  are drawn into holes  90  by magnetic attraction when posts  88  are placed in the vicinity of holes  90 . Thus, magnetic posts  88  key into holes  90  in stabilizer foot  12  thereby providing mechanical support by the connecting mechanism in addition to the magnetic support. Although stabilizer foot  12  is a suction type stabilizer foot as shown in  FIG. 14  with a suction tube  91  supplying negative pressure to ports  13 , it is noted that the magnetic/mechanical connection mechanism described may be similarly applied to other types of stabilizer feet including mechanical type stabilizer feet.  
         [0129]     Support arm  16  as shown in  FIG. 14  is a multi-link arm formed of multiple articulating links which render it flexible in a relatively untensioned state. A cable  23  and tensioning mechanism (not shown) are provided for applying tension to the links to lock support arm in an assumed configuration. The support arm  16  in the embodiment of  FIG. 14 , as well as in other embodiments described herein, may take alternate forms, such as a straight rigid shaft, a curved rigid shaft, a curved rigid tubular member, and adjustable length shaft or tube, a malleable elongated member, or other arrangements of multiple links including multiple ball joint members, multiple links, multiple alternating links and balls.  
         [0130]     Examples of alternative support arm configurations that may be used and/or modified for use with the presently disclosed devices can be found, for example, in U.S. Pat. Nos. 6,290,644; 6,315,717; 6,394,951 and 6,673,013, as well as in copending U.S. application Ser. No. 09/769,964. U.S. Pat. Nos. 6,290,644; 6,315,717; 6,394,951 and 6,673,013 are each hereby incorporated herein, in their entireties, by reference thereto, and U.S. application Ser. No. 09/769,964 has already been incorporated by reference above.  
         [0131]     Whatever the form of support arm  16 , it is preferably, although not necessarily connected to the connecting base  89  for posts  88  by an articulating joint such as a ball and socket arrangement  93 . Such a connection provides more flexibility for alignment of posts  88  with holes  90 . However, as noted, an articulating joint is not absolutely required, as support arm may be directly fixed or integrally joined with base  89 .  
         [0132]      FIG. 15  shows an example of a stabilizer assembly in which one or more vacuum lines  91  that are used to supply negative pressure to a vacuum-type stabilizer foot  12  are also used to guide and align the connecting mechanism for joining support arm  16  with stabilizer foot  12 . A yoke  94  is fixed with respect to a distal end portion of support arm  16  and is configured to slide over one or more vacuum lines  91  thereby maintaining jaws  24  in alignment with ball member  22  with which the connection will be made. In the example shown, yoke  94  is threaded over two vacuum lines  91  which provide very accurate alignment of jaws  24  with ball  22 . However, the same principle may be applied where only one vacuum line  91  is employed, whereby yoke  94  would slide over the single vacuum line to assist in maintaining the alignment of the connecting mechanism. Also, although jaws  24  and ball member  22  with stem  20  are shown as the connecting mechanism in  FIG. 15 , other connecting mechanisms as described herein may be substituted, while still applying the alignment mechanism discussed with regard to  FIG. 15 . Further, although a multi-link support arm is shown in  FIG. 15 , other alternative support arm configurations may be substituted, as described above. Still further, this same concept may be applied by providing a wire or tube other than a vacuum line over which support arm  16  may be guided to direct alignment of the connecting elements between support arm and stabilizer  12 . This is particularly applicable to mechanical stabilizer assemblies in which no vacuum line is used, but may also be used in vacuum stabilizer assemblies, in addition to, or alternatively to use of one or more vacuum lines as a guide.  
