Abstract:
A surgical device including: a punch slidingly disposed in a housing for forming a hole in a first vessel; a cartridge movably disposed in the housing between a cutting and deploying positions, the cartridge having a second vessel and a coupler for coupling the first and second vessel loaded therein; a punch actuator for sliding the punch between the cutting and deploying positions; a cartridge actuator for moving the cartridge between the cutting and deploying positions, wherein while in the cutting position, the punch and cartridge are in position to permit the punch to form the hole in the first vessel and while in the deploying position, they are in position to deploy the second vessel; and a deployment mechanism for deploying the second vessel and coupler into the hole of the first vessel while the punch and cartridge are in the deploying position to create an anastomosis.

Description:
BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     The present invention relates generally to surgical devices, and more particularly, to a surgical device for creating an anastomosis between first and second hollow organs, preferably between the aorta and a harvested vessel. 
     2. Prior Art 
     To perform a coronary artery bypass graft (CABG), a cardiac surgeon traditionally hand sutures the proximal and distal ends of the harvested graft vessel, which is usually a portion of the saphenous vein or radial artery. The proximal end attaches to the patient&#39;s aorta and the distal end attaches to the diseased coronary artery, bypassing the blockage. Hand suturing the graft vessel is a time consuming procedure requiring great surgical skill, and typically requires a sternotomy or thoracotomy for access to the surgical site. Anastomosis devices have been developed which comprise a handle, which is interchangeably used with a hole puncher for creating the aortotomy, and a delivery device that is supplied with the anastomotic coupler and that must be “loaded” with the graft vessel prior to deployment of the vessel and coupler to the aorta. The delivery device is approximately 30 cm long and has controls for deploying the coupler and the vessel. Because of the size of these devices, cardiac surgeons may prefer to perform the proximal anastomosis to the aorta prior to the distal anastomosis to the coronary artery on the heart. Surgeons prefer this order so that loading of the vessel into the delivery device, and subsequent manipulation of the device while performing the proximal anastomosis, is not hampered by the vessel graft (only about 12-20 cm long) being already attached on its distal end to the heart. 
     These anastomosis devices generally have different sizes of anastomotic couplers (for differently sized graft vessels), each of which is supplied to the user in an appropriately labeled delivery device. If the surgeon should decide to open the sterile package for the delivery device containing the first size and then decides to change to the second size, or if the first device is unintentionally rendered inoperable due to misleading, etc., then the entire first device must be discarded. Also the surgeon may need to perform multiple bypasses when two or more graft vessels are anastomosed to the aorta. 
     The anastomosis devices of the prior art also require that the operator first assemble the punch with the handle in order to create the aortotomy. Next the punch must be removed from the handle while the distal end of the handle is held steadily in the aortotomy to prevent leakage of blood. While still holding the handle with the distal end in the aortotomy, the operator assembles the delivery device, already loaded with a graft vessel and the anastomotic coupler, into the handle. The surgeon must exchange these instrument components within the surgical opening providing access to the aorta resulting in a leakage of blood from the aorta. 
     SUMMARY OF THE INVENTION 
     Therefore it is an object of the present invention to provide a surgical device for creating an anastomosis between first and second hollow organs that allows a distal anastomosis to be more easily performed first before a proximal anastomosis, in case this is the surgeon&#39;s preference. 
     It is another object of the present invention to provide a surgical device for creating an anastomosis between first and second hollow organs which has a relatively low cost component that is separate from the delivery device, contains the anastomotic coupler, and may be loaded with the graft vessel. 
     It is yet another object of the present invention to provide a surgical device for creating an anastomosis between first and second hollow organs wherein the remainder of the device (other than the component discussed immediately above) is reloadable and has controls that may be reset for multiple use. 
     It is still another object of the present invention to provide a surgical device for creating an anastomosis between first and second hollow organs, which minimizes blood leakage and/or injury to the hollow organs. 
     It is still another object of the present invention to provide a surgical device for creating an anastomosis between first and second hollow organs, which eliminates instrument exchanges. 
     Accordingly, a surgical device for creating an anastomosis between first and second hollow organs is provided. The device comprises: a housing; a punch slidingly disposed in the housing for forming a hole in the first hollow organ; a cartridge movably disposed in the housing between a cutting position and a deploying position, the cartridge having the second hollow organ and a coupler for coupling the first and second hollow organs loaded therein; punch actuation means for sliding the punch between the cutting and deploying positions, wherein while in the cutting position the punch is in position to form the hole in the first hollow organ and while in the deploying position, the punch is in position to permit the deployment of the second hollow organ; cartridge actuation means for moving the cartridge between the cutting and deploying positions, wherein while in the cutting position, the cartridge is in position to permit the punch to form the hole in the first hollow organ and while in the deploying position, the cartridge is in position to deploy the second hollow organ; and deploying means for deploying the second hollow organ and coupler into the hole while the punch and cartridge are in the deploying position to create the anastomosis. 
