Abstract:
An illuminated suction apparatus including a hand-held surgical device combining a high-performance non-fiber optic optical waveguide with suction. This device is useful in a wide array of surgical procedures including open and minimally invasive orthopedics.

Description:
CROSS-REFERENCE 
       [0001]    The present application is a non-provisional of, and claims the benefit of U.S. Provisional Patent Application No. 61/423,813 (Attorney Docket No. 40556-718.101, formerly 028638-001600US) filed Dec. 16, 2010, the entire contents of which are incorporated herein by reference. 
     
    
     BACKGROUND OF THE INVENTION 
       [0002]    In various surgical procedures, illumination of the surgical field is typically achieved through the use of headlamps and surgical microscopes. There are scenarios in which these illumination sources provide lighting that is either poor in quality or poorly directed. As an example, during spinal surgery from the lumbar approach, access to the desired anatomical target area may be achieved through an angled incision on one side of the patient&#39;s midline. Light emanating from an operating microscope is static and may be poorly directed relative to the angle of surgical access. Conversely, light from a headlamp may be adjusted as a physician tilts or moves his head to redirect the output beam, but still may be blocked by various anatomical structures such as the spinous process or layers of tissue and muscle. Lighting from either source may not be adequate as the physician progresses through various phases of the procedure requiring visualization of the anatomy at varied depths from the skin-level incision. 
         [0003]    Hand-held instruments such as suction devices are routinely used during surgical procedures such as spine surgery. These devices are typically connected to a standard suction source in the operating room, enabling the physician to dynamically and efficiently remove blood, bone fragments, or fluid previously irrigated into the surgical site. These suction devices are sometimes also used to provide low force retraction of fat, muscle, or other structures during the procedure. The surgeon holds the suction device from its proximal end, manipulating the distal portion of the suction device during the surgical procedure in order to provide suction at the desired location. Hand-held suction devices are widely available in a variety of distal tip configurations suited to various surgical applications (Frazier, Poole, Fukijima, etc). 
         [0004]    Conventional suction devices have been constructed with fiber optic cable encased in metallic tubing and connected to metallic suction devices to provide some level of illumination. These devices face multiple challenges. Inefficiencies in the fiber-to-fiber coupling with high intensity light leads to light losses at the interface which produces heat. Losses are caused by non-transmissive zones between the optical fibers and Fresnel reflections at the interface. The spatial zones between the fibers are frequently the dominant cause of light loss and heat. Excess heat at the interface can cause thermal damage to the tissues and is also a fire hazard in the operating room. Some manufacturers recommend limiting the amount of light that can be transmitted to the operative device and interface, reducing the inherent heat transmission. 
         [0005]    Therefore improved illuminated suction apparatuses are still needed. At least some of the challenges described above will be overcome by the embodiments disclosed herein. 
       SUMMARY OF THE INVENTION 
       [0006]    The present invention relates generally to the field of surgical illumination and more specifically to illumination systems with integrated surgical tools. 
         [0007]    The devices described below provide improved illumination in a surgical suction device. The illuminated suction device described below includes a metal suction tube having a proximal end and a distal end connected by a central portion. The proximal end of the suction tube is provided with fittings for connection to a vacuum source. The suction tube has an inner surface and an outer surface, with a layer of optical cladding having a refractive index that may be between 1.29 and 1.67 on the outer surface of the central section of the suction tube, and an illumination waveguide having a proximal end and a distal end. The illumination waveguide is formed surrounding the optical cladding on the central portion of the suction tube, and serves to conduct light around the suction tube from the proximal end to the distal end of the illumination waveguide. The illumination waveguide may have a refractive index between 1.46 and 1.7 and may have a numerical aperture between 0.33 and 0.70. An illumination input is formed into the proximal end of the illumination waveguide for conducting light from a source to the illumination waveguide. 
         [0008]    The illuminated suction apparatus includes suction and illumination functions integrated into a hand-held device suited to meet the ergonomic needs of the physician. The hand-held, repositionable suction function already prevalently used in surgical procedures is surrounded by an illuminated waveguide which enables the physician to apply lighting directly to the desired region of the anatomy below the skin regardless of incision angle, depth, and surrounding anatomical obstructions. The illumination waveguide is a solid structure designed to specifically guide light from a high-intensity light source and is fabricated using injection molding of an optical-grade polymer with a specific index of refraction such as cyclo-olefin polymer or copolymer or any other suitable acrylic or plastic. Furthermore, the illumination waveguide can be engineered to efficiently transmit light from its distal output by sheathing or surrounding it with a second material of lower index of refraction properly coordinated to the index of refraction of the core material to preserve Total Internal Reflection (TIR). This solid-state, structure guided illumination waveguide is powered via a fiber optic cable connected to a high intensity light source such as 300 W xenon sources supplied by Luxtec, BFW, and others. 
         [0009]    The illuminated suction apparatus may also include one or more barbs, ridges or other protrusions on the proximal end of the suction lumen enabling the connection of standard PVC surgical tubing or other suitable vacuum conduit. 
         [0010]    The use of a generally solid waveguide for suction illumination, rather than optical fibers, eliminates losses due to the non-transmissive spaces between the optical fibers and reduces losses solely to those associated with Fresnel reflections. The marked reduction in losses associated with a fiber/fiber junction allows for high intensity light transmission to the waveguide without significant heating of the interface or need for heat sink devices or mechanisms at the interface. With a fiber to waveguide connection, light from a standard 300 watt light source can be transmitted with use of standard connectors such as ACMI, with a steady state temperature below the temperatures harmful to body tissue without design alteration. 
         [0011]    Use of total internal reflection and light mixing in an illumination waveguide (also referred to herein as an optical waveguide) enables control of the output light profile and enables custom illumination profiles. Microstructures such as facets, lenses and or lens arrays can be applied to any suitable surfaces of the illumination waveguide and light can be extracted incrementally along the walls of the device with injection molded structures and other suitable structures at minimal added cost. Use of sequential extraction surfaces, changes in the numerical aperture of the device as a function of position, use of extraction structures—either micro or macro structural, with or without changes in the numerical aperture, selective cladding, selective reflective coatings, etc, all can be used to shape the output profile of the waveguide to meet the design specifications or light specifications requested by the user for specific surgical suction illumination applications. 
         [0012]    The device is meant to be disposable, fabricated out of low cost materials to enable leverage of manufacturing efficiencies through use of processes such as high-volume injection molding, over-molding, and metal &amp; polymer extrusion. Device assembly would be engineered to minimize labor costs. A low cost, high-performance combination device provides an attractive alternative to existing discrete illumination and suction devices while minimizing incremental cost to the user. 
