Abstract:
A surgical treatment apparatus includes a first unit including a first vibration transmission member and a first holding member, a second unit including a second vibration transmission member, a second holding member, and an elastic member provided between the second vibration transmission member and the second holding member, configured to be deformed in accordance with a relative arrangement of the second vibration transmission member and the second holding member with respect to the axial direction to give the second vibration transmission member an elastic force in the axial direction, and an adjustment coupling mechanism to couple the first unit and the second unit with each other, arrange the first vibration transmission member and the second vibration transmission member coaxially, and adjust a relative arrangement of the first holding member and the second holding member.

Description:
BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     The present invention relates to a surgical treatment apparatus to treat a living tissue. 
     2. Description of the Related Art 
     A specification in European Patent No. 893971 discloses an ultrasonic treatment apparatus as a surgical treatment apparatus. In the ultrasonic treatment apparatus, a surgical instrument is attachable to/detachable from a handpiece assembly. A horn to expand and transmit ultrasonic vibration is inserted through the handpiece assembly. A transmission rod to transmit the ultrasonic vibration is inserted through a cylindrical housing of the surgical instrument. A distal end portion of the housing has a narrow inside diameter and a step surface formed thereon, a flange is formed on the transmission rod, and an elastic member is interposed between the step surface and the flange. The distal end portion of the handpiece assembly and a proximal end portion of the surgical instrument are coupled with each other, and so a distal end portion of the horn in the handpiece assembly and a proximal end portion of the transmission rod in the surgical instrument are pressed against and coupled with each other. As a method of coupling the handpiece with the surgical instrument, screwing is adopted and besides, there are snap-on coupling and twisting lock fitting. 
     BRIEF SUMMARY OF THE INVENTION 
     In an aspect of the present invention, a surgical treatment apparatus includes: a first unit including a first vibration transmission member extended in an axial direction, including an end portion, and to transmit ultrasonic vibration, and a first holding member holding the first vibration transmission member; a second unit including a second vibration transmission member extended in an axial direction, including an end portion, and to transmit the ultrasonic vibration, a second holding member holding the second vibration transmission member movable in the axial direction of the second vibration transmission member, and an elastic member provided between the second vibration transmission member and the second holding member, configured to be deformed in accordance with a relative arrangement of the second vibration transmission member and the second holding member with respect to the axial direction of the second vibration transmission member to give the second vibration transmission member an elastic force in the axial direction; and an adjustment coupling mechanism to couple the first unit and the second unit with each other, arrange the first vibration transmission member and the second vibration transmission member coaxially to abut the end portion of the first vibration transmission member and the end portion of the second vibration transmission member against each other, and adjust a relative arrangement of the first holding member and the second holding member with respect to a coaxial direction to be constant to adjust a deformation amount of the elastic member to be constant. 
    
    
     
       BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWING 
       The accompanying drawings, which are incorporated in and constitute a part of the specification, illustrate embodiments of the invention, and together with the general description given above and the detailed description of the embodiments given below, serve to explain the principles of the invention. 
         FIG. 1  is a side view showing a surgical instrument according to an embodiment of the present invention; 
         FIG. 2  is a longitudinal cross-sectional view showing the surgical instrument according to the embodiment of the present invention; 
         FIG. 3  is a longitudinal cross-sectional view showing a cam frame according to the embodiment of the present invention; 
         FIG. 4  is a development elevation showing the cam frame according to the embodiment of the present invention; 
         FIG. 5A  is a graph showing a relationship between a compression amount and a pressing force amount of an elastic member according to the embodiment of the present invention; 
         FIG. 5B  is a graph showing a relationship between a rotation angle and a pressure angle of a cam mechanism according to the embodiment of the present invention; 
         FIG. 6  is a partial longitudinal cross-sectional side view showing a surgical instrument according to a first modification of the embodiment of the present invention; and 
         FIG. 7  is a side view showing a surgical instrument according to a second modification of the embodiment of the present invention. 
     
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
     An embodiment according to the present invention will now be explained hereinafter with reference to the accompanying drawings. 