     The first hollow organ is preferably the aorta of the heart and the second hollow organ is preferably a harvested vessel. The coupler is preferably an anastomotic device having a set of pins on each of two ends, one of the sets of pins coupling the anastomotic device to a distal end of the second hollow organ and the other set of pins coupling the anastomotic device to a wall of the second hollow organ about the hole. 
     Preferably, the surgical device for creating an anastomosis between first and second hollow organs comprises: a housing; a punch slidingly disposed in the housing along a central axis for forming a hole in the first hollow organ; a cartridge movably disposed in the housing between a position offset from the central axis and a position aligned with the central axis, the cartridge having the second hollow organ and a coupler for coupling the first and second hollow organs loaded therein; punch actuation means for sliding the punch between cutting and deploying positions, wherein while in the cutting position the punch is in position to form the hole in the first hollow organ and while in the deploying position, the punch is in position to permit the deployment of the second hollow organ; cartridge actuation means for moving the cartridge between the cutting and deploying positions, wherein while in the cutting position the cartridge is in the position offset from the central axis and while in the deploying position, the cartridge is in the position aligned with the central axis; and deploying means for deploying the second hollow organ and coupler into the hole while the punch and cartridge are in the deploying position to create the anastomosis. 
     More preferably, the cartridge is rotatably disposed in the housing and the cartridge actuation means comprises; a cradle rotatably disposed in the housing for accepting the cartridge; and a shaft connected to the housing upon which the cradle rotates. 
     Preferably, the punch comprises: a shaft disposed along the central axis; and a punch tip disposed at a distal portion of the shaft and having a pointed surface for piercing the first hollow organ. More preferably, the punch further comprises means for retracting the pointed surface of the punch tip into a lumen of the shaft. Furthermore, the punch tip preferably has a proximal edge for cutting a wall of the first hollow organ, a grooved portion proximate to the punch tip for capturing a wall of the first hollow organ, and means for retracting the punch tip to sandwich the wall between the proximal edge and a portion of the housing and to sever the wall around a periphery of the proximal edge. 
     The cartridge preferably further comprises a seal for sealing liquid in the first internal organ from entering the device. The cartridge further preferably comprises a splitting means for splitting the cartridge and seal subsequent to deployment of the second hollow organ and coupler for facilitating release of the second hollow organ from the device. The coupler preferably has pins for securing the second hollow organ to the hole of the first hollow organ, the pins being biased in a bent position, where the cartridge further comprises retaining means for retaining the pins in a substantially straight position prior to deployment of the second hollow organ and coupler. In which case the deploying means preferably comprises; means for pushing a distal end of the second hollow organ and the coupler into the hole of the first hollow organ; and means for releasing the restraint on the pins thereby fixing the second hollow organ to the hole of the first hollow organ. The means for pushing the distal end of the second hollow organ and coupler into the hole of the first hollow organ preferably comprises a shaft operatively connected to the cartridge for sliding the cartridge along the central axis such that the distal end of the second hollow organ protrudes from the housing and into the hole of the first hollow organ. The means for releasing the restraint on the pins preferably comprises: a screw tube rotatably disposed in the housing and operatively connected to the cartridge; a knob connected to a distal end of the screw tube, wherein rotation of the knob releases the restraint on the pins. 
     The punch actuation means preferably comprises: a punch lever rotatably disposed on a shaft of the punch, wherein pulling the punch lever in the proximal direction moves the punch from the cutting position to the deploying position; and retainer means for retaining the punch lever in the housing as it is pulled in the proximal direction. Furthermore, the cartridge and punch actuation means preferably also comprise locking means for locking the cartridge, punch lever and punch in the deploying position. 
     Also provided is a method for creating an anastomosis between first and second hollow organs. The method comprising: providing a punch slidingly disposed in a housing along a central axis; providing a cartridge movably disposed in the housing between a position offset from the central axis and a position aligned with the central axis; loading the second hollow organ and a coupler for coupling the first and second hollow organs into the cartridge; sliding the punch distally to create a hole in a wall of the first hollow organ; sliding the punch proximally to provide clearance for rotation of the cartridge into the position aligned with the central axis; moving the cartridge from the axis offset from the central axis to the position aligned with the central axis; and deploying the second hollow organ and coupler into the hole to create the anastomosis. 