         [0013]    The illuminated suction apparatus comprises a hand-held surgical device combining a high-performance illumination waveguide with suction. This device would be useful in various surgical procedures including open and minimally invasive orthopedics. The illumination waveguide may also be combined with other surgical devices such as surgical drills and probes, etc. The illumination waveguide may be fabricated with fiber optic pigtails, index matching liquid and or suction lumens. 
         [0014]    The surgical suction field must be illuminated by the illumination waveguide while the distal suction tip is in active contact with the tissue and or fluid surface. To achieve this effect, the output light from the illumination waveguide must emanate from a point on the waveguide that is proximal to the distal suction tip of the device. Where the design configuration requires the light to exit from the waveguide proximal to the distal tip of the surgical tool, the waveguide shape may be configured to control the numerical aperture of the waveguide and thus, the divergence angle of the exiting light. Similarly, one or more refraction elements such as lenses of any suitable size may be formed in or near the distal end of the waveguide to control the light emitted from the waveguide. In surgery, when using a suction illumination device in which the output light emanates from a point proximal to the distal end of the device, a surgeon may experience difficulty due to glare from the distal tip. 
         [0015]    In an alternate configuration, the distal tip of the suction tube may be configured to transmit light or reflect light such that the surgeon sees the distal tip of the suction as illuminated such that he/she can localize the distal tip of the suction device in their peripheral vision without directly looking at or focusing on the tip of the device. Extending a thin layer of the waveguide to the tip can provide the effect. Strategies that implement this effect include but are not limited to: (a) waveguide extended to the tip with or without surface extraction features to cause light to back reflect or scatter off the tip, (b) Use of a thin layer of optically transmissive material with high scattering coefficient to cause the suction device to glow (c) reflective surfaces applied to the outside of the central suction device (d) reflective surfaces applied with imperfections on the surface to reflect or scatter the light off the outer surface (e) use of a cladding material applied to the walls of the inner suction tube that transmits or scatters a portion of the output light, the input to the cladding being either an imperfection in the cladding or naturally occurring leakage, (f) fluorescent coating on the tip, (g) phosphorescent coatings (h) use of embedded or graded reflectors along or at the tip of the device. Alternatively, the distal tip geometry could be formed to intentionally scatter light (square edges, etc). 
         [0016]    One or more surfaces in an optical waveguide sheath or adapters or connectors may be polarized using any suitable technique such as micro-optic structure, thin film coating or other coatings. Use of polarized light in a surgical environment may provide superior illumination and coupled with the use of complementary polarized coatings on viewing devices such as cameras or surgeon&#39;s glasses may reduce reflected glare providing less visual distortion and more accurate color rendering of the surgical site. One or more surfaces of an optical waveguide sheath may also include light filtering elements to emit light of one or more frequencies that may enhance visualization of specific tissues. 
         [0017]    In a first aspect of the present invention, an illuminated suction device comprises a suction tube having a proximal end, a distal end, and a central portion therebetween. The proximal end is fluidly connectable to a vacuum source, and the suction tube further comprises an inner surface and an outer surface. An inner layer of optical cladding is disposed circumferentially around the outer surface of the central portion of the suction tube, and the device also includes a non-fiber optic optical waveguide. The optical waveguide has a proximal end, a distal end, and a central portion therebetween. Light is transmitted through the waveguide by total internal reflection and the light exits the distal end of the optical waveguide to illuminate a surgical field. The optical waveguide is disposed against the suction tube with the inner layer of optical cladding disposed therebetween. The device also has an outer layer of optical cladding disposed circumferentially around the suction tube and the optical waveguide. 
         [0018]    The suction tube may comprise a tube having a cylindrically shaped cross-section. The distal end of the suction tube may be disposed further distally than the distal end of the optical waveguide. The device may further comprise a suction control mechanism disposed near the proximal end of the suction tube. The suction control mechanism may be adapted to control strength of suction provided by the suction tube. The suction tube may also be electrically conductive and may act as an electrode for conducting an electrical signal. A distal portion of the suction tube main remain free of cladding. A portion of the suction tube may remain unobstructed by the optical waveguide. 
         [0019]    The inner layer of optical cladding may have an index of refraction between 1 and 1.42. The inner layer of optical cladding may form a tube having a substantially circular cross-section. The inner layer of the optical cladding may be concentric with the suction tube. 
         [0020]    The optical waveguide may have a refractive index between 1.46 and 1.70. The optical waveguide may have a numerical aperture between 0.33 and 0.7. The distal end of the optical waveguide may comprise an array of lenses integrally formed in the distal end thereof. The array of lenses may be arranged so that at least a first lens overlaps with a second lens, and such that a spot of light emitted from the first lens overlaps with a spot of light emitted from the second lens. The distal end of the optical waveguide may comprise a plurality of microstructures for extracting light therefrom and the microstructures may be adapted to direct the extracted light to form a pre-selected illumination pattern. The optical waveguide may comprise one or more light extracting structures near the distal end of the waveguide and the light extracting structures may be disposed on an outer surface of the optical waveguide. The light extracting structures may be adapted to extract light from the optical waveguide and they may be adapted to direct the extracted light laterally and distally away from the optical waveguide to form a pre-selected illumination pattern. 
         [0021]    The optical waveguide may have an inner curved surface and an outer curved surface, and the inner curved surface may have a radius of curvature different than that of the outer curved surface. An air gap may be maintained between the suction tube and the optical waveguide. Standoffs may be disposed on the suction tube or on the optical waveguide in order to prevent engagement of the suction tube and the optical waveguide. This helps to maintain the air gap between the suction tube and optical waveguide. The optical waveguide may comprise a polarizing element for polarizing light exiting the distal end of the optical waveguide. The distal end of the optical waveguide may not be flat. Similarly, the optical waveguide may also have a filter element for filtering light so that one or more wavelengths of light are delivered to the illumination area. 
         [0022]    The outer layer of optical cladding may have a refractive index between 1.29 and 1.67. The outer layer of optical cladding may form a tube that is non-concentric with the suction tube. A portion of the outer layer of optical cladding may directly contact a portion of the inner layer of optical cladding. 
