Abstract:
An end effector for use with a surgical instrument comprising an anvil shaft, a first anvil assembly disposed at a distal portion of the anvil shaft and a second anvil assembly mountable on the anvil shaft proximally of the first anvil assembly. Also, a method for performing a surgical procedure is provided including the steps of providing a surgical instrument including a first cartridge assembly and a first anvil assembly having an anvil shaft, approximating the first anvil assembly and first cartridge assembly and ejecting staples from the first cartridge assembly. The method further includes removing the first cartridge assembly from the tubular organ, and inserting a second anvil assembly into the tubular organ to engage the anvil shaft of the first anvil assembly and ejecting staples from a second cartridge assembly towards the second anvil assembly.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
       [0001]    This application is a Divisional of U.S. patent application Ser. No. 13/798,950 filed Mar. 13, 2013, which is a Divisional of U.S. patent application Ser. No. 12/770,182 filed Apr. 29, 2010, now U.S. Pat. No. 8,418,909, which claims benefit of and priority to U.S. Provisional Application No. 61/183,201 filed Jun. 2, 2009, and the disclosures of each of the above-identified applications are hereby incorporated by reference in their entirety. 
     
    
     BACKGROUND 
       [0002]    Technical Field 
         [0003]    The present disclosure relates generally to a surgical instrument and, more specifically, to a surgical instrument for clamping, cutting, and/or joining tissue. 
         [0004]    Background of Related Art 
         [0005]    Certain surgical stapling instruments are used for applying rows of staples through compressed living tissue. These surgical stapling instruments are employed, for example, for fastening tissue or organs prior to transection or resection or during anastomoses. In some cases, these surgical stapling instruments are utilized for occluding organs in thoracic and abdominal procedures. 
         [0006]    Typically, such surgical stapling instruments include an anvil assembly, a cartridge assembly for supporting an array of surgical staples, an approximation mechanism for approximating the cartridge and anvil assemblies, and a firing mechanism for ejecting the surgical staples from the cartridge assembly. 
         [0007]    In use, a surgeon initially advances an alignment pin assembly and subsequently approximates the anvil and cartridge assemblies. Next, the surgeon can fire the instrument to the instrument to place staples in tissue. Optionally, the surgeon may use the same instrument or a separate device to cut the tissue adjacent or between the row(s) of staples. 
       SUMMARY 
       [0008]    The present disclosure in one aspect relates to an end effector for use with a surgical instrument comprising an anvil shaft, a first anvil assembly disposed at a distal portion of the anvil shaft, and a second anvil assembly mountable on the anvil shaft proximally of the first anvil assembly. 
         [0009]    Preferably, the anvil assembly and anvil shaft are aligned by key slots. 
         [0010]    In one embodiment, the first anvil assembly has a first plurality of anvil pockets arranged in a substantially annular row to deform fasteners fired from a first fastener cartridge and the second anvil assembly has a second plurality of anvil pockets arranged in a substantially annular row to deform fasteners fired from a second fastener cartridge. 
         [0011]    Preferably, each of the first anvil assembly and the second anvil assembly is slidable in response to movement of the anvil shaft. The second anvil assembly can include a weakened portion that is configured to break when a knife moves therethrough and the first anvil assembly can have a knife receiving portion for embedding the knife when the knife moves through the second anvil assembly. 
         [0012]    In some embodiments, the second anvil assembly is mountable to the anvil shaft after fasteners are deformed by the first anvil assembly. 
         [0013]    In some embodiments, the anvil shaft is removably mountable to a surgical instrument having a cartridge containing a plurality of fasteners and an actuator for firing the fasteners from the cartridge. 
