Abstract:
A method for removing a vein includes making an incision through a skin layer of a patient, inserting a surgical instrument through the incision, visualizing the vein through the skin layer using a light source positioned subcutaneously and in proximity of the vein, and cutting the vein using the surgical instrument. The vein can be visualized by directing light from the light source at the vein from underneath the vein or from a side of the vein. A device for illuminating a body structure has a housing with a distal end configured for subcutaneous insertion into a patient&#39;s tissue and positioning in proximity of the body structure, a light path supported by the housing and configured for directing light at the body structure, and a fluid lane supported by the housing.

Description:
CROSS REFERENCE TO RELATED APPLICATIONS  
       [0001]     This application is a divisional of U.S. application Ser. No. 10/059,148, entitled METHODS AND APPARATUS FOR REMOVING VEINS, filed Jan. 31, 2002, which is a continuation of U.S. Application Ser. No. 09/444,925, entitled METHODS AND APPARATUS FOR REMOVING VEINS, filed Nov. 24, 1999, which is a continuation-in-part of U.S. application Ser. No. 09/289,172, entitled METHODS AND APPARATUS FOR REMOVING VEINS, filed Apr. 9, 1999, which is a continuation of application U.S. application Ser. No. 08/944,384, entitled METHODS AND APPARATUS FOR REMOVING VEINS, filed Oct. 6, 1997, issued as U.S. Pat. No. 5,893,858. 
     
    
     FIELD OF THE INVENTION  
       [0002]     The present invention relates generally to surgical apparatus and procedures. More particularly, it relates to methods and apparatus for removing veins, such as, varicose veins and spider veins, in a venous system of a patient.  
       BACKGROUND OF THE INVENTION  
       [0003]     Ten to fifteen percent of the population is plagued with varicose veins and spider veins. These veins have usually lost their ability to carry blood back to the heart and blood often accumulates in these veins. As a result, the veins may become swollen, distorted, and prominent. This condition is usually caused by inefficient or defective one-way valves which prevent blood from draining back through the vein.  
         [0004]     A number of factors can contribute to the development of varicose veins and spider veins, including heredity, obesity, posture, standing or sitting for long periods of time, hormonal shifts, and excessive heat. Varicose veins may cause patients to experience various symptoms, such as, for example, aching, burning, swelling, cramping, and itching, while more serious complications of varicose veins can include thrombophlebitis, dermatitis, hemorrhage and ulcers. If these varicose veins are not treated, blood clots may form in the vein, and phlebitis or inflammation of the inside lining of the vein may occur. Even absent such symptoms, many patients seek medical treatment of varicose or spider veins for cosmetic reasons.  
         [0005]     Various approaches have been developed to treat varicose veins. In less complicated cases, elevation of the legs and use of support hosiery may be sufficient therapy to stop or slow the progression of the varicose veins. Alternatively, a technique called “sclerotherapy” may be used to treat varicose veins. In this procedure, the affected veins are injected with a sclerosing solution, such as sodium tetradecyl sulfate or pilocainol. Approximately one injection of the solution is usually administered for every inch of the affected veins, and multiple injections may be administered during a treatment session. The sclerosing solution causes subsequent inflammation and sclerosis of the veins. The sclerosis results in localized scarring or closure of the veins, which forces rerouting of the blood away from the affected veins.  
         [0006]     However, patients usually have to undergo two or more sclerotherapy treatments in order to alleviate the varicose and spider veins to a satisfactory degree. Other fine reddish blood vessels may also appear around the treated area, requiring further injections. Nevertheless, the sclerotherapy technique may not be a permanent or complete solution since the condition of the varicose and spider veins may reoccur within five years.  
         [0007]     Sclerotherapy also has other potential complications, including browning splotches or bruising of the skin, formation of blood clots in the veins, inflammation, adverse allergic reactions, ulceration, phlebitis, anaphylactic overdose, ischemia, skin or fat necrosis, and peripheral neuropathy. Furthermore, sclerotherapy cannot be applied to the saphenous vein in the upper thigh region due to the risk of sclerosis of the deep veins. Thus, the sclerotherapy technique is often combined with an operative procedure, such as ligation of a portion of the saphenous vein.  
         [0008]     Another technique to treat varicose veins is called stabavulsion phlebectomy with hooks. In this technique, one or more incisions are made in the skin of the patient, and a hook is inserted into the incision to grip or hook the veins to be removed. When the veins are grabbed, the veins are pulled through the surgical incision and severed. However, this procedure usually requires two surgeons to perform the procedure and takes about 2-3 hours. In addition, this procedure usually requires multiple incisions in the patient in order to hook the affected veins. Furthermore, it is often difficult to completely remove the entire affected veins using this procedure.  
         [0009]     Varicose veins can also be removed by a procedure commonly referred to as “stripping”. To remove a saphenous vein using this stripping procedure, a large incision is made near the groin area of a patient and the saphenous vein is separated from the femoral vein. The saphenous vein is also usually dissected near the lower portion of the leg. Multiple large incisions are made along the leg in order to sever and ligate the tributary veins of the saphenous vein. A vein stripper, such as a wire, is then inserted into the lumen of the saphenous vein. The wire is then inserted through the saphenous vein to the groin incision and tied to the lower end of the vein. The wire is then removed through the groin incision to extract the vein. After the saphenous vein is completely removed from the leg, the large incisions along the leg are closed.  
         [0010]     However, the stripping procedure is usually painful and often requires overnight hospitalization. In addition, numerous incisions are usually required to remove the saphenous vein and its branches which often leave permanent unsightly scars along the leg of a patient. Additionally, the large incisions create a risk of infection to the patient and may not heal properly, especially patients who have poor circulation in their extremities. There are also associated complications with this technique, such as, for example, blood loss, pain, infection, hematoma, nerve injury, and swelling.  