         [0023]    The device may further comprise a light conducting conduit that is integrally formed as a single piece with the proximal end of the optical waveguide, and the light conducting conduit may be adapted to introduce light from a light source into the optical waveguide. The light conducting conduit may comprise two light conducting conduits each having substantially rectangular cross-sections. The two light conducting conduits may be integrally formed as a single piece with the proximal end of the optical waveguide. The optical waveguide may be slidably coupled with the suction tube. Therefore, proximal movement of the optical waveguide relative to the suction tube increases spot size of the light exiting the distal end of the optical waveguide. Also, distal movement of the optical waveguide relative to the suction tube decreases spot size of the light exiting the distal end of the optical waveguide. The device may further comprise a handle coupled to the proximal end of the optical waveguide and the proximal end of the suction tube. An air gap may be disposed between the waveguide and an inner surface of the handle. Standoffs may be disposed on an inner surface of the handle or on an outer surface of the optical waveguide in order to prevent engagement of the handle and optical waveguide, thereby helping to maintain the air gap therebetween. 
         [0024]    In another aspect of the present invention, a method of illuminating tissue in a surgical field of a patient comprises providing an illuminated suction apparatus having a suction tube and a non-fiber optic optical waveguide that transmits light therethrough by total internal reflection. The suction tube and optical waveguide are coupled together to form a single handheld instrument. The method also comprises positioning a distal end of the illuminated suction apparatus in the surgical field, and illuminating the surgical field by extracting light from the optical waveguide. Light extraction features disposed on a distal end or an outer surface of the optical waveguide are used to extract the light, and also to direct the extracted light to form a pre-selected illumination pattern in the surgical field. While illuminating the surgical field, fluid or debris may be suctioned from the surgical field with the suction tube. 
         [0025]    The illuminated suction apparatus may comprise an inner layer of optical cladding that is disposed around the suction tube. The inner layer of optical cladding may be disposed between the suction tube and the optical waveguide. An outer layer of optical cladding may be disposed around both the suction tube and the optical waveguide. 
         [0026]    The distal end of the illuminated suction apparatus may be positioned into engagement with the tissue while a distal end of the optical waveguide does not engage the tissue. A distal end of the optical waveguide may comprise an array of lenses integrally formed therein. Illuminating the surgical field may comprise projecting a spot of light from each lens in the array such that at least a first spot of light overlaps with a second spot of light in the surgical field. Illuminating the surgical field may also comprise extracting light from the optical waveguide with one or more light extracting structures. The extracted light may be directed laterally and distally away from the optical waveguide. Illuminating the surgical field may comprise illuminating the surgical field with polarized light. Illuminating the surgical field may comprise filtering light delivered by the waveguide so that one or more wavelengths of light are delivered to the surgical field. 
         [0027]    The method may further comprise controlling suction strength provided by the suction tube with a suction control mechanism. The method may also comprise stimulating the tissue with electrical current delivered by the suction tube. The optical waveguide may be slidably positioned relative to the suction tube thereby allowing an increase or decrease in spot size of the extracted light on the tissue. 
         [0028]    In still another aspect of the present invention, a method of manufacturing an illuminated suction apparatus comprises providing a suction tube having a proximal end, a distal end, a central section disposed therebetween, an inner surface and an outer surface, and providing a non-fiber optic optical waveguide having a proximal end, a distal end, and an outer surface. The optical waveguide transmits light therethrough by total internal reflection. An inner layer of optical cladding is fit over the outer surface of the central section of the suction tube, and the optical waveguide is coupled with the suction tube with the inner layer of optical cladding disposed therebetween. An outer layer of optical cladding is fit over the outer surface of the suction tube and over the outer surface of the optical waveguide. 
         [0029]    The suction tube may comprise a tube having a circular cross-section. The optical waveguide may have a first curved side with a first radius of curvature and a second curved side with a second radius of curvature. The first radius of curvature may be different than the second radius of curvature. Fitting the inner layer may comprise heat shrinking the inner layer onto the suction tube. Coupling the optical waveguide with the suction tube may comprise disposing the suction tube in an elongated open or closed channel disposed along the optical waveguide. Fitting the outer layer may comprise heat shrinking the outer layer onto the suction tube and the optical waveguide. 
         [0030]    These and other aspects and advantages of the invention are evident in the description which follows and in the accompanying drawings. 
       INCORPORATION BY REFERENCE 
       [0031]    All publications, patents, and patent applications mentioned in this specification are herein incorporated by reference to the same extent as if each individual publication, patent, or patent application was specifically and individually indicated to be incorporated by reference. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0032]    The novel features of the invention are set forth with particularity in the appended claims. A better understanding of the features and advantages of the present invention will be obtained by reference to the following detailed description that sets forth illustrative embodiments, in which the principles of the invention are utilized, and the accompanying drawings of which: 
           [0033]      FIG. 1  is a perspective view of an illuminated suction apparatus. 
           [0034]      FIG. 1A  is a cross-section view of the illuminated suction apparatus of  FIG. 1  taken along A-A 
           [0035]      FIG. 1B  illustrates an exemplary embodiment of an illuminated suction apparatus with electrodes. 
           [0036]      FIG. 2  is a close up perspective view of the distal end of the illuminated suction apparatus of  FIG. 1 . 
           [0037]      FIG. 2A  is a close up view of a single lens from the lens array of  FIG. 2 . 
           [0038]      FIG. 3  is a perspective view of an illuminated suction apparatus with a handle. 
           [0039]      FIG. 4  is a cross section view of the distal end of the illuminated suction apparatus of  FIG. 3  taken along B-B. 
           [0040]      FIG. 4A  illustrates an exemplary embodiment of light extraction from a lateral surface of the illuminated suction apparatus. 
           [0041]      FIG. 5  is a cross section view of an illumination conduit input according to the present disclosure. 
           [0042]      FIG. 6  is a side view of an alternate illumination conduit. 
           [0043]      FIGS. 6A ,  6 B and  6 C are various cross-section views of the alternate illumination conduit of  FIG. 6 . 
           [0044]      FIG. 6D  is a perspective view of access port of the alternate illumination conduit of  FIG. 6 . 
           [0045]      FIG. 7  is perspective view of the illumination input of an alternate illumination conduit. 
           [0046]      FIG. 8  is perspective view of the illumination input of another alternate illumination conduit. 
           [0047]      FIG. 9  is a perspective view of an illuminated suction apparatus with a handle. 
           [0048]      FIG. 10  is a cross section view of the illuminated suction apparatus of  FIG. 8  taken along C-C. 
           [0049]      FIG. 11  is a cross section view of the handle of the illuminated suction apparatus of  FIG. 10  taken along D-D. 
           [0050]      FIG. 12  is a perspective view of an alternate illuminated suction apparatus. 
           [0051]      FIG. 13  is a perspective view of another alternate illuminated suction apparatus. 
           [0052]      FIG. 14  is another exemplary embodiment if an illuminated suction apparatus. 
           [0053]      FIGS. 14A-14B  illustrate exemplary geometries of a waveguide. 
           [0054]      FIGS. 15A-15C  illustrate an exemplary embodiment of an illuminated suction apparatus with an adjustable illumination waveguide. 
           [0055]      FIG. 16  illustrates an exemplary cross-section of an illuminated waveguide apparatus. 
           [0056]      FIG. 17  illustrates another cross-section of an illuminated waveguide apparatus. 
       