       FIGS. 1 to 5B  show an embodiment of the present invention. 
     A surgical instrument as a surgical treatment apparatus according to this embodiment is an ultrasonic output combined high-frequency surgical instrument for abdominal operations. 
     An outline structure of the surgical instrument will now be explained with reference to  FIGS. 1 and 2 . 
     The surgical instrument includes a handpiece  21  as a first unit to be held and operated by an operator. The handpiece  21  is extended in an axial direction. An electrical cable  23  is extended from a proximal end portion of the handpiece  21 , and the electrical cable  23  is connected with a main body. 
     A vibrator  24  is accommodated in the handpiece  21 , and the vibrator  24  is extended in the axial direction of the handpiece  21 . A piezoelectric element portion  26  to generate ultrasonic vibration is arranged at a proximal end portion of the vibrator  24 , and a horn  31  as a first vibration transmission member to expand and transmit the ultrasonic vibration is arranged on a distal end side of the vibrator  24 . Here, a distal end portion of an ultrasonic cable  33  is connected with the piezoelectric element portion  26 , and the ultrasonic cable  33  is led to the electrical cable  23 . A driving current is supplied from the main body to the piezoelectric element portion  26  through the ultrasonic cable  33 , electrical vibration is converted into mechanical vibration in the piezoelectric element portion  26 , and the vibrator  24  is ultrasonic-vibrated. Here, an axial length of the vibrator  24  is a length corresponding to one wavelength of the ultrasonic vibration, an axial length of the piezoelectric element portion  26  is a length corresponding to a quarter wavelength of the ultrasonic vibration, and an axial length of the horn  31  is a length corresponding to a three quarter wavelength of the ultrasonic vibration. Further, a proximal end of the horn  31  serves as a node position of the ultrasonic vibration and a flange-like fixing portion  34  is formed on it. A distal end of the horn  31  serves as an antinode position of the ultrasonic vibration. On the other hand, a distal end portion of a high-frequency cable  38  is connected with the piezoelectric element portion  26 . The high-frequency cable  38  is led to the electrical cable  23 . A high-frequency current is supplied from the main body to the piezoelectric element portion  26  through the high-frequency cable  38  and the high-frequency current flows through the vibrator  24 . 
     The vibrator  24  is accommodated in an inner housing  39  as a first holding member. The inner housing  39  is extended in the axial direction and formed of a proximal-end-side inner cylinder  41  and a distal-end-side inner cylinder  42 . The piezoelectric element portion  26  is accommodated in the proximal-end-side inner cylinder  41 , and the horn  31  is accommodated in the distal-end-side inner cylinder  41 . A protruding portion  43  is extended on a distal-end-side inner peripheral surface of the proximal-end-side inner cylinder  41  in a circumferential direction. A proximal end portion of the distal-end-side inner cylinder  42  is fitted and screwed into a distal end portion of the proximal-end-side inner cylinder  41 . The distal-end-side inner cylinder  42  is screwed into the proximal-end-side inner cylinder  41  and so the fixing portion  34  of the vibrator  24  is sandwiched and fixed between the protruding portion  43  of the proximal-end-side inner cylinder  41  and a proximal end surface of the distal-end-side inner cylinder  42 . It is to be noted that an annular fixing spacer  44  to adjust the axial fixing position of the vibrator  24  is interposed between a distal end surface of the fixing portion  34  and the proximal end surface of the distal-end-side inner cylinder  42 . 
     The inner housing  39  is accommodated in an outer housing  47 . A hand switch portion  49  is arranged on the outer housing  47 . In the hand switch portion  49  are arranged an incision output switch  52   a , a coagulation output switch  52   b , and a simultaneous output switch  52   c . A switch cable  53  is extended from a switch main body  51  of the hand switch portion  49 , and the switch cable  53  is led to the electrical cable  23 . When the incision output switch  52   a  is pressed, an incision current for high-frequency incision is output from the main body to the piezoelectric element portion  26 , thereby driving the surgical instrument in an incision output mode. When the coagulation output switch  52   b  is pressed, a coagulation current for high-frequency coagulation is output, thereby driving the surgical instrument in a coagulation output mode. When the simultaneous output switch  52   c  is pressed, a high-frequency current for a high-frequency treatment and a driving current for an ultrasonic treatment are simultaneously output, thereby driving the surgical instrument in a simultaneous output mode. 
