Abstract:
A flexible collapsible bag is introduced into the abdominal cavity to remove larger portions of tissue from the abdominal cavity through a threaded casing introduced into the abdominal wall. The bag has a side opening through which the tissue can be moved into the bag. The bag has an end opening which remains extracorporeal to the threaded casing in the abdominal wall. After partially pulling out the bag, the side opening is located outside of the threaded casing, and the tissue, which is tightly enclosed by the portion of the bag remaining in the abdominal cavity, is cut into pieces, as by cutting filaments having portions at the bottom of the bag and extending extracorporeally through the threaded casing and the end opening of the bag.

Description:
This application is a Divisional Application of U.S. patent application Ser. No. 08/494,023, filed Jun. 23, 1995, now U.S. Pat. No. 5,788,709, the contents of which are incorporated herein in their entirety. 
    
    
     FIELD OF THE INVENTION 
     The invention pertains to a method for removal of tissue or such from the abdominal cavity. 
     DESCRIPTION OF THE RELATED ART 
     In minimal invasive surgery, the operative access to the abdominal cavity takes place through trocar casings installed through an abdominal wall. The advantage of minimal invasive surgery is that there is a small surgical wound and the resultant reduced surgical pain, shorter recovery times and unobtrusive surgical scars. The advances in surgical techniques with minimal invasive surgery also makes possible the surgical removal of larger portions of tissue, e.g. of cysts, tumors or even organs or parts of organs, such as the uterus, the kidney or portions of the intestine. If such tissue portions, organs, etc., called generically &#34;tissue&#34; in the application as set forth below, are removed surgically from the abdominal cavity, then the problem remains that this tissue frequently has a larger diameter than the trocar casing. Thus, the tissue cannot be removed from the abdominal cavity through this trocar casing. 
     One possibility for elimination of this problem includes cutting up the tissue in the abdominal cavity. This method has severe disadvantages. When tumors are cut up, there is a danger that malignant cells will move into the abdominal cavity. During the removal of cysts, their content may spill into the free abdominal cavity, which can lead to inflammation and the possibility also to the transfer of malignant cells. In addition, cutting up tissue in the abdominal cavity under the conditions of minimal invasive surgery is technically complicated and very time consuming. In certain methods (with motor-driven morcellators) there is a high danger of injury for the organs and blood vessels in the abdominal cavity. 
     In order to counter these disadvantages, a device using a flexible bag is introduced into the abdominal cavity through the trocar casing. The bag is introduced fully into the abdominal cavity and is held in position by means of filaments. In the interior of the abdominal cavity, the tissue is moved into the bag through the end opening, whereupon the end opening is pulled together and closed by means of filaments run to the outside through the trocar casing. However, the bag with the enclosed tissue cannot be pulled through the trocar casing when the enclosed tissue cannot be pulled through the trocar casing when the diameter of the tissue is too large. The existing skin incision for the trocar casing therefore has to be expanded in order to remove the bag with the tissue in the abdominal cavity. The advantages of the minimal invasive surgical technique are thus mostly lost. 
     The conventional art has provided no suggestion for quickly and efficiently removing tissue pieces that are substantially larger than a mandrin inserted to obtain access to that tissue. The conventional art appears to be limited to relatively slow and cumbersome methods of reducing and removing large tissue samples from within the human body. 
     SUMMARY OF THE INVENTION 
     Accordingly, it is one object of the present invention to provide a method to quickly remove tissue samples from a human body with minimum invasive measures. 
     It is another object of the present invention to provide a method to effect greater ease in the removal of tissue samples from the human body. 
     It is still an additional object of the present invention to speed operative procedures involving the removal of tissue from within the human body. 
     It is yet a further object of the present invention to provide a method to more easily reduce human tissue within a human body for removal of that tissue. 
     These and other objects of the present invention are achieved by a method for removing tissue from a cavity in the human body through the use of a casing, preferably threaded, inserted into the flesh surrounding the cavity. A flexible bag is inserted through the threaded casing into the cavity in the human body. The bag has an end opening that remains outside the human body. The bag has a second opening in the side of the bag, and the bag is constructed to open when the bag has been inserted into the human body so that tissue can be brought into the bag through the second opening. The second opening is configured so that once the tissue has entered the bag through the second opening, the tissue drops into a portion of the bag beneath the side opening so that the bag can be collapsed and pulled through the casing and the portion of the bag including the side opening moved to the exterior of the human body. Cutting of tissue within the bag is effected by at least one cutting filament positioned at the bottom portion of the bag with two ends of the cutting filament placed at the first opening of the bag, so that when one end of the filament is pulled, the filament is moved upwards from the bottom of the bag, cutting through tissue located at the bottom of the bag. Thus, the tissue is reduced in size for easy removal. 