         [0014]    In another aspect, the present disclosure relates to a method for performing a resection. This method includes the steps: providing a surgical instrument including a first cartridge assembly and a first anvil assembly having an anvil shaft; inserting the first anvil assembly into a tubular organ; approximating the first anvil assembly toward the first cartridge assembly; ejecting staples from the first cartridge assembly towards the first anvil assembly; removing the first cartridge assembly from the tubular organ such that the first cartridge assembly operatively disengages the anvil shaft of the first anvil assembly; inserting a second anvil assembly into the tubular organ such that the second anvil assembly operatively engages the anvil shaft of the first anvil assembly; and ejecting staples from a second cartridge assembly towards the second anvil assembly. 
         [0015]    The method can further include the step of inserting the first cartridge assembly into the tubular organ such that the first cartridge assembly operatively engages the first anvil assembly prior to the step of approximating the first cartridge. 
         [0016]    The method can further include the step of inserting a second cartridge assembly into the tubular organ such that the second cartridge assembly operatively engages the second anvil assembly prior to the step of approximating the second cartridge. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0017]    Various embodiments of the presently disclosed surgical instruments and methods are disclosed herein with reference to the drawings, wherein: 
           [0018]      FIG. 1  is a perspective view of a surgical instrument according to an embodiment of the present disclosure, the instrument used to fire a second set of fasteners; 
           [0019]      FIG. 2  is a longitudinal cross-sectional view of the surgical instrument shown in  FIG. 1 ; 
           [0020]      FIG. 3  is a longitudinal cross-sectional view of a handle assembly of the surgical instrument shown in  FIGS. 1 and 2 , taken around section  3  of  FIG. 2 ; 
           [0021]      FIG. 4  is a longitudinal cross-sectional view of a distal portion of the surgical instrument shown in  FIGS. 1 and 2 , taken around section  4  of  FIG. 2 ; 
           [0022]      FIG. 4A  is a longitudinal cross-sectional view of a distal portion of another surgical instrument used to fire the first set of fasteners; 
           [0023]      FIG. 5  is a perspective view of the surgical instrument shown in  FIGS. 1 and 2 , illustrating a stage of operation of said surgical instrument; 
           [0024]      FIG. 6  is a longitudinal cross-sectional view of a distal portion of the surgical instrument shown in  FIG. 1 , depicting another stage of operation of said surgical instrument; 
           [0025]      FIG. 7  is a longitudinal cross-sectional view of the handle assembly shown in  FIG. 3  being actuated; 
           [0026]      FIG. 8  is a longitudinal cross-sectional view of the end effector shown in  FIG. 4  shown being moved to the approximated position; 
           [0027]      FIG. 9  is a longitudinal cross-sectional view of a tubular organ with a cartridge assembly and a first anvil assembly of the surgical instrument of  FIG. 4A  positioned therein, showing the first anvil assembly secured inside the tubular organ with a pursestring suture; 
           [0028]      FIG. 10  is a longitudinal cross-sectional view of the tubular organ shown in  FIG. 9  during irrigation after the cartridge assembly depicted in  FIG. 4A  has been removed from the tubular organ; 
           [0029]      FIG. 11  is a longitudinal cross-sectional view of the tubular organ shown in  FIG. 9  with the first anvil assembly and a second anvil assembly positioned therein, and a pursestring suture wrapped around a portion of the tubular member located between the first anvil assembly and the second anvil assembly; 
           [0030]      FIG. 12  is a perspective view of an anvil shaft and the second anvil assembly shown in  FIG. 11  in cross-section; 
           [0031]      FIG. 13  is a longitudinal cross-sectional view of the tubular organ shown in  FIG. 9  with the first anvil assembly, the second anvil assembly, and the cartridge assembly of the surgical instrument of  FIG. 1  positioned therein, showing the surgical instrument before approximation and firing; 
           [0032]      FIG. 14  is a longitudinal cross-sectional view of the tubular organ shown in  FIG. 9  with the first anvil assembly, the second anvil assembly, and the cartridge assembly of the surgical instrument of  FIG. 1  positioned therein, showing the surgical instrument after it has been approximated and fired; and 
           [0033]      FIG. 15  is a longitudinal cross-sectional view of the tubular organ shown in  FIG. 9  after the surgical instrument has been fired and removed from the tubular organ. 