     The surgical instrument includes a sheath unit  22  as a second unit to treat a living tissue. In the sheath unit  22 , a probe  61  as a second vibration transmission member is inserted through a cylindrical sheath assembly  54  as a second holding member. 
     The sheath assembly  54  is formed of a distal-end-side sheath  55  and a proximal-end-side sheath  56 . In the distal-end-side sheath  55 , a small-inside-diameter portion  57 , a medium-inside-diameter portion  58 , and a large-inside-diameter portion  59  are sequentially formed from a distal end side toward a proximal end side. A distal end portion of the proximal-end-side sheath  56  is fitted and screwed into the large-inside-diameter portion  59  of the distal-end-side sheath  55 . A rotation dial  60  to operate the sheath unit  22  to rotate with respect to the handpiece  21  is formed in a middle portion of the proximal-end-side sheath  56  with respect to the axial direction. 
     On the other hand, in the probe  61 , a treatment portion  62 , a small-outside-diameter portion  63 , a tapered portion  64 , and a large-outside-diameter portion  66  are sequentially formed from a distal end side toward a proximal end side. The treatment portion  62  is used for treating a living tissue and has a non-rotation symmetrical hook-like shape. In the tapered portion  64 , an outside diameter is increased from a distal end side toward a proximal end side, and a flange-like pressing portion  65  is formed on this tapered portion  64 . Here, an axial length of the probe  61  is a length corresponding to a half wavelength of the ultrasonic vibration, a distal end and proximal end of the probe  61  serve as antinode positions of the ultrasonic vibration, and the pressing portion  65  serves as a node position of the ultrasonic vibration. It is to be noted that an outside diameter of the pressing portion  65  of the probe  61  is equal to or smaller than an outside diameter of the large-outside-diameter portion  66 . 
     The pressing portion  65  of the probe  61  is fitted into the medium-inside-diameter portion  58  of the distal-end-side sheath  55  of the sheath unit  22  such that the pressing portion  65  is slidable in the axial direction but not rotatable around a central axis of the probe  61 . That is, with respect to the sheath assembly  54 , the probe  61  is movable in the axial direction but not rotatable around the central axis of the probe  61 . A step surface between the small-inside-diameter portion  67  and the medium-inside-diameter portion  58  of the distal-end-side sheath  55  forms a support surface  70 . An annular elastic member  67  is arranged on the distal end side and an annular pressing spacer  68  is arranged on the proximal end side between the support surface  70  of the distal-end-side sheath  55  and the distal end surface of the pressing portion  65  of the probe  61 . The pressing spacer  68  adjusts the compression amount of the elastic member  67 . A proximal end surface of the pressing portion  65  of the probe  61  is supported by a distal end surface of the proximal-end-side sheath  56  screwed to the large-inside-diameter portion  59  of the distal-end-side sheath  55 . That is, the support surface  70  of the distal-end-side sheath  55  and the distal end surface of the proximal-end-side sheath  56  in the sheath assembly  54  sandwich the elastic member  67 , the pressing spacer  68  and the pressing portion  65  of the probe  61  with respect to the axial direction such that the probe  61  is movable in the axial direction with respect to the sheath assembly  54 . 
     A cam mechanism to detachably couple the sheath unit  22  and the handpiece  21  with each other will now be explained with reference to  FIGS. 2 to 4 . Here, the sheath unit  22  and the handpiece  21  are coaxially coupled with each other, and one of circumferential directions for a coaxis is referred to as a coupling direction whilst the other is referred to as a separating direction. 
