Tubular tissue welding device without moving parts

Abstract: Exoscopes for joining tubular like objects have a housing made in two sections which clamp around the objects to be welded together. The end of the objects are held in place by an internal stent which claps the ends of the object together. Optical fibers or the like connected to a radiant energy source, e.g., laser, terminate in the housing in such a way that the conducted energy beam is directed simultaneously circumferentially around the abutting ends to be welded. There are no moving parts during the welding.

Description: BACKGROUND 1. Field of the Invention This invention relates to apparatus for effecting surgical anastomosis by means of radiant energy, e.g., laser, welding. 2. Description of the Prior Art US patent 4633870 discloses an exoscope, or surgical apparatus for laser welding, and a method for welding a pair of tubular tissues at their juxtaposed ends with a laser beam. The exoscope has two semi-cylindrical jaws which are releasably attachable around the abutting ends of a pair of tubular tissues that are held together by a tubular stent. A shuttle, which revolves in the jaws 360° around the outside of the junction of the tissues, is connected to a tubular conduit, that extends slidably through a handle on one of the jaws to the exterior of the instrument. The conduit contains at least three fiber-optic cords, the inner ends of which are connected to the shuttle for movement therewith, and to register with a mirror which is also mounted on the shuttle. The outer ends of the cords are connected, respectively, to a light source for illuminating the seam which is to be welded, to a source of laser energy for directing a laser beam onto the seam, and to a lens which is utilized for observing the site where the welding is to take place. In many instances the surgical field does not offer adequate opportunity to advantageously use the foregoing exoscope. Therefore, it is an object of this invention to provide an exoscope without moving parts, thereby avoiding the possibility of parts seizing together. An additional object is to provide exoscopes which can be of smaller size than presently possible. These and other objects will be apparent to those skilled in the art upon reference to the following detailed description. SUMMARY OF THE INVENTION In accordance with this invention there is provided an exoscope in accordance with claim 1 below. In this way, the invention provides an exoscope which has no parts which move during welding. BRIEF DESCRIPTION OF THE DRAWINGS Fig 1 is a perspective view of an embodiment of exoscope according to this invention; Fig 2 is a cross sectional view of Fig 1 taken along line B-B'; and Fig 3 is a cross section of the assembled exoscope of Fig 1 taken along line A-A'. The exterior of a preferred embodiment of this invention is shown in Fig 1 wherein the hand-manipulable laser housing 10 is composed of a first section 11 and a second section 12 which are movable relative to each other and which when engaged together form a central opening through the housing 10. The housing sections can be made from a variety of material well known in the art as desired. Flexible, radiant energy transmissive conduits or elements 13 extending at one end in both sections 11, 12 of the housing 10 and disposed to be connected at their opposite end to a source of laser energy 14 operable to direct a beam of energy through the conduits 13 into the housing 10. The source of energy or light is not shown since the mechanical aspects of obtaining this type of energy is well known in the art and beyond the scope of this invention. The housing sections 11, 12 are equipped with a energy beam directing means or aiming device 15. The aiming device 15 is set in a fixed position so the laser energy will always be directed to the same place. The aiming device 15 may be a flat mirror, a prism, or a concave mirror to achieve greater focusing. The degree of focusing desired to achieve finer or thinner welds is a function of conduit 13 cone size, degree of concavity on the reflecting surface and proper conjugates. The aiming device 15 may be made from reflective metal, optical glass or a plastic such as polymethyl methacrylate or other polymeric compositions such as are used for the manufacture of contact lenses. The conduits 13 convey the radiant energy, e.g., laser energy, source not shown, to the aiming device 15. The aiming of the energy onto the living tissue or organ is achieved by the placement of the aiming device 15. The construction of energy conduit 13 can be varied depending on the particular form and source of energy desired. A particularly useful conduit material is optical fiber. One of the uses of the exoscope of this invention is shown in the accompanying drawings. The ends of two sections of the bowel 20 are physically clamped together on the inside by use of a stent 21. The stent is comprised of two interlocking parts, one part 16 having a male coupler portion and the other part 17 having a cooperating female coupler portion. The stent 21 is sized to the approximate diameter of the organ or blood vessel 20, e.g. bowel, to be welded or fused together. The stent is more fully described in U.S. Patent 4,633,870, discussed above. After the bowel 20 is clamped together, first one section 11 of the exoscope is placed around the clamped junction of the bowel 20. The second section 12 is then engaged with the first section 11 to complete the central opening of the housing 10. Then the surgeon exposes the bowel 20 to laser energy until separated sections of the bowel 20 are fused together. The stent can be left to