Abstract:
Disclosed is a device for isolating a cardiac surgical site. The device comprises a first finger having a clinging accessory for attaching the first finger to a heart, a second finger having a clinging accessory for attaching the second finger to the heart, a first joint disposed on the first finger so that the first finger may rotate on a surface of the heart such that said rotation stretches a surgical site, a first stopper disposed on the first finger for preventing undesired rotation of the first finger to isolate the surgical site, and a link for coupling the first finger to the second finger. Several embodiments of the fingers and clinging accessories are disclosed. A guard is provided to protect sutures from the clinging accessory. The guard is equipped with a sprayer to wash the surgical site. Also disclosed is a method of isolating a cardiac surgical site. The method comprises the steps of disposing a first finder on a heart, clinging the first finger to the heart surface. disposing a second finger on a heart, clinging the second finger to the heart surface. and then rotating the first finger for achieving selective isolation of the heart surface.

Description:
CROSS REFERENCE  
       [0001]    This application is a continuation in part of U.S. Ser. No. 09/376,538 filed Aug. 18, 1999, which claims the benefit of U.S. Provisional application Serial No. 60/143,023, filed Jul. 8, 1999. 
     
    
     
       FIELD OF THE INVENTION  
         [0002]    The invention relates generally to medical surgical devices. and more particularly to a device and method of stabilizing a surgical site during cardiac or cardiovascular surgery.  
         BACKGROUND OF THE INVENTION  
         [0003]    Heart disease and associated cardiovascular problems have become so common in the United States that over 400,000 open heart surgeries are performed each year. Traditionally, physicians would open the chest and stop the heart before performing a surgical procedure on the heart. However, medical practices have improved, and physicians now recognize that there are advantages to performing surgery on a beating heart. For example, performing surgery on a beating heart avoids the necessity to expose the heart to filters, oxygenators, tubes, and other devices. This decreases the trauma associated with stopping the heart. as well as avoids other dangers that stopping the heart poses to a patient. In addition, by avoiding the use of these devices, the physician can lower the expense of an operation. Furthermore, performing surgery on a beating heart lowers the risk of ischemic damage to heart and surrounding tissue.  
           [0004]    Unfortunately, there are many difficulties and challenges which must be overcome to successfully perform surgery on a beating heart. For example, every time the heart beats, the heart moves. This makes it difficult to isolate a specific site on the heart for surgery. Furthermore, physicians typically must develop great skill and expertise to accommodate the movement of the heart with existing instruments which were designed for use with a heart that is stopped. Because of the increased demands of performing surgery on a beating heart, surgery on a beating heart often takes longer than surgery on a stopped heart. Fortunately, devices and methods are being developed which decrease the amount of time and expertise it takes to identify and isolate a target vessel and thus, reduce the time it takes to perform open heart surgery.  
           [0005]    One family of instruments which have been developed to facilitate surgery on a beating heart are known as cardiac immobilization devices or heart stabilizers (devices). A number of these devices function by attaching to the heart at two or more points. The points are then moved further apart, thus stretching the surface area of the heart about which surgery is to be performed (surgical site). The devices typically grip the heart surface by suction. Unfortunately, there are a number of disadvantages associated with these methods of isolating a surgical site.  
           [0006]    Some cardiac immobilization devices often appear to be little more than steak tongs or clamps which have been slightly altered to attach to a heart surface. Other devices use flex links or rods to attach to a retractor and then use a metallic foot to stabilize the heart surface. Suction devices may comprise a plurality of suction cups, or may have at least one hollow cylinder with holes in it, which is then attached to a pump which pulls a vacuum at the holes.  
           [0007]    [0007]FIG. 1A (prior art) shows a cardiac immobilization device  130  attached to a heart surface  140 . To perform open heart surgery, typically a chest retractor  110  is braced within a rib cage and used to maintain an opening in the chest wall  112  which provides access to the heart surface  140 . A stabilizing member, such as a flexible arm assembly  120  is used to securely locate a cardiac immobilization device  130  upon the heart surface  140 . Accordingly, the stabilizing member  120  is coupled to the retractor  110  via a clamp  126  and holds the cardiac immobilization device  130  in a predetermined position.  
           [0008]    The flexible arm assembly  120  includes a flexible arm  124  which may be bent and twisted into various shapes and geometries to access different locations on the heart surface  140 . At the end of the flexible arm  124  closest to the heart surface  140  is a socket  128  for attaching the flexible arm  124  to the cardiac immobilization device  130 . At the other end of the flexible arm  124  is a handle  122  which when turned tightens a cable (not shown) within the flexible arm  124 . The tightening of the cable makes the flexible arm  124  rigid and immobile. The tightening of the cable also tightens the socket  128 , allowing the socket  128  to grip an object, such as a ball  132  (the ball  132  is part of the cardiac immobilization device  130 ).  
           [0009]    The shown cardiac immobilization device  130  uses suction to attach to a surface of the heart  140 . To attach the cardiac immobilization device  130  to the heart surface  140 , the cardiac immobilization device  130  utilizes a foot plate  136  with holes thereunder (not shown) on which a vacuum is placed. The vacuum is maintained by air hoses  134  which are attached to an air pump (not shown) and the foot plate  136 . Thus, the cardiac immobilization device  130  is held stationary on the heart surface  140  at the end of the flexible arm  124  of the flexible arm assembly  120  so that the heart surface  140  located within the foot plate  136  can be isolated.  
           [0010]    One disadvantage of many tong type attachments is that they provide an uneven spread (the heart surface closest to the tong&#39;s hinge point is spread a smaller distance than the heart surface at the end of the tong).  