     In the sheath unit  22 , a cam pin  69  as an actuating portion is protruded in a radial direction toward the outside at the proximal end portion of the proximal-end-side sheath  56 . On the other hand, in the hand piece  21 , a proximal end of a coupling cylinder  71  is coaxially coupled with the distal end portion of the distal-end-side inner cylinder  42  of the inner housing  39 . A cam frame  72  is fitted into and fixed on a distal end side of the coupling cylinder  71 . A cam receiving portion  73  convex in the radial direction toward the inside is formed on an inner peripheral surface of the cam frame  72  on a distal end side. A side surface arranged on the separating direction side and facing to the proximal end in side surfaces of the cam receiving portion  73  forms a cam surface  74  as an actuation receiving portion. The cam surface  74  forms an introduction surface  75 , an actuation surface  76 , and a coupling surface  77  from the distal end side toward the proximal end side. The introduction surface  75  is extended in the axial direction, the actuation surface  76  faces to the separating direction and the proximal end as a whole and is spirally extended around the central axis of the cam frame  72 , and the coupling surface  77  faces to the proximal end and is extended in the circumferential direction. Further, a coupling convex surface  78  protruding toward the proximal end is formed at a separating direction end portion of the coupling surface  77 , and a rotating convex surface  79  protruding toward the proximal end is formed at a coupling direction end portion of the coupling surface  77 . An engaging convex surface  80  serving as a coupling position where the cam pin  69  is engaged is formed between the coupling convex surface  78  and the rotating convex surface  79 . Furthermore, four cam receiving portions  73  are arranged at equal intervals with respect to the circumferential direction. A side surface arranged on the coupling direction side and face to the distal end as a whole in side surfaces of the cam receiving portion  73  has a shape that does not obstruct movement of the cam pin  69  along the cam surface  74  of a cam receiving portion adjacent to this cam receiving portion  73  on the coupling direction side, and an introducing groove portion  82  is formed between the cam receiving portions  73  adjacent to each other. It is to be noted that a pair of guide surfaces  83  spreading toward the distal end side in the circumferential direction and to guide the cam pin  69  are formed at distal end portions of both side surfaces of the introducing groove portion  82 . 
     The cam pin  69  of the sheath unit  22  is positioned to the introducing groove portion  82  of the cam frame  72  of the handpiece  21  and the proximal end portion of the sheath unit  22  is inserted in the axial direction into the distal end portion of the handpiece  21 , and so the cam pin  69  is moved in the axial direction along the introducing groove portion  82  of the cam frame  72 . Here, the probe  61  held by the sheath unit  22  is coaxially arranged with respect to the horn  31  fixed to the handpiece  21 , and the proximal end surface of the probe  61  is brought into contact with the distal end surface of the horn  31 . The sheath unit  22  is operated to rotate in the coupling direction with respect to the handpiece  21 , the cam pin  69  moves along the actuation surface  76  of the cam surface  74 , and the sheath assembly  54  of the sheath unit  22  is moved toward the proximal end with respect to the handpiece  21 . Here, since the proximal end surface of the probe  61  of the sheath unit  22  is in contact with the distal end surface of the horn  31  of the handpiece  21 , the probe  61  cannot move toward the proximal end with respect to the horn  31 . Therefore, the sheath assembly  54  is moved toward the proximal end side with respect to the probe  61  in the sheath unit  22 , and the elastic member  67  interposed between the probe  61  and the sheath assembly  54  is compressed in the axial direction. The elastic member  67  is compressed in the axial direction, and so a pressing force toward the distal end is applied to the sheath assembly  54  and a pressing force toward the proximal end is given to the probe  61 . Due to the pressing force toward the distal end applied to the sheath assembly  54 , the cam pin  69  of the sheath assembly  54  is pressed against the cam surface  74  arranged on the distal end side. On the other hand, due to the pressing force toward the proximal end given to the probe  61 , a pressing force act between the proximal end surface of the probe  61  and the distal end surface of the horn  31 . Further, the sheath unit  22  is operated to rotate in the coupling direction with respect to the handpiece  21 , and so the cam pin  69  gets over the coupling convex surface  78  of the cam surface  74  to be engaged with the engaging concave surface  80 , thereby coupling the sheath unit  22  with the handpiece  21 . When the cam pin  69  gets over the coupling convex surface  78  of the cam surface  74  to be engaged with the engaging concave surface  80 , a sense of clicking, e.g., a click sound is produced, it is possible to recognized that the sheath unit  22  and the handpiece  21  are coupled with each other. When separating the sheath unit  22  from the handpiece  21 , the sheath unit  22  is operated to rotate in the separating direction with respect to the handpiece  21 . 