         [0133]     In use, stabilizer foot  12  and vacuum lines  91  may be inserted through primary opening/thoracotomy  102  and then the proximal ends of surgical tubes are drawn into the surgical site and then routed back out through a secondary opening, such as opening  106  or another opening, thereby removing vacuum lines  91  from the primary opening  102  and establishing them through the opening that support arm  16  is to be inserted through. Next yoke  94  is threaded over vacuum lines  91  and vacuum lines  91  are connected with a source of vacuum. After at least grossly positioning stabilizer foot in a desired orientation, support arm is advanced toward stabilizer foot, guided by the interaction of yoke  91  with vacuum lines  91 , until jaws  24  are positioned to lock over ball member  20 . Upon locking the connection, any further positioning of the stabilizer foot is accomplished if needed, and then a vacuum is applied via vacuum lines  91  to fix stabilizer foot  12  to the surface or the organ. Support arm is then locked to a relatively stationary object, as described above. When a flexible support arm  16 , such as a multi-link support arm is employed, the arm itself may be locked prior to connecting jaws  24  to ball member  22 , prior to further positioning after connecting jaws to ball member  22 , or just prior to fixing the support arm  16  to a relatively stationary object, depending upon the circumstances of the particular procedure being performed.  
         [0134]      FIG. 16  shows a stabilizer assembly  10  that does not require support arm  16  in order to stabilize a portion of the organ (such as a beating heart) to which it is attached. Stabilizer assembly  10  of  FIG. 16  employs a vacuum-type stabilizer foot  12  capable of attaching to the organ through the application of vacuum, as described previously. One or more vacuum tubes  91  are fluidly connected with stabilizer foot  12  to lead out of the patient&#39;s body and connect with a source of vacuum to deliver negative pressure to stabilizer foot  12  for establishing suction between stabilizer foot  12  and the surface of an organ to be stabilized. Vacuum tube(s)  91  may extend out of the primary opening  102  through which the stabilizer foot has been inserted, or may be rerouted through another opening to provide maximum working space through primary opening  102 .  
         [0135]     Soft tissue retracting tapes  97  are attached or fixed to stabilizer foot  12  and extend therefrom, as shown. In use, stabilizer foot  12  is passed through opening  102  and maneuvered to the desired position and orientation on the surface of the organ in a location where stabilization is desired. Although not shown in  FIG. 16 , any of the configurations for grab members  62  or connecting members  62  may be provided on stabilizer foot  12  to assist in properly positioning stabilizer foot in the desired location and orientation. Alternatively or additionally, the superior surface of stabilizer foot  12  may include a viscoelastic layer as described above. Once properly positioned and oriented, vacuum is applied to stabilizer foot  12  via vacuum line  91 , whereby the stabilizer foot fixes to the surface of the organ in the desired location, and any graspers  64  employed for positioning stabilizer foot  12  are removed from any openings that they had been inserted through to access stabilizer foot  12 .  
         [0136]     Tension is next applied through soft tissue retracting tapes  97  to draw stabilizer foot  12  and the attached surface of the organ toward opening  102  by a distance that substantially stabilizes the surface of the organ, particularly between the members  12   a  and  12   b  of stabilizer foot  12 . Soft tissue retracting tapes are then fixed relative to the patient, by fixation outside of the opening  102 . For example, soft tissue retracting tapes may be provided with an adhesive  97   a  on the side adjacent the patient&#39;s skin so that soft tissue retracting tapes can be adhered to the skin of the patient to maintain the tension on stabilizer foot  12 . Other means of fixation may be substituted, such as sutures or a retraction mechanism external to the patient, for example. Thus, localized stabilization is accomplished without the need to fix stabilizer foot  12  to a support arm  16  that is in turn fixed to a relatively stationary object.  
         [0137]     Turning now to  FIG. 17A , an organ manipulator  200  for use in closed-chest or limited space surgical sites is shown. Manipulator  200  includes a low profile suction member  202  configured to engage with and maintain a grasp of an organ, such as a heart for example, with a sufficient strength so as not to break contact when suction member  202  is moved, so that the organ is moved by moving suction member  202 . As shown, suction member  202  is a low profile suction cup, which may be made of silicone or other biocompatible elastomer sufficient to maintain the suction between suction member  202  and the organ as the organ is moved via movement of suction member  202 . Further alternatively, suction member  202  may be made up of more than one suction cup, or other multiple members adapted to apply negative pressure, such as multiple arms having ports, for example.  