       SUMMARY OF THE INVENTION  
       [0011]     In view of the above, the present invention provides methods and apparatus for removing undesired veins, such as, varicose and spider veins, in a venous system of a patient. The apparatus and methods of the present invention provide an efficient and minimally intrusive procedure to remove the undesired veins. The undesired veins can be completely removed with minimal scarring and without hospitalization. The methods and apparatus can also reduce operating time in the removal of the undesired veins, and the entire procedure can be performed by a single surgeon in less time than traditional procedures.  
         [0012]     According to one aspect of the invention, a method for removing a vein includes making an incision through a skin layer of a patient, inserting a surgical instrument through the incision, visualizing the vein through the skin layer using a light source positioned subcutaneously and in proximity of the vein, and cutting the vein using the surgical instrument.  
         [0013]     Embodiments of this aspect of the invention may include one or more of the following features.  
         [0014]     Visualizing the vein includes directing light from the light source at the vein from underneath the vein or from a side of the vein.  
         [0015]     In one illustrated embodiment, the surgical instrument is provided with the light source. The light source is a fiberoptic, e.g., a fiberoptic bundle.  
         [0016]     The method further includes irrigating and tumescing a surgical region in proximity to the vein using the surgical instrument, and aspirating cut veinous tissue through the surgical instrument.  
         [0017]     In another embodiment, visualizing the vein includes providing a second instrument including the light source, making a second incision through a skin layer of the patient, and inserting the second instrument through the incision. A surgical region in proximity to the vein is irritated and tumesced using the second instrument.  
         [0018]     According to another aspect of the invention, a method of visualizing a body structure includes positioning an illuminating device subcutaneously such that light is directed at the body structure, and observing the body structure through a skin layer of the patient overlying the body structure.  
         [0019]     Embodiments of this aspect of the invention may include one or more of the following features.  
         [0020]     Visualizing the body structure includes directing light from the illuminating device at the body structure from underneath the body structure or from a side of the body structure.  
         [0021]     According to another aspect of the invention, a device for illuminating a body structure has a housing with a distal end configured for subcutaneous insertion into a patient&#39;s tissue and positioning in proximity of the body structure, a light path supported by the housing and configured for directing light at the body structure, and a fluid line supported by the housing.  
         [0022]     Embodiments of this aspect of the invention may include one or more of the following features.  
         [0023]     The housing includes a connector for connecting the light path to a light transmitter. The connector extends from a proximal end of the housing substantially in the direction of a longitudinal axis of the housing. The housing has a generally hour glassed-shape handle in cross-section. The light path is a fiberoptic, e.g., a fiberoptic bundle.  
         [0024]     According to another aspect of the invention, a device for cutting tissue includes a surgical instrument with a distal end configured for subcutaneous insertion into a patient&#39;s tissue and positioning in proximity of the tissue. The surgical instrument includes an outer tube defining a lumen, and an inner tube located within the outer tube. The inner tube has a cutter and is movable relative to the outer tube to cut tissue. A light path is supported by the surgical instrument and is configured for directing light at a region adjacent the cutter and at a skin layer overlying the tissue.  
         [0025]     Embodiments of this aspect of the invention may include one or more of the following features.  
         [0026]     A fluid line is supported by the surgical instrument. The inner tube defines an aspiration path, and the inner tube and outer tube define a fluid path therebetween. The inner tube is configured to rotate at a speed of about 500-2000 rpm.  
         [0027]     Among other advantages, the illuminating device of the invention can provide the surgeon with a subcutaneous light source that has more fibers, is of smaller size, is less traumatic, and has superior ergonomics to presently available surgical light sources such as endoscopes. Furthermore, as compared to an endoscope, if the illuminating device of the invention is bent during use, there are no expensive optics that can be damaged.  
         [0028]     The invention, together with further attendant advantages, will best be understood by reference to the following detailed description of the presently preferred embodiments of the invention, taken in conjunction with the accompanying drawings. It is to be understood that both the foregoing general description and the foregoing detailed description are exemplary and explanatory and are intended to provide further explanation of the invention as claimed. 
     
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0029]      FIG. 1  is a side elevational view of a surgical system to remove undesired veins in a venous system or a patient;  
         [0030]      FIG. 1A  is a fragmentary side view of the distal end of a surgical instrument of the surgical system of  FIG. 1 ;  
         [0031]      FIG. 2  is a cross-sectional view taken about line  2 - 2  of  FIG. 1 ;  
         [0032]      FIG. 3  is a diagrammatical view of undesired veins being removed from the legs of a patient by the surgical system of  FIG. 1 ;  
         [0033]      FIG. 4  shows a pattern of movement of the surgical instrument of the surgical system of  FIG. 3  to remove undesired veins;  
         [0034]      FIG. 5  is a cross-sectional view taken about line  5 - 5  of  FIG. 4 ;  
         [0035]      FIG. 6  is a fragmentary view of the distal end of a surgical instrument of the surgical system of  FIG. 1 ;  
         [0036]      FIG. 7  is a fragmentary view of another embodiment of the distal end of a surgical instrument of the surgical system of  FIG. 1 ;  
         [0037]      FIG. 8  is another embodiment of a distal end of a surgical instrument of the surgical system of  FIG. 1 ;  
         [0038]      FIG. 9  is a fragmentary view of another embodiment of the distal end of the surgical instrument of the surgical system of  FIG. 1 ;  
         [0039]      FIG. 10  is a fragmentary view of another embodiment of the distal end of the surgical instrument of the surgical system of  FIG. 1 ;  
         [0040]      FIG. 11  is a side elevational view of another embodiment of a surgical system to remove undesired veins in a venous system of a patient;  
         [0041]      FIG. 12  is a cross-sectional view taken about line  12  of  FIG. 11 ;  
         [0042]      FIG. 13  shows an additional embodiment of a surgical instrument for removing undesired veins;  
         [0043]      FIG. 13A  is a cross-sectional view of a proximal end f the surgical instrument of  FIG. 13 ;  
         [0044]      FIG. 14  illustrates a fiberoptic transilluminator;  
         [0045]      FIG. 14A  is an end view of the fiberoptic transilluminator of  FIG. 14 , taken along lines  14 A- 14 A;  
         [0046]      FIG. 15  illustrates the placement of the fiberoptic transilluminator beneath a patient&#39;s skin;  
         [0047]      FIG. 16  illustrates an additional embodiment of a fiberoptic transilluminator;  
         [0048]      FIG. 17  shows an additional embodiment of a surgical instrument for removing undesired veins; and  
         [0049]      FIG. 17A  is an end view of the surgical instrument of  FIG. 17 , taken along lines  17 A= 17 A. 