     The punch preferably comprises a shaft disposed along the central axis; and a punch tip disposed at a distal portion of the shaft and having a pointed surface for piercing the first hollow organ, in which case the method further comprises retracting the pointed surface of the punch tip into a lumen of the shaft. Preferably, the punch tip has a proximal edge for cutting the wall of the first hollow organ and a grooved portion proximate to the punch tip, in which case the method further comprises: capturing the wall of the first hollow organ in the grooved portion; and retracting the punch tip to sandwich the wall between the proximal edge and a portion of the housing to sever the wall around a periphery of the proximal edge. 
     Preferably, the method further comprises sealing liquid in the first internal organ from entering the device and splitting the cartridge and seal subsequent to deployment of the second hollow organ and coupler for facilitating release of the second hollow organ from the device. 
     The coupler preferably has pins for securing the second hollow organ to the hole of the first hollow organ, the pins being biased in a bent position, in which case the method further comprises retaining the pins in a substantially straight position prior to deployment of the second hollow organ and coupler. The method also preferably further comprises; pushing a distal end of the second hollow organ and the coupler into the hole of the first hollow organ; and releasing the restraint on the pins thereby fixing the second hollow organ to the hole of the first hollow organ. Preferably, a screw tube is rotatably disposed in the housing and operatively connected to the cartridge, wherein the releasing comprises rotating a knob connected to a distal end of a screw tube to release the restraint on the pins. Preferably, the method also further comprises restraining the rotation of the knob in the direction that releases the restraint on the pins and releasing the restraint and allowing the knob to be reset to an initial position for subsequent operations of the device. 
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS 
     These and other features, aspects, and advantages of the apparatus and methods of the present invention will become better understood with regard to the following description, appended claims, and accompanying drawings where: 
     FIG. 1 illustrates a perspective view of a preferred implementation of the surgical device of the present invention. 
     FIG. 2 illustrates a perspective view of a vessel cartridge used in the device of FIG. 1, the cartridge shown before loading of a second hollow organ therein. 
     FIG. 3 a  illustrates a perspective view of the vessel cartridge of FIG. 2 with the second hollow organ loaded therein. 
     FIG. 3 b  illustrates a cross sectional view of the vessel cartridge of FIG. 3 a  with the vessel loaded therein. 
     FIG. 3 c  illustrates a distal end of the vessel cartridge of FIG. 3 b.    
     FIG. 4 a  illustrates a side view of the cartridge of FIGS. 2 and 3 with the pins of a coupler device pierced through an everted portion of the loaded second hollow organ. 
     FIG. 4 b  illustrates a cross sectional view of the vessel cartridge of FIG. 4 a.    
     FIG. 4 c  illustrates a distal end of the vessel cartridge of FIG. 4 b.    
     FIG. 5 a  illustrates a top view of the surgical device of FIG. 1 with the cartridge loaded therein and the punch in the cutting position. 
     FIG. 5 b  illustrates a section view corresponding to the proximal end of the surgical device of FIG. 5 a.    
     FIG. 6 illustrates an isometric view of the punch assembly of the surgical device of FIG.  5 . 
     FIG. 7 a  illustrates a cross sectional view of a distal portion of the punch assembly of FIG. 6 with the punch point extended. 
     FIG. 7 b  illustrates a cross sectional view of a proximal portion of the punch assembly of FIG. 6 with the handle positioned to correspond to the punch point being extended. 
     FIG. 8 illustrates a side view of the surgical device of FIG. 5 with the punch point retracted. 
     FIG. 9 a  illustrates a cross sectional view of a distal portion of the punch assembly of FIG. 6 with the punch point retracted. 
     FIG. 9 b  illustrates a cross sectional view of a proximal portion of the punch assembly of FIG. 6 with the handle positioned to correspond to the punch point being retracted. 
     FIG. 10 illustrates a side view of the surgical device of FIG. 5 with the punch tip retracted. 
     FIG. 11 a  illustrates a cross sectional view of a distal portion of the punch assembly of FIG. 6 with the punch tip retracted. 
     FIG. 11 b  illustrates a cross sectional view of a proximal portion of the punch assembly of FIG. 6 with the handle positioned to correspond to the punch tip being retracted. 
     FIG. 12 illustrates an isometric view of a distal portion of the surgical device of FIG. 5 with the punch tip retracted to cut a hole in the first hollow organ. 
     FIG. 13 illustrates an isometric view of a distal portion of the surgical device of FIG. 12 with the punch assembly retracted into a deploying position. 
     FIGS. 14 a  and  14   b  illustrate isometric views of the surgical instrument of FIG. 13 with the cartridge rotated into the deploying position. 
