Laparoscopic instrument and related surgical method

A medical instrument insertable through a cannula, the instrument comprising an elongate shaft; and an operative tip having a first jaw and a second jaw movable with respect to the first jaw. The operative tip disposed at a distal end of said elongate shaft and being disposed on said shaft for rotation relative to at least a distal end portion of said shaft about a longitudinal axis of said distal end portion.

FIELD OF THE INVENTION

The present invention relates to surgical instruments, surgical port assemblies, and an associated method. The instruments, port assemblies and method are particularly useful in the performance of laparoscopic procedures entirely through a single entry path into a patient, for instance, through the umbilicus.

BACKGROUND OF THE INVENTION

Abdominal laparoscopic surgery gained popularity in the late 1980's, when benefits of laparoscopic removal of the gallbladder over traditional (open) operation became evident. Reduced postoperative recovery time, markedly decreased post-operative pain and wound infection, and improved cosmetic outcome are well established benefits of laparoscopic surgery, derived mainly from the ability of laparoscopic surgeons to perform an operation utilizing smaller incisions of the body cavity wall.

Laparoscopic procedures generally involve insufflation of the abdominal cavity with C02 gas to a pressure of around 15 mm Hg. The abdominal wall is pierced and a 5-10 mm in diameter straight tubular cannula or trocar sleeve is then inserted into the abdominal cavity. A laparoscopic telescope connected to an operating room monitor is used to visualize the operative field, and is placed through (one of) the trocar sleeve(s). Laparoscopic instruments (graspers, dissectors, scissors, retractors, etc.) are placed through two or more additional trocar sleeves for the manipulations by the surgeon and surgical assistant(s).

Recently, so-called “mini-laparoscopy” has been introduced utilizing 2-3 mm diameter straight trocar sleeves and laparoscopic instruments. When successful, mini-laparoscopy allows further reduction of abdominal wall trauma and improved cosmesis. However, instruments used for mini-laparoscopic procedures are generally more expensive and fragile. Because of their performance limitations, due to their smaller diameter (weak suction-irrigation system, poor durability, decreased video quality), mini-laparoscopic instruments can generally be used only on selected patients with favorable anatomy (thin cavity wall, few adhesions, minimal inflammation, etc.). These patients represent a small percentage of patients requiring laparoscopic procedure. In addition, smaller, 2-3 mm, incisions may still cause undesirable cosmetic outcomes and wound complications (bleeding, infection, pain, keloid formation, etc.).

Since the benefits of smaller and fewer body cavity incisions are proven, it would be attractive to perform an operation utilizing only a single incision in the navel. An umbilicus is the thinnest and least vascularized, and a well-hidden, area of the abdominal wall. The umbilicus is generally a preferred choice of abdominal cavity entry in laparoscopic procedures. An umbilical incision can be easily enlarged (in order to eviscerate a larger specimen) without significantly compromising cosmesis and without increasing the chances of wound complications. The placement of two or more standard (straight) cannulas and laparoscopic instruments in the umbilicus, next to each other, creates a so-called “chopstick” effect, which describes interference between the surgeon's hands, between the surgeon's hands and the instruments, and between the instruments. This interference greatly reduces the surgeon's ability to perform a described procedure.

Thus, there is a need for instruments and trocar systems, which allow laparoscopic procedures to be performed entirely through the umbilicus while at the same time reducing or eliminating the “chopstick effect”. A laparoscopic procedure performed entirely through the umbilicus, using the laparoscopic instruments and trocar system according to an embodiment of the present invention, allows one to accomplish the necessary diagnostic and therapeutic tasks while further minimizing abdominal wall trauma and improving cosmesis.

SUMMARY OF THE INVENTION

The present invention contemplates the facilitation of laparoscopic or minimally invasive surgical procedures wherein several laparoscopic or minimally invasive instruments are inserted into a patient through respective cannulas all extending through the same opening in the patient, for instance, through the umbilicus. The advantages of such an operation include minimizing trauma to the patient and accelerating the patient recovery.

The present disclosure provides instruments and cannula or port assemblies for the performance of surgical procedures, particularly including laparoscopic procedures, for instance, entirely through the umbilicus. The present invention aims in part to provide improved laparoscopic instruments and associated methods for facilitating operations through the umbilicus. The instruments of the present invention can also be used for performance of surgical procedures through single incisions other than through the umbilicus. In addition to laparoscopic procedures, the instruments can be used for thoracoscopic procedures or other endoscopic or minimally invasive procedures.

A medical instrument insertable through a cannula comprises, in accordance with the present invention, an elongate shaft and an operative tip having a first jaw and a second jaw movable with respect to the first jaw, the operative tip disposed distally of a distal end of the distal shaft, the operative tip being disposed for rotation relative to at least a distal end portion of the shaft about a longitudinal axis of the distal end portion.

Pursuant to further features of the present invention, the shaft may include a tubular sheath and the instrument may further comprise a cable or rod member extending longitudinally through the sheath, the cable or rod member being operatively connected to the operative tip for actuating the operative tip and for rotating the operative tip about the axis of the distal end portion. Where the instrument further comprises a handle, the tubular sheath is preferably connected to the handle and rotatable relative to the handle about a longitudinal axis of a proximal portion of the shaft. The cable or rod member is preferably longitudinally shiftable and rotatable relative to the sheath.

Where the operative tip includes a pair of jaws pivotably hinged to one another, the cable or rod member is preferably linked to the jaws for pivoting the jaws. The jaws may be mounted between prongs or legs of a clevis, the clevis being rotatably attached to a distal end of the sheath.