     
    
     DESCRIPTION OF THE PREFERRED EMBODIMENTS  
       [0050]     Before explaining the preferred embodiments in detail, it should be noted that the invention is not limited in its application or use to the details of construction and arrangement of parts illustrated in the accompanying drawings and description, because the illustrative embodiments of the invention may be implemented or incorporated in other embodiments, variations and modifications, and may be practiced or carried out in various ways. Furthermore, unless otherwise indicated, the terms and expressions employed herein have been chosen for the purpose of describing the preferred embodiments of the present invention for the convenience of the reader and are not for the purpose of limitation.  
         [0051]     Referring now to the drawings in detail, and particularly to  FIG. 1 , a preferred embodiment of a surgical system  100  to remove undesired veins in a venous system of a patient is illustrated. The surgical system  100  allows a single surgeon to remove veins from a patient more quickly than traditional techniques. The undesired veins can be completely removed with minimal scarring and without hospitalization. The surgical system  100  can also allow two or more surgeons to remove undesired veins of a patient at the same time.  
         [0052]     As shown in  FIG. 1 , the surgical system  100  generally includes a control unit  110  and a surgical instrument  120 . The control unit  110  sends electrical signals through a cable  112  at a selected amplitude and frequency. The electrical signals energize a motor  122  of the surgical instrument  120  which drives a cutting element  141  at a selected speed. The speed of the cutting element  141  of the surgical instrument  120  is controlled and monitored by the control unit  110 .  
         [0053]     The surgical instrument  120  of the surgical system  100  can be utilized by a surgeon to remove undesired veins in a leg  190  of a patient. A second handpiece assembly (not shown) may also be connected to the control unit  110  to allow a second surgeon to remove undesired veins in the other leg  192  or another portion of the patient. It will be recognized that any suitable number of surgical instrument  120  can be attached to the control unit  110  to remove undesired veins.  
         [0054]     As illustrated in  FIG. 3 , one or more small incisions  152  (one being shown) are made through the skin layer  194  of the patient near the undesired veins. The distal end of the surgical instrument  120  is inserted through the small incision  152 . Once the distal end of the surgical instrument  120  is inserted through the incision  152 , the cutting element  141  is energized at a desired speed. The cutting element  141  is then placed in contact with an undesired vein  195  of the patient as shown in  FIG. 3  and  5 . The portion of the vein  195  that contacts the cutting element  141  is cut up into small or tiny particles or pieces.  
         [0055]     The particles of the undesired vein  195  are removed from the surgical sire to a suction or vacuum source  160 . After the particles are removed, the small incision  152  can be closed with steri-strips or any suitable closure material. Although these incisions can be closed with sutures, it is considered unnecessary due to the small size of the incisions, and is also undesirable since suturing the skin can cause scarring.  
         [0056]     Referring again to  FIG. 1 , the control unit  110  of the surgical system  100  preferably includes a control system (not shown) integral to the control unit  110 , an on-off switch  112 , jacks or connectors  114  and  115 , a power control switch  116 , and a display  118 . The control unit  110  sends signals to the surgical instrument  120  to control the acceleration, deceleration, and speed of the cutting element  141  of the surgical instrument  120 . The control unit  110  may also monitor the speed of the cutting element  141  in order to limit the speed and the torque of the cutting element  141  to within preselected limits for optimum performance of the surgical instrument  120  being used. It will be recognized that the control unit  110  may drive the cutting element  141  at any suitable speed and torque.  
         [0057]     The on-off switch  112  of the surgical system  100  controls the electrical power to the control unit  110  to allow the surgeon to actuate the cutting element  141  of the surgical instrument  120 . When the on-off switch  112  is activated, the control unit  110  provides power to drive the cutting element  141  of the surgical instrument  120  at a desired speed.  
         [0058]     The jack  114  of the control system  110  is attached to the proximal end of the cable  112  to allow the surgical instrument  120  to be connected to the control unit  110 . The jack  115  of the control system provides another connector to allow another cable of a surgical instrument to be coupled to the control unit  110 . Although only two jacks  114  and  115  are shown, it is contemplated that any suitable number of jacks may be incorporated into the control unit  110 .  
         [0059]     The control unit  110  also has a power line  118  for insertion in an electro-signal unit or conventional outlet.  
         [0060]     It is contemplated that the control unit  110  may also be powered by a direct current (DC) source, such as a battery.  
         [0061]     The control unit  110  may be any suitable control unit, such as Model No. PS3500EP™ or Dyonics®EP-1 surgical drive system available from Smith &amp; Nephew.  
         [0062]     Referring still to  FIG. 1 , the surgical instrument  120  generally includes a motor drive unit or handpiece assembly  121  and a blade assembly  140 . The handpiece assembly  121  includes a motor  122 , a suction nozzle  124 , a housing or an outer casing  125 , a trigger mechanism  126 , and a vacuum switch  128 . The distal end of the handpiece assembly  121  is sized and configured to receive the blade assembly  140 , and proximal end of the handpiece assembly  121  is coupled to the control unit  110  by the cable  112 . The cable  112  may include ducts or vents to allow air or a cooling fluid to be introduced into the handpiece assembly  121  to cool the motor  122 . A suitable handpiece assembly  121  may be Model Nos. 72-05354, 72-5355, or 72-5357, available from Smith &amp; Nephew.  