           [0011]    There are also many disadvantages associated with using suction to isolate a surgical site. For example, many patients have a heart which is surrounded with fatty tissue. Since the fat surrounding the heart moves, when a physician uses a suction device to isolate a heart surface, the suction cups or suction holes attach to the fat (rather than the heart surface). The operative result of the device attaching to the fatty tissue is that the heart surface can still beat underneath the fatty tissue, which means that isolation and stabilization of the surgical site is poor. Furthermore, the fatty tissue may be drawn into the device (at a hole, for example) by the suction, and may clog the suction device thereby stopping suction at the holes which are further along and at the end of the device. In addition, after attachment to the heart is made with a suction device, the ability to spread the heart surface is limited by the force of suction on the heart surface. Should the suction break, the device must be repositioned and reattached to the heart, which consumes time and is a nuisance to the physician. Furthermore, when strong enough suction is applied to the heart surface to achieve adequate spreading and to prevent slippage, the suction can cause blood to accumulate and clot just beneath the heart surface, a hematoma (this condition is also commonly referred to as a “heart hickie”).  
           [0012]    Therefore, what is needed is a device and method of isolating a surgical site for cardiac and cardiovascular surgery. The device should contact a minimal surface of the heart, accommodate the non-planar geometry of the heart, grip the heart firmly, yet gently, and should be easy to apply to and to remove from a beating heart. The present invention provides such a device and method.  
           [0013]    Blood in arteries can spew out from the anastomosis site during surgery, which reduces visualization for the surgeon. Periodically, blood must be manually removed by an assistant typically with a blower. The surgeon, therefore, must stop the procedure so that blood can be removed. What is needed, therefore, is a stabilization device integral with a blower device so that the blower could be operated remotely without interfering with the procedure.  
         SUMMARY OF THE INVENTION  
         [0014]    The present invention provides a device and method for isolating a heart surface, particularly, the surface of a beating heart during cardiovascular surgery. The device utilizes rotation to attach to the heart surface and then spread the heart which isolates the spread portion of the heart for surgery.  
           [0015]    Disclosed is a device for isolating a cardiac surgical site. The device generally comprises a first finger (which may be cylindrical) having a clinging accessory for attaching the first finger to a heart. Furthermore the device could comprise a second finger having a clinging accessory for attaching the second finger to the heart, a first joint disposed on the first finger so that the first finger may rotate on a surface of the heart such that said rotation stretches a surgical site, and a link for attaching the first finger to the second finger. In addition, a first stopper may be disposed on the first finger for preventing undesired rotation of the first finger to isolate the surgical site.  
           [0016]    The accessory for attaching could comprise a plurality of tines, a plurality of suction points, or a rough textured surface such as a surface similar to sandpaper, for example. In addition, the first joint or a second joint (disposed on the second finger) could comprise a rotatable handle coupled in a sleeve. Furthermore, the first stopper or a second stopper (disposed on the second finger) could be configured such that the rotatable handle comprises at least one notch and the sleeve has at least one rib. Likewise, the first stopper or the second stopper (disposed on the second finger) could be configured such that the rotatable handle comprises at least one rib and the sleeve has at least one notch. The handle could comprise an O-ring groove for securing an O-ring about an end of the handle.  
           [0017]    The link could comprise a ball and socket joint disposed between the first finger and the second finger for providing multi-axis articulation of the first finger and the second finger, as well as a first attachment bar coupled between the first handle and the ball and socket joint, and a second attachment bar coupled between the second handle and the ball and socket joint. Conversely, the link could comprise a first ball and socket joint associated with the first handle, a second ball and socket joint associated with the second handle, and an attachment bar for coupling the first ball and socket joint to the second ball and socket joint.  
           [0018]    More generally, the present invention provides a means for isolating a cardiac surgical site. The means for isolating comprises a first support means, such as a finger or a functional equivalent, having a clinging means for attaching the first support means to a heart, and a second support means, such as a second finger or a functional equivalent, having a clinging means for attaching the second support means to the heart. The means for isolating also includes a rotating means, such as a cylinder or a functional equivalent, disposed on the first support means so that the first support means may rotate on a surface of the heart, a locking means, such as a rib and notch, or a functional equivalent. disposed on the first support means for preventing undesired rotation of the first support means. An attaching means, such as a link or a functional equivalent, connects the first support means to the second support means.  
           [0019]    There is also provided a shield or guard attached to the fingers so the clinging means will not catch sutures, gloves or tissues during the medical procedure. The shield may also have a sprayer for washing the surgical site.  
           [0020]    In another embodiment, the present invention provides a method of isolating a cardiac surgical site. The method comprises disposing a first finger on a heart, clinging the first finger to the heart surface, disposing a second finger on a heart, clinging the second finger to the heart surface, and rotating the first finger for achieving selective isolation of cardiac tissue. The method may further comprise rotating the second finger, locking the first finger to prevent rotation, or locking the second finger to prevent rotation. The method may also provide that clinging comprises penetrating the surface of the heart, applying suction to the surface of the heart, or applying an abrasive surface for frictionally gripping the surface of the heart. In addition, when applying a finger, the method may further comprise the step of compressing the finger onto the heart surface. Furthermore, the method could include the step of elevating the finger while maintaining its attachment to the heart surface.  
           [0021]    The rotational action of the present invention allows the physician to overcome problems associated with fatty tissue on the heart surface, to adjust the spread of the heart surface during surgery, and to attach and detach the present invention from the heart quickly.  