         [0138]     Suction member  202  may be further provided with a plurality of grab members  62  around the periphery or spaced about the superior surface thereof, that extend from the superior surface of suction member  202  so that they can be readily grasped by a tool such as grasper  64 . A typical grasper  64  includes a small diameter shaft  65  (e.g. in the vicinity of 5 mm outside diameter) which extends the jaws of the grasper through an opening  102 ,  106  or other opening, while permitting an operator to operate the jaws from outside the patient to grab and release grab members  62  in the process of effectively moving and/or repositioning the instrument from which grab members  62  extend. Grasper  64  may be a conventional surgical tool and operated by a simple scissor-type actuator, for example, or other conventional, readily available grasping tool dimensioned to be useable through thoracotomy  102  or other opening or port through the chest wall. As shown, grab members  62  are configured as semi-circular flaps or fins that are integrally molded with suction member  202  to extend therefrom. However, grab members  62  may have other configurations, such as loops or other extensions extending from suction member  202  that may be easily grasped by grasper  64 . Grab members  62  are typically grasped to position organ manipulator  200  on an organ in a desired position and orientation prior to applying suction, buy may also be used to move organ manipulator  200  and the organ after suction has been applied and organ manipulator  200  has become fixed to the organ. When using multiple graspers, one of the grab members may be is grasped by a second grasping tool before releasing a grasp of the same or another grab member by a first grasping tool. Alternatively, grab members may be simultaneously grasped by at least first and second grasping tools to triangulate forces on the suction member foot to move the suction member during positioning or manipulation. Such first and second grasping members may simultaneously engage the same grab member, or, more typically, different grab members.  
         [0139]     Further, each suction member  202  may be provided with seal  205 , as shown in  FIG. 17B , which may be made of closed-cell foam that enhances the ability of suction member  202  to conform to the surface of the organ and to establish a vacuum seal therewith.  FIG. 17B  also illustrates a side view of one configuration of grab member  62 . Suction member may also be provided with a layer of open-cell foam  207  or mesh, as shown in  FIG. 17C , to act as a diffuser and prevent or substantially reduce the possibility of the surface of the organ from being sucked against one or more ports  209  that establish the vacuum seal. Although shown with only one port  209  entering from the periphery of suction member  202 , suction member  202  may alternately be provided with a port that enters suction member from the center or top of suction member  202 . Further, suction member  202  may be provided with a plurality of suction ports  209  to deliver negative pressure to the interior thereof. Further design variations that may be applied to suction member  202  are described in co-pending, commonly assigned application Ser. No. 10,615,007 filed Jul. 8, 2003 and titled “Organ Manipulator Apparatus”, in U.S. Patent Application Publication No. 2003/0009080 A1, and in U.S. Pat. No. 6,338,712. Application Ser. No. 10,615,007; U.S. Patent Application Publication No. 2003/0009080 A1; and U.S. Pat. No. 6,338,712 are each hereby incorporated herein, in their entireties, by reference thereto.  
         [0140]     Manipulator  200  may further include an elongated member  203  including a vacuum line  203  extending from suction member  202  for delivery of negative pressure to suction member  202  from a location outside of the body. Elongated member  203  may be a flexible, air impermeable tubing or alternatively may further employ a structure for facilitating manipulation of suction member  202 , such as a torque tube which is flexible in bending, but resistant to torquing motions. Still further, a stylet or other shaping member may be inserted through member  203  to maintain elongated member in a desired shape. Further details about torque tubes/positioners and shaping members suitable for use here are described below with regard to  FIGS. 18-19F .  
         [0141]     In one embodiment, manipulator  200  includes a flexible suction member  202  with a substantially circular opening having an inside diameter of about one to about one and a half inches and an outside diameter of about one and a half to about two inches, with seal  205  extending from the bottom surface of the flexible member  202  by a thickness of about ⅛ to ⅜ inches. Elongated member  203  extends from suction member  202  by about twelve to eighteen inches, and comprises a torque tube that is flexible in bending but resistant to torquing motions about the longitudinal axis of elongated member  203 . It should be noted here that these dimensions are with regard to a particular embodiment, and may vary depending upon the patient, size of the organ to be manipulated, and location of entry though which the manipulator  200  is inserted, etc.  