         [0063]     The housing  125  of the handpiece assembly  121  is adapted to isolate the operator from the inner components of the handpiece assembly  121 . The housing  125  is preferably substantially cylindrically shaped and is adapted to be held by a user in a conventional manner, but may be any suitable shape or size which allows it to be grasped by the user. While a single or unitary component housing  125  is illustrated, the housing  135  may comprise multiple parts or pieces.  
         [0064]     The housing  125  of the handpiece assembly  121  can be constructed from a plastic, titanium, aluminum, or steel. It is also contemplated that the housing  125  may be made from a variety of materials including other plastics (i.e., liquid crystal polymer (LCP), nylon, or polycarbonate) or any other suitable material.  
         [0065]     The triggering mechanism  126  of the handpiece assembly  121  allows a surgeon to activate the control unit  110  so that power may be continuously supplied to the motor  122  of the handpiece assembly  121 . The triggering mechanism  126  preferably includes a switch incorporated in the handpiece assembly  121 . It will be recognized that the triggering mechanism  126  may alternatively include a foot activating switch  136  that is detachably coupled or attached to the control unit  110  by a cable or cord  138 .  
         [0066]     The suction nozzle  124  of the handpiece assembly  121  is coupled to a vacuum source  160  by a hose  162 . When the vacuum source  160  is activated, the source  160  draws a vacuum through a conduit (not shown) defined through the handpiece assembly  121  and the surgical instrument  120 . The vacuum source  160  causes vein tissue and other fluids to be drawn from the surgical site through the conduit of the blade assembly  140  and handpiece assembly  121  into the vacuum source  160 . The vacuum source  160  can be any suitable vacuum or suction source to remove vein tissue from the surgical site. It is also contemplated that the vacuum source  160  can be a separate tool, such as, for example, a cannula, or any other suitable instrument that can be inserted in the incision to remove vein tissue.  
         [0067]     The motor  122  of the handpiece assembly  121  is preferably disposed within the handpiece assembly  121 . The motor  122  receives power from the control unit  110  over wires (not shown) in cable  112 . The motor  122  preferably includes a housing  122   a  and a drive shaft  122   b . When the motor  122  is activated, the drive shaft  122   b  rotates to drive the cutting element  141  of the surgical instrument  120  at a desired speed. The motor  122  is preferably a reversible rotational drive motor that can turn the drive shaft  122   b  in either direction or oscillate the shaft  122   b  back and forth. It will be recognized that the motor  122  an me any suitable device that can drive or actuate the cutting element  141  of the surgical instrument  120 .  
         [0068]     The blade assembly  140  of the surgical instrument  120  preferably includes an outer stationary member  170  and a rotatable member  180 . The blade assembly  140  is preferably a disposable unit to eliminate resterilization of the portions of the assembly that enters into the patient&#39;s body. Therefore, the blade assembly  140  is removed from the handpiece assembly  121  after use and disposed of. The blade assembly  140  may include any suitable blade from the EP-1 family from Smith &amp; Nephew, such as, for example, the full radius 3.5 mm blade (Ref. No. 7205305), or any suitable blade from Xomed® Endoscopy Products.  
         [0069]     The distal end of the outer stationary member  170  is sized for insertion into an incision of the body via a puncture opening made through the skin. The outer stationary member  170  includes a fitting  172  and an elongated member  174 . It is contemplated that the distal end of the blade assembly  140  may be bendable or may be articulable in various directions.  
         [0070]     The fitting  172  of the outer stationary member  170  is preferably adapted to be threaded or snapped into the distal end of the handpiece assembly  121 . The fitting  172  is preferably constructed from a plastic material and has an aperture  173  extending therethrough. It is contemplated that the fitting  172  may be fabricated from any suitable material. The distal end of the fitting  174  is coupled or attached to the proximal end of the elongated member  174  of the outer stationary member  170 .  
         [0071]     The elongated member  174  of the outer stationary member  170  preferably includes an aperture  176  extending longitudinally therethrough and one or more ports or openings  178  (one being shown). The elongated member  174  preferably has a length of about 5 inches and is fabricated from stainless steel. It is contemplated that the elongated member  174  may have any suitable length and can be manufactured from any suitable material.  
         [0072]     The port  178  of the elongated member  174  is preferably located at or near the distal end of the elongated member  174 . As shown in  FIGS. 1A and 2 , the port  178  has a generally cylindrical shape and preferably includes a pair of cutting edges  178   a  and  178   b . The port  178  allows vein tissue to enter into the aperture  176  so that the cutting element  141  of the surgical instrument  120  can sever the tissue as further described below. It will be recognized that the port  178  can be any size and shape to receive vein tissue. It is also contemplated that a guard (not shown) may also be disposed across the port  178  to limit the amount of extraneous tissue that can enter into the port  178  to be severed.  
         [0073]     The aperture  176  of the elongated member  174  and the aperture  173  of the fitting  172  are adapted to receive the rotatable member  180 . The rotatable member  180  preferably includes a base  182  and an elongated member  184 . The base  182  is preferably fabricated from plastic. It will be recognized that the base  182  may be fabricated from any suitable material. The inner rotatable member  180  is preferably rotated at various speeds by the motor  122 .  
         [0074]     The distal end of the base  182  of the rotatable member  180  is coupled to the proximal end of the elongated member  184 , and the proximal end of the base  182  is coupled to the drive shaft  122   b  of the motor  122 . When the drive shaft  122   b  of the motor  122  is energized, the drive shaft  122   b  rotates the base  182  and the elongated member  184  of the rotatable member  180  at a desired speed.  
         [0075]     The elongated member  184  of the rotatable member  180  preferably includes an aperture  186  extending longitudinally therethrough and a cutting element  141 . The elongated member  184  is preferably disposed coaxially within the elongated member  174  of the outer stationary member  172 . The elongated member  184  is preferably fabricated from stainless steel. It is contemplated that the elongated member  184  may be constructed from any suitable material.  