The handle can include a rotary actuator knob operatively linked to the sheath carrying a pair of annular toothed members spring loaded into toothed engagement to provide the rotary knob and the sheath with a plurality of angular rest positions.

The handle may additionally include a ratchet member releasably locking the operative tip in a plurality of different operative configurations. Where the handle includes two first finger grips or handle parts pivotably coupled to one another, the ratchet member is preferably pivotably mounted to one of the finger grips or handle parts and provided with teeth cooperating with a stop on the other of the finger grips or handle parts. The handle may also include a trigger cooperating with the ratchet member for releasing the ratchet member from each of a plurality of locked positions each corresponding to a respective one of the operative configurations of the operative tip. A movable member provided on the handle may cooperate with the ratchet member for deactivating the ratchet member.

The shaft may include a distal end portion extending at an acute angle relative to the proximal shaft portion wherein the proximal shaft portion is rotatable relative to a handle about a longitudinal axis of the proximal shaft portion.

A medical instrument insertable through a cannula comprises, in accordance with another aspect of the present invention, a handle and an elongate shaft having at least two portions including a proximal shaft portion and a distal shaft portion, the proximal shaft portion being attached at a proximal end at least indirectly to the handle, the proximal shaft portion being rotatable relative to the handle about an axis of the proximal shaft portion, the distal shaft portion extending at an angle relative to an axis of the proximal shaft portion. An operative tip is rotatable relative to the distal shaft portion.

A surgical method comprises, in accordance with another aspect of the present invention, (a) inserting a distal end portion of a surgical instrument into a patient, the instrument having a tubular shaft member and first and second jaws, (b) rotating the tubular shaft member about a proximal axis of the tubular shaft member, (c) independently rotating the jaws of the instrument about a distal axis of the tubular shaft member and relative to a distal end of the tubular shaft member, and d) moving at least a first jaw with respect to a second jaw between closed and opened positions.

Where a cable or rod member longitudinally traverses the tubular shaft member, the rotating of the operative tip preferably includes rotating the cable or rod member inside the tubular shaft member.

Where the cable or rod member is operatively connected to the operative tip, the method preferably further comprises longitudinally shifting the cable or rod member relative to the tubular shaft member to move a component of the operative tip about an additional axis oriented at a non-zero angle relative to the distal axis.

Where the distal axis and the proximal axis are oriented at a non-zero angle relative to one another, the rotating of the tubular shaft member preferably entails moving the operative tip along a circular arc about the proximal axis.

A laparoscopic medical instrument insertable through a laparoscopic trocar sleeve comprises, in accordance with another aspect of the present invention, (i) a handle, (ii) an elongate shaft, at least a portion of the shaft being rotatable relative to the handle about a longitudinal axis of the shaft, (iii) an operative tip disposed at a distal end of the distal shaft portion, and (iv) a rotary actuator knob operatively linked to the shaft, the handle carrying a pair of annular toothed members spring loaded into toothed engagement to provide the rotary knob and the shaft with a plurality of angular rest positions. The instrument may include a tubular sheath, in which case the instrument may further comprise a cable or rod member extending longitudinally through the sheath and being operatively connected to the operative tip for actuating the operative tip and for rotating the operative tip about the axis of the distal shaft portion.

The present invention also provides a method of performing a surgical procedure through an incision in a patient comprising the steps of:

inserting a first curved instrument through a first cannula of a cannula assembly, the first instrument having a handle, a shaft and first and second jaws, the jaws being rotatable relative to the shaft and the shaft being rotatable relative to the handle;

inserting a second curved instrument through a second cannula of the cannula assembly, the second instrument having a handle, a shaft and third and fourth jaws, the jaws being rotatable relative to the shaft and the shaft being rotatable relative to the handle; and

manipulating the instruments in a crossed configuration.

The method preferably further includes the step of opening and closed the first and second jaws. The method may further include the step of locking the jaws in an open position.

The present invention also provides a surgical access system comprising a cannula assembly, a first curved instrument and a second curved instrument. The cannula assembly includes a first cannula and a second cannula, the first cannula being movable with respect to the second cannula. The first curved instrument has a handle, a shaft and first and second jaws, the jaws being rotatable relative to the shaft and the shaft being rotatable relative to the handle. The second curved instrument has a handle, a shaft and third and fourth jaws, the jaws being rotatable relative to the shaft and the shaft being rotatable relative to the handle.

Preferably, the first instrument includes a jaw actuating mechanism to move the jaws between open and closed positions and the second instrument includes a jaw actuating mechanism to move the jaws between open and closed positions. One embodiment of a surgical port assembly that facilitates the performance of laparoscopic surgical procedures utilizing the above-described instruments and methods may comprise a cannula unit including at least one cannula member, and a holder disposable in an opening in a patient's skin for receiving the cannula component so that the cannula component is movable relative to the holder during a surgical procedure. Preferably, the cannula unit is rotatable with respect to the holder about a longitudinal axis of the holder or cannula unit. It is contemplated that the holder is fastened to the patient during the surgical operation, so that the cannula unit is movable relative to the patient.

The one cannula may be wholly or partially flexible. The cannula may have a relaxed configuration that is linear.

The cannula unit may be partially insertable into the holder, while the port assembly further comprises a connector member for removably attaching the cannula unit to the holder, the connector also being partially insertable into the holder.

In using laparoscopic instruments pursuant to the present invention, one forms an opening in a patient, inserts a port assembly at least partially through the opening, and inserts a plurality of elongate medical instruments through respective cannulas of the port assembly. During a laparoscopic procedure, the instrument shafts are rotated about respective longitudinal axes and the operative tips of the instruments are rotated relative to the distal ends of the instrument shafts, about longitudinal distal axes of the instrument shafts.