       
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0022]    Other aspects of the invention, including specific embodiments, are understood by reference to the following detailed description taken in conjunction with the drawings in which:  
         [0023]    [0023]FIG. 1A (prior art) shows a cardiac immobilization device attached to a heart surface;  
         [0024]    [0024]FIG. 1 is an isometric view of one embodiment of a device according to the teachings of the present invention;  
         [0025]    [0025]FIG. 2 shows a side view of the device shown in FIG. 1;  
         [0026]    [0026]FIG. 3 is an exploded view of one arm of the device of FIG. 1;  
         [0027]    [0027]FIG. 4 is a front view of the finger having tines attached to the holes;  
         [0028]    [0028]FIG. 5 is a cut rear view of the handle taken along line  5 - 5  of FIG. 3;  
         [0029]    [0029]FIG. 6 shows the sleeve in greater detail;  
         [0030]    [0030]FIG. 7 is a cut side view of an arm in a locking position where the locking position is defined as the position of the device when the rib is set in a notch;  
         [0031]    [0031]FIG. 8 illustrates the sleeve relative to the handle when the device is in a rotatable position;  
         [0032]    [0032]FIG. 9 is a flow diagram of one method of practicing the present invention;  
         [0033]    [0033]FIG. 10 is an isometric drawing of the present invention which includes a flexible arm assembly;  
         [0034]    [0034]FIG. 11 a  is a side view of another embodiment of the present invention;  
         [0035]    [0035]FIG. 11 b  is an isometric drawing of the embodiment shown in FIG. 11 a;    
         [0036]    [0036]FIG. 11 c  is a front view of the embodiment shown in FIG. 11 a;    
         [0037]    [0037]FIG. 12 a  is a side view of another embodiment of the present invention;  
         [0038]    [0038]FIG. 12 b  is an isometric drawing of the embodiment shown in FIG. 12 a;    
         [0039]    [0039]FIG. 13 a  is a side view of another embodiment of the present invention;  
         [0040]    [0040]FIG. 13 b  is a portion of a front view of the embodiment shown in FIG. 13 a;    
         [0041]    [0041]FIG. 14 a  is a side view of another embodiment of the present invention;  
         [0042]    [0042]FIG. 14 b  is an exploded view of FIG. 14 a;    
         [0043]    [0043]FIG. 14 c  is a section view of the embodiment shown in FIG. 14 a;    
         [0044]    [0044]FIG. 14 d  is a section view of the embodiment shown in FIG. 14 a  adjacent to the surface of a heart;  
         [0045]    [0045]FIG. 15 a  is a front view of the fingers  10  and  12  (FIG. 2) with another embodiment of a clinging accessory;  
         [0046]    [0046]FIG. 15 b  is a front view of the device shown in FIG. 2 with another embodiment of a clinging accessory;  
         [0047]    [0047]FIG. 15 c  is a front view of the device shown in FIG. 2 with another embodiment of a clinging accessory;  
         [0048]    [0048]FIG. 15 d  is a front view of the device shown in FIG. 2 with another embodiment of a clinging accessory;  
         [0049]    [0049]FIG. 15 e  is a front view of the device shown in FIG. 2 with another embodiment of a clinging accessory;  
         [0050]    [0050]FIG. 16 a  is an isometric drawing of one embodiment of the present invention:  
         [0051]    [0051]FIG. 16 b  is an exploded isometric view of FIG. 16 a;    
         [0052]    [0052]FIG. 16 c  is another isometric drawing of the embodiment shown in FIG. 16 a  of the present invention;  
         [0053]    [0053]FIG. 16 d  is an exploded isometric view of FIG. 16 a;    
         [0054]    [0054]FIG. 17 a  is an isometric drawing of another embodiment of the present invention; and  
         [0055]    [0055]FIG. 17 b  is a combination top view and schematic view of another embodiment of the present invention.  
         [0056]    References in the detailed description correspond to like references in the figures unless otherwise indicated. 
     
    
     DETAILED DESCRIPTION  
       [0057]    The present invention provides devices and methods for isolating a heart surface. and particularly the surface of a beating heart, during cardiovascular surgery. The device attaches to the heart surface and then utilizes rotation to spread the heart and isolate the spread portion of the heart (surgical site) for surgery. The rotational action of the present invention allows the physician to overcome problems associated with fatty tissue on the heart surface to adjust the spread of and tension on the surgical site during surgery, and to attach and detach the device from the heart quickly. Other advantages and uses of the present invention will be apparent to those of ordinary skill in the art from the following description of the drawings.  
         [0058]    [0058]FIG. 1 is an isometric view of one embodiment of a device according to the teachings of the present invention. The device generally comprises a pair of stainless steel fingers  10 ,  12  which are mounted in stainless steel handles  14 ,  16 . Of course, the fingers  10 ,  12  and the handles  14 ,  16  may be made of any other material, such as plastics, rubber, other metals, or composite materials, for example. Furthermore, the fingers  10 ,  12  and the handles  14 ,  16  could be formed, cut or molded as a single unit. Stainless steel sleeves  20 ,  22  fit over the handles  14 ,  16  and are held in place about the handles  14 ,  16  by resilient O-rings  24 ,  26 . Of course, sleeves  20 ,  22  could be made out of any material, including plastic, nylon, or rubber. The combination of a finger, a handle, a sleeve, and an O-ring is called an “arm.” To couple two arms together, the sleeves,  20 ,  22  are attached together by a link  18  which is shown in FIG. 1 as a ball and socket assembly, for example. the combination of both arms and link  18  is known as a finger assembly  36 .  