       
    
    
     DETAILED DESCRIPTION OF THE EMBODIMENTS 
       [0034]    Embodiments of the presently disclosed surgical instrument and method are described in detail with reference to the drawings, wherein like reference numerals designate corresponding elements in each of the several views. In the description that follows, the term “proximal” refers to the end or portion of the surgical instrument closer to the clinician, whereas the term “distal” refers to the end or portion of the surgical instrument further away from the clinician. 
         [0035]      FIGS. 1 and 2  illustrate an embodiment of the presently disclosed surgical instrument  10  when both first and second anvil assemblies are positioned on the anvil shaft. As will be described in more detail below, a first instrument is used for firing a first set of fasteners with respect to a first anvil assembly. The first instrument is then separated from the anvil assembly and removed from the body. The second anvil assembly is then inserted onto the anvil shaft of the first anvil assembly and a second instrument is utilized to fire a second set of fasteners with respect to the second anvil assembly.  FIG. 1  illustrates the second instrument used to fire fasteners against second anvil assembly  32 ;  FIG. 4A  illustrates a portion of the first instrument used to fire fasteners against first anvil assembly  30 . As shown in  FIGS. 1 and 2 , the first anvil assembly  30  is positioned distally of the second anvil assembly  32 . 
         [0036]    In the interest of brevity, the present disclosure focuses on end effectors for the disclosed second surgical instrument  10 . U.S. Pat. No. 7,303,106, the entire contents of which are hereby incorporated by reference, describes in detail the structure and operation of an embodiment of surgical instrument  10 . 
         [0037]    Turning first to the second surgical instrument and with reference to  FIGS. 1 and 2 , in general, the second surgical instrument  10  includes a handle assembly  12 , an elongated central body portion  14  including a curved elongated outer tube  14   a , and an end effector or distal head or end portion  16 . Elongated central body portion  14  extends distally from handle assembly  12  and operatively couples end effector  16  to handle assembly  12 . In operation, end effector  16  fires fasteners into anvil assembly  32 , deploys a cutting device  62  ( FIG. 8 ), or both, upon actuation of handle assembly  12 . 
         [0038]    Handle assembly  12  includes a stationary handle  18 , a firing trigger  20 , a rotatable approximation knob  22  and an indicator  24 . In certain embodiments, stationary handle  18  is made of a thermoplastic, such as polycarbonate. In other embodiments, stationary handle  18  is formed of an elastomeric material. Stationary handle  18  may nevertheless be formed of any suitable material. In some embodiments, stationary handle  18  has a hollow body that houses internal components of handle assembly  12 . U.S. Pat. No. 7,303,106, the entire contents of which have already been incorporated by reference, describes in detail the internal components of handle assembly  12 . 
         [0039]    Handle assembly  12  further includes a trigger lock  26  for preventing, or at least minimizing, the risk of inadvertently firing surgical instrument  10 . In the embodiment depicted in  FIG. 1 , trigger lock  26  is pivotally mounted to stationary handle  18 . During use, trigger lock  26  is configured to move relative to stationary handle  18  between a locked position and an unlocked position. In the locked position, trigger lock  26  engages firing trigger  20  and precludes, or at least hinders, movement of firing trigger  20  with respect to stationary handle  18 . In the unlocked position, trigger lock  26  allows firing trigger  20  to move or pivot relative to stationary handle  18 . Stationary handle  18  additionally includes an indicator  24  to indicate to a clinician whether end effector  16  is approximated and/or is ready to be fired. In some embodiments, indicator  24  has a bulbous or convex shape extending outwardly from a top surface of stationary handle  18 . Stationary handle  18  also includes approximation knob  22  operatively coupled to end effector  16 . Approximation knob  22  is configured to rotate with respect to stationary handle  18 . A rotation of approximation knob  22  relative to stationary handle  18  causes end effector  16  to move between an open position ( FIG. 4 ) and an approximated position ( FIG. 6 ). 