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
       [0057]    Referring to  FIGS. 1 ,  1 A,  2  and  2 A, illuminated suction apparatus  10  includes suction tube  12  made of any suitable material such as aluminum, stainless steel or any suitable acrylic or other polymer. Suction tube  12  encloses suction lumen  12 L. Illumination waveguide  14  is secured over cladding layer  15  on central portion  12 A of suction tube  12  leaving input or proximal portion  12 P and distal portion  12 D exposed. Illumination waveguide  14  may have one or more sides, surfaces or other portions that are configured such as flat side  14 S or side  14 T to optimize light mixing as light  11 L travels from illuminator input end  14 P to exit through light output face, or distal face  14 F on output end  14 D. 
         [0058]    Illumination waveguide  14  is made of an optical grade engineering thermoplastic such as cyclo olefin polymer which efficiently transmits light. Any other suitable material such as Cyclic Olefin Copolymer, Polycarbonate, Acrylic and or TPC may also be used. The angles and bends of the waveguide structure are engineered so light transmits through the waveguide via total internal reflection (TIR). The side walls and other features have angles and flat areas such that light is mixed and not allowed to escape until it reaches the distal end  14 D of the waveguide and exits with a selected uniformity. Light that is reflected by TIR is internally reflected with high efficiency (nearly 100% efficiency). Suction tube  12  introduces a curved interface with illumination waveguide  14  that changes the angle of reflection and creates unwanted scatter of the light. Thus an uncoated or untreated suction tube will cause a small portion of light to be lost to absorption and or scattering at each reflection, ultimately resulting in poor light transmission efficiency. In order to preserve TIR through the waveguide, cladding material  15  with a specific index of refraction is placed between the suction tube and the waveguide. TIR can also be potentially disrupted by blood or foreign matter from the surgical site coming into contact with exterior exposed surface  14 X of illumination waveguide  14 . Exterior cladding layer  15 X having a specific refractive index can also be attached to the outside of the waveguide. The waveguide material may or may not completely surround suction tube  12  in order to provide an illumination pattern from distal end  14 D unobstructed by a shadow from the metallic or malleable plastic suction tube. The waveguide and TIR-preserving materials are chosen to provide an optimized light exit angle, total light output, and illumination suited to properly visualize the surgical site. Suction tube  12  could be treated (for example anodized in the case of aluminum) in order to reduce glare or reflections resulting from interaction with light output from the illuminator. 
         [0059]      FIG. 1B  illustrates an alternative embodiment of an illuminated suction apparatus  10   a  having electrodes. One or more electrodes  13   e  may be disposed on a distal portion of the suction tube  12 , and/or one or more electrodes  15   e  may be disposed on a distal portion of the waveguide  14 . The electrodes allow the illuminated suction apparatus to be used as a probe for stimulating various tissues such as nerves, or for cauterizing tissue. Wires or other conductors may couple the electrodes to the proximal end of the illuminated suction apparatus  10   a  which may then may be coupled with an energy source that provides the current delivered by electrodes  13   e  or  15   e . The electrodes may be attached to the outer surface of the suction tube, or a portion of the outer cladding  15  may be removed to allow the metal suction tube to be exposed and used as an electrode. Thus, the suction tube itself may be used as a conductor and electrode. Similarly, electrodes may be attached to the outer surface of the waveguide, or a portion of the cladding  15 X may be removed to allow portions of the waveguide to be exposed and used as an electrode if conductive, or the electrodes may be coupled to the waveguide. The illuminated suction apparatus may then be operated in monopolar or bipolar mode. 
         [0060]    In an alternate configuration, distal face  14 F of waveguide  14  may include any suitable surface treatment to control how light  11 L forms illumination pattern  19 . One or more lenses, or lens arrays such as lens array  24  may be formed on distal face  14 F. Suitable optical features such as lens array  24  may include lenses of identical, similar or different shapes and sizes to produce the desired illumination pattern or patterns. Combinations of lens shapes and radii may be used to optimize lens arrangement on the distal or output face of the waveguide. The lens array may include lenses on any portion of distal face  14 F. Distal face  14 F is generally planar and may be described with respect to orthogonal axes  26 X and  26 Y. Individual lenses of lens array  24  may also be oriented differently, i.e. have a different pitch, relative to planar axes  26 X and  26 Y. In one exemplary embodiment, a plurality of lenses is disposed on the distal face  14 F. Light is projected from each lens distally toward the surgical field in an illumination pattern. The pitch of the lenses may be adjusted such that the illumination patterns are discrete and separate from one another, or the pitch of the lenses may be adjusted such that the illumination patterns overlap with one another. Overlapping illumination patterns help eliminate non-uniform illumination that results from optical defects in the lenses and/or waveguide. Optical defects may be caused by parting lines, gates, scratches, etc. in the optical waveguide and lenses. By overlapping illumination patterns, the non-uniformities are “covered up” or “washed out” by other illumination patterns provided by adjacent lenses in the lens array. Additional details about this feature are disclosed below. 
         [0061]    Individual lenses such as lens  24 A may adopt any suitable geometry and may be curved or faceted with one or more facets such as facets  25 . Polygonal shapes such as lens  24 A allow the lenses to be located immediately adjacent to each other eliminating undirected light leakage between the lenses. 
         [0062]    In still other embodiments, the distal end of the waveguide may be flat or it may be curved (convex or concave) in order to help shape and direct light to the surgical field. Polarizing elements or filters may also be coupled to the distal end so that the waveguide delivers polarized light to the surgical field which may be advantageous in preferentially visualizing certain tissues. The polarizing elements may also be a wire grid polarizer. 
         [0063]      FIG. 14  illustrates another exemplary embodiment of an illuminated suction apparatus  1400 . The illuminated suction apparatus  1400  includes an illumination waveguide  1410  disposed adjacent a suction tube  1402 . The suction tube may be formed of malleable metal or another malleable material such that it has a straight relatively rigid distal section  1402   r , and a pre-bent flexible proximal section  1402   f . The suction tube  1402  may be joined to a flexible tubing  1406  that fluidly connects the suction tube  1402  to a vacuum source (not illustrated) and thus the distal tip  1404  of the suction tube  1402  may be used to remove fluid or other material from the surgical field. Illumination waveguide  1410  is preferably a non-fiber optic waveguide (preferably as are any of the waveguides described herein). The waveguide may be cylindrical as illustrated in  FIG. 14 , or it may have other profiles such as a square cross-section, rectangular, oval, elliptical, ovoid, etc., or any of the other geometries described herein. The pre-bent malleable section  1402  allows a surgeon or other operator to bent the suction device so that it can access various surgical sites and accommodate differing anatomies. Another possible cross-section for the illumination waveguide is illustrated in  FIGS. 14A-14B  where the height h of the waveguide  1410   a  tapers down such that the proximal end is higher than the distal end. Also, the width of the waveguide  1410   a  may also increase from the proximal end to the distal end as seen in  FIG. 14B . This geometry results in a trumpet shaped waveguide having a lower profile so that it may fit in a smaller incision and take up less space in the surgical field. 