     FIGS. 15 a  and  15   b  illustrate isometric views of the surgical instrument of FIGS. 14 a  and  14   b  with the cartridge indexed distally such that the everted portion of the second hollow organ protrudes from the distal portion of the surgical device. 
     FIG. 15 c  illustrates an isometric view of the distal portion of the surgical instrument of FIGS. 15 a  and  15  showing an initial position of a timing mechanism for deploying the second hollow organ and coupler. 
     FIG. 15 d  illustrates a section view corresponding to the proximal end of the surgical device of FIG. 15 b.    
     FIG. 16 a  illustrates a side view of a distal portion of the surgical instrument of FIGS. 15 a  and  15   b  in which the cartridge pull plate is pulled proximally. 
     FIG. 16 b  illustrates a top view of the surgical device of FIG. 16 a  showing a corresponding position of the timing mechanism. 
     FIG. 17 illustrates an isometric view of a distal end of the surgical device where second hollow organ is deployed and the cartridge is about to split, FIG. 17 having a portion of the handle removed for clarity. 
     FIG. 18 illustrates an isometric view of a distal end of the surgical device where the cartridge is split. 
     FIG. 19 illustrates a partial cross sectional view of a second hollow organ deployed in the wall of a first hollow organ. 
     FIG. 20 illustrates a cross sectional view of a proximal end of the surgical instrument after deployment of the second hollow organ and being reset to an initial position for acceptance of another loaded cartridge. 
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT 
     Although this invention is applicable to numerous and various types of hollow organs, it has been found particularly useful in the environment of CABG to create an anastomosis between the aorta and a harvested vessel, such as a saphenous vein or radial artery. Therefore, without limiting the applicability of the invention to the environment of CABG to create an anastomosis between the aorta and a harvested vessel, the invention will be described in such environment. 
     Referring now to FIG. 1, there is illustrated a surgical device for creating an anastomosis between first and second hollow organs, the device generally referred to by reference numeral  100 . As discussed above, the device is particularly useful in a CABG where the first hollow organ is the aorta and the second hollow organ is a harvested saphenous vein or radial artery or a synthetic vein. The device comprises a housing  102 . The housing  100  preferably is integrated with a handle  104  for a user to grasp and manipulate the device  100 . The handle is preferably fabricated from right and left halves  106 ,  108 , respectively, which are assembled into a unitary housing for ease of assembly of internal elements. The housing  102  is fabricated from any medical grade material, preferably a thermoplastic. The housing  102  and the entire device  100  is preferably configured for an “open” type surgical procedure as shown, but may also be configured for endoscopic type procedures. Furthermore, the device  100  and/or any portions thereof can be disposable, reusable, or semi-reusable. 
     Referring now to FIGS. 2,  3   a , and  3   c , the device  100  includes a removable cartridge  200 . The cartridge  200  has a body  202  having a nose section  203 . The main body  202  is preferably a medical grade thermoplastic, which as discussed below can be easily split. The cartridge further has an internal contra tube  204  (alternatively referred to herein as a contra) which is preferably fabricated from a resilient medical grade material, such as stainless steel. A coupler  206  is loaded on the contra  204 . The coupler  206  is preferably an anastomodic coupler which has distal and proximal sets of pins  208 ,  209 , respectively, on the distal and proximal ends of the coupler  206 . Although the proximal set of pins  209  are known as adventitia pins in the art because they deploy on the adventitial (outside) side of the aorta, they are generally referred to herein as the proximal set of pins  209 . Similarly, although the distal set of pins  208  are known as intimal pins in the art because they deploy on the intimal (inside) side of the aorta, they are generally referred to herein as the distal set of pins  208 . Although, the distal and proximal sets of pins  208 ,  209  can be similarly configured, it is preferred that the proximal set include a “crows feet” configuration at their ends. The pins are normally biased in a bent position for securing the second hollow organ to a hole in the first hollow organ. The anastomodic coupler  206  further preferably has a body  210 , which expands radially when deployed. Such anastomodic couplers  206  are known in the art, such as those disclosed in WO 0056228, to Loshakove et al., filed Mar. 20, 2000, which is incorporated herein by its reference. The cartridge  200  further having retaining means for retaining the pins  208 ,  209  in a substantially straight position and the body  210  in a contracted radial position prior to deployment of the second hollow organ and coupler  206 . The retaining means generally comprises retaining the coupler  206  with the interior of the main body  202 . The coupler body  210  and distal set of pins  208  are preferably disposed distally to a distal end  204   a  of the contra  204 , and the contra  204  preferably has longitudinal grooves  212  at the distal end  204   a  corresponding to the proximal set of pins  209  for accepting and retaining the same therein. The contra  204  is slidingly disposed in cartridge  200  and is attached at a proximal end  204   b  to a button  214 . The distal end  204   a  of the contra  204  is split while the proximal end  204   b  is not split. The contra also has a pin  216 , which rides in a slot  218  in the cartridge body  202 . The pin  216  extends past an outside surface of the cartridge body  202 . Preferably, a pin  216  and slot  218  are provided on each of two sides of the cartridge  200 . The cartridge body  202  further has wings  220  each having a slot  222 , a handle  224 , and a proximal groove  226 . A slot  228  extends longitudinally on the upper side of the cartridge body  202  and having first, second, and third portions  230 ,  232 ,  234 , respectively. 
