Endoscope assembly and surgical instrument for use therewith

An endoscope assembly, and the surgical instrument associated with it, capable of providing superior visibility of an operative site while at the same time insuring the transmission of tactile information to the surgeon through the handle of the instrument. The endoscope assembly comprises an optical head equipped with a connector or connectors for externally and releasably attaching the head to a surgical instrument at the neck portion adjacent the operating end thereof, an eyepiece or other viewing unit remote from the head, and an elongated flexible cable extending between the two. In the embodiment disclosed, the cable contains a light-transmitting waveguide for illuminating the operative area and a fiberoptic bundle for transmitting a coherent image of the area so illuminated. The cable may also be provided with a passage for delivering irrigating fluid (liquid or gas) to the operative site.

BACKGROUND AND SUMMARY 
Various types of specialized forceps, clamps, and other surgical 
instruments have been developed over the years for use in performing 
specific surgical operations, and in many cases the configuration and 
construction of such instruments has been based not only on anatomical 
considerations but also on the importance of providing the surgeon with 
tactile information essential in achieving proper control over such an 
instrument. Thus, forceps used for removal of kidney stones generally have 
angular shank portions of minimal length so that the closed jaws of such 
an instrument can be readily inserted into the kidney through an incision 
in the renal pelvis, and the tips of the closed jaws may then be used as a 
probe to help the surgeon locate the stones requiring removal. Visual aids 
such as fluoroscopy and x-radiography are often used, but a surgeon 
manipulating such an instrument must nevertheless rely primarily on 
tactile sensitivity to locate, grasp, and remove the calculi. 
More recently, endoscopic instruments have been developed to provide 
surgeons with an internal view of the organ or body passage requiring 
treatment, such endoscopes typically having channels through which a 
miniaturized forceps, commonly called flexible instruments, are inserted 
and advanced. While such a system does provide the surgeon with an 
internal view of the operative site, miniaturization reduces the 
effectiveness of the flexible instrument for many functions such as, for 
example, grasping and removing larger size kidney stones. Moreover, the 
flexibility of the grasping (or cutting) instrument, and the distance 
between its jaws and the remote handles held by the surgeon, all but 
eliminate the transmission of tactile signals and require that almost 
complete reliance be placed on endoscopic observation in performing 
surgical manipulations. Not only are the surgeon's hands spaced well away 
from the distal end of the endoscope and the jaws of the instrument, but 
they are normally fully occupied by the manipulations required at the 
proximal end of the equipment. One hand is commonly used to hold and 
direct the endoscope while the other is used to direct and operate the 
flexible instrument and also to control the irrigation system--all such 
manipulations occurring at the proximal end of the endoscopic system, well 
away from the organ or body part undergoing surgical treatment. Any 
tactile feedback is minimal because of the lack of rigidity of the 
instrument and the distance between its jaws and operating controls. 
References illustrative of the state of the art are U.S. Pat. Nos. 
3,960,143, 4,046,149, 4,046,150, 4,043,323, and 3,413,976. Other 
publications are Tsuchida, S., A New Operative Fiberpyeloscope, Journal of 
Urology, 117:643-5 (May 1977), Olinger, C. P. & R. L. Ohlhaber, 
Eighteen-Guage Needle Endoscope with Flexible Viewing System, Surg. 
Neurol. 4:537-8 (1975), Stotter, L., H. J. Wiendl, & B. Ultsch, An 
Improved Flexible Cholangioscope, Endoscopy 7:150-3 (1975), Gittes, R. S., 
Operative Nephroscopy, Journal of Urology, 116:148-52 (1976), Miki, M., Y. 
Inaba, & T. Machida, Operative Nephroscopy with Fiberoptic Scope: 
Preliminary Report, Journal of Urology, 119:166-8 (February 1978). 