         [0064]    In the embodiment illustrated in  FIG. 14 , the illumination waveguide therefore has a flat upper surface and a flat lower surface, as does the suction tube  1402 . Therefore, the bottom surface of the illumination waveguide lays flush against the upper surface of the suction tube. An outer sheath  1414  such as heat shrink may then be used to hold the illumination waveguide and suction tube together. The outer sheath  1414  may be selected to have desirable optical properties in order to minimize loss of light. For example, FEP heat shrink has a desirable index of refraction so that light is transmitted along the waveguide  1410  and then extracted from the distal portion  1412  using any of the extraction features described herein. The outer sheath  1414  may also be a tight fitting polymer sheath that is stretched over the waveguide and suction tube, and may not be heat shrink tubing. Additionally, a separate layer of cladding such as heat shrink tubing or tightly fitting tubing (not illustrated) that can be stretched may be disposed over the suction tube in order to minimize light loss caused by contact between the suction tube and the illumination waveguide. The separate layer of cladding may be FEP tubing or any of the other materials described herein, and preferably is disposed entirely around the circumference of the suction tube. A fiber optic cable  1408  couples the illumination waveguide with an external light source (not shown). The fiber optics cable in this embodiment is preferably integral with the waveguide (e.g. injection overmolded together) so as to be fixedly connected to one another. In alternative embodiments, the fiber optic cable is releasably connected to the waveguide. By joining the fiber optic cable  1408  to the waveguide near the connection point between the suction tube and flexible tubing  1406 , allows the surgeon or operator to easily flex or otherwise manipulate the suction tube without interference from the fiber optic cable. The fiber optic cable  1408  may be coupled with the waveguide  1402  such that when the malleable bent portion  1402  is bent, the fiber optic cable  1408  bends with the suction tube  1402   f , or in other embodiments, the fiber optic cable  1408  need not be coupled with the bent malleable portion  1402   f  and may hang freely and independently of the suction tube. 
         [0065]    In any of the embodiments disclosed herein, the waveguide position along the suction tube may be adjustable. For example, in  FIG. 15A  illuminated suction apparatus  1500  includes an illumination waveguide  1502  coupled to a fiber optic cable  1504 . The illumination waveguide  1502  is slidably disposed over suction tube  1506  which is connected to flexible vacuum tubing  1508 . The waveguide may slide proximally or distally relative to the suction tube  1506  and this permits regulation of light output spot size and brightness in the surgical field. In  FIG. 15B , the waveguide  1502  is advanced distally relative to the suction tube  1506  thereby resulting in a smaller spot of light  1510  and a more brightly lit distal tip of the suction tube and surgical field. In  FIG. 15C , the illumination waveguide is retracted proximally relative to the suction tube and thus the light spot size  1510  is larger and more diffuse than in  FIG. 15B  and therefore less brightly lighting up the distal tip of the suction tube as well as less brightly illuminating the surgical field. The waveguide  1502  in  FIG. 15A  may have a circular cross-section or it may have other cross-sections such as flat, curved, rectangular, or any of the cross-sections disclosed herein. In some embodiments, the waveguide has a concave inner surface that forms a saddle for receiving the suction tube, and a convex outer surface. This allows the waveguide to be mated with the suction tube with a low profile, as discussed herein with respect to  FIG. 16 . 
         [0066]    Referring now to  FIG. 3 , Light  11 L from light source  11  is conducted to the illumination waveguide using any suitable apparatus such as fiber optic cable  11 C and is then conducted through waveguide  14  and exits from any appropriate structure or structures on or near distal end  14 D of the waveguide. Alternatively, the light source, such as an LED could be integrated into the suction handle eliminating the need for a fiber optic connection. Vacuum from suction source  13  is conducted to illuminated suction apparatus  20  using any suitable suction tube such as tube  13 T which is connected to vacuum input  22 P. The vacuum available at the distal end of suction tube  12  may be controlled by covering all or a portion of suction hole H in handle  22 . 
         [0067]    Illuminated suction apparatus  10  may be integrated into a handle such as handle  22  made of relatively low-cost engineering plastic such as ABS or polycarbonate. Handle  22  may be formed from two or more components that could be separate injection molded components designed to be snap fit, glued, or ultrasonically welded together. Alternatively, the handle could be formed over an illuminated suction apparatus such as apparatus  10  through an over-molding process. The proximal portion of the combined device such as illuminated suction apparatus  20  would also contain a hole, hole H, properly positioned to allow the surgeon to enable the suction function by obstructing all or a portion of the hole with a finger; the hole communicates with the suction pathway in the device, disabling suction by creating a “suction leak” when it is not blocked. Varying the hole geometry, as in the case of Fukijima suction, affords finer modulation of the suction function. The proximal end of handle  22  may also contain inputs for a traditional fiber optic cable to be attached to illumination waveguide  14 , such as a male ACMI connection or other suitable connector, and a vacuum port such as vacuum port  22 P which may be a barbed fitting suitable for standard flexible suction PVC suction tubing of various sizes to be attached. The fiber optic cable is attached to a high-intensity light source such as light  11 . Suction tube  13 T is attached to any standard vacuum source in the OR such as a waste collection container with integrated vacuum pump such as vacuum source  13 . 
         [0068]    Referring now to  FIG. 4 , light beam  11 B exits waveguide distal face  14 F at a specific angle based on the optical properties such as the numerical aperture (NA) of the input source, index of refraction of the material, and shape of the waveguide. Light pattern  19  cast onto the target surgical field is optimized based on the specific distance  16  the illuminator is set back from the distal tip  12 D of the suction tube. For a given light source configuration, divergence angle  18  of light beam  11 B results in a specific illumination pattern  19  with a total light output and illumination size  17  at any target plane normal to the illuminator such as plane  21 . The plane at the distal tip of the suction tube is of particular interest, since the physician will place the distal tip at the desired surgical target to enable suction or retract tissue. 
         [0069]      FIG. 4A  illustrates an alternative embodiment of an illuminated suction apparatus having light extraction features  23  on a lateral surface of the illumination waveguide that extract light  25  and direct the light  25  laterally and distally toward the surgical field. This may feature may be used alone or in combination with the distal features previously described above. The extraction features may include prisms, lenses, lenslets, multiple facets, or other surface features known in the art that extract light from the waveguide and direct the light to a desired area in a desired pattern. The extraction features may be disposed in a discrete area to extract light only from that area, or the extraction features may be disposed circumferentially around the waveguide so that a uniform ring of light emits from the waveguide. Using both lateral extraction features and distal light features allows diffuse light to emit from the lateral surfaces of the waveguide while more focused light can be emitted from the distal tip of the waveguide. 
         [0070]    Referring now to  FIG. 5 , light source  11  is transmitting light  11 L into cyclo olefin polymer core  30  with refractive index  1 . 52 , fluorinated ethylene propylene (FEP) cladding  32  with refractive index  1 . 33 , and an external environment  34  surrounding cladding  32 . Light source  11  is assumed to be in air with a refractive index of 1 and a numerical aperture (NA) of 0.55 which corresponds to a half-cone angle, angle  36 , of 33.4 degrees. The NA of source  11  is the angle of incidence on the core when light  11 L is coupled in which corresponds to angle  37 . Internal light rays  31  initially enter core  30  at the half cone angle of 33.4 degrees and are refracted at an angle of 21.2 degrees, internal refraction angle  39  when they pass into core  30 . Internal light  31  then intersects core-cladding boundary  40  at an angle of 68.8 degrees which is angle  41 . As long as angle  40  is greater than the critical angle determined by the core and cladding indexes, light  31  will undergo TIR and none of light  31  will be transmitted into the cladding. In this case (n-core=1.52 &amp; n-cladding=1.33) the critical angle is 61.0 degrees. 
         [0071]    This ray trace can be worked backwards from the critical angle to determine the maximum source NA that will still allow for all light to undergo TIR at the core-cladding boundary. If reflection angle  41  is 61.0 degrees which corresponds to the critical angle for the selected core and cladding, then internal refraction angle  39  is 29 degrees which means that angle  37  must be 47.4 degrees. From 47.4 degrees, the source NA is calculated to be 0.74. Therefore, when using the cyclo olefin polymer/FEP combination, an input source with a much higher NA/Efficiency can be used. 
         [0072]    If the source NA is such that all the light coupled into the waveguide undergoes TIR at the core-cladding boundary, then no light is propagating in the cladding and the environment index does not affect the waveguide transmission and no light is hitting the cladding-environment boundary. The data in the following table shows how the critical angle changes at the core-cladding boundary as the cladding index changes from 1.0 to 1.46 for a cyclo olefin polymer core (n=1.52). This is particularly relevant when designing refractive structures. Knowing the critical angle ahead of time, based on the environment or cladding, the structures can be designed to preferentially leak light from the illumination conduit. 
         [0000]    
       