dissolve in due course or, depending upon the nature of the surgery, can be removed through an opening formed in one of the other of the tubular tissues at a point axially spaced from the welded ends. The exoscope of this invention requires no moving parts to produce a 360° circumferential laser weld of tubular tissue. Instead of having a mobile cart that carries the lasing fiber in a path around the seam, this device uses an array of multiple stationary conduits 13. In this embodiment the system employs a dissolvable or removable intraluminal stent 21 that in some uses circumferentially holds the ends of tubular organs 20 in abutment. It also features a housing 10 with two parts 11, 12 that can be opened and closed around the stent-tissue complex This housing 10 holds multiple conduits 13 that are positioned parallel to and completely surround the viscus to be welded. The proximal end of these energy conduits 13 are arranged in a typical round or square bundle, which can be irradiated by a single or multiple radiant beam. The distal end of this energy, or optical, cable is modified to a "spot-to-slit" conformation. Approximately half of the fiber conduits 13 go to the first section 11 of the housing 10, the remainder go to the second section 12. The distal conduits 13 of this system end just proximal to the seam to be yielded. A prism or mirror 15 is positioned at an angle (e.g., 45°) above the entire length of the seam, so that the incoming radiant energy will be reflected onto the underlying abutted tissue. Thus, once this housing 10 is properly set, a single firing of the appropriate laser can produce a circumferential tissue weld. Of course the multiple fiber conduits 13 could travel through the housing 10 perpendicular to the axis of the viscus (i.e., radially) and could overlie the seam to directly irradiate the abutted tissue. This would eliminate the need for a mirror 15. Because energy may be lost with acute bends in optical fibers, the path of the fibers in this radial arrangement may require a larger O. D. of the housing. From the foregoing discussion it will also be readily apparent that welds along only a part of the circumferential seam can be obtained by directing the energy or light to only a selected portion. The exoscope is amenable to minor modifications for specific usages. A foot pedal or button for finger tip energy activation can easily be added to this system. With the provision of thermocouple or other heat sensing device (not shown) connected to a gauge (not shown) the surgeon can more accurately control the amount of radiant energy applied to the tissue and insure a fusing action rather than allow the tissue to become overheated and destroyed. In a more preferred embodiment, the thermocouple is connected to a computer (also not shown) which is programed to monitor and limit, as a function of increase of temperature, the amount of radiant energy applied. The computer can be additionally programed to limit available energy as a function of other parameters, e.g. time. From the foregoing it will be readily recognized that the limit on the amount or thickness of tissue, or polymeric material, to be fused is a function of the depth to which the fusing is to occur and the nature of the substrate to be fused, e.g., conductivity of energy and heat decomposition point. The invention is capable of being used with many different types of radiant energy. The radiant energy for these applications typically has a wave length from approximately 0.1 micron to 11 microns. The preferred form of radiant energy has a coherent wave pattern. The more preferred form of energy for this invention is laser energy. Any radiant energy that is transmissible through an optical fiber or a wave guide could be used; however, the optimal spot size, configuration irradiance, exposure time, etc. will vary for each tissue type and the type of energy used. There are a number of surgical devices which are capable of generating a laser beam which can be applied to the laser energy conduit or optical fiber 13 of the illustrmted embodiment. The Neodymium: Yttrium Aluminum Garnet (more commonly referred to as Neodymium: YAG or Nd:YAG), Argon-dye and copper/gold lasers can provide the laser energy for distribution by optical fibers 13. The carbon dioxide laser apparatus, which has been used in laser microsurgery is capable of producing carbon dioxide laser energy densities ranging from 50 to 750 J/cm², the densities which have proved in the past to be suitable for the laser welding together of rabbit tissues. Low powered carbon dioxide lasers of this variety have also been used successfully in welding together severed tissues of experimental animals such as rats. This is further discussed in "Laser-assisted Vas Anastomosis, A Preliminary Report" by Charles M. Lynn, MD, et al., published Lasers in Surgery and Medicine 3:261-263, 1983. However, because of the long wavelength of carbon dioxide laser energy, satisfactory optical fibers 13 are not yet commercially available. The exact means for generating the laser beam for use in connection with applicant's herein disclosed instruments, it will be understood, is a matter of choice and forms no part of the instant invention. Energy control is important in the use of surgical energy, e.g. laser, tissue welding. In general, as the wavelength of the energy increases, its absorption in biological tissues becomes higher and less energy is reflected. For lasers producing visible light, the absorption coefficient is strongly dependent on the color of the tissue as well as the wavelength. For example, with the long wavelength (10.6 µm) of the invisible infrared carbon