     Here, a pressing force amount acting between the proximal end surface of the probe  61  and the distal end surface of the horn  31  corresponds to a pressing force amount given to the probe  61  from the elastic member  67 , the pressing force amount of the elastic member  67  is determined corresponding to the compression amount of the elastic member  67 , and the compression amount of the elastic member  67  is determined corresponding to a relative axial position of the sheath assembly  54  with respect to the probe  61 . Moreover, the relative axial position of the sheath assembly  54  with respect to the probe  61  is determined corresponding to the relative axial position of the sheath assembly  54  with respect to the horn  31 . Since the horn  31 , the inner housing  39 , and the coupling cylinder  71  are integrally fixed in the handpiece  21 , the relative axial position of the sheath assembly  54  with respect to the horn  31  is determined corresponding to the relative axial position of the sheath assembly  54  with respect to the coupling cylinder  71 . That is, the pressing force amount acting between the proximal end surface of the probe  61  and the distal end surface of the horn  31  is determined corresponding to the relative axial position of the sheath assembly  54  with respect to the coupling cylinder  71 . When the sheath unit  22  is coupled with the handpiece  21 , the relative axial position of the sheath assembly  54  with respect to the coupling cylinder  71  can be very accurately determined by appropriately setting the axial position of the coupling surface  77  of the cam surface  74 , i.e., the axial position of a bottom surface of the engaging concave surface  80  of the cam surface  74 . Therefore, the pressing force amount acting between the proximal end surface of the probe  61  and the distal end surface of the horn  31  can be very accurately determined. 
     Additionally, a rotating operation force amount required to operate the sheath unit  22  to rotate with respect to the handpiece  21  in the coupling direction against the pressing force amount of the elastic member  67  is fixed. That is, as shown in  FIG. 5A , a pressing force amount P l  of the elastic member  67  is increased with respect to an increase in the compression amount x of the elastic member  67 . A value obtained by multiplying an axial movement amount δ1 of the sheath assembly  54  with respect to the coupling cylinder  71  by the pressing force amount P l  of the elastic member  67  corresponds to a value obtained by multiplying a rotation angle amount be of the cam mechanism by a rotating operation force amount P θ . That is, P l (x)*δ1∝P θ *δθ is achieved. Here, If a pressure angle α of the actuation surface  76  of the cam surface  74  is fixed with respect to a rotation angle θ of the cam mechanism, the axial movement amount δ1 of the sheath assembly  54  with respect to the rotation angle amount δθ of the cam mechanism, i.e., δ1/δθ is fixed. In this case, when the rotation angle θ of the cam mechanism is increased, the compression amount x of the elastic member  67  is increased and the pressing force amount P l (x) is increased, the necessary rotating operation force amount P θ ∝P l (x)*(δ1/δθ) is increased. On the other hand, in this embodiment, as shown in  FIG. 5B , the pressure angle α of the actuation surface  76  of the cam surface  74  is appropriately increased with respect to a rise in the rotation angle θ of the cam mechanism, and the axial movement amount δ1 of the sheath assembly  54  with respect to the rotation angle amount δθ of the cam mechanism, i.e., δ1/δθ is appropriately reduced, thereby fixing the rotating operation force amount P θ ∝P 1 (x)*(δ1/δθ). 