     Referring now to FIG. 3 a , the cartridge  200  is illustrated therein after loading with the second hollow organ  300 , which is generally a harvested vein. The second hollow organ  300  is passed through a lumen in the cartridge  100  with its proximal end  302  exiting through the second portion  232  of the slot  228  and its distal end  304  being everted over the nose section  203  of the cartridge body  202 . Typically, the second hollow organ  300  such as a harvested vein to be used in a CABG procedure is approximately 10 inches long, in which case the proximal end  302  hangs free from the cartridge  200 . However, the proximal end  302  of the second hollow organ  300  is shown shortened for clarity. 
     Referring now to FIG. 4, prior to loading the cartridge  200  in the device  100 , the button  214  is depressed distally into the cartridge body  202  to slide the contra  204  distally relative to the cartridge body  202  which causes the pins  216  to move distally in their corresponding slot  218  and which further moves the coupler  206  distally until some of the restraint on the distal set of pins  208  is removed whereby the distal set of pins  208  pierce the folded portion  304   a  of the everted distal end  304  of the second hollow organ  300  and partially return to their bent position. Therefore, before loading the cartridge  200  into the housing  102 , the second hollow organ can be inspected to determine if it is adequately pierced by the distal set of pins  208 . 
     Referring now to FIG. 5 a , the cartridge  200  is then disposed in the housing  102 , preferably in a distal portion of the housing  102 . The cartridge  200  is movably disposed in the housing between a cutting position and a deploying position. The cutting position is defined as any position in which the cartridge  200  does not interfere with the cutting of a hole in the first hollow organ and in which a punch assembly  600  is positioned to make the hole in the first hollow organ. The deploying position is defined as any position in which the cartridge  200  is positioned to deploy the second hollow organ  300  into the hole in the first hollow organ and in which the punch assembly  600  is positioned so as not to interfere with the cartridge  200 . FIG. 5 a  shows the punch assembly  600  and cartridge in the cutting position. A punch tip  602  of the punch assembly  600  is extended about a central axis A and the cartridge is offset from the central axis A about axis B. 
     The cartridge  200  is preferably rotated between the cutting and deploying positions, as will be discussed below. However, the cartridge  200  can also translate between the cutting and deploying positions. Furthermore, the cartridge  200  is preferably rotated from an axis B which is offset from axis A, as will also be discussed below. However, the cartridge  200  and the distal end of the punch assembly  600  do not have to be on offset axes. For instance, although not preferred, the cartridge  200  can translate along the central axis A between cutting and deploying positions where the punch assembly  600  is flexible and slides around the cartridge  200  while in the cutting position where the distal end of the punch assembly  600  slides along central axis A and the remainder slides along an offset axis. 
     Referring now to FIG. 5 b , a cross sectional view of the proximal end of the housing  202  is shown corresponding to the device  100  illustrated in FIG. 5 a , that is, where the cartridge  200  is in the cutting position and the punch assembly  200  is proximally retracted from the cutting position but free to be deployed into the cutting position. While initially in the cutting position, a knob  500 , rotation of which is used to deploy the second hollow organ  300 , is locked from rotation. The knob is preferably locked with gears  502 ,  504  one of which is attached to the knob  500  and the other of which is biased proximally by a spring  506 . In the locked position, horizontal portions  502   a ,  504   a  of the gears  502 ,  504 , respectively, are engaged which prevent relative motion of the knob  500  with respect to the screw tube  506 . Furthermore, while in the initial cutting position, namely after initially loading the cartridge  200  into the housing  102 , a knob cap  508  is retracted proximally from the housing  102 . The knob cap is connected to a proximal end of a screw tube  510 , which engages the cartridge  200  at a distal end. 