         
               
               
               
             
               
               
               
             
           
               
                   
                   
               
               
                   
                 Cladding Index 
                 Core-Cladding Critical Angle (degrees) 
               
               
                   
                   
               
             
             
               
                   
               
             
          
           
               
                   
                 1.00 
                 41.1 
               
               
                   
                 1.10 
                 46.4 
               
               
                   
                 1.20 
                 52.1 
               
               
                   
                 1.30 
                 58.8 
               
               
                   
                 1.40 
                 67.1 
               
               
                   
                 1.417 
                 68.8 
               
               
                   
                 1.42 
                 69.1 
               
               
                   
                 1.44 
                 71.3 
               
               
                   
                 1.46 
                 73.8 
               
               
                   
                   
               
             
          
         
       
     
         [0073]    When using FEP as a cladding with cyclo olefin polymer, the critical angle is smaller than the angle from the 0.55NA (68.8 degrees). If no cladding is used, at the index of 1.417 and higher, the critical angle equals to the input angle causing light leakage because TIR is not maintained. Moreover, the combination of a cyclo olefin polymer core with FEP cladding allows the use of an input source with NA exceeding 0.55. The input source would enable greater light capture from a source due to the larger acceptance angle and provide more light through the illumination conduit assuming constant transmission efficiency. Understanding the critical angles of FEP and open environment, structures can be designed more accurately to extract the light from the illumination conduit. 
         [0074]    Any suitable cladding materials such as FEP can be applied to central portion  12 A of suction tube  12  through methods such as manual or semi-automated shrink-application of oversized FEP with a heat gun or focused heat from a hot-box nozzle, leveraging FEP&#39;s characteristic shrink ratio. Any other technique of a cladding such as FEP may be used such as applying a liquid coating or vapor deposition of FEP to central portion  12 A or any other suitable surface to be clad. Suction tube  12  with integrated cladding  15  can then have illumination waveguide  14  insert-molded (via conventional high-volume injection molding) and waveguide  14  will able to maintain total internal reflection. Use of cladding  15  between suction tube  12  and illumination waveguide  14  enables the suction tube to be formed of any suitable material such as metal or plastic. The choice of the plastic material for the suction tube needs to be such that the index of that material is below 1.42 for use with a waveguide having an index of 1.52 to maintain the differential at the interface of the suction tube and the waveguide. However, use of plastic may create challenges with injection molding processes which require relatively high temperatures and pressures inside of the molding cavity. Alternatively the device can be manufactured such that illumination waveguide  14  is formed with an internal lumen with no additional suction conduit running through it. The challenge posed by this approach is the potential light transmission efficiency losses stemming from evacuating biological material (blood, etc) through the lumen and making contact with the internal surface of the illumination waveguide lumen throughout the procedure. 
         [0075]    Cladding with an index of 1.33 shows no light transmission dependence on the refractive index of the surrounding environment or the cladding thickness when used with an illumination waveguide having a refractive index at or near 1.52. For a cladding with an index of 1.33, the light coupled into the illumination waveguide is constrained to the core due to total internal reflection at the core-cladding interface. Thus, there is no light propagating through the cladding, making the cladding-environment boundary condition a negligible factor in transmission. Teflon FEP with an index of 1.33 used as a cladding material with a cyclo olefin polymer core with index  1 . 52 , shows no dependence on cladding thickness in three representative simulated surgical environments. 
         [0076]    While preferred embodiments use heat shrink as the cladding over the suction tube and/or over the waveguide, in other embodiments, a low index of refraction polymer may be injection molded or otherwise formed over the waveguide.  FIG. 17  illustrates an illumination waveguide  1704  having such a polymer  1706  molded thereover. This allows the polymer to minimize light loss from the waveguide, and also allows the polymer  1706  casing to be used for attaching to the suction tube or other surgical instruments. For example, the two may be bonded together, solvent bonded, welded, or otherwise joined together. In still other embodiments, snaps or other coupling mechanisms may be joined to the polymer and suction tube forming a snap fitting. 
         [0077]    An illumination waveguide formed from material with a refractive index of 1.46, showed light transmission dependence on both cladding thickness as well as the external environment. This is a result of introducing light into the illumination waveguide at an NA of 0.55. Under this condition, light enters the core at an angle that is less than the critical angle of the core-cladding boundary, resulting in light propagating into the cladding. Since light propagates through the cladding, the cladding-environment boundary condition (critical angle) is a factor in the light transmission. Due to light propagating through the cladding, the cladding thickness also affects the transmission, because as the thickness increases, the rays bounce at the boundaries fewer times as they traverse the length of the waveguide. 
         [0078]    Straight waveguide geometry in which the light traversing the structure encounters no bends or radii results in the greatest optical efficiency. However, due to ergonomic constraints or compatibility &amp; management of essential accessories related to the device such as proximally attached fiber optic cables and suction tubing, it may be advantageous to design the proximal light input such that it creates an angle relative to the distal transmission body of the waveguide structure. 
         [0079]    Referring now to  FIGS. 6 and 6A , to preserve TIR and maximize transmission efficiency in illuminated waveguide  51  of suction apparatus  50 , central portion  52  between light input section  54  and illuminated waveguide body  55  should be curved to form angle  53  between the input and body as close to 180 degrees as possible. Almost any bend or radius in the tube will cause some light leakage. However, if angle  53  in central portion  52  is limited to 150 degrees or greater, the light leakage is very low and the light transmission efficiency is maximized. Where angle  53  is less than 150 degrees, light leakage may be reduced by reducing or otherwise controlling the divergence of the light within the waveguide or by using any other suitable technique. 
         [0080]    The shape of illuminated waveguide  51  morphs or cylindrically “sweeps” or “blends” from a solid cylindrical input, input section  54  into a circular hollow tube of waveguide body  55 . Waveguide bore  56  may accommodate any suitable surgical tools such as suction tube  58 . Suitable surgical tools access waveguide bore  56  through access opening  59 . As discussed above, light exits waveguide body at or near distal end  60  with the majority of light exiting through distal surface  61 . Distal surface  61  may be flat or it may any other suitable simple or complex shape. Distal surface  61  may have any of the surface features disclosed herein for extracting and directing light to a field of illumination. 