     In the cam mechanism, the four engaging concave surfaces  80  as coupling positions where the cam pin  69  is engaged are arranged at equal intervals with respect to the circumferential direction, and the sheath unit  22  can be coupled with the handpiece  21  in four relative rotation arrangements. When inserting the proximal end portion of the sheath unit  22  into the distal end portion of the handpiece  21  in the axial direction, the introducing groove portion  82  into which the cam pin  69  is to be inserted is selected from the four introducing groove portions  82 , and so the relative rotation arrangement of the sheath unit  22  with respect to the handpiece  21  is selected from the four relative rotation arrangements. Furthermore, when the handpiece  21  is being coupled with the sheath unit  22  and the sheath unit  22  is operated to rotate with respect to the handpiece  21  in the coupling direction, the cam pin  69  gets over the rotating convex surface  79  and moves from the engagement concave surface  80 . Since the cam pin  69  is pressed toward the distal end due to the function of the elastic member  67 , the cam pin  69  is separated from the cam surface  74  against which the cam pin  69  has been pressed, moved toward the distal end, and shifted to the cam surface  74  of the cam receiving portion  73  adjacent to the former cam receiving portion  73  on the coupling direction side. When the sheath unit  22  is operated to further rotate with respect to the handpiece  21  in the coupling direction, the cam pin  69  is moved along the cam surface  74  to which the cam pin  69  has been shifted to be again engaged with the engaging concave surface  80 , thereby coupling the sheath unit  22  with the handpiece  21 . In this manner, when the sheath unit  22  is being coupled with the handpiece  21 , the sheath unit  22  is movable with respect to the handpiece  21  between the four relative rotation arrangements through operating the sheath unit  22  to rotate with respect to the handpiece  21  in the coupling direction. Therefore, the treatment portion  62  of the probe  61  can be arranged with respect to the hand switch portion  49  of the handpiece  21  in an arbitrary direction. 
     Therefore, the surgical instrument according to this embodiment demonstrates the following effects. 
     In the surgical instrument according to this embodiment, when coupling the handpiece  21  with the sheath unit  22 , the elastic force given to the probe  61  from the elastic member  67  is adjusted to be constant and the pressing force amount acting between the horn  31  and the probe  61  is adjusted to be constant through adjusting the deformation amount of the elastic member  67  to be constant. In particular, using the cam mechanism to couple the handpiece  21  with the sheath unit  22  enables very accurately adjusting the pressing force amount. Here, when the pressing force amount is lower than an appropriate range, ultrasonic vibration cannot be normally transmitted from the horn  31  to the probe  61 . On the other hand, when the pressing force amount is higher than the appropriate range, a dynamic impedance is increased, a resistance of the vibrator  24  rises, and a vibration efficiency is reduced. Furthermore, a rotating operation force amount required to operate the sheath unit  22  to rotate with respect to the handpiece  21  against the pressing force amount of the elastic member  67  is increased, thereby making it difficult to perform the rotating operation. In this embodiment, since the pressing force amount is adjusted to fall within the appropriate range, the horn  31  and the probe  61  can be appropriately ultrasonic-vibrated, and the rotating operation is facilitated. 
     Moreover, the rotating operation force amount is fixed irrespective of the deformation amount of the elastic member  67  in the rotating operation for the handpiece  21  and the sheath unit  22  through changing the pressure angle with respect to the rotation angle in the cam mechanism. Therefore, the rotating operation can be smoothly effected. 
     Additionally, since the cam pin  69  gets over the coupling convex surface  78  to be engaged with the engaging concave surface  80  and a sense of clicking is produced at the time of engagement with the engaging concave surface  80 , it is possible to recognize that the sheath unit  22  and the handpiece  21  is coupled with each other. 
     Further, the cam pin  69  can be engaged with a desired engaging concave surface  80  in the four engaging concave surfaces  80  arranged at different positions with respect to the circumferential direction, and the sheath unit  22  can be coupled with the handpiece  21  in a desired relative rotation arrangement in the four relative rotation arrangements. Therefore, the surgical instrument can have a conformation suitable for an immediate surgical treatment. In particular, since how to hold the handpiece  21  is appropriately determined in accordance with an arrangement of the hand switch portion  49  in the handpiece  21 , in a case where the treatment portion  62  of the probe  61  has a non-rotation symmetrical shape like this embodiment, using the surgical instrument is difficult if the sheath unit  22  cannot rotate with respect to the handpiece  21  and the direction of the treatment portion  62  cannot be changed, but such a situation is avoided in this embodiment. 