         [0142]      FIG. 17D  shows a manipulator assembly  200  in which grab members  62  are formed as extending nubs and extend from locations distributed over the superior surface of suction member  202 , i.e., are not limited to distribution around the perimeter of the upper surface.  FIG. 17E  shows another variation of grab members  62  in which a continuous, ring-like projection  62  is formed around the suction member  202  to extend therefrom.  FIG. 17F  shows still another variation in which a single tab-like grab member extends from the center or top of the superior surface of suction member  202 . The example in  FIG. 17G  includes suction member  202  having a tab or flap on the superior surface thereof, as well as rectangular shaped flaps  62  extending radially from the periphery of suction member  202 .  FIG. 17H  shows another arrangement in which nubs  62  extend radially from the periphery of suction member  202 .  
         [0143]     Referring now to  FIG. 18 , manipulator  200  includes grab members  62 , such as flaps, nubs or the like, as described above.  FIG. 18  shows use of positioner  210  to grab or grasp a grab member  62  and then translate and or rotate positioner  210  to move and reposition suction member  202 . After moving with a first grab member  62 , another grab member  62  may be grabbed by positioning member  210  and moved as described to extend the range over which positioner  210  may move suction member, without requiring more space for moving the shaft  213  of positioner than is provided by the opening through which positioner  210  has been inserted. This process may be repeated with multiple grasp members  62  until suction member  202  has been moved to a desired location and orientation. Once the desired orientation has been achieved, vacuum may be applied though vacuum line  203  to fix the position and orientation of suction member against the surface of the tissue or organ upon which it has been placed and oriented.  
         [0144]     Positioner  210  may include handle  211  at the proximal end that is hand controllable, outside of the patient, to control distal end  212  (jaws) for positioning movements against grasped grab members  62 . The shaft  213  of positioner  210  may be malleable so that it can be reshaped as desired to improve the range over which distal end  212  is capable of contacting grab points  62 . Reshaping of malleable shaft  213  may be performed between positioning movements for example, by withdrawing positioner  210  from an opening through which it has been placed to accomplish a first positioning movement, reshaping malleable shaft  213  by bending it into a desirable configuration, and reinserting positioner  210  through the same or a different opening to perform another positioning movement.  
         [0145]     In use, suction member  202  may be folded into a cylindrical shape and passed through an opening (e.g., opening  102 ) to be placed on the surface of an organ to be manipulated. Vacuum line  203  may be pulled into the operating space and rerouted though another opening to remove it from obstructing the working space in the opening through which suction member was passed, and/or to provide a desired orientation/direction of vacuum line  203  for use in effecting the movement of the organ, described below. Alternatively, vacuum line  203  may be maintained in its position extending through opening  102  to deliver vacuum to suction member Suction member is then maneuvered to a desired position and orientation on the surface of the organ in a location judged best for applying leverage to the organ to move the organ to a desired orientation/location. As described previously, grab members  62  may be grabbed and pulled, pushed and/rotated to effect the desired positioning of suction member  202 .  
         [0146]     Once suction member has been properly positioned and oriented, vacuum is applied to suction member  202  via vacuum line  203 , whereby suction member  202  fixes to the surface of the organ in the desired location with sufficient strength so that suction member  202  can be moved to move the organ without losing its grasp on the organ. Any graspers  64  employed are removed from any openings that they had been inserted through to access suction member  12 . As noted above, shaft  113  of positioner  201  may be malleable so that it can be reshaped as desired to improve the range over which suction member  202  may be placed on the heart.  
         [0147]     Tension is next applied on suction line  203  in sufficient amounts to pull and move suction member  202 , thereby also moving the organ to the desired position or location or orientation. Suction line may then be fixed to a relatively stationary object outside of the patient, or may be hand held to maintain the desired orientation of the organ until such orientation is no longer desired, such as when a surgical procedure has been completed. Suction member  202  may be released and repositioned on the organ if a further procedure is to be performed where the organ needs to be placed in a different location or orientation.  
         [0148]      FIG. 19A  is another example of manipulator  200  having positioner  210  which is connected to suction member  202  and which has a shaft  213  that is very flexible in bending but very stiff with regard to torsion. This is made possible by overlaying a coil  215  (preferably a metallic coil, e.g., stainless steel or the like) over a braided tube  217  (see partially cutaway view of  FIG. 19D ) which is also preferably made of metal, such as stainless steel or the like. Tubular braid  217  is formed over an inner polymeric sleeve  218 , which is preferably made of a polymer. Braid  217  is typically encapsulated in sleeve  218 , such as by molding, extrusion, forming, or the like. Sleeve  218  may be made from PEBAX® resins (polyether-block co-polyamide polymers), nylon, silicone, urethane or other flexible, biocompatible polymer, or combinations thereof, for example.  