     Referring now to FIGS. 6,  7   a , and  7   b  there is illustrated a punch assembly  600 , alternately referred to simply as a punch  600  for forming a hole in the first hollow organ. The punch  600  is preferably slidingly disposed in the housing  102 . The punch  600  has an outer punch tube  604  fixed at a proximal end to a punch body  616  and having a lumen  609 . The punch  600  further has an inner punch tube  605  disposed in the lumen  609  and has a grooved portion  606  and punch tip  602  at a distal end. The inner punch tube  605  has a lumen  608  for acceptance of a punch shaft  610 . The punch shaft  610  has a punch point  612 , which retracts into a distal portion  614  of the lumen  608 . The punch body also has a punch slide  618  for engaging a corresponding slot  619  (shown in FIG. 12) in the housing  102  to retain and slidingly dispose the punch  600  therein. 
     The punch body  616  further has a punch lever  620  rotatably disposed thereon about a first pined joint  622 . The punch body  618  further has an internal cavity  623  in which a plunger  624  is slidingly disposed. The plunger is biased toward the distal direction by a spring  626 . The punch shaft  610  is connected to the plunger  624  while the inner punch tube  605  is connected to a slide  625 , which is also slidingly disposed in the internal cavity  623 . The punch lever  620  is further connected to the plunger  624  by a link  628  having a rotatably pinned connection at each of two ends  630 ,  632 . While the punch lever  620  is in an upright position as shown in FIGS. 1,  6 , and  7   b , the punch point  612  is extended from the punch tip  602  to facilitate piercing of a wall of the first hollow organ, such as the aorta. 
     Referring now to FIGS. 8,  9   a , and  9   b , after piercing the wall  900  of the first hollow organ  902 , the punch point  612  is retracted, as shown in FIGS. 8 and 9 b , by rotating the punch lever  620  a first predetermined angle α from the position shown in FIG. 7 b . Rotating the lever  620  causes the link  628  to slide the plunger  624  proximally against the bias of the spring  626  which pulls the punch shaft  610  proximally until the punch point  612  retracts into the distal portion  614  of the lumen  608  and a stop  634  on the slide  625  engages a corresponding stop  636  on the plunger  624 . Preferably, the punch point  612  is retracted immediately after piercing the wall so as to minimize the possibility of piercing completely through (backwalling) the first hollow vessel. As shown in FIG. 9 a , after piercing the wall  900  of the first hollow organ  902 , a puncture  904  is created in the wall  900  and with further pressure in the distal direction, the wall  900  is positioned in the grooved portion  606  of the punch tube  604 . 
     Referring now to FIGS. 10,  11   a ,  11   b , and  12 , the captured wall  900  in the grooved portion  606  is cut to form a hole  905  for subsequent insertion of the second hollow organ  300 . To cut the hole  905 , the punch tip  602  is retracted by depressing the lever  620  completely as shown in FIG. 11 b  to withdraw the inner punch tube  605  against the outer punch tube  604 . Upon depressing the lever  620  past the angle α, the stops  634 ,  636  are engaged and the plunger  624  drags the slide  625  proximally to retract the inner punch tube  605 . The cutting of the hole is accomplished with a rear cutting edge  906  of the punch tip  602  that presses against a corresponding surface for the outer punch tube  604  to cut the hole  905 . After cutting the hole  905 , a nose sleeve  110  disposed on the distal portion of the housing  102 , and approximately the same size as the hole  905 , is positioned into the hole  905 . 
     Referring now to FIGS. 13,  14   a , and  14   b , with the nose sleeve  110  inserted into the hole  905 , a punch actuation means is used to slide the punch  600  between the cutting and deploying positions. Preferably, as discussed above, the punch slide  618  of the punch body  616  slides in the slot  619  of the housing  102  to move the punch  600  proximally from the cutting position into the deploying position. Preferably, the punch  600  includes a means for locking the punch lever  620  and punch  600  in the deploying position. After retraction of the punch  600 , a seal  633  (shown in FIG. 18) in the distal portion of the housing prevents any liquid in the first hollow organ from entering the device. The seal  633  is preferably an elastomer sheet with a tiny puncture, which stretches for passage of the punch tip  602  and cartridge  200  and which returns to its shape after withdrawal of the punch  600 . Once the punch  600  is in the deploying position, a cartridge actuation means is used to move the cartridge from the cutting position to the deploying position. As shown in FIG. 14 a , and discussed above, the cartridge  200  is preferably rotated into the deploying position. FIG. 14 b  shows the punch  600  retracted proximally into the deploying position, the cartridge  200  rotated into alignment with the central axis, which is centered on the hole  905 , and the knob cap  508  retracted proximally. 