         [0040]    End effector  16  generally includes a cartridge assembly  28 , a first anvil assembly  30  having an anvil shall  34  and a second anvil assembly  32  slidably mountable on the anvil shaft  34 . Cartridge assembly  28  houses an array of fasteners, such as staples, and is configured to eject those fasteners in a distal direction into engagement with anvil pockets on second anvil assembly  32  (As noted above, anvil assembly  30  receives fasteners of a different surgical instrument). Cartridge assembly  28  includes slots  29  ( FIG. 4 ) dimensioned to receive the fasteners  74  ( FIG. 4 ). Slots  29  may be arranged in one or more substantially annular rows or in any other suitable configuration. 
         [0041]    Turning now to the first anvil assembly  30 , anvil assembly  30  includes a blunt or round distal head  36  and a tubular member  40  and is configured to receive fasteners of the first surgical instrument of  FIG. 4A . More specifically, with reference to  FIGS. 1 and 4A , tubular member  40  is movable with respect to distal head  36 . In some embodiments, a biasing member, such as a spring  99 , biases tubular member  40  in a proximal direction. Tubular member  40  defines a lumen configured to receive anvil shaft  34 . Distal head  36  includes a circumferential groove  38  adapted to receive a purse string suture. Groove  38  surrounds distal head  36  and may have a concave configuration. Distal head  36  further includes a proximal surface  42  located proximally relative to groove  38 . Proximal surface  42  has a plurality of anvil pockets  41  adapted to receive and deform fasteners  174  ejected from cartridge assembly  128  of the first surgical instrument. In disclosed embodiments, proximal surface  42  is made of a metal, such as stainless steel or aluminum. In some embodiments, these pockets are arranged in one or more substantially annular rows on proximal surface  42 . Other arrangements are contemplated to correspond to arrangements of the fastener slots  129 . 
         [0042]    Anvil shaft  34  extends proximally from first anvil assembly  30  and has a proximal end  46  and a distal end  44 . Distal end  44  of anvil shaft  34  is attached to first anvil assembly  30 , whereas proximal end  46  of anvil shaft  34  is configured to be releasably coupled to the rod extending from the cartridge assembly  128 . Anvil shaft  34  additionally includes longitudinal keys  48  extending between proximal end  46  and distal end  44 . Longitudinal keys  48  are configured to engage second anvil assembly  32  to guide the translation of second anvil assembly  32  along anvil shaft  34 . In use, longitudinal keys  48  block, or at least hinder, rotation of second anvil assembly  32  relative to anvil shaft  34 . 
         [0043]    Turning now to second anvil assembly  32 , configured for use with the second surgical instrument of  FIG. 1 , and with reference to  FIGS. 1, 4 and 12 , second anvil assembly  32  includes a tubular member  50  and a ring  52  disposed around tubular member  50 . Tubular member  50  has a proximal end  54  and a distal end  56 . In addition, tubular member  50  includes a guide  60  adapted to guide a knife or any suitable cutting device  62  deployed from cartridge assembly  28  of instrument  10 . In certain embodiments, guide  60  has a tubular shape and defines a longitudinal opening  64  configured to slidably receive anvil shaft  34 . In some embodiments, guide  60  includes one or more slots (not shown) disposed along an inner surface thereof. The slots (not shown) of guide  60  are adapted to engage longitudinal keys  48  of anvil shaft  34 . The engagement between longitudinal keys  48  and the slots of guide  60  facilitate axial translation of second anvil assembly  32  along anvil shaft  34 , while precluding, or at least inhibiting, rotation of second anvil assembly  32  relative to anvil shaft  34 . Guide  60  defines an annular space  66 . Annular space  66  is dimensioned to receive cutting device  62  and is disposed adjacent a weakened or breakable portion  68  of tubular member  50 . Weakened portion  68  may be made of a polymer or any material suitable to break upon passage of cutting device  62  therethrough. Cutting device  62  is made of a metal, such as stainless steel or aluminum, or any material suitable to cut tissue. Weakened portion  68  is disposed adjacent distal end  56  of tubular member  50 . The break away portion of anvil assembly  32  can pass through the body or otherwise be captured and removed from the body. 