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS 
     FIG. 1 is a sectional view of apparatus used in practicing the method of the present invention. 
     FIG. 2 is a sectional view showing a further step. 
     FIG. 3 is a sectional view of the next step. 
     FIG. 4 is an exploded view of an apparatus and a related method for inserting a bag into a human body. 
     FIG. 5 is an exploded schematic diagram showing a bag partially inserted. 
     FIG. 6 is an elevational view with part in section, showing the bag fully inserted into a cavity of a human body. 
     FIG. 7 is a view showing the placement of a severed tissue into the bag. 
     FIG. 8 is a view showing the severed tissue moved to the bottom of the bag. 
     FIG. 9 show partial withdrawal of the bag from the cavity. 
     FIG. 10 shows the initiation of cutting the tissue while in the bag by a single cutting filament. 
     FIG. 11 shows further cutting of the tissue. 
     FIG. 12 shows the removal of a severed portion of human tissue from the bag. 
     FIG. 13 shows the cutting of tissue in the bag by a hollow cylinder punch and a plurality of cutting filaments. 
     FIG. 13a is a schematic transverse sectional view of tissue after it has been severed by plural cutting filaments. 
     FIG. 14 shows the withdrawal of the hollow cylinder punch with a portion of the tissue therein. 
     FIG. 14a is a schematic sectional view of the tissue after removal of the punch of FIG. 14. 
    
    
     DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     The present invention is directed to a method for removing tissue from an abdominal cavity after it has been severed by using a bag for the removal of tissue through an end opening; in addition to this end opening, the bag also has a side opening in the wall region between the end opening and the base of the bag. The bag is introduced into the abdominal cavity through a preferably threaded casing, but in such a manner that it does not go entirely into the abdominal cavity, but rather its end opening remains outside the casing the human body. The tissue is moved into the bag in the abdominal cavity through the side opening which is located within the abdominal cavity. Next, the bag is pulled out through the casing until the side opening is located extracorporeally outside of the casing. Thus, the tissue is fully enclosed in the abdominal cavity in an uptake volume at the base of the bag, whereby the interior of the bag now is accessible only from outside the body. 
     If the diameter of the tissue is smaller than the inside diameter of the casing, then the bag with the enclosed tissue can be pulled out completely through the casing. However, if the tissue enclosed in the bag has a larger diameter than the inside diameter of the casing, the tissue is cut up in the bag since the interior space of the bag is externally accessible through its end opening, and through the casing. The uptake volume of the bag holding the tissue is located within the abdomen and is fully enclosed so that there is no danger that tissue fragments, malignant cells, cyst content or similar material can get into the free abdominal cavity when cutting up the tissue. 
     The intra-abdominal cutting up of the tissue in the bag can occur from the outside using suitable instruments, such as microforceps, micropunches, microshears or hollow cylinder punches which are inserted from the open end of the bag and through the casing. Cylinder punches can preferably have a continuous diameter adjustment and thus they can be readily adapted to the situation and to the different diameters of the casing. For better removal of the tissue, the interior wall of the threaded casing can be shaped or coated so that tissue can slide in only one direction. 
     If the tissue is a cyst, then it can be punctured externally through eh open end of the bag and suctioned out. When dealing with soft, easily cuttable tissue, then preferably, cutting devices can be placed in the bag that are externally operable to transect the tissue in the bag. Cutting devices of this type are preferably cutting or sawing filaments that surround the tissue located in the bag and can be pulled out from the outside in order to cut through and cut up the tissue. 
     In order to simplify the cutting and dissecting of the tissue, in the region of the uptake volume of the bag, in its interior, mounting features are provided that securely hold the tissue in the bag so that it cannot escape from the cutting tools. The mounting features are preferably positioning pins in the region of the base of the bag that penetrate into the tissue and keep it in a fixed position. Alternatively or, in addition, for fixing the tissue in place, the inner wall surface of the bag can also be made rough. The bag can also be double-walled to optimize dependability; it can have two overlapped walls which can contain tissue inlays (thin wire mesh, plastic mesh, cloth mesh) for reinforcement. In addition, spacers of solid, liquid or gaseous materials can be installed between the doubled bag walls. 
     FIG. 1 shows schematically the abdominal wall 10 which seals off the abdominal cavity 12. The abdominal wall 10 is perforated by a trocar. By using a mandrin 14 which is employed in place of a conventional trocar, the abdominal wall 10 is kept open. A casing 16, which is preferably provided with an external thread, is seated on the mandrin 14. 