         [0149]     An outer polymeric sleeve  219  may be provided over coil  215 , as also shown in  FIG. 19D . Similarly, coil  215  is encapsulated in sleeve  219 , such as by molding, forming, extrusion or the like. Sleeve  219  may be made from any of the polymers described with regard to sleeve  218 . The polymeric sleeves function to maintain vacuum integrity, i.e., so that no significant leakage of vacuum occurs along the sleeves  218 , 219 . Additionally, by embedding the coil and braid components into the respective sleeves, the sleeves add significant mechanical support to the coil and braid. This configuration provides a tubular structure that is very flexible with regarding to bending (e.g., with respect to it&#39;s longitudinal axis), but very stiff in torsion, so that torquing of tubular member by an operator will transfer the torsional forces effectively to suction member  202  to effect repositioning. Alternatively, braid  217  may be slid over sleeve  218  and/or sleeve  219  may be slid over coil  215  or heat shrunk thereon, but if the coil and braid are not embedded in the sleeves, then the mechanical support by the sleeves decreases substantially.  
         [0150]      FIG. 19E  shows another configuration for positioner shaft  213  that is also very flexible in bending but stiff under torsion. In this example, oppositely wound spring coils  221 , 222  (preferably metallic, such as stainless steel of the like) are provided in the shaft. For example, a counterclockwise inner spring  221  may be provided over inner polymeric sleeve  218 , and a clockwise outer spring  222  may be provided over inner spring  221 . Like the previous example, an outer sleeve  219  is provided over outer spring  222 . Of course, this arrangement may be altered so that inner spring  221  is clockwise wound and outer spring  222  is counterclockwise wound. Spring  221  is typically encapsulated into sleeve  218  and spring  222  is typically encapsulated into sleeve  219 , such as by any of the techniques described above with regard to the previous example. However the springs and coils may alternatively be slid into place over one another, although some mechanical support by the sleeves in such a configuration may be diminished.  
         [0151]     The aforementioned configurations are particularly useful for endoscopically delivering and positioning the manipulator device  200  and subsequent attachment to an organ and manipulation thereof. Placement of the manipulator and maneuvering of suction member  202  are improved with the use of a rigid and/or malleable stylet, an example of which is described hereafter.  
         [0152]     A malleable stylet  214  is shown in  FIG. 19B  that is configured to be passed within the tubular shaft  213  of positioner  210 . Stylet  214  may be made from a malleable metal, such as such as annealed stainless steel, nickel-titanium alloy or malleable polymer, for example. Stylet  214  can be bent into any desirable curvature or compound curvature desired, and retains sufficient stiffness after bending to force tubular shaft into a conforming curvature when stylet  214  is passed therethrough. Stylet  214  may be provided with a handle  216  at its proximal end to facilitate use and manipulation thereof for insertion through tubular shaft  213 , as described below.  
         [0153]     By bending the stylet  214  as desired and inserting it into tubular shaft  213 , an optimal or near optimal orientation angle of approach of the inferior surface of suction member  202  can be established with respect to the location of the organ to be grasped, as illustrated in  FIG. 19C . Further, once the organ  1  has been contacted and fixed by suction member  202 , as shown in  FIG. 19C , rotation of torsionally stiff tubular shaft  213  transfers the rotational force to suction member  202  to turn it and the organ with it.  
         [0154]      FIG. 19F  shows an exploded view of manipulator  200 , stylet  214  and a valved connector  220  used to facilitate insertion of stylet through tubular shaft  213 , as well as to fluidly connect manipulator  200  with a source of vacuum. Connector  220  may be connected to positioner  210  via a Luer connector or other well-known connection fitting that provides a vacuum-tight seal between the components. Suction member  202  may be provide with one or more ports (not shown) which may be fluidly connected, via tubular shaft  213  and vacuum connector  224 /vacuum port  223 . Vacuum connector  224  is provided as an integral branch of connector  220 .  