The shafts and in particular the tubular sheath members of the present laparoscopic instruments are substantially rigid throughout so that they cannot be bent. The instrument shafts exemplarily have a hockey-stick shape. Two laparoscopic surgical instruments each having a hockey stick shape are advantageously used in a crossed configuration, which markedly improves the degrees of freedom of the instruments, particularly during lateral (medial-lateral) movements.

Examples of other surgical port assemblies that can be used with the medical instruments described herein are disclosed in patent application Ser. No. 12/079,599, filed Mar. 27, 2008, the entire contents of which is incorporated herein by reference.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

As depicted inFIGS. 1-3, a laparoscopic port or cannula assembly100comprises a cannula unit102and a connector104associated therewith for removably fastening the cannula unit to an annular port holder106(FIGS. 4-8and10) that is disposed in an opening (e.g., formed in the umbilicus) in a patient. Cannula unit102is coupled to port holder106by connector104so as to permit rotation of cannula unit102about a longitudinal axis108(FIGS. 7 and 10) of holder106.

Cannula unit102comprises a base or frame110that is insertable into and removably attachable to port holder106. Base or frame110includes a planar panel or wall112defining a closure surface or plane SC extending, during a laparoscopic surgical procedure, substantially tangentially to the patient's skin at the opening through with port holder106extends. Base or frame110further includes a seating ring114and a sealing ring116.

Cannula unit102additionally comprises three cannula members118,120,122each connected to base or frame110and defining a respective access path through closure surface SC. Cannula members118,120,122each extend at an acute angle relative to closure surface SC so that the cannulas are inclined relative to the patient's skin surface during a laparoscopic surgical procedure. Cannula members118,120,122include flexible tubular portions124,126,128that have linear configurations in a relaxed or unstressed condition.

Each cannula member118,120,122defines a respective plane P1, P2, P3(FIG. 3) oriented perpendicularly to closure surface or plane CS (the main plane) and spaced from a longitudinal axis130of base or frame110. These secondary planes P1, P2, and P3are disposed at angles of 120° relative to each other, as indicated inFIG. 3. Connector104is loosely coupled to cannula unit102so as to be freely movable along axis130of the cannula unit, between base110and valve components of cannulas118,120,122.

Connector104includes a frustoconical portion132insertable into port holder106(seeFIG. 10) and further includes a pair of flanges134,136for temporarily locking cannula unit102to holder106. To that end, flanges134,136are provided with dual-lobed slots138,140for receiving respective pins or projections142,144on port holder106(seeFIGS. 4,5,7,8,9). Flanges134and136are also provided with respective pairs of upturned ears146and148functioning in part as thumb and finger rests for swiveling connector104about axis108(and130) to reversibly secure connector106and concomitantly cannula unit102to port holder106.

As illustrated inFIGS. 4-7, port holder106includes a tapered, slightly frustoconical sleeve150provided along an outer surface with a pair of annular beads or ribs152and154and along an inner surface with a shoulder156that serves as an abutment or rest for seating ring114of cannula unit102. At a wider end of sleeve150, holder106includes a pair of diametrically opposed flanges158,160and a pair of diametrically opposed ears162,164. Pins or projections142,144are rigid with flanges158,160, while ears162,164carry respective flat-headed posts166,168around which sutures are wound to fasten holder106to the skin of the patient. Rubber gaskets167and169may be provided for clamping suture threads to posts166and168. Alternatively or additionally, sutures anchoring port holder106to the body wall of the patient may be inserted through slots163a,163band165a,165band partially wrapped around bases171and173of ears162,164(seeFIG. 5).

After placement of holder106in an opening in the patient (and after removal of an insert assist member170,FIGS. 19-22, from the holder), base or frame110of cannula unit102is inserted into holder106until seating ring114engages shoulder15(seeFIG. 10). Cannula unit110is secured to holder106by an insertion and a subsequent rotation of connector104relative to holder106, as indicated by an arrow172inFIGS. 8 and 9, so that projections142,144and slots138,140are interlocked (seeFIGS. 8-10). After this locking of connector104to holder106, cannula unit102is rotatable about axes108and130in opposition to a frictional drag force exerted by virtue of sealing ring116.

As illustrated inFIGS. 11-14, cannula unit118includes valve component174connected to tubular portion124. Valve component124includes an insufflation port175for receiving a tube (not shown) for guiding carbon dioxide gas from a pressurized source into the patient. As shown particularly inFIG. 13, valve component124of cannula member118includes a valve box or casing176with a cover or closure178to which an extension tube180is attached. At an end opposite valve casing176, extension tube180is provided with a sleeve182, a valve seal184, a disc185, and a cap186. Valve component174further includes a valve door188that is biased into a closure position shown inFIG. 13by a helical or coil spring190. Door188is supported by a mounting bracket and associated hardware191. An O-ring seal192is provided for inhibiting the escape of insufflation gas from a patient through extension tube124when a laparoscopic surgical instrument does not traverse cannula member118.

As illustrated inFIGS. 1-3and8-10, cannula members120and122include respective valve components194and196connected to respective flexible tubular portions126and128. These valve components are structurally identical, a representative component194being depicted inFIGS. 15-18. Valve component194includes a valve box or casing198with a cover or closure200to which an extension tube202is attached. At an end opposite valve casing198, extension tube202is provided with a sleeve204, a valve seal206, a disc208, and a cap210. Valve component194further includes a valve door212that is biased into a closure position shown inFIG. 17by a helical or coil spring214. Door212is supported by a mounting bracket and associated hardware216. An O-ring seal218is provided for inhibiting the escape of insufflation gas from a patient through extension tube202when a laparoscopic surgical instrument does not traverse the respective cannula member120(or122).