         [0076]     The cutting element  141  of the elongated member  184  is disposed at or near the distal end of the elongated member  184 . Vein tissue that is exposed to the cutting element  141  through the port  178  of the outer stationary member  170  is cut by the cutting element  141  into small pieces. The pieces are drawn through the aperture  186  of the rotatable member  180  and through the suction nozzle  124  of the handpiece assembly  121  by the use of suction applied by the vacuum source  160 .  
         [0077]     The cutting element  141  of the rotatable member  180  preferably includes one or more ports or openings  188  (one being shown) disposed in the outer surface of the elongated member  184 . The port  188  has a generally cylindrical shape and preferably includes a pair of cutting edges  188   a  and  188   b . The cutting edges  188   a  and  188   b  of the port  188  of the rotatable member  180  are sharp and cooperate with sharpened edges  173   a  and  178   b  of the port  178  of the outer stationary member  170 . The cutting element  141  may also comprise a blade, abrading burr, or ultrasonic element.  
         [0078]     The cutting edges  188   a  and  188   b  of the port  188  are configured for cutting vein tissue when the rotatable member  180  is rotated in either direction of rotation, as selected by the surgeon. As the rotatable member  180  rotates, the port  188  of the rotatable member  180  periodically aligns with the port  178  of the outer stationary member  170  to admit vein tissue. When the vein tissue enters into the ports  178  and  188 , the vein tissue is severed or sheared between the cutting edges  188   a  and  188   b  of the rotatable member  180  and the cutting edges  178   a  and  178   b  of the outer stationary member  170 . The severed tissue is removed via the aperture  186  in the rotatable member  180  and through the suction nozzle  124  via a conduit (not shown) in the handpiece assembly  121  to the vacuum source  160 . It is also contemplated that the cutting element  141  may include any suitable cutting implement and may be vibrated at a high rate of speed (i.e., in an ultrasonic range).  
         [0079]     Referring now to  FIGS. 6-10 , a number of embodiments of the distal end of the surgical instrument  120  that can be used to remove varicose veins are illustrated. As shown in  FIG. 6 , the surgical instrument preferably includes an outer stationary member  210  and an inner stationary member  220 . The outer stationary member  220  includes a fitting (not shown) and an elongated member  212 .  
         [0080]     The elongated member  212  of the outer stationary member  210  preferably includes an aperture  214  extending longitudinally therethrough and two ports or openings  216  and  218 . The ports  216  of the elongated member  210  are preferably located at or near the distal end of the elongated member  210  and are arranged in a row along the side of the elongated member  210 . The ports  216  and  218  have a generally cylindrical shape and each preferably include a pair of cutting edges  230 ,  232 ,  234 , and  236 . It will be recognized that the ports  216  and  218  can be any size and shape to receive vein tissue. A guard  220  is preferably disposed across the port  218  to limit the amount of vein tissue that can enter into the port  178  to be severed.  
         [0081]     The rotatable member  220  preferably includes a base not shown) and an elongated member  222 . The elongated member  222  of the rotatable member  220  preferably includes an aperture  224  extending longitudinally therethrough and two cutting elements  226  and  228 . The elongated member  222  of the rotatable member  220  is preferably disposed coaxially within the elongated member  212  of the outer stationary member  210 . The elongated member  222  of the rotatable member  220  is preferably fabricated from stainless steel. It is contemplated that the elongated member  222  may be manufactured from any suitable material.  
         [0082]     The cutting elements  226  and  228  of the elongated member  222  of the rotatable member  220  are disposed near the distal end of the elongated member  222 . The cutting elements  226  and  228  of the rotatable member  220  preferably includes two ports or openings  240  and  242  disposed in the outer surface of the elongated member  222 . The ports  240  and  242  have a generally cylindrical shape and each preferably includes a pair of cutting edges  244 ,  246 ,  248 , and  250 . The cutting edges  244 ,  246 ,  248 , and  250  of the ports  240  and  242  are sharp and cooperate with sharpened edges of the ports  216  and  218  of the outer stationary member  210 . It will be recognized that the cutting elements  226  and  228  may be a blade, abrading burr, or an ultrasonic element.  
         [0083]     As the rotatable member  220  rotates, the ports  216  and  218  of the rotatable member  220  periodically aligns with the ports  240  and  242 , respectively, of the outer stationary member  210  to admit vein tissue. When the vein tissue enters into the ports, the vein tissue is severed or sheared between the cutting edges  244 ,  246 ,  248  and  250  of the rotatable member  220  and the cutting edges  230 ,  232 ,  234 , and  236  of the outer stationary member  210 . The severed tissue is removed from the surgical site by a vacuum source (not shown).  
         [0084]     Referring now to  FIG. 7 , a distal end of another surgical instrument  300  to remove undesired veins is illustrated which in many respects corresponds in construction and function to the previously described surgical instrument of  FIG. 6 . Components of the surgical instrument  300  which generally correspond to those components of the surgical instrument  200  of  FIG. 6  are designated by like reference numerals in the three-hundred series. As shown in  FIG. 7 , the surgical instrument  300  includes another port  360  in the outer stationary member  310  and a corresponding port  370  of the rotatable member  320  to sever vein tissue. It will be recognized that the surgical instrument  300  may include any suitable number of ports in the outer stationary member  310  and the rotatable member  320  to cut vein tissue.  
         [0085]     Referring now cc  FIG. 10 , a distal end of another surgical instrument  500  to remove undesired veins is illustrated which in many respects corresponds in construction and function to the previously described surgical instrument  300  of  FIG. 7 . Components of the surgical instrument  500  which generally correspond to those components of the surgical instrument  300  of  FIG. 5  are designated by like reference numbers in the five-hundred series. As shown in  FIG. 10 , the surgical instrument  500  includes guards  580  and  590  that extend across ports  560  and  570  of the surgical instrument  500 , and the distal port  518  is configured without a guard.  
         [0086]     Referring now to  FIG. 8 , a distal end of another the surgical instrument  400  is illustrated. The surgical instrument  400  preferably includes an outer stationary member  410  and a rotatable member  420 . The outer stationary member  410  includes a fitting (not shown) and an elongated member  412 .  