         [0155]     A second branch  207  of connector  220  provides a port  209  for inserting stylet  214  therethrough in a manner as described above. Port  209  includes a seal therein for making a vacuum tight seal with the shaft of stylet  214  upon insertion therein. Additionally, branch  207  is provided with a valve, so that stylet may be removed from port  209  and the manipulator may continuously provide vacuum to suction member without loss of vacuum pressure through port  209 . With this configuration, vacuum may be applied to suction member  202  by connecting vacuum port  223  with a source of suction, and vacuum may be maintained simultaneously with the use of (including insertion and/withdrawal of) stylet  214 . This provides the user with a great deal of flexibility, as it may be preferred, in some instances to remove stylet  214  after positioning suction member  202  and establishing a grasp of the organ in the desired place, where afterwards, further maintenance of positioning and/or manipulation may be accomplished by applying tension through positioner  213  without the use of stylet  214 . On the other hand, in some instances it may be desirable to leave stylet  214  in the inserted position, or to reinsert it after a removal, to aid in further manipulation. All of these options are available, as facilitated by the arrangement of connector  220 .  
         [0156]     As already noted above, manipulation of an organ, such as the beating heart, other organ or stopped heart, while operating through an opening smaller than a full sternotomy generally requires a manipulator with size and profile optimized for the surgical space that is available in which to perform manipulation. FIGS.  20 A-F show various of examples of suction members that may be employed in a manipulator to perform manipulation in a limited surgical space. These various configurations offer some different advantages, and may be chosen for use based upon the available space for performing the manipulation.  
         [0157]     FIGS.  20 A-B show examples of relatively high profile suction members  202  (e.g., suction cups) that are fixed to rigid positioning shafts  225 . Vacuum may be provided to the suction members  202  of each of these examples through the positioning shafts  225  by connecting the proximal end of the positioning shaft (eternal of the opening) to a source of vacuum. The manipulator of  FIG. 20B  is configured so that suction cup  202  is axially aligned with shaft  225 , while the example of  FIG. 20B  provides shaft  225  mounted to the apex of suction cup  202  at approximately a right angle. Choice of use between these two configurations depends upon the angle of access that an opening provides, with respect to the surface of the tissue/organ to be grasped by suction member  202  for performing manipulation. In either case, a fairly generous amount of space is required above the surface to be grasped in order to employ these relatively high-profile suction members. However, when it is possible to employ one of these configurations, rigid, positively attached positioning shaft  225  provides excellent positive positioning control of movement of suction member  202  (and grasped organ/tissue) both with pushing and pulling motions, as well as rotations, twisting and other angular movements within the limits set by the opening through which positioning shaft  225  extends.  
         [0158]      FIG. 20C  shows a sectional view of a suction member  202  that is similar to the suction members of  FIGS. 20A-20B , in that it is a relatively high profile suction cup, but this example lacks the rigid positioning shaft of the examples of  FIGS. 20A-20B . Rather, at least one grab member  62  is provided to extend from the external surface of suction member  202  to be grasped and manipulated in the manner described above with regard to  FIGS. 17A-18 . Use of this configuration may be selected where there is sufficient surgical space vertically above the organ/tissue to be manipulated, but where the opening to be worked through, and/or peripheral space around the organ/tissue to be manipulated, limits the amount of lateral and/or rotational movement that would be needed to effectively manipulate using a rigid positioner  225 . In using the device of  FIG. 20C , suction member is first inserted through an opening and grossly positioned on the organ/tissue to be manipulated. Next, positioning and orientation of suction member into the desired placement is performed using one or more graspers, for example as described above. Once properly positioned and oriented, negative pressure is generated between suction member  202  and the organ/tissue, by Inserting a syringe through valve  227 , drawing a vacuum, and then removing the syringe. Manipulation may then be accomplished by moving suction member  202  through additional grasping and manipulation with a grasper.  