         [0044]    Ring  52  is positioned around distal end  56  of tubular member  50  and has a proximal surface  70  and a distal surface  72 . In some embodiments, ring  52  is made of metal, such as stainless steel or aluminum, or any other material suitable to deform fasteners  74  ejected from cartridge assembly  28 . In some embodiments, proximal surface  70  of ring  52  includes fastener deforming pockets or concavities  71  configured to deform fasteners  74  deployed from cartridge assembly  28  of the second surgical instrument  10  upon contact with the pockets. 
         [0045]    With reference to  FIGS. 3-8 , firing trigger  20  is operatively coupled to a fastener pusher  73  ( FIGS. 4 and 6 ) positioned inside first cartridge assembly  28 . In several embodiments, surgical instrument  10  includes a firing link assembly  75  ( FIG. 3 ) operatively interconnecting firing trigger  20  and fastener pusher  73 . Firing link assembly  75  extends from handle assembly  12  to cartridge assembly  28 . In operation, actuation of firing trigger  20  causes a distal translation of fastener pusher  73  due to distal translation of firing link assembly  75 . Fastener pusher  73  includes one or more fingers  77  ( FIG. 4 ) dimensioned to be received in slots  29  of first cartridge assembly  28 . When fastener pusher  73  moves distally in response to an actuation of firing trigger  20 , fingers  77  move distally toward slots  29  and urge fasteners  74  toward second anvil assembly  32 . 
         [0046]    With continued reference to  FIGS. 3-8 , surgical instrument  10  further includes an approximation link assembly  89  operatively coupling approximation knob  22  to anvil shaft  34 . As seen in  FIG. 4 , approximation link assembly  89  includes a rod or shaft  91  protruding distally from cartridge assembly  28 . Rod  91  is disposed in mechanical cooperation with anvil shaft  34  (e.g., in a friction-fit relationship). In certain embodiments, anvil shaft  34  defines a longitudinal opening  93  dimensioned to receive rod  91 . Longitudinal opening  93  extends through a proximal portion  95  of anvil shaft  34 . In operation, a rotation of approximation knob  22  effects a translation of approximation link assembly  89 . Rotation of knob  22  rotates an internal screw which is operatively connected to link assembly  89  via pin  87  to thereby move link assembly  89  in a proximal or distal direction, depending on the direction of rotation of knob  22 . As approximation link assembly  89  translates, rod  91  moves proximally or distally as it is connected to link assembly  89  via pins  92 . Since rod  91  is coupled to anvil shaft  34 , movement of rod  91  causes anvil shaft  34  to move as well. While anvil shaft  34  moves, second anvil assembly  32  correspondingly moves in a distal or proximal direction. 
         [0047]    It should be noted that similarly, when rod  191  of first instrument  110  of  FIG. 4A  moves, it moves anvil shaft  34  to move first anvil assembly  30  in a proximal or distal direction. That is, a user may approximate first anvil assembly  30  to cartridge assembly  128  by rotating an approximation knob (similar to approximation knob  122  of  FIG. 1 ) in a first direction (e.g., clockwise). In response, the approximation link assembly moves proximally and urges rod  191  in a proximal direction. As rod  191  moves proximally, anvil shaft  34  translates proximally and pulls first anvil assembly  30  toward cartridge assembly  128  from an open position to an approximated position, as described in detail below. 