         [0081]    As the cross sectional area of illuminated waveguide  51  increases along the light transmission path from section  63  of input section  54  to central section  65 , to distal cross-section  67  near distal end  60 , the NA of the illumination waveguide increases, thus increasing the light divergence as light emerges from the distal end of the illuminator. The NA can also be influenced by bends. It may be possible to counter-bend to adjust the NA. Other techniques for controlling the NA of the waveguide may also include molding or machining features into the surfaces of the waveguide. The concepts illustrated above can also be manufactured as two halves that are over molded around any suitable surgical tool such as suction tube  58 .  FIGS. 6A-6C  illustrate various cross-sections of the waveguide in  FIG. 6 , and  FIG. 6D  highlights the area surrounding opening  59 . Thus, in the embodiment of  FIG. 6B , a suction tube  1610  is disposed in the concave saddle portion  1604  of the waveguide  1602  as seen in  FIG. 16 . Optical cladding  1606  such as heat shrink tubing is disposed circumferentially entirely around the suction tube  1610 , and then another layer of optical cladding  1608  such as heat shrink is dispose entirely around the circumference of both waveguide  1602  and suction tube  1610 . A portion of the cladding on the suction tube contacts a portion of the outer cladding where no waveguide surrounds the suction tube. Additionally, in this embodiment, the inner saddle has a first radius of curvature and the outer surface has a different radius of curvature (here larger than the inner radius of curvature). Alternative embodiments may have other combinations of radii of curvature. 
         [0082]    Referring now to  FIG. 7 , disposable illuminated waveguide  70  can be supplied as a stand-alone device. Various suction devices or other suitable tools such as suction tool  71  can be inserted though central bore  72 , the working channel of the illumination waveguide. A connection could be constructed between waveguide  70  and a surgical tool such as suction tool  71  that would allow the waveguide to be secured to various suction devices, enabling both waveguide  70  and suction tool  71  to be manipulated as a single unit. This concept can be applied to other devices that would fit through central bore  72  such as drills, etc. Additionally, illuminated surgical apparatus  74  lends itself to dynamic positioning of the waveguide  70  relative to any surgical tool inserted in central bore  72 , such as suction tool  71 . For example, the user could rotate the illuminator about the suction device as in rotation  75 , as well as telescope illuminator along the length of the suction tube along path  76 , repositioning or expanding or contracting illumination field  77  as needed during the procedure. 
         [0083]    An alternative approach involves splitting the solid input circle or ellipse such as input  78  of  FIG. 7  and split input  80  is formed as in  FIG. 8  in which half of input light  11 L is directed to one half of the input, arm  82 , and the other half of input light  11 L is directed to the second half of the input, arm  83 . Here, arms  82  and  83  come together in a generally rectangular cross-section as input  80  to engage fiber optic cable  11 C. However, input  80  can have circular cross-section with semi-circular arm(s), elliptical or multi faceted for better mixing of light. Inputs  78  and  80  may be hollow or tubular and may also be shaped to operate as a lens or may include a plurality of lenses. The configuration could also have FEP cladding strategically applied to one or more areas of each arm to preserve TIR. To enable proper function of the light extraction features, holes, or other suitable shapes could be cut into the FEP or other cladding, enabling a desired balance of TIR preservation and suitable light leakage from specific zones of the device. In the embodiments of  FIGS. 6 ,  6 A- 6 D, and  FIG. 7 , a fiber optic cable may be coupled to the input portion of the waveguide thereby allowing light from an external light source to be delivered from the light source to the waveguide. The fiber optic cable may be releasably coupled with the light input portion of the waveguide, or the fiber optic cable may be a single piece fixedly coupled with the light input portion of the waveguide and integral therewith (e.g. by overmolding the fiber optic cable with the light input portion of the waveguide). The integrated fiber optic cable, or the releasably coupled fiber optic cable may be used with any of the waveguide embodiments disclosed herein. The integrated fiber optic cable or the releasable fiber optic cable may also be used in any of the other embodiments disclosed herein. 
         [0084]    During fabrication, particularly injection molding, various artifacts may be formed in or on an optical part that may result in unpredictable performance of the optical part. Features such a gate scar, injector pin marks, parting lines, molded-in stress and any bends or sharp edges may create irregular and unpredictable output light patterns. To correct an irregular light output pattern the output surface of the waveguide may simply be roughened which will diffuse the light output. Roughened output surfaces cause significant efficiency loss and raise the output angle of the light. An alternative approach may be to create a pattern that projects multiple overlapping images of the defect pattern which will result in uniform illumination while minimizing efficiency loss and output angle. This can be achieved with a lens array on output surface such as lens array  24  of  FIG. 2 . 
         [0085]    The design of a lens array for the input or output of an illumination waveguide should consider the focal length of the lenses, the quantity of lenses in the array, any suitable patterns for the array, and the spacing between the lenses. The lens focal length of the lenses needs to be selected to minimize diffusion, and to maximize the radius of the lenses of the array. The lens diameter should also consider the tooling to be used to create the lenses. Tool marks left or created by the tooling should be a small percentage of the diameter of the lenses. Similarly, making the lenses too small makes them difficult to manufacture and diffuses the light output. If the lenses are too large, there will be too few overlapping images and the resulting light pattern will not be uniform. 
         [0086]    Incoherent and uncollimated light is going to diverge due to the geometry and refractive index of the waveguide; any divergence added by the lens array needs to be considered. Divergence of five to 10 degrees due to the lenses would be selected to maintain output light divergence close to the inherent divergence of the waveguide. 
         [0087]    Lens array pattern is also important. The lens array pattern is a balance between manufacturing complexity and lens spacing. Hexagonal lenses provide minimal inter-lens spacing and minimal wasted space while maintaining light projection characteristics similar to spherical lenses. A rectangular lens array pattern may be selected of a square or rectangular spot pattern is desired. Similarly, a rectangular illumination pattern may be produced by varying the lens pitch between the X and Y dimensions in the plane of the output face on which the lenses are formed. For example, additional microstructure features can be added to the distal end of an illumination waveguide to optimize control of the illumination pattern as well as to homogenize the light output field. Anti-reflection features, typically diffractive in nature and sub-micron in size, can be added to the input and output faces of the illuminator to reduce normal Fresnel reflection losses. The features of the waveguide, such as curves, bends, and mounting features, can cause undesired reflections, light leakage, glare, and non-uniform output patterns resulting in poor performance. Adding microstructure features which may be refractive or diffractive on or near the distal portion of the illumination waveguide can potentially provide better light uniformity and or to bias the divergence or convergence of the illumination pattern as well to homogenize the light output of the illumination field. Features or tapering of the waveguide can also be added to the outside of an illumination waveguide to control the illumination output. Furthermore, micro lenses such as lens  78 L or other micropattern structures can be added to an illumination waveguide input such as input  78  to better control the input beam shape or other light input characteristics. The light input arm can be round, square or multi faceted to provide a better mix of the light. 
         [0088]    The waveguide can be made in various shapes or cross sections. Currently preferred cross-sectional shapes are round, elliptical, or hexagonal. Other cross-sectional shapes such as rectangles, triangles, or squares are possible. However, generally regular surfaces of the waveguide, as well as odd number of surfaces may cause a secondary pattern at the output. This pattern would manifest as bright and dark spots. Cross sections resembling even numbered higher order polygons such as the hexagon are currently preferred. As the number of faces in the cross-section increase, these cross sections would approach a circle, such a device design would potentially complicate manufacturing processing (such as injection molding), thereby increasing costs. 
         [0089]    The illuminator can be tapered to increase or decrease its cross section as light travels from the input to extraction zones. Tapering biases the NA, causing either a tighter output spot (for increased area at the exit) or a larger more diffuse spot (decreased exit surface area, breaking TIR). 