As shown inFIG. 19, insert assist member170includes a rounded conical tip220, a cylindrical middle portion222and a slightly tapered or frustoconical outer portion224. Outer portion224is provided with a pair of flanges226,228for temporarily locking insert assist member170to port holder106. To that end, flanges226,228are provided with dual-lobed slots230,232for receiving respective pins or projections142,144on port holder106, as depicted inFIGS. 20-22. Flanges226and228are formed with respective pairs of upturned ears234and236that are manually engageable by a user to reversibly secure connector insert assist member170to port holder106.

After a small incision or opening is made in a patient, port holder106with insert assist member170connected thereto is inserted through the incision. Sutures (not shown) are stitched to the patient and are wound around and tied to posts166,168to firmly secure the port holder106to the patient. Insert assist member170is then removed, by a reverse rotation unlocking flanges226,228from pins or projections142,144and by separating the inset assist member from holder106. Cannula unit102is then attached to holder106as described above.

FIGS. 24-29depict a laparoscopic surgical instrument238insertable through a laparascopic trocar sleeve or cannula such as cannula member118,120, or122of the port assembly ofFIGS. 1-3and8-10for executing a laparoscopic surgical operation. It should also be appreciated that the laparascopic instrument238as well as other instruments described herein are insertable through other cannulas, such as the cannulas disclosed in commonly assigned co-pending patent application Ser. No. 12/079,599, filed Mar. 27, 2008. The entire contents of this application is incorporated herein by reference. Instrument238comprises an elongate shaft240, an operative tip242disposed at one end of the shaft, and a hand-grip-type actuator244disposed at an opposite end of the shaft. Actuator244is operatively connected to operative tip242via shaft240for controlling the operation of the operative tip.

Shaft240has a straight proximal end portion246, a curved middle portion248and a straight distal end portion250, the distal end portion extending at a non-zero angle with respect to the proximal end portion, as shown inFIGS. 24,26and27. Proximal end portion246is provided with a first rotary joint252so that distal end portion250and operative tip242are rotatable about a longitudinal axis254of proximal end portion246. Distal end portion250is provided with a second rotary joint256so that operative tip242is rotatable about a longitudinal axis258of the distal end portion. A rotary actuator or knob260disposed at the proximal end of instrument238is operatively connected to proximal end portion246of instrument240for rotating distal end portion250and operative tip242about longitudinal axis254. Another rotary actuator or knob262disposed at the proximal end of instrument238is operatively connected to distal end portion250of shaft240for rotating operative tip242about longitudinal axis258.

Proximal end portion246, middle portion248and distal end portion250of instrument shaft240are each substantially rigid throughout and can only be rotated about joints252and256and not bent. The angle between axes254and258are such that shaft240has a shape reminiscent of a hockey stick. In an alternative embodiment of instrument238, middle portion248of shaft240may be flexible to permit shaft240to alternately assume a linear configuration and the hockey-stick configuration ofFIGS. 24 and 26. In that case, a handle assembly274is provided with an actuator (not shown) for enabling a bending of middle portion248.

As shown inFIGS. 24-26, instrument238may be provided with further actuators, such as a slidable toggle switch264, for example for performing a locking function or inducing a pivoting of operative tip242about an axis perpendicular to axis258.

Actuator244includes a hand grip member266fixed relative to shaft240and further includes a pivotable hand grip268. A proximal end270of shaft240is journaled in a bearing272about which rotary knob262. Actuator244, rotary knobs260and262, and toggle switch264are parts of a handle assembly274also incorporating yokes276and278, a stopper pin278, a set screw280.

FIG. 27illustrates further parts of a shaft assembly282including shaft240, a slider member283, a socket set screw284, an outer bearing286, a motion bar288, a bend tube290, a ring292, and an O-ring seal294.

Rotary joint256is representative of joint254and comprises, as shown inFIG. 27, a proximal pin or inner shaft portion296, a distal pin or inner shaft portion298, a pair of coupling elements300and302, and a transverse connector pin304.

As illustrated inFIGS. 28 and 29, operative tip242exemplarily includes a pair of jaws306and308pivotably connected to a distal end of distal end portion250via a pivot pin310. Jaws306and308are rotatable about pin310through the action of levers or arms312,314that pivot in response to a longitudinal motion of a tip rod316.

After a deployment of cannula unit102in a patient as described above, operative tip242and shaft240of instrument238are insertable for example through a cannula member118,120, or122, with the respective tubular portion124,126, or128bending to accommodate the bent shaft240. The bent shape of shaft240, as well as the rotary joints252and256facilitate the performance of laparoscopic surgical procedure using multiple laparoscopic instruments extending through a single opening in a patient, for instance, in the umbilicus. Such a procedure involves the rotation of distal end portion250and operative tip242together about axis254and the rotation of operative tip about axis258. In addition, the entire instrument assembly including cannula unit102and multiple instruments238can be rotated about collinear axes108and130, to optimize the simultaneous or successive access of multiple operative tips242to a surgical site inside a patient.

As can be appreciated, when two laparascopic instruments238are inserted through the cannula members ofFIGS. 1-3, they are positioned and manipulatable in a crossed configuration. Due to the configuration of the shaft (or in alternate embodiments the ability to change the angle of a portion of the shaft), the instrument tips are angled toward each other and toward the target site to facilitate the surgical procedure.