     As FIG. 2 shows, the threaded casing 16 is installed in the perforation hole of the abdominal wall 10 and is fixed in place in the abdominal wall 10 by means of its outer thread. 
     As FIG. 3 shows, the mandrin 14 is now removed so that the abdominal cavity 12 is accessible by means of the threaded casing 16. If necessary, the threaded casing 16 can be provided with a valve in a known manner. 
     FIG. 4 shows a bag 18 made of a flexible, tear-resistant and elastic plastic that is preferably made of optically transparent material and is collapsed or folded together for insertion into an insertion and safety casing 20. The axial length of the insertion and safety casing 20 can correspond to the axial length of the threaded casing 16. The insertion and safety casing 20 can be an adapter sleeve open on one side. 
     As FIG. 5 shows, the insertion and safety casing 20 is inserted into the threaded casing 16 and its end flange 22, which makes a gas-tight seal, is supported outside the body against the threaded casing 16. The bag 18 is open outside the body where its end opening 26 is detachably connected to a sealing element 42 of the insertion and safety casing 20. 
     After insertion of the insertion and safety casing 20 into the threaded casing 16, the bag 18 is introduced into the abdominal cavity 12, as FIG. 6 shows. In this case, an insertion tool 24 can be used that extends into bag 18 through the end opening 26 of the bag 18 and is fastened by a predetermined breaking point 28 to a central positioning pin 30 of the strengthened base of the bag 32. By coaxial insertion of the tool 24, the bag 18 is deployed in the abdominal cavity 12. Alternatively, the bag 18 can be deployed within the abdominal cavity by a manipulation loop 43. At the side of the wall of the bag 18, there is a side opening 34 that is located in the abdominal cavity 12 and deployed. An expanding ring with shape memory keeps the side opening 34 open when the bag 18 is deployed in the abdominal; cavity 12. A precise placement of the side opening 34 in the abdominal cavity 12 is possible with the tool 24 or the manipulation loop 43. 
     After insertion of the bag 18, the tool 24 is twisted off at the predetermined breaking point 28 and pulled out of the bag 18. As FIG. 7 shows, any surgically separated tissue 36 in the abdominal cavity 12 can now be moved through the side opening 34 into the bag 18. 
     As FIG. 8 shows, the tissue 36 moves into an uptake volume in the bottom part of the bag 18 that is between the base 32 of the bag 18 and the side opening 34. Now the tissue 36 is seated on positioning pins 30 that are installed in the reinforced base 32 of the bag 18 or are formed onto said base and whose points extend into the interior of the bag 18. These positioning pins 30 are constructed so that they cannot cause any injury to the bag 18. 
     As FIG. 9 shows, the insertion and safety casing 20 is pulled upwardly and the bag 18 is thereby partially withdrawn from abdominal cavity 12, collapsing from adjacent end opening 26 to adjacent the base of bag 18 as it passes through casing 16. 
     If the diameter of the tissue 36 is less than the inside diameter of the threaded casing 16, then the bag 18 with the enclosed tissue 36 can be pulled out entirely so that the tissue is thereby removed from the abdominal cavity. 
     However, if the tissue 36 has a greater diameter than the inside diameter of the threaded casing 16, as illustrated in FIG. 9, then the bag 18 can only be pulled out until the tissue 36 within the bag 18 causes the outwardly bulging part of bag 18 to come into contact with the intra-abdominal end of the threaded casing 16, as shown in FIG. 9. Thus, the intra-abdominal space is sealed gas-tight. The side opening 34 is located at a distance from the base 32 of the bag 18 such that the side opening 34 is entirely pulled past the threaded casing 16 and is located outside of the threaded casing 16 when the bulge in bag 18, caused by enclosed tissue 36, comes to rest against the threaded casing 16. Thus, the tissue 36 is sealed tight within the abdominal cavity 12 due to the bag 18. 
     If the bulge in bag 18 caused by tissue 36 comes to rest against the threaded casing 16 when pulling out the bag 18, the tensile force applied to the bag 18 causes the positioning pin 30 of the base of the bag 32 to press into the tissue 36. The tissue 36 is thus fixed between the positioning pin 30 and the threaded casing 16 to prevent rotation and lateral movement. In addition, due to its elastic property, the bag 18 can compress the enclosed tissue 36 and this is reinforced by the prevailing intra-abdominal pressure (after CO 2  insufflation of the pneumoperitoneum). 