An object of this invention therefore lies in providing an endoscope 
assembly and surgical instrument which allow a surgeon to use both hands 
at the surgical site, thereby providing maximum tactile input through hand 
contact with the organ and the surgical instrument used to enter that 
organ, while at the same time providing endoscopic visualization of the 
interior of the organ and the tip action of the instrument involved. A 
further object is to provide a system which allows a surgeon to use an 
instrument having greater holding capacity and effectiveness than a 
miniaturized intraluminal grasping instrument, and which also provides the 
surgeon with both tactile input and visual confirmation. Another object is 
to provide an endoscopic attachment for a rigid surgical instrument having 
jaws for probing, grasping, and/or cutting, the attachment being removable 
when not needed, or when its use is required with another related type of 
instrument. A still further object is to provide a low profile endoscopic 
attachment which contains flexible transmitting means for illuminating and 
transmitting images, and which also provides a passage for irrigation of 
the operative site. 
In brief, the instrument used in the combination of this invention may be 
any of a variety of specialized instruments used for probing and grasping 
or, in some cases, cutting, which are designed to be held and operated by 
one hand and which provide the surgeon with a high level of tactile input. 
For that purpose, such an instrument should have a handle or shank portion 
of rigid construction. For example, where the instrument is to be used for 
nephrolithotomy or phelolithotomy with calyceal stone extraction, the 
instrument may be a modified version of conventional Ray or Randall 
forceps. Such instruments are rigid enough to be precisely manipulated by 
the surgeon's hand in close proximity to the kidney (preferably with the 
other hand holding and manipulating the kidney), while providing maximum 
tactile sensitivity and sufficiently greater capability for grasping and 
removing larger stones (those having a diameter greater than about 0.8 
centimeters) as well as stones of smaller size. 
The endoscope assembly includes an elongated flexible cable equipped at one 
end with an eyepiece or other viewing means and at the other with an 
optical head. Only the head is directly and externally connected to the 
instrument, such rigid connection being made to the instrument's neck 
portion adjacent the jaws thereof. The cable transmits images or 
image-producing signals from the illuminated operative site at the head 
back to the viewing means so that the surgeon will have visual 
confirmation of the action of the instrument's working end as well as 
direct tactile input transmitted through the rigid handle or shank of the 
hand-held instrument. 
In the particular embodiment disclosed, the connection between the optical 
head and the instrument is releasable, the head being equipped with one or 
more spring clips for detachably engaging the instrument's neck portion. 
The head is generally crescent-shaped in cross section so that its contour 
complements that of the instrument. A coherent optic bundle extends from 
the head and through the flexible cable to the eyepiece for providing the 
surgeon with visual confirmation of the instrument's tip or jaw action 
which, as already indicated, is also confirmed by direct tactile input. 
The illuminating means may take the form of a ligh-transmitting waveguide 
extending through the cable to illuminate the operative area, such 
waveguide being connected at its proximal end to a suitable high-intensity 
light source. Ideally, the cable also provides a flow passage for the 
delivery of fluid (liquid or gas) for irrigation or other purposes, the 
flow passage and the illuminating means being disposed on opposite sides 
of the coherent image-transmitting waveguide. 
A support is provided for holding the eyepiece so that the surgeon's hands 
are free to remain near the operative site at the distal end of the 
instrument. The support may take the form of a standard adapted to be 
mounted upon a floor, table, or other stationary surface, or a headband 
worn by the surgeon. 
Other features, objects, and advantages of the invention will become 
apparent from the specification and drawings.

DETAILED DESCRIPTION OF PREFERRED EMBODIMENT 
Referring to the drawings, the numeral 10 generally designates a complete 
operating system comprising a hand-holdable surgical instrument 11, an 
endoscope assembly 12, support means 13 for the eyepiece of that assembly, 
a light source 14, and one or more sources 15 and 16 of irrigating fluid. 