As illustrated inFIG. 30, a stand-alone laparoscopic medical instrument in accordance with an alternate embodiment is insertable through a laparoscopic trocar sleeve or cannula. The instrument comprises an elongate shaft380formed of a plurality of a plurality of rigid cylindrical segments including a middle segment382, three proximal end segments384,386, and388, and three distal end segments390,392, and394. During a laparoscopic procedure utilizing the instrument ofFIG. 30, middle segment382traverses a laparoscopic cannula, trocar sleeve, or instrument holder as described herein, while proximal end segments384,386, and388are located outside the patient and distal end segments390,392, and394are located inside the patient. An operative tip396is disposed at one end of the shaft380, more particularly at a free end of distal end segment394, and actuator handles or hand grips398are disposed at an opposite end of the shaft, more particularly at a free end of proximal end segment388. Actuator handles398are operatively connected to operative tip396via shaft380for controlling the operation of the tip.

Proximal end segments384,386and388form a proximal shaft portion400that is independently bendable to form, for example, a C shaped configuration. Proximal end segments384,386, and388are connected to one another via joints or articulations402and404and to middle segment382via a joint or articulation406.

Distal end segments390,392and394form a distal shaft portion408that is independently bendable to form, for example, a C shaped configuration. Distal end segments390,392, and394are connected to one another via joints or articulations410and412and to middle segment382via a joint or articulation414.

Operative tip396may be rotatable about a longitudinal axis415. Further rotational capability may be provided by including a joint416,418,420along distal end segments390,392or middle segment382, where relative rotation of proximal and distal parts is effectuated about a longitudinal axis of the respective segment.

Proximal end portion388is provided with rotary actuators or knobs422for modifying the angles between adjacent distal end segments390,392,394, for rotating operative tip396relative to distal end segment394about axis414, and for implementing the longitudinal-axis rotation at joints416,418, and/or420. Wing-nut-type clamps424may be provided at knobs422for releasably locking those actuators to maintain the angles between adjacent distal end segments390,392,394, the rotary position of operative tip396, and the longitudinal-axis rotation at joints416,418, and/or420.

Clamping elements426,428,430may be provided at the articulations or joints402,404,406for locking the relative positions of middle segment382, and proximal end segments384,386,388. Alternatively, further knobs and wing-nut clamps (not shown) may be provided at the proximal end of the instrument for changing the angles between pairs of adjacent segments382,384,386,388.

During a laparoscopic surgical procedure, the axial position of operative tip396may be adjusted by sliding the laparoscopic instrument ofFIG. 30into and out of the patient, for example, by modifying the position of middle segment382relative to the respective cannula or instrument holder aperture. In addition, the axial position of operative tip396may be changed by adjusting the configuration of distal end portions390,392,394relative to one another. Strongly arced configurations have a shorter axial extent than configurations with more shallow arcs. Further degrees of freedom in the positioning of operative tip396relative to a surgical site are provided by the rotatability of operative tip396about axis414and the rotatability at joints416,418,420. The positional adjustability provided by articulations or joints410,412,414greatly enhances the practical capabilities of the instrument.

FIG. 31depicts another stand-alone laparoscopic medical instrument having a shaft432insertable through a laparoscopic trocar sleeve or cannula. Shaft432has a continuously flexible proximal end portion or segment434, a rigid straight middle portion or segment436, and a distal end portion438. Proximal end portion434and distal end portion436are connected to opposite ends of middle portion436via respective articulations or joints440and442, so that the proximal end portion and the distal end portion are laterally swingable relative to the middle portion, as indicated by dual headed arrows444and446. Middle portion436constitutes about one-third of the total length of shaft432.

Shaft432is provided at a proximal end, i.e., at the free end of proximal end portion434, with a pair of hand grip actuators448, and is further provided at a distal end, i.e., at the free end of distal end portion438with an operative tip450such as a scissors, a forceps, a clamp, a cauterizing element, etc. Operative tip450is rotatable about a longitudinal axis452relative to the end of distal end portion438, as indicated by a bidirectional arrow454. As indicated by another bidirectional arrow457, proximal end portion434and distal end portion438may be rotable relative to one another about a longitudinal instrument axis456, owing to a rotable joint458exemplarily provided along middle portion436.

Distal end portion438includes two segments or sections460and462pivotably connected to one another via an articulation or joint464, as indicated by a dual headed arrow466. Distal-most section462is continuously bendable along its length into an infinite number of smoothly curved generally C-shaped configurations, as indicated by an arrow468. The more proximal section460may be rigid and linear or, alternatively, also continuously flexible along substantially its entire length and formable into a multitude of smoothly arced generally C-shaped configurations.

Proximal end portion434is provided along a linear proximal section (not separately labeled) with a plurality of actuator knobs470and locking elements472for controllably modifying (a) the degree of curvature of proximal end portion434and distal end portion438, particularly distal-most section462, (b) the angles between portions434and436and portions436and438, (c) the angle between sections460and462, (d) the degree and direction of rotation of operative tip450about axis452, and (e) the relative angular position of proximal end portion434and distal end portion438, as determined by the operational status of joint458. By way of illustration, a modified position and curvature of distal-most section462is indicated inFIG. 31at474. A modified position of proximal section460and a corresponding modified curvature of distal most section462are indicated in phantom at476. An alternate position of proximal end portion434with respect to middle portion436is shown in phantom at478.

FIGS. 32A-32Fdepict additional possible positional and curvature configurations of the instrument ofFIG. 31, particularly distal end portion438.