         [0087]     The elongated member  412  of the outer stationary member  410  preferably includes an aperture  414  extending longitudinally therethrough and opening or port  416 . The port  416  of the elongated member  412  is preferably located at or near the distal end of the elongated member  412 . The port  416  has a generally round shape and preferably includes a cutting edge  418 . It will be recognized that the port  416  can be any size and shape to receive vein tissue. A guard  440  (see  FIG. 9 ) may be disposed across the port  416  to limit the amount of vein tissue that can enter into the port  416  to be severed.  
         [0088]     The rotatable member  420  preferably includes a base (not shown) and an elongated member  422 . The elongated member  422  of the rotatable member  420  preferably includes an aperture  424  extending longitudinally therethrough and a cutting element  426 . The elongated member  422  of the rotatable member  420  is preferably disposed coaxially within the elongated member  412  of the outer stationary member  410 . The elongated member  412  is preferably fabricated from stainless steel. It is contemplated that the elongated member  412  may be manufactured from any suitable material.  
         [0089]     The cutting element  426  of the elongated member  422  is disposed at or near the distal end of the elongated member  422 . The cutting element  426  preferably includes a port or opening  428  disposed in the outer surface of the elongated member  422 . The port  428  has a generally substantially round shape and a cutting edge  430  disposed around the periphery of the port  428 . The cutting edge  430  of the port  428  is sharp and cooperates with the sharpened edge of the port  416  of the outer stationary member  410 . It will be recognized that the cutting element  426  may comprise a blade, abrading burr, or ultrasonic element.  
         [0090]     As the rotatable member  420  rotates, the port  428  of the rotatable member  420  periodically aligns with the port  416  of the outer stationary member  410  to admit vein tissue. When the vein tissue enters into the port, the vein tissue is severed or sheared between the cutting edge  430  of the rotatable member  420  and the cutting edge  418  of the outer stationary member  410 . The severed tissue is removed from the surgical site by a vacuum source (not shown).  
         [0091]     Referring now to  FIG. 11 , another surgical system  700  is illustrated which in many respects corresponds in construction and function to the previously described surgical system  100  of  FIG. 1 . Components of the surgical system  700  which generally correspond to those components of the surgical instrument  100  are designated by like reference numbers in the seven-hundred series.  
         [0092]     As shown in  FIGS. 11 and 12 , the surgical system  700  includes an irrigation assembly  800  that allows saline or other materials to be introduced into the surgical site of the patient. The irrigation assembly  800  preferably includes an elongated member  810  and a saline bag  820 . The elongated member  810  has an aperture extending therethrough to allow the saline to flow from the saline bag  820  through the elongated member  810  and into the handpiece assembly via a coupling member  822  when a trigger member  823  is depressed. The saline flows through a conduit  824  and into the surgical site. It is also contemplated that the coupling member  822  can be located at the distal end of the handpiece assembly or near the proximal end of the elongated member. It will be recognized that the tip of the instrument can be dipped into saline to introduce the saline into the surgical site or the saline can flow through a gap formed between the outer surface of the rotatable member and the inner surface of the outer stationary member. The saline can be suctioned from the surgical site when the vacuum source is activated.  
         [0093]     Referring now to  FIGS. 3-5 , the operation of the surgical system to remove undesired veins, such as, varicose and spider veins, of legs of a patient will be described. Initially, a lower extremity venous doppler is taken of the patient to reveal the incompetent valves of the veins between the superficial vein system and the deeper vein system. If there is incompetence in the greater saphenous veins going into the femoral veins and the lesser saphenous veins going into the popliteal veins, the greater saphenous veins will be ligated and divided. During this procedure, the patient may undergo a general anesthetic, regional anesthetic (i.e., spinal or epidural), or a local anesthetic.  
         [0094]     To disconnect the saphenous vein, an incision is made in the groin area to ligate the saphenous vein at its juncture with the femoral vein. All branches of the saphenous vein are ligated and divided with titanium clips and the main greater saphenous vein is ligated proximally and distally. Alternatively, the saphenous vein can be disconnected from the deep veins at a lower point along the leg, such as behind the knee at the lesser saphenous-popliteal junction. This alternative technique may be advisable in circumstances in which treatment of various veins is only necessary in the lower leg.  
         [0095]     When the saphenous vein is disconnected from the femoral vein, the blood from the deep veins will be prevented from flowing backing into the saphenous vein, eliminating the primary cause of the varicose veins. While blood can still enter the saphenous vein through the numerous tributary veins, the subsequent permanent closure of the saphenous vein will effectively prevent this occurrence. Once the saphenous vein is disconnected from the femoral vein, the varicose and/or spider veins can be treated. It will also be recognized that the saphenous vein may not have to be disconnected.  
         [0096]     To remove the undesired veins, the patient is placed in a trendelenburg position, i.e., feet up, and the incision site is prepared. After proper preparation of the incision site, a surgeon makes a small incision  152  through the skin layer and subcutaneous tissue of the patient. The incision is approximately 2-3 mm and only needs to be large enough to permit the distal end of the surgical instrument  120  to pass therethrough. The incision  152  may be made by a blade, such as a small surgical scalpel, such as a Number  67  scalpel blade. The incision  152  is preferably made near the center of the undesired veins to reach the most veins. It should be apparent that the selection of the incision  152  is for exemplary purposes only and the incision may be made at any suitable location.  
         [0097]     After completing the incision  152 , the distal end of the surgical instrument  120  is inserted through the incision  152  made at the skin with the motor  122  of the handpiece assembly  121 . It is also contemplated that the distal end of the surgical instrument  120  may have a sharp point that enables it to be inserted through the skin layer without having to first make an incision. For example, the surgical instrument  120  may have a retractable scalpel blade.  