     The bag 18 can now be separated at its open end 26 from the sealing element 42, unfolded along the fracture lines 41 and spread out over the threaded casing 16, as shown in FIG. 10. In this position, the bag 18 is secured in place preferably to the threaded casing 16 due to insertion of the insertion and safety casing 20 (in threaded casing 16), which presses the bag 18 against the inside wall of the threaded casing 16, due to its construction as a clamping sleeve open on one side, and which has on its flange 22 a clamping mechanism to fix the bag 18 in place. Thus, the bag 18 is secured against sliding into the abdominal cavity and the tissue 36 is held in fixed position. The insertion and safety casing 20 can also be formed by two casings, an insertion casing and a safety casing. 
     For example, if the tissue 36 is a cyst, it can be punctured under direct view through the insertion and safety casing 20 and the end opening of the sack 18 and suctioned. After suctioning and emptying the cyst, it can be pulled out and removed together with the bag through the casing 16. 
     Other tissue 36 can be cut by suitable instruments, e.g. forceps, punches or shears that are introduced from the outside while being viewed, through the insertion and safety casing 20 into the bag 18, in order to cut up the tissue 36 held against the inner end of the casing 16. The cut up pieces of tissue can be pulled out by means of a grasping instrument or suction, or removed with a hollow cylinder punch. The cutting up process can be tracked extracorporeally, and, by means of a laparoscope lens (from an existing, second incision), intra-abdominally. 
     In the case of easily cuttable tissue 36, e.g. tumors, organs or parts of organs, preferably cutting elements are present in the bag 18, as is shown in the figure. The cutting elements can be introduced through the insertion and safety casing 20 and after initial use of the cutting elements, they may be employed for additional cutting up of the tissue. 
     These cutting elements consist, in the illustrated embodiment, of cutting filaments 38 that are shown in the form of a loop in the bag 18. The loops of cutting filaments 38 in this case are installed mostly in an axial plane in the bag 18 and are releasably mounted to the inside wall of the bag 18 by suitable means. The cutting filaments 38 run along the base of the bag 32 between the positioning pins 30 and are releasably mounted to the base of the bag 32. Due to the placement of cutting filaments 38 between the positioning pins 30, slippage of the cutting filaments 38 from the tissue 36 is impossible and the cutting direction is established. The axial plane of the loops of the individual cutting filaments 38 in this case are offset to each other at an angle. For example, three loops offset by 120° to each other are provided. The free ends of the loops of the cutting filaments 38 are run out through the end opening 26 of the bag 18, and the ends of each loop are attached to one of the extractor rings 40. The extractor rings 40 of the individual cutting filaments 38 are seated axially on each other and are supported by the seating element 42. Since the loops of the cutting filaments 38 intersect at the base 32 of the bag 18, the extractor rings 40 are situated so that the cutting filament 38 which is the top one at the point of intersection of the cutting filaments 38 is attached to the uppermost of the extractor rings 40, the other cutting filaments 38 are in sequence attached to the other extractor rings. 
     Due to the arrangement and mounting of the cutting filaments 38 to the inside wall of the bag 18, the tissue 36 necessarily moves into the loops when it is moved through the side opening 34 into the bag. The loops of the cutting filaments 38 surround the tissue 36 in cutting planes which are axially offset to each other, as shown in FIG. 10. 
     As FIG. 11 shows, the first top extractor ring 40 is moved upwardly. The cutting filament 38 connected to this extractor ring 40 is thus separated from its mounts to the wall of the bag 18 and to the base of the bag 32 and cuts the tissue 36. Since the tissue 36 is held in place by the positioning pin 30 and the threaded casing 16, the tissue 36 cannot escape the cutting motion of the cutting filament 38. Due to the sequential extraction of the cutting filament 38 by means of the extractor rings 40, the tissue 36 is cut up into parts in the shape of orange sections, as shown in FIG. 13a. The cutting filaments 38 can have a rough, saw-like surface, in a favorable manner, to optimize the cutting process. 
     After extracting all the cutting filaments 38, the tissue 36 has been cut into small pieces that can be removed through the threaded casing 16 and/or the insertion and safety casing 20, as FIG. 12 shows. The tissue pieces can also be punched out with the hollow cylinder punch 44 (FIG. 13). The volume from which the punched out tissue was removed (FIG. 14) is filled by the surrounding pieces of tissue, which are pressed together and migrate inwardly due to the compression action of the elastic bag 18 and the interior chamber of the abdomen. Due to repeated application of the cylinder punch 44, even large tumors can be easily and dependably removed. Once all pieces of the tissue 36 are removed, the bag can be pulled out completely, and the insertion and safety casing 20 and the threaded casing 16 are removed. 
     Although a number of embodiments of this invention have been described by way of example, it is not intended that this invention be limited thereto. Accordingly, the invention should be considered to include any and all modifications, variations, combinations, equivalent methods or expansions falling within the scope of the following claims.