         [0048]    Referring back to the second instrument, as shown in  FIG. 4 , cartridge assembly  28  of the second surgical instrument further may include a knife blade, or any suitable cutting device  62  movable between a retracted or proximal position and a deployed or distal position. In some embodiments, knife  62  is operatively connected to fastener pusher  73  and may have an annular configuration or shape. Knife  62  may be made of a metal, such as stainless steel. In the retracted position, knife  62  is positioned within cartridge assembly  28 . In the deployed position, knife  62  is at least partially positioned outside of cartridge assembly  28 . While knife  62  moves between the retracted and deployed positions, at least a portion of knife  62  passes through an annular space  66  defined in second anvil assembly  32  and through breakable annular portion  68 , as discussed below. 
         [0049]    With continued reference to  FIG. 4 , second anvil assembly  32  is slidably positioned on anvil shaft  34  and includes annular space  66  defined in tubular portion  50 . Annular space  66  surrounds longitudinal opening  64  and is dimensioned to receive knife  62 . During use, annular space  66  guides the translation of knife  62  through second anvil assembly  32 . Second anvil assembly  32 , as discussed above, also includes a breakable or weakened annular portion  68  substantially axially aligned with annular space  66 . Breakable annular portion  68  may be made of ceramic, plastic, or any other suitable material and is positioned distally of annular space  66 . Breakable annular portion  68  is made of a material that can be broken by knife  62  during the firing process. As knife  62  moves from the retracted position to the deployed position, knife  62  passes through annular space  66  of second anvil assembly  32  and then breaks breakable annular portion  68  of second anvil assembly  32 . After knife  62  breaks through breakable annular portion  68 , knife  62  continues moving toward first anvil assembly  30  wherein it becomes embedded. More specifically, first anvil assembly  30 , coupled to anvil shaft  34 , includes tubular portion  40  having a proximal surface  101 . Proximal surface  101  of tubular portion  40  serves as a knife cutting target. As such, proximal surface  101  of tubular portion  40  receives knife  62  and stops further distal translation of knife  62  during the firing process as the knife becomes embedded therein. The anvil assembly  30  can include a cut ring. 
         [0050]    Cutting device  62  is configured to move between a proximal or retracted position and a distal or deployed position. In the retracted position, cutting device  62  is positioned inside cartridge assembly  28 , whereas, in the deployed position, cutting device  62  is at least partially positioned outside of cartridge assembly  62 . In some embodiments, cutting device  62  moves from the retracted position to the deployed position concomitantly with distal advancement (firing of) the fasteners upon actuation of handle assembly  12 . In other embodiments, cutting device  62  can be selectively advanced independently of the fasteners stored in cartridge assembly  28 . In these embodiments, the clinician can eject the fasteners housed in cartridge assembly  28 , while maintaining cutting device  62  in the retracted position. Subsequently, cutting device  62  would be actuated. 
         [0051]    With reference to  FIGS. 9-15 , the method of use of the surgical instruments disclosed herein to cut, fasten, and/or join tissue in a number of surgical procedures is disclosed. For example, surgical instrument  10  may be employed in a lower anterior resection where it is desirable to clamp an upper portion of the bowel for cleaning the rectum prior to resection and joining the two tissue sections. 
         [0052]    In one exemplary procedure, a clinician inserts first anvil assembly  30  along with anvil shaft  34  into a tubular vessel or organ “O”, such as the intestine (see  FIG. 9 ). First anvil assembly  30  may be inserted into the intestine through a patient&#39;s anus. Irrespective of the insertion method, first anvil assembly  30  may be positioned, for example, adjacent a tumor. In particular, first anvil assembly  30  may be placed just distally of the tumor. After placing the first anvil assembly  30  in the desired site, the clinician fixes the position of first anvil assembly  30  relative to tubular organ “O.” To fix the position of first anvil assembly  30 , the clinician may wrap a purse string suture “S 1 ” around a portion of tubular organ located around groove  38 , as shown in  FIG. 9 . Then, the clinician tightens string “S 1 ” to secure first anvil assembly  30  within tubular organ “O.” Alternatively, the clinician secures first anvil assembly  30  inside tubular organ “O” with a mechanical clamp. 