During a laparoscopic surgical procedure, the axial position of operative tip450may be adjusted by sliding the laparoscopic instrument ofFIG. 31into and out of the patient, for example, by modifying the position of middle portion436relative to the respective cannula or instrument holder aperture. In addition, the axial position of operative tip450may be changed by adjusting the configuration of distal end portion438, as depicted inFIGS. 32A-32F. Strongly arced configurations (FIGS. 32B and 32C) have a shorter axial extent than configurations with more shallow arcs (FIGS. 32A,32E). Further degrees of freedom in the positioning of operative tip450relative to a surgical site are provided by the rotatability of operative tip450about axis452and the rotatability at joint458.

One or more of the actuator mechanisms including knobs470and locking elements472may be operatively connected to shaft432for bending distal section462(and optionally section460) in a direction out of the plane of the drawing sheet.

Where proximal portion434of shaft432assumes a first C-shaped configuration in response to operation of a respective one of the knobs470and distal portion438(or462) of the shaft assumes a second C-shaped configuration in response to operation of a second one of the knobs470, the C-shaped configurations may face opposite sides of the shaft, thus forming shaft432into a generally S-shape.

FIGS. 34-36depict a distal end portion of an alternate embodiment of a laparoscopic instrument, designated by reference numeral500, whileFIGS. 37 and 38show the handle and actuator assembly502at the proximal end of the instrument. The instrument is preferably sterilizable and reusable. As shown inFIGS. 34 and 35, instrument500includes a shaft504and an operative tip or end effecter506operatively connected to and extending from the distal end of the shaft. End effecter506exemplarily includes a pair of grasper jaws508pivotably connected via a pivot pin510to one another and to a rigid clevis member512. (Although grasper jaws508(and568described below) are shown by way of example, other types of jaws are contemplated such as other grasper jaw configurations and jaws configured for cutting and severing tissue.) Clevis512is in turn rotatably connected and longitudinally fixed to an annular coupling element514. Thus, clevis512is rotatable relative to the coupling element514but longitudinally stationary relative thereto. Coupling element514is in turn fixed to a distal tip of a tubular sheath member516that forms an outer part of shaft504.

A flexible cable member518is positioned within sheath member516(FIGS. 36 and 38) and is connected at a distal end to a rigid rod520. Rod520traverses coupling element514and a rear end portion of clevis512and pivotably connects via links522to rear or proximal ends of jaws508in a space (not labeled) between two prongs524of clevis512. As shown inFIG. 34A, sheath member516is connected to coupling element514via mating screw threads519, while rod520terminates in an elongate tab or plate521that pivotably carries links522at its distal end. Tab or plate521traverses a rectangular slot (not shown) in a support disk523that is rotatably seated in coupling element514.

A longitudinal motion of cable518and rod520relative to sheath member516, coupling element514and clevis512induces jaws508to turn about pivot pin510to open and closed configurations. Rod520is rotatably entrained to clevis512, for instance, via jaws508and pivot pin510, so that a rotation of cable518and rod520relative to tubular sheath member516and coupling member514about a longitudinal axis538of the distal end (not separately labeled) of sheath member516rotates jaws508and clevis512relative to coupling element514and sheath member516.

As shown inFIG. 38A, longitudinal axis538and the associated distal end portion (FIGS. 34-36) of shaft504and sheath member516are oriented at an acute angle a1relative to a longitudinal axis534of a proximal portion (FIGS. 37 and 38) of shaft504and sheath member516. Thus, shaft504may be angled to form a “hockey-stick” configuration, like that illustrated inFIGS. 24 and 26.

As illustrated inFIGS. 37 and 38, handle and actuator assembly502of instrument500includes a housing526, a finger grip528stationary relative to the housing, and a thumb grip530that is pivotably connected to the housing. A first rotary knob532on housing526is used for rotating shaft504about longitudinal axis534of the shaft at the handle and actuator assembly502. Because of the hockey-stick-type bend depicted inFIG. 38A, a turning of knob532moves operative tip or end effecter506along a circular arc533about axis534. The angled shaft of the instrument500(as well as the other instruments described herein, including instrument560described below) results in the instrument tips of two (or more) separate instruments angling toward each other when inserted into the body through cannula members as described herein. The rotational movement of the tips, and the rotational movement of the shaft to move the tips in a circular arc, increase the range of movement of the instrument tip and thus improve accessibility to the target site in the relatively minimal space provided in minimally invasive surgical procedures.

As depicted inFIG. 37A, rotary knob532is formed along a rear side with a plurality of inwardly pointing teeth537. Rotary knob532is automatically locked at any desired one of a plurality of angular positions or orientations (18in the disclosed embodiment), the locking being releasable via a lever or trigger535operable by an index finger to maintain a distal end portion of shaft504.

As further illustrated inFIGS. 37 and 38, handle and actuator assembly502includes a second rotary knob536for rotating operative tip or end effecter506about longitudinal axis538of a distal end portion of shaft504. To that end, rotary knob536is rotationally entrained to a proximal end of cable member518(seeFIG. 38) while cable518is longitudinally translatable relative to knob536. At a proximal end, cable member518is fixed to a pair of spaced cylinders540and542that cooperate with thumb grip or movable handle lever530to effectuate the alternate opening and closing of end effector jaws508. Thumb grip or handle lever530carries a ball544that is received between cylinders540and542for enabling a linear shifting of cable member518regardless of the angular position of rotary knob536. Thumb grip or handle lever530is swingably secured to handle housing526via a pivot pin546. Thus, the jaws508are normally in the closed position. To open the jaws, handle lever530is moved toward finger grip528, thereby pulling cable member518proximally as the cylinders540,542are forced in a proximal direction.