         [0098]     Once the distal end of the surgical instrument  120  is passed through the incision, the surgeon then activates the switch  128  to cause vacuum suction. The distal end of the surgical instrument  120  is placed on the undesired vein in order to move the vein away from the skin and to remove as much vein tissue with the vacuum suction. The distal end of the surgical instrument  120  is then guided underneath or on the side of the vein to be removed. The surgeon then activates the switch  126  to actuate the cutting element  141  of the surgical instrument  120  at a predetermined speed.  
         [0099]     The surgeon can control rotational speed and direction (either unidirectional or oscillatory) using the switch  126  on the handpiece assembly  121  or the foot switch  136 . The cutting element  141  can rotate over a wide range of speeds, for example, approximately 500-2000 rpm, and preferably in the range of 800-1200 rpm. Oscillation can be in the ultrasonic range. Saline can also be introduced into the surgical site.  
         [0100]     The vacuum suction  16 C draws the vein tissue to be cut into the port  178  of the outer stationary member  170 . As the vein is drawn into the port  178 , the vein is severed by the cutting element  141  of the rotary member  180  and cut into small particles.  
         [0101]     As shown in  FIG. 4 , the surgeon can move the surgical instrument  120  back and forth under the skin and pushing it in and out in a fan-like or circular fashion as permitted to progressively cut away the vein. The amount of cutting varies with the speed of the rotatable member  180 , the amount of pressure applied by the surgeon, the sharpness of the cutting edges, and the number and size of the ports on the outer stationary member  170 .  
         [0102]     After the vein is removed, the incision is closed by conventional techniques, such as, with steri-strips. While suturing of the incision is also possible, it is considered unnecessary due to the small size of the incision, and is also undesirable since suturing the skin can cause scarring. This procedure can then be repeated at another location.  
         [0103]     Once the undesired veins are removed, a stocking can be rolled up on the patient&#39;s leg and a convatec duoderm elastaplast type stocking can be placed from just proximal to the toes to the upper thigh in order for compression to take place.  
         [0104]     The apparatus and methods of the present invention allow various veins to be removed with minimal scarring and without hospitalization. Moreover, the procedure can be performed on an outpatient basis without any of the usual complications of conventional surgical procedures. The procedure can be performed in a short period of time to avoid physician fatigue, minimize anesthesia time for the patient, and increase the number of procedures possible with a given operating room facility.  
         [0105]     Although the present invention has been described in detail by way of illustration and example, it should be understood that a wide range of changes and modifications can be made to the preferred embodiments described above without departing in any way from the scope and spirit of the invention. Thus, the described embodiments are to be considered in all respects only as illustrative and not restrictive, and the score of the invention is, therefore, indicated by the appended claims rather than the foregoing description. All changes that come within the meaning and range of equivalency of the claims are to be embraced within their scope.  
         [0106]     An additional embodiment of a surgical instrument for removing veins is shown in  FIG. 13 . Referring to  FIGS. 13 and 13 A, surgical instrument  900  includes a housing  901  with an outer stationary member  902  having a proximal hub  904  for attaching member  902  to a handpiece (not shown), and an inner member  906  rotatably received within outer member  902 . Inner member  906  includes a proximal hub  908  driven by a motor (not shown).  
         [0107]     Outer member  902  has a cylindrical wall  910  defining a lumen  912  in which inner member  906  is received. Inner member  906  defines a lumen  920  through which cut tissue is aspirated, as described above. Hub  904  of outer member  902  includes an irrigation/tumescence inlet connector  914  communicating with a port  916  which extends through outer member wall  910  permitting access of irrigation/tumescence fluid to a channel  918  defined between outer member  902  and inner member  906 .  
         [0108]     Distal end  922  of outer member  902  includes a window  924  providing access to a cutter  926  located at a distal end  928  of inner member  906 . Window  924  is preferably a full radius window with smooth cutting edges (such as is formed on the Smith &amp; Nephew 4.5 mm Full Radius Resector, part no. 3443), and cutter  926  is preferably an incisor blade with serrated cutting edges (such as that formed on the Smith &amp; nephew 4.5 mm Incisor, part no. 3810). This blade combination advantageously produces a surgical instrument for cutting veins which is more aggressive than a standard full radius blade (which has smooth cutting edges on the inner and outer members) but less aggressive than an incisor blade (the inner and outer members of which both have serrated cutting edges).  
         [0109]     Hub  904  includes a handpiece attachment element  930  and a locator tab  932  for attaching hub  904  to a handpiece, as described in U.S. Ser. No. 08/630,537, entitled SURGICAL INSTRUMENT HANDPIECE AND SYSTEM, incorporated by reference herein. Referring to  FIG. 1 , the trigger mechanism  126  on the handpiece for controlling the rotation of inner member  906  is aligned with window  924  such that trigger mechanism  126  is easily accessible to the surgeon during use of surgical instrument  900  (cutting window  924  generally faces the surgeon during use, as described below).  
         [0110]     Vacuum switch  128  can be used to turn off the suction for aspiration of cut tissue such that irrigation channel  918  can be used to deliver tumescence fluid to the surgical site.  
         [0111]     While surgical instrument  900  is shown having constant diameter inner and outer members  902 ,  906 , the members can be enlarged at all but there distal ends to reduce potential clogging of cut tissue in lumen  920  with their diameters sloping to smaller diameter distal ends. Window  924  can be elongated to provide a larger tissue entry port.  
         [0112]     Referring to  FIG. 14 , a light source, e.g., fiberoptic illuminating device  950 , is provided to aid in visualizing a vein during the cutting procedure. The light source is positioned subcutaneously and in close proximity to the vein to be cut, e.g., about 1 to 2 cm from the vein, with light directed at the vein from below or from the side of the vein causing the vein to be shadowed. This enables the surgeon to see the vein through the patient&#39;s skin, greatly improving the accuracy, efficacy, and efficiency of the procedure, and enabling the surgeon to see even small, branching veins which can also be advantageously removed using surgical instrument  900 .  
