Combination instrument for laparoscopical tube sterilization

A surgical combination instrument for atraumatically grasping human or animal tissue, for performing bipolar coagulation by means of high frequency current, for cutting tissue in the coagulated area and for removing tissue remaining uncoagulated between the coagulated areas. These functions can be performed without requiring a change in instruments. The cut tissue removed by means of the instrument can be made available for a histological identification.

BACKGROUND OF THE INVENTION 
1. Field of the Invention 
The invention relates to surgical instruments and, more particularly, to a 
combination instrument for atraumatic grasping, bipolar coagulation by 
means of high frequency current and cutting out human or animal tissue. 
The instrument is particularly intended for the purpose of making the 
fallopian tubes in a woman impassable by means of an abdominal specular 
operation, hereinbelow called laparoscopical tube sterilization. 
2. Description of the Prior Art 
Surgical operations have long been performed in human medicine for the 
purpose of sterilization, for instance, to make impassable the fallopian 
tubes in women or the sperm ducts in men. First used for this purpose were 
surgical methods in open surgery which made the organs impassable by 
blocking them by means of a thread and subsequently sharply cutting them. 
As early as 1937, Anderson (USA) utilized the tissue destroying effect of 
high frequency current for laparoscopical tube sterilization in 
gynecology. This technique was further developed after appropriate 
instruments were designed, for instance, by SEMM (Germany), the companies 
Karl Storz GmbH and Richard Wolf GmbH. The technique is still used today 
for laparoscopical tube sterilization. 
Two methods of coagulating tissue by means of high frequency current are 
used today. They are (1) the unipolar high frequency method and (2) the 
bipolar high frequency method. 
In the unipolar high frequency method, a neutral electrode, usually 
attached to the thigh of the patient, forms one pole. A functional device 
at the laparoscopical instrument forms the other pole for the high 
frequency current (for instance, unipolar hooked scissors according to 
SEMM). 
In the bipolar high frequency method, wherein both electrodes are opposite 
one another in the area of the functional unit of the surgical instrument 
(for instance, bipolar grasping forceps, Karl Storz GmbH), the high 
frequency current is conducted only through the tissue grasped by the 
functional units. 
In order to perform a laparoscopical tube sterilization by coagulation with 
high frequency current and to remove tissue, it is presently necessary, 
after applying a pneumoperitoneum and inserting an optical instrument, 
first to grasp the tube, for instance, with the bipolar grasping forceps 
(Richard Wolf GmbH) and to coagulate the tube, then to remove this 
instrument, insert a cutting instrument, for instance, the unipolar 
hook-type cutter according to Frangenheim, to cut out a portion of the 
tube in the coagulated area, and, after another instrument change, to 
remove the cut tube portion from the abdominal cavity by means of grasping 
forceps. 
The use of unipolar high frequency current for tube coagulation should be 
considered obsolete today because the current may cause uncontrolled 
burning at completely different portions of tissue which were not even 
touched by the surgeon. 
When using the bipolar high frequency method for the coagulation of tubes, 
the instruments available today make it necessary, after insertion of a 
bipolar grasping forceps and subsequent coagulation of a tube portion, to 
again remove the forceps, insert a cutting device, and to cut the tube in 
the area which previously was coagulated. If, in addition, a tube section 
is to be removed, several cuts must be made which is particularly 
difficult with cuts at an angle of 90.degree. to the guide sleeve of the 
cutting instrument, because the cutting device is rigid relative to the 
guide sleeve. This has the serious disadvantage that these manipulations 
result in cuts in non-coagulated areas and cause dangerous bleeding. In 
addition, the instrument must be changed for a third time in order to 
remove the cut out tissue from the abdominal cavity. 
Since the bipolar grasping forceps used today have an electrode width of 
only 5 to 6 mm, the tube is grasped and coagulated several times, so that 
sometimes the tube is unnecessarily destroyed over its entire length. 
In addition, coagulation frequently takes place far beyond the tubes in the 
appendages because these instruments have no stops against the electrodes 
and, consequently, the tissue, in this case the tubes, may reach much too 
deeply between the grasping units of the bipolar forceps. If tissue is 
successfully removed in spite of these difficulties, the removed tissue is 
completely destroyed by the coagulation and can be histologically 
identified only with difficulty or not at all. Although tissue removal for 
histological identification is internationally demanded, it is usually not 
performed because (1) the surgical risk is substantially increased, and 
(2) a proper histological identification is doubtful. 