         [0159]     A sectional view of a low profile suction member  202  is shown in  FIG. 20D . Rather than a conical or cup-shaped configuration, suction member  202  in  FIG. 20D  is provided with a more flattened configuration. A pillow-shaped main body portion  230  includes superior and inferior flexible membranes  231   a , 231   b  separated by a dispersing material  232 , such as felt or other resilient porous material to ensure maintenance of vacuum flow through main body  230  and prevent collapse of the membranes  231   a , 231   b  against one another when a vacuum is drawn thorough suction conduit  234 . Membranes  231   a , 231   b  may be made from polyurethane film or thin laye4rs of any flexible, biocompatible polymer wherein films of the polymer can be joined by direct application of heat, radiofrequency energy, ultrasound energy, microwave energy or laser, for example. Seal  205  may be provided around the perimeter of inferior flexible membrane  231   b,  and may be made of closed-cell foam, for example, to enhance the ability of suction member  202  to conform to the surface of the organ and to establish a vacuum seal therewith. Suction member  202  may also be provided with a layer of open-cell foam  207  or mesh within the confines of seal  205 , to act as a diffuser and prevent or substantially reduce the possibility of the surface of the organ from being sucked against one or more ports  209  provided through inferior membrane  231   b  that deliver the vacuum to the surface of the organ to establish the vacuum seal.  
         [0160]     Vacuum conduit  234  may be configured in a flexible but torsionally rigid shaft  213 , such as described above with regard to FIGS.  19 A and  19 C- 19 E, or may be simply a flexible vacuum tube. However, when only a flexible vacuum tube is employed, suction member  202  may need to be provided with features to facilitate placement and orientation, e.g., grab members  62 , and manipulation through use of a simple vacuum tube is limited to application of tension only.  
         [0161]      FIG. 20E  is a perspective view of another low profile manipulator in which suction member may be constructed similarly to that described above with regard to  FIG. 20D . In the example shown, suction member  202  is oval-shaped, although circular or other shaped suction members may be employed in this type of configuration as well. In this example, a rigid positioning shaft  225  is fixed to suction member  202  and also functions to deliver the vacuum thereto. Accordingly, when the surgical space is somewhat limited, but the opening through which the manipulator is to be inserted allows a fairly straight line approach to positioning, orientation and manipulation, this configuration allows the same positive positioning aspects described above with regard to the examples of  FIGS. 20A and 20B , while permitting such control in a surgical space that offers very little vertical space above the surface of the organ/tissue to be manipulated.  
         [0162]      FIG. 20F  shows a planar view and  FIG. 20G  shows a side view of an extremely low profile manipulator  204 . Manipulator  204  includes a main body  204   a  formed of a flexible membrane so that manipulator  204  occupies negligible vertical space above the surface of the organ/tissue to be manipulated. The flexible membrane of main body  204   a  may be made from silicone, polyurethane, polyester, or other flexible, biocompatible polymer, for example. Grab members  62  may be provided on the superior surface of main body  204   a  to facilitate positioning and orientation such as by use of one or more graspers in manners as already described above. The inferior surface or contact surface of main body  204   a  is provided with an adhesive  206  that adheres to the surface of the organ or tissue to be manipulated. The adhesive should be a high-tack, removable, biocompatible adhesive, any of which are known in the art. Once adhered, manipulation may be performed using one or more graspers to grasp one or more grab members  62  and pull, push, rotate, twist or perform other manipulations of the organ/tissue. A non-adhesive layer (not shown) may be provided over the adhesive  206  during insertion and placement/orientation of main body  204   a.  Once properly positioned and oriented, the non-adhesive layer may be removed to allow adhesion of main body  204   a  to the surface of the organ/tissue to be manipulated. Main body  204   a  may be constructed in a wide variety of shapes and sizes. For example, circular configurations, as shown, may be manufactured to have a diameter in the range of about one inch to about 12 inches, or lesser or greater diameters as needed for the particular manipulation to be performed.  
         [0163]     While the present invention has been described with reference to the specific embodiments thereof, it should be understood by those skilled in the art that various changes may be made and equivalents may be substituted without departing from the true spirit and scope of the invention. In addition, many modifications may be made to adapt a particular situation, material, composition of matter, process, process step or steps, to the objective, spirit and scope of the present invention. All such modifications are intended to be within the scope of the claims appended hereto.