         [0090]    For an illuminated suction device, in many surgical applications, there is a need for circumferential illumination around the device. The illumination may need to be uniformly circumferential or delivered in an off axis orientation for most of the lighting to orient anterior to the retractor. 
         [0091]    Referring now to  FIGS. 9 and 10 , handle  93  of illuminated suction device  90  can be used to preserve TIR within illumination waveguide  94  through creation of air gap  91  (n=1.0) around waveguide  94 . The design of the handle structure could include a portion that partially or fully covers the length of waveguide  94  to create the desired air gap. Features such as standoffs  93 X can be molded into the surface of the handle in contact with the illuminator and need to be located in optical dead zones (zones where there is little or no TIR) to create a gap between components and minimize light leakage through the contact points. A similar configuration may be formed between suction tube  92  and illuminated waveguide  94 , air gap  95  can be formed without standoffs based on the design tolerance between the ID of the illuminator and OD of the suction tube or with one or more standoffs such as standoff  92 X or standoff  94 X or any suitable combination. The air gaps between the handle/waveguide and/or wavguide/suction tube may be used in any of the illuminated suction apparatus embodiments disclosed herein. 
         [0092]    The divergence of light output from illuminated waveguide  94  can be controlled by permitting all or a portion of distal casing  96  to slide along axis  97  over the illuminator. The user can slide the tube down over the illuminated waveguide  94  to reduce the divergence angle and reduce the divergence of light  99 L. 
         [0093]    Referring now to  FIG. 11 , the design of handle  93  must accommodate a suitable routing and termination of the suction channel and solid-state illuminator such that a suction flow control hole H is presented to the user in an ergonomically favorable position. Based on the way a user is expected to hold and manipulate an illuminated suction apparatus and the flow pattern of evacuated material from the patient, hole H may be present at or near the top surface  98  of the proximal handle. This can accomplished by forming handle  93  with at least two parts such as top section  93 T and bottom section  93 B. In addition to providing a shield for and proximal terminus for the illuminated waveguide  94 , top handle portion  93 T also contains suction flow control hole H. Suction flow control may also be provided by a valve or other similar apparatus that enables controlled adjustable suction. The top and bottom handle portions are sealed, with the bottom portion  93 B creating a chamber in communication with proximal termination  92 P of suction tube  92 . Evacuated debris can be kept from flowing through to vacuum tube conduit  93 P and out of hole H based on the geometry of the chamber  100  and pathway to flow control hole H. Alternatively a “strainer” or “filter” such as filter  102  may be included in handle  93  to capture any solid or liquid debris and prevent the debris from making their way out through hole H. Features in handle  93  could also allow the user to disassemble the top and bottom portions to clear any collected debris. 
         [0094]    While the concepts presented thus far focus on a completely disposable non-modular device, alternative architectures are possible including the following: 
         [0095]    a. Disposable suction tips (varying French sizes &amp; styles such as yankaeur, etc.) that integrate with a disposable device through a “quick-connect” attach &amp; detach scheme. 
         [0096]    b. Disposable illumination sheaths such as waveguide sheath may accommodate any suitable surgical instrument such as for example, a drill, burr or endoscope which is encased, enclosed or otherwise surrounded by optical waveguide sheath. Illumination sheaths can be various materials such as flexible silicone. 
         [0097]    c. Disposable distal suction tips or other implements (nerve probes, etc) can also be integrated with a reusable proximal illuminator containing a traditional fiber optic bundle. This would enable rapid tip style exchange without the need to unplug cables. This approach also provides a means of unclogging trapped evacuated material. 
         [0098]    d. Reusable proximal handles with removable single use illuminators/suction tubes. Enables easy change-out of devices without need to unplug cables. 
         [0099]    Referring now to  FIG. 12 , suction lumen  108  may be formed in suction element  109  that may be formed around an illuminator such as waveguide  110 , as shown in illuminated suction apparatus  111 . This configuration would allow for output light  112  to exit from a cylindrical source such as waveguide  110  without the shadowing caused by having a central illumination tube coaxial to the illuminator. 
         [0100]    The routing of the suction conduit through the illuminator can be varied to optimize the illumination output and balance ergonomic considerations. 
         [0101]    Referring now to  FIG. 13 , illuminated suction apparatus  116  is configured to enable suction tube  118  to be strategically routed through illumination waveguide  120  at angle  121  such that (1) proximal exposed end  118 P is at the top of the device where the suction control function can be more readily accessed by the user; and (2) distal end  118 D of the suction tube emerges from the bottom of the device below illumination output  122 , providing optimized lighting of the surgical site from above the suction tube. In this configuration the suction tube changes light transmission paths through the illumination waveguide by introducing reflective surfaces which more thoroughly mix the light. It is possible to maintain the efficiency by using high reflective coatings, air gaps and cladding such as cladding  123 . However, the added reflectance surfaces of the suction tube may cause the NA to increase. 
         [0102]    Rotationally symmetric illuminated suction devices such as illuminated suction apparatus  116  may produce circumferential, uniform light output with strategic positioning of the suction tube that mitigates shadowing from the suction tube protruding from the distal surface of the waveguide. Light traversing the illuminated waveguide may have challenges with secondary reflectance surfaces, thus widening the light output pattern. Illuminated suction apparatus  116  is also expected to have a very large NA. 
         [0103]    Illumination waveguides such as waveguides disclosed above may also be made malleable out of material like silicone. This can be useful to “pull over” an instrument like suction tube. The illumination waveguide can be made of a malleable material such as silicone allowing it to be pulled over a rigid suction tube, potentially lowering cost. Alternatively the malleable illumination waveguide material can be formed over a deformable suction tube structure, or a deformable structure that contains selective strength members (beams, etc). This would enable dynamic shaping of the suction tube to various desired shapes suited to the clinical application. 
         [0104]    The illumination waveguide can be fabricated with materials of varying indices in a “stacked” or “composite” structure to shape and control the light output. 
         [0105]    An alternative approach involves splitting an illumination waveguide with a solid light input with a circular or elliptical cross-section, routing and re-combining the waveguide into the original starting geometry. An illumination waveguide can then be molded over an internal suction tube. Alternatively, the suction tube in this configuration could run alongside the spit illuminator geometry. 
         [0106]    If the cross section area is maintained (that is, distal and proximal ends on either side of split have same cross section, the intermediate shape of the waveguide can be manipulated. In the configuration listed above, there should be no significant loss of efficiency or change in NA. Thus, the input and output light patterns should be very similar in shape and intensity. 
         [0107]    While preferred embodiments of the present invention have been shown and described herein, it will be obvious to those skilled in the art that such embodiments are provided by way of example only. Numerous variations, changes, and substitutions will now occur to those skilled in the art without departing from the invention. For example, any of the features disclosed in one embodiment of an illuminated suction apparatus may be used in any of the other embodiments of illuminated suction apparatuses disclosed herein. It should be understood that various alternatives to the embodiments of the invention described herein may be employed in practicing the invention. It is intended that the following claims define the scope of the invention and that methods and structures within the scope of these claims and their equivalents be covered thereby.