         [0053]    Once first anvil assembly  30  has been secured to tubular organ “O,” the clinician inserts the first surgical instrument  110  of  FIG. 4A  containing cartridge assembly  128  into tubular organ “O” such that cartridge assembly  128  operatively engages first anvil assembly  30 . Specifically, the clinician advances cartridge assembly  128  through tubular organ “O” and cartridge assembly  128  is operatively connected to anvil shaft  34  via rod or (anvil retainer),  191 , as seen in  FIG. 9 . As can be appreciated, at this point second anvil  32  has not yet been attached to anvil shaft  34 . Cartridge assembly  128  may be inserted into the subject&#39;s intestine through the anus. Cartridge assembly  128  includes a plurality of fasteners for contact with the anvil pockets of anvil assembly  30 , but preferably does not include a knife. 
         [0054]    After operatively coupling cartridge assembly  128  of first surgical instrument  110  (of  FIG. 4A ) with first anvil assembly  30 , the clinician draws a portion of the tubular organ “O” located between first anvil assembly  30  and cartridge assembly  28  toward anvil shaft  34 , as illustrated in  FIG. 10 . To pull said portion of tubular organ “O” toward anvil shaft  34 , the clinician wraps a purse string suture “S 2 ” around said portion of tubular organ and then tightens string “S 2 .” The anvil assembly  30  is then approximated toward the cartridge assembly  128  by rotation of an approximation knob (not shown) similar to rotation knob  22  of instrument  10 . Subsequently, the clinician actuates a handle assembly (not shown) similar to handle assembly  12  of instrument  10  to eject fasteners  174  stored inside cartridge assembly  128  to fasten the portion of tubular organ pulled with string “S 2 .” Upon actuation of the handle assembly (similar to handle assembly  12  of  FIG. 1 ), fasteners  174  are ejected from cartridge assembly  128  and move toward first anvil assembly  30 , penetrating the portion of the tubular organ located between cartridge assembly  128  and first anvil assembly  30 . When fasteners  174  reach pockets  41  on proximal surface  42  of first anvil assembly  30 , fasteners  174  deform and fasten the portion of the tubular organ “O” located between cartridge assembly  128  and first anvil assembly  30 . The clinician then moves end effector  16  back to the open position (e.g., by rotating the approximation knob in the opposite direction), disengages cartridge assembly  128  from anvil shaft  34  by separating shaft  191  from anvil shaft  34 , and removes cartridge assembly  128  from tubular organ “O” and instrument  110  from the patient&#39;s body, leaving first anvil assembly  30  inside tubular organ “O.” Tubular organ “ 0 ” may then be irrigated to clear said section from debris and tumor cells, as schematically shown in  FIG. 10  by dashed lines “I.” In one exemplary process, the clinician irrigates the anorectal canal with water or a saline solution. 
         [0055]    Next, the clinician inserts second anvil assembly  32  into tubular organ “O” and slides second anvil assembly  32  over anvil shaft  34 , as shown in  FIGS. 11 and 12 . Second anvil assembly  32  may be inserted, for example, through the subject&#39;s anus. Longitudinal keys  48  guide the placement of second anvil assembly  32  along anvil shaft  34 . The clinician then inserts cartridge assembly  28  of a second surgical instrument  10  (shown e.g. in  FIGS. 1 and 4 ) containing a cutting device  62  into the tubular organ “O.” This cartridge assembly  28  may be similar to the cartridge assembly  128  that was inserted previously except cartridge assembly  28  has a cutting device  62  capable of moving independently of the fasteners. Alternatively, the clinician may insert a cartridge assembly  28  different from the cartridge assembly  128  inserted previously. In any case, the clinician may insert cartridge assembly  28  through the subject&#39;s anus. Cartridge assembly  28  is advanced through tubular organ “O” until cartridge assembly  28  operatively engages anvil shaft  34  ( FIG. 13 ) due to the engagement of rod  191 . It should be appreciated that instead of using two separate instruments  10 ,  110 , it is also contemplated that the instrument can be provided with a removable cartridge so that the same instrument can be used to fire fasteners  174  and fasteners  74 , with a first cartridge for firing fasteners  174  not having a knife and after use, it is removed and replaced with a second cartridge for firing fasteners  74  and having a knife. 