         [0113]     Illuminating device  950  includes a housing  951  having a handle  952  and an elongated member  954  terminating in a tip  956 . Housing  951  contains a fiberoptic bundle  958 . Handle  952  includes a lightpost  960  for connecting fiberoptic bundle  958  to a light transmitter (not shown). Lightpost  960  is positioned at proximal end  962  of handle  952  substantially in the direction of a longitudinal axis, A, of illuminating device  950  such that lightpost  960  does not contact the patient during use, which would potentially interfere with the placement of illuminator tip  956  within the patient, and does not interfere with the surgeons grip on handle  952 .  
         [0114]     Member  954  has a small outer diameter of, e.g., only about 0.165″, to minimize tissue trauma. Tip  956  of illuminating device  950  or the distal end of fiberoptic bundle  958  (or both) is oriented at an oblique angle, θ, to the longitudinal axis, A. As a result, light emitted from device  950  is directed at an angle to axis, A, in the range of about 30-85°, preferably about 70°. Member  954  has a length, L 1 , of about 7.5″, such that a large vascular region can be accessed from a single skin portal, and handle  952  has a length, L 2 , of about 3.75″_Member  954  and handle  952  are preferably made from stainless steel.  
         [0115]     Referring also to  FIG. 14A , handle  952  is somewhat hourglass shaped for ease of handling by the surgeon. Handle  952  has, e.g., a thickness, Ti, at waist section  964  of about 0.375″, and a larger thickness, T 2 , of about 0.5″ nearer to its upper and lower ends. Sides  966 ,  968  of handle  952  include grooves  970  to facilitate grasping of handle  952  by the surgeon.  
         [0116]     Referring to  FIG. 15 , in use, the surgeon uses an ink marker to outline on the patient&#39;s skin  971  the veins to be removed. The surgeon places illuminating device  950  through a first incision in the patient&#39;s skin to a location in proximity of a vein  973  to be removed, with the light from illuminating device  950  directed generally upwardly or to the side of the vein to shadow the vein. When placed beneath the vein, illuminating device  950  directs a light cone  975  upward so the surgeon can see the vein shadowed through the skin. Alternatively, the vein can also be shadowed and seen through the skin when the cone of light is directed at the vein from the side of the vein.  
         [0117]     Once the vein is in view, the surgeon makes a second incision in the patient&#39;s skin spaced by a few inches from the first incision with the vein to be removed located between the incisions. The surgeon then places cutting instrument  900  through the second incision and locates distal end  922  of cutting instrument  900  underneath the vein and facing tip  956  of illuminating device  950 . The surgeon then activates cutting instrument  900  to cut the vein.  
         [0118]     Illuminating device  950  permits the surgeon to visualize the vein and the distal end  922  of the cutting instrument  900  through the patient&#39;s skin during cutting. Illuminating device  950  also aids the surgeon in identifying other diseased vessels, particularly small branches of veins which are otherwise difficult to see.  
         [0119]     Tumescence is preferably carried out prior to cutting to shrink the vessels thus limiting blood loss and improving illumination. After cutting is completed, further tumescence can limit blood flow and speed healing. Irrigation is preferably carried out during cutting. Tumescence and irrigation fluid can be delivered through surgical instrument  900 , through the illuminating device, as described below, or through both instruments.  
         [0120]     Referring to  FIG. 16 , an alternative fiberoptic illuminating device  950   a  includes a fiberoptic bundle  958  as shown in  FIG. 14 , and a separate fluid channel  972 . Fluid channel  972  is preferably a straight channel having an internal diameter of about 1 mm. Handle  952   a  includes a connector  974  for attaching an input fluid line (not shown) to handle  952   a  to supply fluid to a proximal end  982  of fluid channel  972 , and a valve  976  for controlling flow of irrigation and tumescence fluid. The curvature in fiberoptic bundle  958  leading to lightpost  960  facilitates the placement of both lightpost  960  and connector  974  at the proximal end  962  of handle  952   a.    
         [0121]     Connector  974  has, e.g, either or both of a luer fitting  978  and a tapered hose barb  980 . Valve  976  is spring loaded to be biased in an off position, and can be pushed for intermittent supply of fluid or locked on for continuous fluid supply. Channel  972  has an open distal end  982   a , and can include distal side openings (not shown) to provide an alternative flow profile of irrigation and tumescence fluid. Member  954   a  has a small outer diameter of, e.g., only about 0.165″, to minimize tissue trauma.  
         [0122]     Referring to  FIGS. 17 and 17 A, an integral surgical illuminating device  984  includes an outer cutting member  986 , an inner cutting member  986 , and a fiberoptic bundle  985  attached to the external surface of outer cutting member  986 . A distal tip  987  of fiberoptic bundle  985  is set at an angle relative to the longitudinal axis of device  984  of, e.g., about 0 to 90°, preferably about 45 to 70°, and positioned adjacent to the outer member window  988  to direct the light at a vein positioned above or beside outer member window  988 . In the embodiment shown, surgical instrument  984  also includes a separate line  989  attached to the external surface of outer member  986  and distally directed along the longitudinal axis of instrument  984  for delivering fluid to the surgical site. Tine  999  can replace fluid supply channel  918  defined between the inner and outer members (described above), or line  989  can be in addition to fluid channel  918 . Alternatively, surgical instrument  984  need not include line  989  and both tumescence and irrigation are conducted through channel  918 .  
         [0123]     Attached to proximal end  997  of outer member  986  is a hub  990  having a connector  992  for introduction of fluid to line  989 , a lightpost  993  for attaching fiberoptic bundle  985  to a light source (not shown), and a connector  994  for introduction of fluid to channel  918  (described above). Surgical instrument  984  is otherwise as described above with reference to  FIG. 14 .  
         [0124]     Other applications for the use of illuminating devices  950 ,  950   a , and  984  include lipoma (fatty tumor removal) and liposuction. During these procedures, the illuminating device can provide visualization of the veins in the area of surgery to aid the surgeon in avoiding the veins.  
         [0125]     Other embodiments are within the scope of the following claims.