The instrument 11 includes a handle portion 17 dimensioned and constructed 
to be held and operated by one hand, a rigid shank portion 18 which 
extends a limited distance from the handle and which, in the embodiment 
illustrated, is curved near its distal end, a neck portion 19 which may 
constitute a distal extension of the shank portion, and jaws 20 
operatively connected to the operating elements of handle portion 17 and 
adapted to open and close when the elements of the handle portion are 
manipulated. In its general outline and construction, the particular 
instrument 11 illustrated in the drawings is essentially a modified 
version of a forceps commonly known as a Ray kidney stone forceps, 
although it will be understood that for other types of surgery the 
instrument 11 may assume a substantially different appearance. It is 
believed essential, however, that regardless of the configuration and 
intended use of the instrument, such instrument must be small enough to be 
held and operated by one hand, have an operating end normally provided 
with jaws for grasping and/or cutting, and be rigid enough to provide the 
surgeon with positive tactile feedback in use. 
Handle portion 17 is shown having a pair of lever elements 17a and 17b 
equipped with finger loops 17c. While such an arrangement has been found 
effective for purposes of instrument manipulation and control, other 
arrangements may be substituted. For example, a handle composed of a pair 
of reciprocable elements, as generally disclosed in certain of the 
aforementioned patents, may also be effectively used. 
Endoscope assembly 12 includes an elongated flexible cable 21 equipped at 
its proximal end with eyepiece 22 and at its distal end with optical head 
23. The cable 21 has a sheath 24 formed of any suitable resilient and 
flexible polymeric material through which flexible transmitting means 25 
and 26 extend. One such means 26 transmits energy from source 14 to the 
head 23 for illuminating the site of surgical treatment. The other 
transmitting means 25 transmits images or image-producing signals from 
head 23 to the viewing means (eyepiece) 22. 
In the embodiment illustrated, the transmitting means 25 comprises a 
coherent bundle of glass fibers capable of transmitting an image from the 
operative site to the viewer, although it is conceivable that such means 
might take other forms such as, for example, a flexible conductive lead 
for transmitting electrical signals from a receiver or scanner in the head 
to the viewing means where such signals are then processed to produce the 
visual images. Similarly, while illuminating means 26 is depicted and 
described herein as a fiberoptic bundle, it might take the form of a 
flexible electrical conductor acting in combination with a head-mounted 
lamp or other illuminating device, or a waveguide consisting essentially 
of a single light-transmitting fiber or tube. 
In the preferred embodiment shown in the drawings, the flexible cable is of 
rounded or oval cross section and the image-transmitting bundle 25 extends 
through that cable along the central axis thereof. The illuminating bundle 
or waveguide 26 may be of smaller cross sectional area than the 
image-transmitting bundle and may be disposed alongside the latter, in 
which case the illuminating bundle 26 may be crescent-shaped in cross 
section (FIG. 5). 
The flexible sheath 24 of the cable may also include a flow passage 27 
extending along that side of the coherent fiberoptic cable 25 opposite 
from the illuminating cable 26 (FIG. 5). The flow passage may be defined 
by an inner protective flexible tube 28 which extends through the cable 
and which exits therefrom at or near eyepiece 22. As shown in FIG. 1, tube 
28 may extend to a branched coupling 29 equipped with check valves 30 and 
31. One of the branches may lead through hose 32 to a pulsatile source of 
irrigating fluid 16, whereas the other branch may lead through hose 33 to 
a suspended bag 15 which serves as a non-pulsating fluid source. A 
manually-operated valve (not shown) may be provided in line 33 to control 
fluid flow, it being understood that during an operative procedure a 
continuous flow at low pressure is normally required for internal viewing. 
When pulsatile flow is needed, source 16, which may be driven by an 
electric vibrator in a manner well known in the art in connection with 
oral hygiene irrigating devices, may be activated and deactivated by a 
suitable foot controller 34. The pulsatile flow from source 16 is intended 
to be used for clearing away any tissue particles, blood, or other matter 
to prevent obscuring of the view through eyepiece 22 and/or for dislodging 
small particles from the organ's interior (such as stone particles within 
the calyces of the kidney). 