SUMMARY OF THE INVENTION 
I have discovered a combination instrument for laparoscopical tube 
sterilization which overcomes the above disadvantages of conventional 
instruments and specifically meets the following requirements: 
1. Atraumatic grasping of tissue without shifting of functional units of 
the instrument relative to the guide sleeve of the instrument. 
2. Safe coagulation of the grasped tissue area by means of bipolar high 
frequency current, wherein the engagement of the functional units with one 
another takes place in such a way that undesirable carbonizations cannot 
occur. The grasped tissue is coagulated at two points, leaving an 
essentially non-coagulated tissue portion between the two points. 
3. Cutting the tissue within the coagulated area, i.e., the bloodless 
tissue, using the same instrument, i.e, without changing instruments. 
4. Catching and holding the essentially non-coagulated tissue portion with 
the same instrument and removing the tissue portion without effort from 
the instrument, after the instrument has been removed from the abdominal 
cavity, so that the tissue portion can be made available for histological 
examination. 
5. Performing individually and independently from one another, with one 
instrument the work steps of atraumatic grasping, bipolar coagulation and 
removal of a tissue portion. 
The combination instrument can also be used for detaching adhesions, 
removing tissue specimens and, finally, for atraumatic grasping and moving 
of tissue to gain an overview in diagnostic abdominal specular 
examinations. In addition, the combination instrument can also be used in 
open surgery. 
This task is accomplished by a combination instrument which combines all 
the functions of atraumatic grasping, bipolar coagulation of tissue at two 
points by means of high frequency current, cutting tissue within the 
coagulated area, i.e., bloodless tissue, and catching the cut-out tissue 
portion, which is essentially non-coagulated. In addition, it is possible 
to also perform the described work steps independently from one another. 
Since the combination instrument according to the present invention is 
simple and safe to handle, the time required is reduced and the surgical 
risk is minimized. For the first time, it is possible to perform a 
complete laparoscopical tube sterilization, i.e., grasping, coagulating 
and cutting of both tubes successively with additional tissue removal, 
without having to change instruments. It should be particularly emphasized 
that the cutting out of tissue with the new combination instrument takes 
place only within the coagulated area and, consequently, the risk of 
bleeding is significantly reduced. 
In addition, a safe histological identification of the removed tissue 
portion is now possible because the tissue portion removed with the 
combination instrument is essentially non-coagulated. The safe 
histological identification of the removed tissue is particularly 
important when operating on the tuba uterina. The tuba uterina is located 
in the close vicinity of the ligamentum rotundum and it is necessary to 
identify the tissue which has been cut out in order to ensure that it is 
indeed the tuba uterina which has been operated on and has been made 
impassable. 
The combination instrument according to the present invention has the 
advantage that a later refertilization is possible because the tuba 
uterina is coagulated and interrupted at only one location along a length 
which corresponds to the width of the instrument. As a result, the tuba 
uterina is not destroyed along its entire length as is common at the 
present time. 
The cutting device of the combination instrument serves as a stop for the 
tube portion to be coagulated, so that an unintended coagulation deep into 
the tube appendages is prevented. The grasping elements of the combination 
instrument move toward one another during closing, so that the tissue 
grasped at the points to be coagulated, is uniformly pressed together and, 
consequently, an optimum atraumatic grasping and/or coagulation is 
possible. Also, during use, the grasping and cutting elements of the 
instrument do not move relative to the guide sleeve, so that a safe 
grasping of the tissue is possible. Due to this construction of the 
combination instrument, tissue other than tubes, for instance, adhesion 
strands can be grasped, coagulated bipolarly and cut bloodlessly. 
Depending on its width, the tissue strand can be grasped and coagulated 
once again and then cut further so that a path is cut through the tissue 
wherein the cut edges coagulate all around, i.e., are bloodless. 
The combination instrument according to the invention can be used for (1) 
laparascopy, (2) laparotomy, and (3) posterior colpotomy. 
The principal use is in the field of laparoscopical tube sterilization. But 
the instrument can also be used for the detachment of adhesions, the 
removal of tissue samples and the lifting of tissue, i.e, atraumatic 
grasping and moving of tissue, to gain an overview in diagnostic 
laparoscopies. 
The combination instrument is simple to clean without having to be 
disassembled, and it is maintenance free. It can be sterilized with all 
conventional sterilization methods.