dioxide laser absorption is independent of tissue color and energy is almost completely immediately absorbed by tissue water. The short wavelength (0.51 µm) of the green light of the argon laser is strongly absorbed by red oxygenated hemoglobin of blood and has much scattering. The 1.06 or 1.3 µm wavelength of the Nd: YAG laser light falls between that of carbon dioxide and argon. The Nd:YAG energy is thus absorbed by both water and tissue pigments; this absorption pattern appears best for the welding of most tissue types. While it is known that laser energy can cause fusion of tissue, the complete process that produces a tissue weld is not fully understood. It is well accepted that tissue collagen provides for the vast majority of the strength of most tissues. In earlier work with rabbit bowel, using collagen specific tissue stain and light microscopy, alteration of collagen at the tissue weld sites was demonstrated. In a recent report in Science , the mechanism of tissue welding was further explored. These authors maintained that laser induced alterations of the collagen substructure allows for microsurgical tissue welding via a heat induced homogenization change in collagen with interdigitalization of the altered individual collagen fibrils. In other words, as clearly seen in their electron microscopy slides, the usually well organized tissue collagen becomes unraveled during tissue welding. During tissue cooling, this unraveled collagen appears to become tangled in adjacent unraveled collagen to produce tissue bonds. Direct radiant effects from the laser light may also provide some small component of weld strength by a yet undescribed effect on other tissue proteins. Thus, most investigators agree that tissue welding is primarily produced by a thermal induced fusion of tissue collagen; the most effective welding temperature is presently believed to be approximately 62°C. The exoscope of this invention is also useful for welding many other types of tissue (e.g. blood vessels - for hemostasis or anastomoses, etc.). Also, the exoscope can be used to fuse prosthetic materials e.g., polyfluoroethylene of a polyimide, to human tissue as in the replacement of veins or arteries. Thus, the substance to be welded by an exoscope can be a living tissue and/or a non-living material. Outside a living body the exoscope can be used to fuse two or more tubes made from the above plastics or other materials when delicate, precise welding is required. Because there are no moving parts, this exoscope device has the following advantages: 1. No moving parts to jam or malfunction. 2. It can be smaller. The size of the previously patented exoscope is limited by the required diameter of the cart track. The device of this invention could potentially have a diameter of several millimeters. 3. Can easily he made and used as a disposable device. 4. Arrangement of the lasing path is unlimited. In addition to end-to-end anastomoses as described, end-to-side (T or Y configurations) and fish-mouth patterns are some examples of where a side branch tube is attached to the main tube. 5. Entire seam can be irradiated at once. Duration of lasing mandated by tissue requirements, not by time it takes for cart to travel.

Claims: An exoscope for welding together tubular-like objects, the exoscope comprising: a hand-manipulable elongate housing (10) having first (11) and second (12) sections selectively movable relative to each other to form a unitary housing with a central opening lengthwise through said housing, said housing sections being movable away from each other at the conclusion of a welding operation, thereby to permit withdrawal of the housing from the welded cylindrical objects and disengagement from the latter, said two housing sections being the only housing sections required for joining two tubular-like objects one to the other, means (21) for releasably supporting the tubular-like object (20) in said central opening formed in said housing, and with confronting ends of said objects to be welded together abutting each other along at least one seam located within said central opening, a plurality of flexible radiant energy transmissive elements (13), and means (15) in said housing for directing a radiant energy beam emitted from said transmissive elements to said central opening and onto said seam characterized in that the plurality of flexible radiant energy transmissive elements (13) extends at one end into fixed sites in both sections of the housing and is disposed to be connected at their opposite end to a source of radiant energy operable to direct a beam of radiant energy through said transmissive element to said housing, and further characterised in that said beam directing means (15) simultaneously direct said beam circumferentially around said central opening to a plurality of selected portions of said seam thereby welding together said abutting ends along said seam. An exoscope as claimed in claim 1 wherein the central opening is adopted for welding two or more seams simultaneously. An exoscope as claimed in claim 2 wherein the housing forms a T-shaped central opening. An exoscope as claimed in claim 2 wherein the housing forms a Y-shaped central opening. An exoscope as claimed in any one of the preceding claims wherein the plurality of energy transmissive elements (13) extend through the housing (10) perpendicular to the longitudinal axis of the housing, whereby the radiant energy beams emitted by the elements (13) impinges directly onto said seam.

Inventors: SAUER JUDE S, SAUER, JUDE S.
Applicants: LASERSURGE INC, LASERSURGE, INC.
Application year: 1989
Main classification: A61B17
IPC codes: A61B18, A61B17