         [0059]    A link is any device or collection of devices used to associate a finger and a stabilization device, such as another finger. The link  18  of FIG. 1 comprises a stainless steel ball  17 , which is weldedly coupled to each sleeve  20 ,  22  by stainless steel attachment bars  19 . The ball  17  is securely fastened in a socket  128  of the flexible arm assembly  120  shown in FIG. 1 a . Of course, other link devices may be used. For example, the link  18  could comprise an attachment bar alone. Furthermore, ball  17  could be made out of plastic or nylon and molded as a single unit to attachment bars  19 . Likewise, stabilizing members may have a variety of designs, and these other designs may use other types of mechanical links to maintain a predetermined distance between the fingers.  
         [0060]    [0060]FIG. 2 shows a side view of the device illustrated in FIG. 1. Finger  10  has a plurality of tines  30  which function as a clinging accessory to attach the device to a heart surface. Accordingly, a clinging accessory provides a finger traction to a heart surface. Other clinging accessories (such as suction holes, suction cups, rough textured surfaces (such as sandpaper), barbs, or electrostatic attachment, for example) are well known in the art and may be adapted for use with the present invention. Also, the handle  14  has a knob  42  which extends higher than the sleeve  20  so that the physician may grasp and rotate the handle  14 . The sleeve  20  has a plurality of notches  50 , and the handle  14  has a rib  40  which fits securely inside of one notch  50 . Accordingly, the combination of the rib  40  and a notch  50  together form a stopper which may be set to prevent rotation of the fingers  10 ,  12  as discussed below. A better understanding of the form and function of the present invention may be gained by examining the devices&#39; individual components and their interrelations.  
         [0061]    [0061]FIG. 3 is an exploded view of one arm of the device of FIG. 1. In FIG. 3, the finger  10  is seen to possess a plurality of holes  32  which accept the tines  30 . Although three holes  32  and three tines  30  are shown in FIG. 3, it should be understood that the finger  10  may have any number of holes  32  and a corresponding number of tines  30 . The holes  32  are of sufficient depth so that the tines  30  may be attached therein with solder, glue or by other means. Although the finger  10  of FIG. 3 is shown to be cylindrical, it should be understood that a finger may have any geometry so long as it may attach to a heart surface and stretch a surgical site by rotating. Finger  10  also has an attachable portion  34  which fits securely in a cylinder  44  of the handle  14 .  
         [0062]    The handle  14  has a grippable knob  42  which is capable of being securely grasped and turned. Abutting the grippable knob  42  is the rib  40 . At the other end of the handle  14  is a groove  48  which functions as an O-ring seat. The end of the handle  14  having the groove  48  is preferably shaped like a hemisphere to facilitate placing the O-ring  24  onto the groove  48 .  
         [0063]    [0063]FIG. 4 is a front view of the finger  10  having tines  30  attached and holes  32 . From FIG. 4 it is seen that the tines  30  have a hook shape which minimizes heart surface penetration and which facilitates the release of the tines from the heart muscle. The tines are of a stiffness so that should a stretching rotation require the releasing of the tines from the heart surface, they may release without ripping the heart surface, and then re-penetrate the heart surface at a new location, if necessary. Also, it should be noted that the tines point generally in the direction of the grabbing rotation. Although four linear rows are shown in FIG. 4, the invention may have any number of rows which may include non-linear, or even apparently random, row formations. In one embodiment, the tines have a length of about one quarter inch. Of course, other methods of attachment are well known in the art. These include but are not limited to, rough textured surfaces such as sandpaper, barbs, electro-statics, and suction holes, for example.  
         [0064]    [0064]FIG. 5 is a cut rear view of the handle  14  taken along line  5 - 5  of FIG. 3.  
         [0065]    From this view it can be seen that the grippable knob  42  extends both above and below the cylinder  44 . The portion of the grippable knob  42  extending below the cylinder  44  forms a lip  46  which is of a width that matches the circumference of the sleeve  20  such that when the sleeve  20  fits over the cylinder  44  the outside of the lip  46  aligns with the outside of the sleeve  20 . This view also illustrates that the rib  40  is of a width and size to accommodate the notch  50 .  
         [0066]    [0066]FIG. 6 shows the sleeve  20  in greater detail. As shown, sleeve  20  has a plurality of notches  50 . Although four notches are shown in FIG. 6, the sleeve  20  may have any number of notches  50  so that the rotation of the fingers may be held at varying degrees of rotation. In addition, one side of the sleeve  20  has a hole  54 , or other surface preparation, for accepting the attachment bar  19  (of course, the sleeve  20  may have other apertures attached to it depending on the link  18  used; likewise, the sleeve  20  may be connected to a link via welding, which avoids the need for apertures or modifications). The O-ring  24  pushes against the handle  14  so as to apply tension to the sleeve  20  to securely force a rib  40  over notch  50 , as described below. Accordingly, the sleeve  20  has a cylinder  56  which at the end opposite the notches  50  has a tapered lip  52  which is shaped to accept the O-ring  24  to minimize wear on the O-ring  24 .  
         [0067]    [0067]FIG. 7 is a cut side view of an arm in a locking position where the locking position is defined as the position of the device when the rib  40  is set in a notch  50 . Also, when in the locking position, the sleeve  20  fits securely against the handle  14 . In the locking position, the O-ring  24  in groove  48  exerts a force upon the sleeve  20  to keep it in place abutting the handle  14 . Furthermore, note that the rib  40  also abuts the sleeve  20 , indicating that a notch  50  (not shown) is in position about the rib  40 , forming a stopper.  