DESCRIPTION OF THE PREFERRED EMBODIMENT 
The combination instrument shown in FIG. 1 includes a grip member which is 
held in the hand. The functional unit illustrated in FIGS. 2 and 3 is 
constructed in such a way that its individual parts can be moved toward 
one another. These movements are transmitted by means of rods onto a 
grasping device A and B and a cutting device F. 
The grip member has three grip elements. Grip elements 2 and 3 are attached 
at grip element 1 and are pivotable relative to this element. 
A guide sleeve 8 is attached at grip element 1. Guide sleeve 8 houses push 
and pull rods D and H which are moved by means of grip elements 2 and 3, 
respectively. 
Adjacent the grip member, guide sleeve 8 has mounted on it a plug device 7 
which is insulated from the guide sleeve and is used for the high 
frequency current supply. In addition, in the guide sleeve there are the 
conductors N and O which connect the plug device 7 with the grasping 
devices A and B. The guide sleeve 8 is lined on the inside with an 
insulating layer. 
Arranged at the end of the guide sleeve opposite the grip member, there is 
the functional unit which is capable of performing three functions: 
grasping, coagulating and cutting. 
The functional unit includes the grasping devices A and B and the cutting 
device F. The stationary grasping device A serves as abutment for the 
pivotable grasping device B. For this purpose, the joint C is provided on 
grasping device A. Grasping devices A and B serve as the electrodes for 
high frequency current. The grasping device A is insulated from B in joint 
C. The push and pull rod D is attached at joint C to grasping device B. 
Thus, using rod D, the grasping device B can be opened to approximately 
60.degree. in relation to the grasping device A which makes a secure 
grasping of the tissue possible. 
Inside the grasping device A which, for this purpose, is U-shaped, there is 
a cutting device F which is pivotable in the grasping device about a joint 
G. The push and pull rod H is connected to cutting device F by means of a 
joint J. Opening of the cutting device F in relation to the grasping 
device A is also possible to approximately 60.degree.. In the closed 
position, the cutting device F is lowered into grasping device A. 
The grasping device B and the stationary grasping device A are arranged in 
such a way that they approach one another uniformly along the entire 
length of the grasping distance of the tissue. In other words, the tissue 
is pressed by the movable grasping device B uniformly onto the stationary 
grasping device A, so that all grasped tissue portions can be coagulated 
uniformly. 
The grasping device A has an opening for the cutting device F. A wire 
basket K to catch the cut out tissue portions is provided underneath this 
opening. The cutting device F is constructed in such a way that, during 
cutting, the resected tissue is pressed into the wire basked K. The wire 
basket K can hold several tissue pieces, so that a complete sterilization 
can be performed without changing instruments, i.e., two tubes can be 
operated on successively. 
The grasping device A is connected rigidly with the guide sleeve 8 by means 
of an insulating element L. The insulating element L also serves to guide 
the push and pull rods D and H. Inside the guide sleeve 8, a portion each 
of rods D and H are formed by insulating elements M. 
The grasping device B is pivoted by means of gripping member 2 and push and 
pull rod D. The cutting device F is moved by means of gripping element 3 
and push and pull rod H. The lever path of the gripping element 3 is set 
by means of the setting screw 4. 
A laparoscopical tube sterilization is performed with the combination 
instrument according to the present invention as follows: 
After the application of a pneumoperitoneum and insertion of an optical 
instrument, the combination instrument is inserted into the abdominal 
cavity by means of a second paracentesis with a conventional 10 mm trocar 
(manufactured, e.g., by Wolf GmbH). The plug device 7 of the instrument is 
connected to a conventional bipolar high frequency current generator. 
After locating a tube and opening the grasping device B and the cutting 
device F, the tube is grasped by closing the grasping device B and 
pressing it against the stationary grasping device A. Now the high 
frequency current is conducted through grasping devices A and B, so that 
the tube is coagulated in a U-shape between the grasping devices A and B. 
After completion of the coagulation step, without opening the grasping 
device B, the cutting device F is actuated and the tube portion located 
within the coagulated area is cut out and pressed into the wire basket K. 
Then, the grasping device B is opened. This completes the steps of 
rendering the tube impassable and the removal of tissue. For a complete 
sterilization, the same steps are performed at the second tube without 
changing instruments. When the instrument is removed from the abdominal 
cavity, the tissue portions lying on top of one another in the operating 
sequence are removed and a histological examination is performed. This is 
particularly necessary for forensic reasons.