As depicted inFIG. 37B, knob536is formed with a sectioned aperture539generally having a D-shape with a straight edge541. An enlarged portion543of cylinder540is provided with a flat545in a region about knob536. Flat545engages edge541and prevents rotation of cable518relative to knob536, while permitting longitudinal sliding of the cable relative to the knob.

Rotary knob532carries a unitary toothed hub548that meshes with a cylindrical toothed clutch550that is slidably but not rotatably mounted to housing526. Clutch550is biased towards hub548by a helical spring552. The spring constant is sufficiently small that turning knob532easily pushes clutch member550in a distal direction against the biasing force of spring552under a camming action between the teeth (not designated) of hub548and clutch550. Clutch member550and hub member548illustratively have eighteen teeth whereby knob532and operative tip or end effector506have eighteen discrete angular rest positions about axis534. A different number of teeth and angular rest positions is also contemplated.

Rotary knob532is formed on a rearward or proximal side with eighteen grooves or slots (not separately designated) defined by teeth537(FIG. 37A), that alternately receive a leading edge of a locking plate554rigid with trigger535, to temporarily fix or lock rotary knob532in a respective one of its eighteen alternative angular positions. A different number of angular positions is also contemplated. Locking plate and release trigger525are pivotably mounted to housing526via a pivot pin556and biased by a helical tension spring558into a locking position in engagement with knob532.

FIGS. 39-41depict a distal end portion of another embodiment of a laparoscopic instrument, designated by reference numeral560, whileFIGS. 42 and 43illustrate a handle and actuator assembly562at a proximal end of the instrument. The instrument560is preferably disposable. As shown inFIGS. 39 and 40, instrument560includes a shaft564and an operative tip or end effecter566disposed at the distal end of the shaft. End effecter566exemplarily includes a pair of grasper jaws568pivotably connected via a pivot pin570to one another and to a rigid clevis member572. Clevis572in turn carries an annular coupling element574(FIG. 41). The coupling element is fixed to a proximal side of clevis512and is rotatably attached to a distal tip of a tubular sheath member576that forms an outer part of instrument shaft504.

Coupling element574has a pair of terminal annular flanges565′ and565″ that define an annular groove567(FIG. 41). Sheath member576is punched in at569to form a tooth571(FIGS. 39 and 40) that extends into groove567and contacts a distally facing transverse surface (not separately designated) of flange565′ to thereby prevent a distal displacement of clevis572and end effecter566relative to sheath member576. A proximal displacement of clevis572and end effecter566relative to sheath member576is arrested by an annular shoulder573of clevis572, which abuts the transverse distal end face (not separately designated) of sheath member576. Clevis572is thus translationally fixed to sheath member576.

A partially flexible shifter member578(FIG. 41), positioned within shaft564, is connected at a distal end to a rigid rod580via a sleeve581. Shifter member578and rod580are inserted into opposite ends of sleeve581and may be fastened thereto by crimping, braising, ultrasonic welding, adhesive or any other suitable technique. Rod580extends from sleeve581through coupling element574and a rear end portion of clevis572and pivotably connects via a pair of links582(seeFIG. 39A) to rear or proximal end plates583of jaws568in a space (not labeled) between two prongs584of clevis572. A longitudinal motion of shifter member578and rod580relative to sheath member576, coupling element574and clevis572induces jaws568to turn about pivot pin570. Rod580is rotatably entrained to clevis572via jaws568and pivot pin570, so that a rotation of shifter member578and rod580relative to sheath member576rotates jaws568, clevis572, and coupling element574relative to the sheath member.

As illustrated inFIGS. 42 and 43, handle and actuator assembly562includes a housing586with an integral finger grip handle588and further includes a thumb ring handle590that is pivotably connected to the housing. A first rotary knob592on housing586is used for rotating sheath member576and accordingly shaft564about a longitudinal axis594of the shaft at the handle and actuator assembly562. Shaft564includes a hockey-stick-type bend591so that axis612of the distal end portion of shaft564is disposed at an acute angle a2relative to axis594, as depicted inFIG. 48. (Shifter member578is preferably flexible only in a region about the bend591, to enable a negotiation of the bend in the substantially rigid sheath member576by the shifter member.) Accordingly, a turning of knob592moves operative tip or end effecter566along a circular arc593about axis594. Rotary knob592is automatically locked at a desired angular position or orientation, the knob being releasable by pulling it in a distal direction away from handle housing586in opposition to a force exerted by a helical biasing spring596(FIGS. 45 and 46) tending to pull knob592in a proximal direction onto handle housing586.

As depicted particularly inFIGS. 45 and 46, knob592is slidably disposed on a nose portion652of handle housing586. Knob592is connected, via a pin (not shown) inserted into a channel654, to a locking member596that is slidably connected to sheath member576and rotationally entrained thereto. Specifically, locking member596includes a tubular shaft portion654with a pair of diametrically opposed longitudinal ribs656that extend into respective slots (not designated) on sheath member576. The slots are defined by two arcuate prongs602(only one shown inFIG. 46) at the proximal end of sheath member576.