The viewing means or eyepiece 22 shown in FIG. 1 is mounted upon support 
means 13 in the form of a standard 35 adapted to be secured at its lower 
end 36 to a table, floor, or other stationary support surface. The 
standard should be capable of telescoping, and should be provided with a 
pivotal connector at its upper end, to permit vertical and angular 
adjustment of the eyepiece. The base 37 of the standard may take the form 
of a clamp, suction cup assembly or tripod leg construction, all as known 
in the art. 
The standard-equipped support 13 represents a preferred construction 
because it may be used to locate the eyepiece 22 in any suitable position 
selected by the surgeon while still readily permitting the surgeon to look 
away from the eyepiece when direct viewing of the operative site, or 
instrument 11, or any other object or person, is required. However, it has 
also been found effective to provide support means in the form of a 
headband 38 and connector 39 as depicted in FIG. 6. The connector 39 is 
secured to both the headband and eyepiece 22 and is adjustable to 
facilitate positioning of the eyepiece directly in front of the wearer's 
eye. Band 38 may also be adjustable as indicated in FIG. 6. 
Head 23 is an extension of cable 21 and contains extended portions of 
fiberoptic bundles 25 and 26 as well as of irrigation tube 28. Objective 
lens 25a is mounted at the extreme distal end of bundle 25 and, if 
desired, a similar lens 26a may be provided at the distal end of bundle 
26, the latter being more useful for preventing fluids from invading 
bundle 26 than for optical purposes. A protective casing 23a formed of 
rigid material may extend about the head, not only to prevent damage to 
the optics encased within the head but also to provide a secure attachment 
for one or more attachment clips 40. 
Referring to FIGS. 3 and 4, it will be observed that a pair of spring clips 
40 are secured to the underside of head casing 23a and are provided with 
arcuate spring arms which receive the neck portion 19 of instrument 11. 
The straps or arms 41 of the clips are received in peripheral grooves or 
channels 42 that, as indicated in FIG. 4, extend about at least the 
underside the neck portion 19 to secure head 23 against longitudinal 
sliding movement along the neck and to assist the user in properly 
positioning the head when endoscope 12 is to be coupled to instrument 11. 
To insure a rigid but releasable interconnection between head 23 and 
instrument 11, a pair of longitudinally-spaced clips 40 are shown in the 
drawings; however, it is to be understood that a greater or smaller number 
of such clips may be suitable for purposes of this invention. 
In the operation of this system as, for example, in the case of kidney 
stone removal, a surgeon may find that a number of different instruments 
11, all of the same general construction but with different shank 
curvatures, will be necessary in order to enter different calyces for 
stone detection and removal. In that event, head 23 may be readily 
detached from one instrument and clipped to the neck of another instrument 
of different curvature. Furthermore, in certain instances where the 
surgeon concludes that visual verification through an endoscope is 
unnecessary, and where tactile input and external observation are 
sufficient, the endoscope 12 may be completely disconnected and at least 
temporarily laid aside. 
While the scope assembly 12 has been described in conjunction with surgical 
instruments, it is believed evident that such assembly might be adapted 
for use with any essentially rigid hand-held instrument that must be 
oriented and manipulated under conditions which require the operator to 
receive and respond to tactile signals transmitted through the instrument 
itself and which, because of the nature of the operation, prevent the 
operator from directly viewing the working end of the instrument and the 
operative site. Under such circumstances, the rigidity of the instrument, 
and the fact that it is hand held, allow the instrument to function as an 
extension of the hand and to be oriented, steered, and manipulated in part 
through tactile sensations which yield a perception of the action of the 
instrument in the "mind's eye" of the user. The visual input provided by 
the scope assembly 12 serves to confirm and supplement such tactile input 
to give the operator greater control over the operation of the instrument, 
whether it be in a surgical or non-surgical procedure. 
While in the foregoing I have disclosed an embodiment of the invention in 
considerable detail for purposes of illustration, it will be understood by 
those skilled in the art that many of these details may be varied without 
departing from the spirit and scope of the invention.