     Referring briefly to FIGS. 15 a  and  16   a , the cartridge is loaded shown loaded onto a cradle  1000 , the cradle is rotatably disposed in the housing  102  by way of a distal portion of the screw tube  510 . The screw tube  510  runs through the cradle  1000  and is retained in housing  102  by a groove  1002  and corresponding tab  1004  on the screw tube  510 . The cradle  1000  includes a cartridge pull plate  1006  and a contra pull plate  1008 . The cartridge pull plate  1006  engages the cartridge body  202  at the slot  226  and the contra pull plate  1008  engages the contra  204  by way of the pins  216  and corresponding slots  217  on the contra pull plate  1008 . The cradle  1000  further has a wedge  112 , which engages a lower slot of the cartridge  200 . 
     Referring now to FIGS. 15-18, a preferable deploying means for deploying the second hollow organ and coupler into the hole to create the anastomosis will be described. Referring first to FIGS. 15 a ,  15   b ,  15   c , and  15   d , subsequent to the cartridge  200  being rotated into the deploying position, the knob cap  508  is advanced distally to engage the knob  500 . Preferably, the knob  500  and knob cap  508  engage by means of tabs  1010  having hook ends  1012 , which are captured, in a cavity  1014  in the knob  500 . Tab buttons  1016  are also provided to release the knob cap  508  from the knob  500 . The advancement of the knob cap  508  advances the screw tube  510 , which in turn advances the cartridge  200  and the cradle  1000  distally such that the everted portion  304  of the second hollow organ  300  protrudes through the nose  110  and into the hole  905  thereby locking the cartridge  200  in the deploying position. At this point, the distal set of pins  208  embed in an inner surface of the wall  900  circumferentially about the hole  905 . 
     Also upon advancement of the knob cap  508 , the slot  222  in the wings  220  of the cartridge body  202  engage a corresponding protrusion  1018  on the nose piece  110  of the housing  102 . Further, a distal free end  1020  of a leaf spring  1022  disposed in the housing  102  engages a first slot  1024  in the contra pull plate  1008 . The leaf spring  1022  further has a pin  1026  fixed to the leaf spring  1022  and slidingly disposed in a hole  1028  in the housing  102 . As will be discussed later, the leaf spring is a preferred implementation of a timing means for timing the movement of the cartridge and contra pull plates  1006 ,  1008 . Lastly, upon advancement of the knob cap  508 , causes gear  502  to advance distally such that tapered portions  502   b ,  504   b  of gears  503 ,  504  engage upon rotation in one direction (clockwise) thereby permitting a ratchet type motion of the knob  508  and screw tube  510 . In this position, the knob  500  and screw tube  510  attached thereto can rotate in the clockwise direction but are restricted from rotating in the counterclockwise direction. 
     Referring now to FIGS. 16 a  and  16   b , the cartridge pull plate  1006  is retracted distally a predetermined amount X while the contra pull plate  1008  is held stationary which in effect advances the contra  204  distally to fully expose the distal set of pins  208 . The cartridge pull plate  1006  is retracted by turning the knob  500 , which in turn turns the screw tube  510 . After the cartridge pull plate  1006  is advanced the predetermined distance X, the pin  1026  rides over a cam  1030  to remove the distal end  1020  of the leaf spring  1022  from the first slot  1024 . In this position, continued turning of the knob  500  retracts both the cartridge pull plate  1006  and the contra pull plate  1008 . 
     Referring now to FIGS. 17 and 18, upon continued rotation of the knob  500 , the pin  1026  moves past the cam  1030  and the distal end  1020  of the leaf spring  1022  engages a second slot  1032  in the contra pull plate  1008 , thereby stopping its movement. Continued rotation of the knob  500  retracts only the cartridge pull plate  1006  relative to the contra pull plate  1006  and contra  204 . Referring now to FIG. 18, a knife  1034  attached to the contra  204  is forced through the distal portion  234  of the slot  228  and eventually splits the cartridge body  202 , seal  633 , and nose piece  110  in half and separates the contra  204  to remove the restraint from the coupler body  210  and proximal set of pins  209  and to deploy the coupler  206  and second hollow organ  300  to create the anastomosis. The wedge  112  facilitates the splitting of the cartridge body  202  and contra  204 . 
     Referring now to FIG. 19, after deployment, the coupler  206  expands radially to sandwich the everted portion of the second hollow organ between the inner surface of the hole  905  and the coupler body  210  to create a seal between the first and second hollow organs. The distal set of pins  208  pierce the turned over portion  304   a  of the everted second hollow organ  300  and lodge in an inner surface  907  of the wall  900  of the first hollow organ circumferentially about the hole  905 . The proximal set of pins  209  are fully unrestrained and lodge in an outer surface  909  of the wall  900  of the first hollow organ  902  circumferentially about the hole  905 . 