Locking member596further includes an enlarged proximal terminus658with external teeth (not shown) that cooperate with internal teeth660on a fixed ring662(fixed relative to handle housing586) to lock knob592and sheath member576and prevent their rotation relative to housing586). In order to ensure proper alignment of locking member596with fixed ring662, an alignment ring595is disposed inside housing nose652about shaft portion654of locking member596. Alignment ring595and locking member596each have eighteen or some other number of teeth598that cooperate to position locking member at any one of either (or so) angular positions about axis594, the permissible angular positions being aligned with the 18 (or some other number of) internal teeth660of fixed ring662. Locking member596and alignment ring595are biased into toothed engagement with one another by a helical compression spring664disposed about locking member shaft654and inside housing nose652. Alignment ring595is rotationally keyed to housing nose652so that a rotation of locking member596by knob592causes the ring to temporarily move distally against the action of spring664and then to pop back in the proximal direction at the next permissible angular position defined by teeth598.

Compression spring664also biases both locking member596and alignment ring595in the proximal direction to maintain locking member in a locked rotational position inside fixed ring662.

Thus, as knob592is pulled in a distal direction, locking member596is pulled out of engagement with fixed ring662, against the action of compression spring664, enabling the user to turn knob592about shaft axis594. As knob592is turned, locking member596is impelled into a series of discrete positions defined by alignment ring595, each position corresponding to a permissible orientation of locking member596relative to fixed ring662. Upon a release of knob592, locking member596slides back into engagement with fixed ring662.

As shown inFIG. 46, shifter member578has a step down666from a larger diameter portion668.

Referring toFIG. 46, prongs602of sheath member576traverse respective generally C-shaped apertures (not shown) in knob592, thereby enabling a rotational entrainment and yet a sliding coupling of sheath member576to knob592. Sheath member576is fixed against translational movement relative to housing586by a pair of C-shaped locking rings604that register with circumferential grooves (not shown) in outer surfaces of sheath prongs602and are disposed on opposite sides of a disk606disposed between two annular partitions608integrally molded with and disposed inside housing586.

As further illustrated inFIGS. 42-44, handle and actuator assembly562includes a second rotary knob610for rotating operative tip or end effecter566about a longitudinal axis612of a distal end portion (FIGS. 39,40) of shaft564. To that end rotary knob610is rotationally entrained to a proximal end of shifter member578(FIGS. 43 and 44). Specifically, shifter member578, which is a substantially rigid rod proximal of the hockey-stick bend in shaft564, is provided along a proximal end portion with a flat surface614to assume a D-shaped cross-section. The D-shaped section of shifter member578passes through a D-shaped aperture (not shown) in rotary knob610, whereby knob610is rotationally entrained to shifter member578. Flat surface614extends along a sufficient length of shifter member578to enable a limited relative longitudinal shifting of the rod through knob610, to accommodate motion sufficient to operate jaws568.

At a proximal terminus, shifter member578is linked to thumb ring handle590via a hollow cylindrical anchor616. As shown inFIG. 47, anchor616comprises a pair of disks617(only one shown) assembled to one another via mating pins619and holes621. Disks617cooperate to define a through hole623with an inwardly projecting annular stop625defining a central neck portion (not separately labeled). Shifter member578is formed at is proximal terminus with a circumferential groove627that receives neck portion625so to enable free rotation of shifter member578about longitudinal axis594of shaft564. Shifter member578extends into handle590via a slot629therein. Slot629accommodates the relative motion of shifter member578and handle590as the handle pivots about a pin618.

Anchor616, ensconced in an upper end of thumb ring handle590and revolving about pin618when the handle pivots about the pin, moves shifter member578alternately in a distal and a proximal direction, depending on the direction of rotation of thumb ring handle590. That is, the jaws568are normally in the closed position. To open the jaws, handle590is pivoted toward stationary handle598, thereby pulling the shifter member578proximally.

In the embodiments described herein both jaws are movable to open and close the jaws. However, it is also contemplate that alternatively one jaw can be fixed and the other jaw movable with respect to the other jaw between and open and closed position.

An electrocautery current may be conveyed through shifter member578and from thence to jaws568via a slotted connecting lug620fixed to housing586and via a leaf spring622with a curved end624in sliding contact with shifter member578.

Handle and actuator assembly562includes an L-shaped ratchet member626that enables an automatic locking of jaws568in a succession of ever more closed configurations during a squeezing of thumb ring handle590towards finger grip handle588. Ratchet member626is pivotably mounted to finger grip handle588at a pin628and includes a first leg630extending along a lower edge of thumb ring handle590and a second leg632extending inside the finger grip handle. Leg630is formed along an upper edge with a series of teeth634that cooperate with a locking pin636on thumb ring handle590to prevent a separation of thumb ring handle590from finger grip handle588. Ratchet member626is spring biased to push leg630towards locking pin636. The biasing is implemented by a helical compression spring638seated at one end in a cup-shaped holder640on finger grip handle588and at an opposite end on a projection642on ratchet leg632.

Jaws568are released from any locked position by pressing a trigger644on finger grip handle588. Trigger644is pivotably mounted to finger grip handle588via a pin646and is pivotably linked to ratchet member626via another pin648. Pressing of trigger644moves teeth634out of engagement with locking pin636.

Ratchet member626may be deactivated by moving a slider650(in a direction toward the ratchet) so that it engages an upper end of ratchet arm632and pushes the ratchet member in a counter-clockwise direction (as seen in the drawing), further compressing spring638and bringing teeth634out of engagement with locking pin636.

The instruments have been described herein for use through a cannula assembly inserted into the umbilicus of a patient to perform a surgical procedure, such as a cholecystectomy, through a single incision. However, the surgical access ports and the instrumentation can also be used for performance of surgical procedures through single incisions other than through the umbilicus. Moreover, in addition to laparoscopic procedures, the instruments (and ports) can be used for thoracoscopic procedures or other endoscopic or minimally invasive procedures.