         [0068]    [0068]FIG. 8 illustrates the sleeve  20  relative to the handle  14  when the device is in a rotatable position. Here, it can be seen that the sleeve  20  is pushed against the O-ring  24 , causing distortion of the O-ring  24 . The separation of the sleeve  20  from the grippable knob  42  removes the notch  50  from the rib  40  and allows for the handle  14  to be rotated. Accordingly, as the handle  14  rotates so does the finger  10 . Then, depending on the direction of the rotation, the heart surface will either be stretched or compressed. A three dimensional drawing of the present invention is illustrated in FIG. 10 in which finger assembly  36  (FIG. 1) is mounted on a flexible arm assembly  190 . Flexible arm assembly  190  includes a flex arm  191  which may be bent and twisted into various shapes to access different locations on the heart surface. Socket  192  is on one end of flexible arm  191 . Socket  192  has a spherical void (not shown) which allows it to mate with ball  17  (FIG. 1). At the other end of flex arm  191  is universal retractor mounting  194  and variable tension lock  195 . Universal retractor mounting  194  mounts to chest retractor  110  (FIG. 1 a ). Variable tension lock  195  tightens a cable (not shown) within flex arm  191 . This tightening causes flexible arm  191  to become rigid and immobile, and thus allows fingers  10  and  12  remain placed against the heart after placement.  
         [0069]    One method of implementing the present invention uses the above disclosed device. Accordingly, FIG. 9 is a flow diagram of one embodiment of a method according to the present invention. First, the chest cavity is cut and opened and held securely in place, typically by a chest retractor, in an expose heart and place retractor step  90 . As advances in open heart surgery are made, less intrusive means of exposing the heart for surgery will be developed and this method should in no way be read to limit its use to open chest cavities, or in the use of retractors.  
         [0070]    Following the securing of the chest retractor, flex arm  191  with a finger  10  attached thereto (FIG. 10) is attached to the retractor in a fix flex arm step  91 . Next, finger  10  is placed about the area of the heart on which surgery is to be performed in a finger placement step  92 . Then, the finger  10  is attached to the heart in a finger attachment step  94  and in a make flex arm rigid step  95 , the flex arm is made stiff, typically by tightening variable tension lock  195  (FIG. 10).  
         [0071]    The fingers  10 ,  12  may be placed together on the heart in a single finger placement step  92  and then attached to the heart in a single finger attachment step  94 , or each finger  10 ,  12  may be placed on the heart surface, and then attached to the heart surface independently of each other. In any event, the result is that the finger  10  lies on one side of the surgical site, and a second finger  12  lies generally on the opposite side of the surgical site. Optionally, to achieve better traction in a following rotation step, and thus better isolation of the heart surface, the fingers  10 ,  12  may be gently pressed onto the heart (the fingers do not penetrate the heart surface).  
         [0072]    Next, in a finger rotation step  96 , at least one finger is rotated in a direction which increases the surface tension of the heart surface across the surgical site until a desired tension is achieved across the surgical site area. Once the desired tension is achieved on the heart surface, the tension is maintained by locking the device in that current state of rotation in a position locking step  98 . Yet even better heart surface isolation may be achieved at this point by lifting the fingers  10 ,  12  (and thus the isolated heart surface) slightly. Surgery may then be performed at the isolated surgical site on the heart as well as on any veins or arteries going to or from the surgical site. If necessary, during surgery, the handles may be rotated in either a gripping or releasing direction to increase or decrease the tension at the surgical site. Then, after the surgery is completed, the above detailed steps may be reversed and the device removed.  
         [0073]    FIGS.  11 - 17  describe various examples and embodiments of the present invention. For brevity and clarity, a description of those parts which are identical or similar to those described in connection with other embodiments illustrated in FIGS. 1 through 10 will not be repeated. Reference should be made to the foregoing paragraphs with the following description to arrive at a complete understanding of these embodiments. It is understood that features of various examples and embodiments may be interchanged, combined or otherwise reconfigured.  
         [0074]    [0074]FIG. 11 a  is a side view of finger assembly  201 . In FIG. 11 a , finger  210  is hidden from view by finger  212 . Fingers  210  and  212  are similar to fingers  10  and  12  (FIG. 1), except that fingers  210  and  212  are cylindrically convex or have a convex cylindrical shape. “Cylindrically convex” means that the diameter of fingers  210  and  212  at end  202  is approximately the same as the diameter at end  204 , but the diameter of fingers  210  and  212  gradually increases from end  202 , at point B, to a maximum diameter at point A (FIG. 11 a ). Point A is approximately at the longitudinal midpoint between end  202  and  204 . The diameter of fingers  210  and  212  at point A is typically twice the diameter of fingers  210  and  212  at point B. However, the diameter of fingers  210  and  212  at point A could be any multiple of the diameter at point B. Thus, fingers  210  and  212  can be said to be cylindrically convex.  
         [0075]    [0075]FIG. 11 b  is an isometric drawing of finger assembly  201  showing fingers  210  and  212  adjacent to the surgical site. In FIG. 11 b , finger  210  is placed on one side of the surgical site  206  and finger  212  is placed on the other side of surgical site  206 . In a method described previously in reference to an earlier embodiment, fingers  210  and  212  may be rotated in a direction which increases the surface tension of the heart surface across the surgical site. The direction and relative magnitude of the surface tension after fingers  210  and  212  is rotated can be represented as arrows  220  through  238  in FIG. 11 b . As can be seen in FIG. 11 b , arrows  224  and  234 , which are approximately at the longitudinal midpoint of fingers  210  and  212 , are significantly longer than arrows  220 ,  228 ,  230 , and  238  which represent the relative surface tension are at the ends of fingers  210  and  212 . Thus, the surface tension in the middle of the site is greater than at the edges. This increase in surface tension at the center of the surgical site is due to the fact that a portion of finger  210  at the midpoint must travel a greater distance than the portion of finger  210  at ends  202  or  204  for the same amount of angular rotation.  