         [0056]    After operatively coupling the second instrument  10  with anvil shaft  34 , the clinician draws a portion of tubular organ “O” located between first anvil assembly  30  and second anvil assembly  32  toward anvil shaft  34 . To pull said portion of tubular organ “O,” the clinician may wrap a purse string suture “S 3 ” around said portion of tubular organ “O” and then tightens string “S 3 ” ( FIG. 13 ) to draw the portion of tubular organ located between first anvil assembly  30  and second anvil assembly  32  toward anvil shaft  34 . A portion of tubular organ “O” located between second anvil assembly  32  and cartridge assembly  28  is pulled toward anvil shaft  34 . In one exemplary method, the clinician wraps a purse string suture “S 4 ” ( FIG. 13 ) around said portion of tubular organ “O” and tightens string “S 4 ” to draw the portion of tubular organ “O” located between second anvil assembly  32  and cartridge assembly  28  toward anvil shaft  34 . Thereafter, the clinician rotates approximation knob  22  to move end effector  16  to the approximated position, e.g. approximate anvil assembly  30  and cartridge  28 , thereby clamping portions of tubular organ “O.” Then, the clinician actuates handle assembly  12  to eject fasteners  80  housed in cartridge assembly  28  and to move cutting device  62  from the retracted position to the deployed position, as depicted in  FIG. 7 . Fasteners  80  may move sequentially or concomitantly with cutting device  62 . 
         [0057]    Upon actuation of handle assembly  12 , fasteners  80  pass through the portion of the tubular organ located between cartridge assembly  28  and second anvil assembly  32  and reach proximal surface  70  of ring  52 . When fasteners  80  reach the pockets  71  of proximal surface  70 , fasteners  80  deform and seal the portion of tubular portion located between cartridge assembly  28  and second anvil assembly  32 . 
         [0058]    While cutting device  62  moves from the retracted position to the deployed position, cutting device  62  passes through annular space  66  and breaks through weakened portion  68  of second anvil assembly  32  to reach tubular member  50  of first anvil assembly  30 . After breaking weakened portion  68  of second anvil assembly  32  ( FIG. 14 ), cutting device  62  cuts the portion of the tubular organ “O” located between first anvil assembly  30  and second anvil assembly  32 . When cutting device  62  engages tubular member  40 , cutting device  62  may urge tubular member  40  distally against the influence of the biasing member  99  of first anvil assembly  30 . It is envisioned that cutting device  62  cuts the portion of tubular organ “O” containing the tumor. 
         [0059]    Finally, the clinician moves end effector  16  to the open position by rotating approximation knob  22  and removes cartridge assembly  28 , first anvil assembly  30 , and second anvil assembly  32  from tubular organ “O.” Any loose sections of second anvil assembly  32  may be removed individually or may pass through the body. After completing the surgical procedure, tubular organ “O” has been cut in two sections A and B with sealed edges C and D, as seen in  FIG. 15 . 
         [0060]    Thereafter, a circular anastomosis instrument can be inserted through the lower tissue portion and into the tubular organ O. The instrument is clamped to approximate the two portions (since a tissue portion in between has been removed) and then staples are fired to join the portions. 
         [0061]    Thus, as can be appreciated, one use of the instrument is in a lower anterior resection procedure. Clamping of the tissue organ O above the intended resection area enables wash out (cleaning out) of the area below the clamping, with stapling occurring below the clamping. This is achieved with access through the anus of the patient. 
         [0062]    While the above description contains many specifics, these specifics should not be construed as limitations on the scope of the present disclosure, but merely as illustrations of various embodiments thereof. Therefore, the above description should not be construed as limiting, but merely as exemplifications of various embodiments. Those skilled in the art will envision other modifications within the scope and spirit of the disclosure.