     Moreover, the tapered portion  64  and the small-outside-diameter portion  63  each having a diameter smaller than that of the large-outside-diameter portion  66  is formed in the probe  61  and the flange-like pressing portion  65  is formed on the tapered portion  64 , and so the outside diameter of the pressing portion  65  is equal to or smaller than the outside diameter of the large-outside-diameter portion  66 . That is, the sheath unit  22  is prevented from having a large diameter, and a reduction in operability of the surgical instrument is avoided. In particular, in the relatively short surgical instrument for abdominal operations like this embodiment, if diameter of the surgical instrument is increased, it is hard to visually recognize the treatment portion  62  at the distal end portion of the surgical instrument and the operability of the surgical instrument is lowered, but such a situation is avoided in this embodiment. 
     It is to be noted that the treatment portion having the non-rotation symmetrical shape is used in this embodiment, but the present invention can be likewise applied to a treatment portion having a rotation symmetrical shape, for example, a treatment portion wherein a distal end of the prove has a spherical shape. 
     Additionally, the present invention can be also applied to various surgical treatment apparatuses other than the ultrasonic output combined high-frequency surgical instrument for abdominal operations. 
     For example, the present invention can be likewise applied to such an ultrasonic output combined high-frequency surgical instrument for endoscopic operations as shown in  FIG. 6 . In the surgical instrument depicted in  FIG. 6 , a handpiece  21  and a sheath unit  22  having the same structures as those in the foregoing embodiment are used. However, the sheath unit  22  is long, and a proximal end portion of an insertion sheath  86  is fitted into and fixed on a distal end portion of a distal-end-side sheath  55 , and a probe  61  is inserted through the insertion sheath  86 . An axial length of the probe  61  is a length corresponding to an integral multiple of a half wavelength of ultrasonic vibration. 
     Further, for example, the present invention can be also applied to such an ultrasonic surgical instrument for endoscopic operations as shown in  FIG. 7 . In the surgical instrument depicted in  FIG. 7 , a probe  61  is inserted through an insertion sheath  86  of a sheath unit  22 . A jaw  92  is pivotally attached to a distal end portion of the insertion sheath  86 , and the jaw  92  is opened/closed with respect to a treatment portion  62  at a distal end portion of the probe  61  such that it can grasp a living tissue in cooperation with the probe  61 . A proximal end portion of the sheath unit  22  is coupled with a distal end side of a handle unit  88 . A pair of handles  91  is protruded from a cylindrical main body portion  89  of the handle unit  88 , and the jaw  92  is opened/closed through opening/closing the pair of handles  91 . Further, a hand switch portion  49  is arranged at the handle  91  on the distal end side. A distal end portion of a vibrator unit  87  is detachably coupled with a proximal end side of the main body portion  89  of the handle unit  88 . Here, the vibrator unit  87  has the same structure as the handpiece  21  in the foregoing embodiment. However, in this modification, the hand switch portion  49  is arranged on the handle unit  88  rather than the vibrator unit  87 , the handle unit  88  is connected with the vibrator unit  87  through an appropriate electrical connection mechanism, and the hand switch portion  49  is connected with a main body. Furthermore, the same cam pin as that in the foregoing embodiment is arranged at a distal end portion of the vibrator unit  87 , and a cam frame is arranged in the main body portion  89  of the handle unit  88 . Moreover, when the vibrator unit  87  is coupled with the handle unit  88  by using a cam mechanism, the proximal end portion of the probe  61  is pressed against the distal end portion of the horn  31  to be coupled with each other in the main body portion  89  of the handle unit  88 . 
     Additional advantages and modifications will readily occur to those skilled in the art. Therefore, the invention in its broader aspects is not limited to the specific details and representative embodiments shown and described herein. Accordingly, various modifications may be made without departing from the spirit or scope of the general inventive concept as defined by the appended claims and their equivalents.