         [0076]    This concept is illustrated in FIG. 11 c , which is a front view of finger  212 . Point B is a point at end  202  on the outer circumference of finger  212 . Point A is also on the outer circumference of finger  212 , but close to the longitudinal midpoint of finger  212  (FIG. 11 a ). As illustrated in FIG. 11 c , when finger  212  is rotated about its longitudinal axis through an angle a, point B moves to point B′. Similarly, point A moves to A′. Point A moves more than point B. In fact, the greater the relative diameter of the circumferences, the greater the relative movement between point A and point B along their respective circumferences. This increase in movement causes a corresponding increase in surface tension. Thus, the surgeon can increase the surface tension in the middle of the surgical site (FIG. 11 b ).  
         [0077]    [0077]FIG. 12 a  is a side view of finger assembly  201 , however, in this embodiment the finger elements are replaced with fingers  310  and  312 . In FIG. 12 a , finger  310  is hidden from view by finger  312 . Fingers  310  and  312  are similar to fingers  10  and  12 , except that fingers  310  and  312  are cylindrically concave or have a concave cylindrical shape. “Cylindrically concave” means that the diameter of fingers  310  and  312  at end  302  is approximately the same as the diameter at end  304 , but the diameter of fingers  310  and  312  gradually decreases from end  302 , at point C, to a minimum diameter at point D. Point D is approximately at the longitudinal midpoint between end  302  and  304 . The diameter of the fingers at point C could be any multiple of the diameter at point D, depending on the amount of relative surface tension desired and the material used.  
         [0078]    [0078]FIG. 12 b  is an isometric drawing of finger assembly  201  showing fingers  310  and  312  adjacent to the surgical site. In FIG. 12 b , finger  310  is placed on one side of the surgical site  206  and finger  312  is placed on the other side of surgical site  206 . In a procedure similar to the one described in the first embodiment, fingers  310  and  312  are be rotated in a direction which increases the surface tension of the heart surface across the surgical site. The direction and relative magnitude of the surface tension of the heart surface is represented in FIG. 12 b  as arrows  320  through  338 . As can be seen in FIG. 12 b , arrows  324  and  334 , which are approximately at the longitudinal midpoint of fingers  310  and  312 , are significantly shorter than arrows  320 ,  328 ,  330 , and  338  which represent the surface tension at the ends of fingers  310  and  312 . This decrease in surface tension at the center is due to fact that the portion of finger  310  at the longitudinal midpoint travels a shorter distance than the portion at ends  302  or  304  for the same amount of angular rotation. The surgeon, therefore, can thus decrease the surface tension in the middle of the surgical site relative to the outside area of the surgical site.  
         [0079]    [0079]FIG. 13 a  is a side view of finger assembly, however, in this embodiment the finger elements are replaced with fingers  410  and  412 . Fingers  410  and  412  have a camber on one side to form a cam shaped cross-section. Fingers  410  and  412  are cylindrically cam-shaped , which means that the diameter of fingers  410  and  412  at end  402  is approximately the same as the diameter at end  404 , but the diameter of fingers  410  and  412  gradually increases eccentrically from end  402 , at point E, to a maximum diameter at point F. Point F is approximately at the longitudinal midpoint between end  402  and  404 .  
         [0080]    [0080]FIG. 13 b  is a front view of finger  412 . In this view, end  402  is shown as circle  406 . Outline  408  represents the cross-sectional outline of finger  412  at approximately point F (FIG. 13 a ). As illustrated in FIG. 13 b , the cross-sectional shape of finger  412  is that of an eccentric cam.  
         [0081]    This embodiment allows the amount of surface tension to be vary, depending on the circumstances and the surgeon&#39;s preferences. If the surgeon feels that greater tension across the middle of surgical site is important, the surgeon can position fingers  410  and  412  with camber side  414  down facing the heart&#39;s surface. On the other hand, if the surgeon desires a more uniform amount of tension across the entire surgical site, the surgeon can keep camber side  414  up, away from the heart.  
         [0082]    As explained previously, there are several disadvantages associated with using suction to isolate a surgical site. Regardless of the disadvantages, many surgeons may prefer to use suction to stabilize the heart. One of the primary disadvantages with using suction is that the horizontal surface tension of the heart must be maintained by a vertical suction force. As explained previously, there are disadvantages with using only a vertical suction force maintain a horizontal surface tension.  
         [0083]    This embodiment of the present invention overcomes many of the limitations of the prior art because it addition to the vertical suction force. this embodiment also increases the surface tension by using a horizontal rotating force.  
         [0084]    Turning now to FIG. 14 a , which is a side view of an embodiment which uses suction to attach the finger elements to the surface of the heart. Because this is a side view, finger  1410  is hidden from view by finger  1412 . In this embodiment, finger  1412  is partially surrounded by a cylindrical cover  1418 .  
         [0085]    [0085]FIG. 14 b  is an exploded view of FIG. 14 a . Finger  1412  is a hollow cylinder which as a plurality of has longitudinal slits  1414  around its perimeter. Finger  1412  also has attachable portion  1434  which, similar to the first embodiment. fits securely in cylinder  1444  of the handle  1414 . However, in this embodiment. attachable portion  1434  is hollow and has connection  1420  at one end. Vacuum tube  1422  fits tightly over connection  1420  such that a hermetic seal is created between vacuum tube  1422  and connection  1420 . Similar to previous embodiments, sleeve  20  fits over cylinder  1444  and is restrained by O-ring  24 .  