     Referring now to FIG. 20, to reset the surgical device  100  for creating further anastomosis, the split cartridge is removed and a reset button  1040  is advanced distally to totally disengage the gears  502 ,  504  allowing rotation of the knob  500  in the counterclockwise direction. The knob  500  is rotated until the cartridge and contra pull plates  1006 ,  1008  of the cradle  1000  abut one another. Furthermore, a new nose piece  110  and seal  633  are replaced and the tab buttons  1016  are depressed to disengage the hooked ends  1012  of the tabs  1010  with the cavity  1014  and the knob cap  508  is separated from the knob  500  and retracted proximally until the cradle  1000  is in position to be rotated into the cutting position. The punch  600  is then slid distally back into the cutting position with the punch point  612  retracted so as not to tear the seal  633  when it is eventually inserted into the nose  110 . The device  100  is then ready to accept another loaded cartridge  200  and create another anastomosis. For instance, other harvested vessels can be anastomosed to the aorta or the distal end of the harvested vessel can be anastomosed around the blockage to the diseased coronary artery. Alternatively, the distal end of the harvested vessel can be hand sewn to the diseased coronary artery and the proximal end of the harvested vessel can be anastomosed to the aorta using the device  100  of the present invention without ripping the distal end free. 
     EXAMPLE 
     As discussed above, the present invention has particular utility in a coronary artery bypass graft procedure (CABG), however, the use of the instruments of the present invention is now described with regard to the CABG procedure by way of example only and not to limit the scope or spirit of the present invention. A patient is prepared for cardiac surgery in a conventional manner using conventional techniques and procedures. The patient is then anesthetized and ventilated using conventional techniques. A conventional CABG procedure is performed by harvesting the greater saphenous vein from one or both of the patient&#39;s legs. The surgeon prepares an opening to the heart by dividing the patient&#39;s sternum (conventional median sternotomy) and spreading the rib cage apart using a surgical retractor. The surgeon next begins dissecting the internal mammary artery (IMA) from the chest wall of the patient, so that the distal end of the vessel may be anastomosed to the diseased lower anterior descending (LAD) coronary artery on the distal side of a lesion on the septum near the left ventricle of the heart as a source of oxygenated blood. During the surgical procedure, the surgeon optionally elects to have the patient&#39;s heart beating to perform a conventional beating heart CABG, although the surgeon has a cardiopulmonary bypass machine (CPB) primed with the patient&#39;s blood and available if it is necessary to convert the beating heart procedure into a conventional stopped heart procedure. 
     The surgeon prepares the heart for attaching the graft vessels by cutting and pulling away the pericardium. After checking the graft vessels for patency, collateral damage and viability, the surgeon prepares to do the anastomoses necessary to bypass the lesions in the coronary arteries. The surgeon attaches the proximal end of each graft vessel to the patient&#39;s aorta with the surgical devices of the present invention. The distal end may be attached to the diseased coronary artery, distal to the blockage or lesion, before or after the proximal end is attached to the aorta. Furthermore, the distal end may be sutured or also attached using the surgical devices of the present invention. The surgeon checks the bypass grafts for adequate blood flow in a conventional manner, and then completes the remainder of the operation in a conventional manner. 
     The veins used in the CABG procedure are harvested endoscopically using vein-harvesting instruments. Using these instruments, initially the patient&#39;s leg is positioned to be slightly bent and is turned to expose the inner leg. A marker is used to show on the skin the location of the vein to be harvested. Then an incision is created on the inner leg near the knee, through the skin and subcutaneous layers. The vein typically lies directly beneath the subcutaneous layers and so a middle portion of the vein is accessed through the incision. After some initial dissection with conventional blunt dissectors around this portion of the vein, a surgical instrument is introduced into the incision. An endoscope provides visualization of the vein and surrounding tissue within the working space inside the head. The instrument is advanced along the vein. Side branches off of the vein are ligated and divided a few millimeters away from the vein, taking great care not to injure the vein in any way. The harvesting procedure continues in this manner until the vein is hemostatically isolated from surrounding tissues and blood supply along the portion to be harvested. Then stab incisions are created through the skin and subcutaneous layers at the distal and proximal ends of the vein, ligation clips are applied, and the vessel is transected in order to remove the vein from the knee incision. Thee harvested vein is prepared for use as grafts in a conventional manner. 
     While there has been shown and described what is considered to be preferred embodiments of the invention, it will, of course, be understood that various modifications and changes in form or detail could readily be made without departing from the spirit of the invention. It is therefore intended that the invention be not limited to the exact forms described and illustrated, but should be constructed to cover all modifications that may fall within the scope of the appended claims.