         [0086]    [0086]FIG. 14 c  is a section view through fingers  1410  and  1412 . Fingers  1410  and  1412  have hollow cylindrical openings  1426  and  1428  running longitudinally through their respective centers. Slits  1414  form a plurality of ribs  1416  and  1417  within the perimeter walls of fingers  1410  and  1412 . Of course, slits  1414  could be a variety of shapes. Also shown in FIG. 14 c , are covers  1418  and  1419  which partially surrounds fingers  1410  and  1412 . Each of covers  1418  and  1419  have a single large slit  1422  and  1424 . Fingers  1410  and  1412  rotate within and relative to covers  1418  and  1419 .  
         [0087]    [0087]FIG. 14 d  is a section view of fingers  1410  &amp;  1412  adjacent to the surface of a heart. In operation, a vacuum pump or source (not shown) is attached to vacuum tube  1422  (FIG. 14 b ) which creates a low pressure or suction in vacuum tube  1422 . This low pressure is transferred through the hollow portion of attachment portion  1434  to cylindrical openings  1426  and  1428 . The low pressure causes a suction force in slits  1414  which allow fingers  1410  and  1412  to attach to heart surface  1430  through suction as shown in FIG. 14 d . Finger  1410  can then be rotated with respect to finger  1412  and vice versa. This rotation causes a horizontal surface tension or stretching in the direction represented by arrows  1434  and  1432 , and thus the surgical site can be stabilized by a lateral force—not a vertical force as in the prior art.  
         [0088]    Various clinging accessories may be used to attach fingers  10 ,  12 ,  210 ,  212 ,  310 ,  312 .  410 , and  412  to the surface tissue of the heart. The clinging accessory previously shown uses plurality of tines  30  in FIGS.  1 - 4 ,  7 - 8 ,  11 - 13 . As previously discussed, tines  30  are only one form of a variety of clinging accessories that could be used with any form of the previous embodiments. Other clinging accessories (such as suction holes, suction cups, rough textured surfaces (such as sandpaper), barbs, or electrostatic attachment, for example) may be used with any embodiment of the present invention. It is understood that as fingers are gently pressed against the heart, they do not penetrate the heart surface but instead engage the surface in a manner that enables manipulation of tissue without tissue damage.  
         [0089]    Nylon or other forms of plastic tines, for instance, may be less traumatic to the heart tissue than the use of stainless steel or tungsten carbide tines. FIG. 15 a  is a front view of an embodiment of a finger assembly with the fingers  10  and  12  (FIG. 2), however finger  10  is surrounded by a plurality of nylon hooks  1502  and finger  12  is surround by a plurality of nylon hooks  1504 , hooks  1502  and  1504  are similar to that used in a Velcro™ fastening system. Hooks  1502  and  1504  are approximately 0.050 inches in length. Hooks  1502  and  1504  are designed to minimize heart surface engagement. The hooks are of a stiffness so that should a stretching rotation require the releasing of the tines from the heart surface, they may release without ripping the heart surface, and then engage the heart surface at a new location, if necessary. Also, it should be noted that the tines point generally in the direction of the grabbing rotation.  
         [0090]    Another embodiment of clinging accessory is illustrated in FIG. 15 b , which employs a plurality of straight nylon tines or bristles  1508  surrounding finger  12  and nylon bristles  1506  surrounding finger  10 . Bristles  1506  and  1508  gently engage into the heart tissue. Of course, bristles  1506  could also be made out of any type of plastic or stainless steel.  
         [0091]    [0091]FIG. 15 c  is a front view of fingers  10  and  12  where the finger elements are surrounded by a plurality of nylon tines or bristles  1510  and  1512 , respectively. In this embodiment, bristles  1510  and  1512  have tiny balls or spheres  1514  at the protruding end of the bristles. The diameter of the balls are larger than the diameter of the bristles. These different embodiments have unique advantages and disadvantages and offer the surgeon more choices based on personal preferences. For instance, bristles  1508  and  1506  offer better traction than bristles  1510  and  1512 . However, bristles  1510  and  1512  reduce trauma to the heart tissue.  
         [0092]    [0092]FIG. 15 d  is a cross section view of fingers  10  and  12  adjacent to heart tissue  1520 . In this embodiment, a plurality of straight nylon bristles  1516  and  1514  are used as the clinging accessory, however bristles  1516  and  1514  use bristles of a progressively different degree of length. As illustrated in FIG. 15 d , bristles  1516  and  1514  are longer on the top side of fingers  10  and  12  than the bristles on the bottom side. The length of each radial row of bristles vary according to the radial or angular position of each row at the perimeter of the surface of the finger. As shown in FIG. 15 d , the shorter bristles are pointed towards heart tissue  1520 . Similarly, FIG. 15 e  is a cross section view of fingers  10  and  12  adjacent to fat tissue  1522  and heart tissue  1520 . In this figure, the longer bristles of bristles  1516  and  1514  pointed down towards the heart tissue. This embodiment provides the surgeon with the option of varying the degree of engagement into the heart or fat tissue.  
         [0093]    Depending on the condition and location of the surgical site, heart tissue  1520  may be surround by fat tissue  1522  (FIG. 15 e ). On the other hand, if little or no fat tissue surrounds the surgical site, the surgeon can simple rotate fingers  10  and  12  so that the shorter bristles are adjacent to heart tissue  1520 , as illustrated in FIG. 15 d.    
         [0094]    As discussed previously. the finger elements use clinging accessories to “grab” the tissue of the heart. The clinging accessories can be hooks, tines, bristles or other rough surfaces. These clinging accessories may tend to catch and snag sutures used by surgeons during the procedure. To avoid snagging of sutures, gloves, and transplanted arteries, a suture guard may be positioned over the finger elements. Such a device is illustrated in FIGS. 16 a.    
         [0095]    [0095]FIG. 16 a  is an isometric view looking down upon finger assembly  36  as it is attached to suture guard  1602 . FIG. 16 b  is an exploded isometric view of FIG. 16 a  showing how suture guard  1602  fits between sleeve  20  and  22 . Suture guard  1602  can be made of metal, plastic or any other acceptable material. Plastic is the preferred embodiment because it can be molded into intricate shapes easily, is lightweight, and it can be clear. Using clear plastic allows the surgeon to see through suture guard  1602 , which allows the surgeon to see as much of the surgical site as possible. FIG. 16 c  is an isometric view looking up at the bottom of finger assembly  36  when it is attached to suture guard  1602 . FIG. 16 d  is an exploded view of FIG. 16 c.    
         [0096]    Turning now to FIG. 16 d , the suture guard  1602  has fins  1604  through  1609  which are shaped to press against the outside perimeter surface of the sleeves  20  and  22 . This dual pressure against the sleeves  20  and  22  restrains the suture guard  1602  and prevents the suture guard  1602  from slipping off the sleeves  20  and  22 . The suture guard  1602  also has a plurality of elements or legs  1612  and  1614 , which cantilever over fingers  10  and  12  to protect any sutures from tines  30 . The legs  1612  and  1614  are generally parallel or longitudinally aligned with the fingers  10  and  12 . In this embodiment, the legs  1612  and  1614  have a cross-sectional shape of an arc. An arc cross-sectional shape allows the legs to closely follow the contours of the fingers  12  and  10  while minimizing any visual obstruction to the surgical site. The legs  1612  and  1614  are attached and supported by the fin  1608  which is attached to a connecting member  1607 . Connecting member  1610  connects the fins  1608 ,  1606 , and  1604 , and thus, distributes and transfers any force from the cantilevered the legs  1612  and  1614  to the fins  1606  and  1604 .  
         [0097]    [0097]FIG. 17 a  is an isometric drawing of finger assembly  36  attached to an embodiment of the suture guard with a blower. In this embodiment, suture guard  1702  has spray tubes  1704  and  1706  along the inside edge of the legs  1712  and  1714 . The spray tubes  1704  and  1706  have a plurality of openings or nozzles  1708 . The spray tubes  1704  and  1706  may be independent of legs  1712  or  1714  or they may be molded together, and thus become integral with legs  1712  and  1714 . In another embodiment, the legs  1712  and  1714  could simply be hollow and have a plurality of nozzles along the inside edge.  
         [0098]    Spray tubes  1704  and  1706  are hermetically joined with y-connection  1710  to pressure tube  1718 . Pressure tube  1718  is a flexible plastic or rubber tube capable of delivering a pressurized fluid from a supply of saline solution, water, air and/or carbon dioxide (FIG. 17 b ) to spray tubes  1704  and  1706 . The pressurized fluid exits through nozzles  1708 . Nozzles  1708  are positioned, or “aimed” at the surgical site such that when a fluid flows through them. a plurality of sprays are created which washes the surgical site.  
         [0099]    [0099]FIG. 17 b  is a combination top view and schematic view of suture guard  1702  attached to finger assembly  36 . Finger assembly  36  is mounted on a flexible arm assembly  190 , which includes a universal retractor mounting  194  and variable tension lock  195 . As discussed previously, universal retractor mounting  194  mounts to chest retractor  110  (FIG. 1 a ). Pressured tube  1718  is shown running alongside of flexible arm assembly  190 . It is important to note, that in another embodiment, pressured tube  1718  could also be incorporated into flexible arm assembly  190 . Attachment connection  1716  is either attached to or integral with universal retractor mounting  194 . Attachment connection  1716  connects pressurized tube  1718  with attachment tube  1719 . Attachment tube  1719  is connected to water/air supply  1724 . Between water/air supply  1724  and attachment connection  1716  is stop lock  1722  and metering valve  1720 , all fluidly connected via attachment tube  1719 .  
         [0100]    Water/air supply  1724 , known in the art, can be a saline bag combined with a gas source, such as carbon dioxide or air. The gas in the source is kept under pressure. Furthermore, there is a certain amount of head pressure in the saline if the saline is hangs above the surgical site. This combined pressure causes the fluid, which is a combination of gas and saline to flow through attachment tube  1719 . Stop lock  1722  cuts off the fluid in the event that metering valve  1720  cannot control the flow of fluid through attachment tube  1719 . Under normal circumstances, however, metering valve  1720  controls the flow of fluid through pressured tube  1718 , and ultimately, to nozzles  1708  (FIG. 17 a ). Metering valve  1720  is a roller clamp valve and is well known in the art.  
         [0101]    The fluid continues to move through attachment tube  1719  to pressured tube  1718 . Pressured tube  1718  joins spray tubes  1704  and  1706  and v-connector  1710  (FIG. 17 a ). As previously discussed, the fluid then moves through spray tubes  1704  and  1706 , out nozzles  1708  in the form of a fine spray (FIG. 17 a ). The fine spray washes the surgical site.  
         [0102]    Though the invention has been described with respect to a specific preferred embodiment, many variations and modifications will become apparent to those skilled in the art upon reading the present application. It is therefore the intention that the appended claims be interpreted as broadly as possible in view of the prior art to include all such variations and modifications.