Abstract:
A surgical instrument is configured to aid in performing a procedure of detaching an internal mammary artery (IMA) and the like, from the connecting tissues and side branch vessels which surround the artery in its native location, wherein the detaching procedure is preliminary to the performing of a coronary artery bypass grafting procedure and wherein the IMA is detached via a minimally invasive thoracotomy. To this end, an elongated slender rod includes a handle at its proximal end and an artery engaging loop, arc, fork configuration, or hook at its distal working end. Embodiments may incorporate electrosurgical capability or electrical insulation. A surgeon thus has means for harvesting an intact and undamaged graft vessel from its native location through a minimally invasive incision with enhanced speed, visibility, and freedom of motion.

Description:
This application is a divisional pending application Ser. No. 08/835,675, filed on Apr. 10, 1997, to be issued on Feb. 16, 1999 as U.S. Pat. No. 5,871,496 and a CIP of Ser. No. 08/619,046 filed on Mar. 20, 1996now abandoned, the disclosures of which are incorporated herein by reference as if set forth in full. 
    
    
     FIELD OF THE INVENTION 
     The present invention relates to minimally invasive surgical instruments and procedures and, in particular, to surgical tools for dissecting and manipulating an artery, such as the internal mammary artery (IMA), from its natural location in connection with a coronary artery bypass grafting (CABG) procedure. cl BACKGROUND OF THE INVENTION 
     Surgeons are constantly striving to develop advanced surgical techniques resulting in the need for advanced surgical devices and instruments required to perform such techniques. Recent advances in the surgical field are increasingly related to surgical procedures which are less invasive and reduce the overall trauma to the patient. To illustrate, in a conventional CABG procedure it has been common practice for surgeons to perform a sternotomy to expose the body cavity in the thoracic region. To this end, a surgeon makes a long incision down the middle of a patient&#39;s chest, saws through the length of the sternum and spreads the two halves of the sternum apart. Retractors then are employed to provide access to the vessels where an anastomosis will be performed. The CABG procedure is further complicated by the need to stop the beating of the heart by means of cardioplegia and to attach the patient to a cardiopulmonary bypass (CPB) machine to continue the circulation of oxygenated blood to the rest of the body while the graft is sewn in place. 
     In a procedure known as an “in situ bypass graft,” the surgeon dissects a sufficient length of the artery from its connective tissue, then transects the artery, and connects the transected end to a diseased target coronary artery distal to an obstruction, while leaving the other end of the dissected artery attached to the arterial supply, thus restoring blood perfusion to the heart. 
     The internal mammary arteries (IMAs), left (LIMA) and right (RIMA), are particularly desirable for use as in situ bypass grafts as they are conveniently located, have diameters and blood flow volumes that are comparable to those of coronary arteries, and in practice typically have superior patency rates. Extending from the subclavian arteries near the neck to the diaphragm and running along the backside of the ribs adjacent the sternum, the IMAs deliver blood to the musculature of the chest wall. The LIMA is typically used as an arterial source for target locations on the left anterior descending coronary artery (LAD), the diagonal coronary artery (Dx), the circumflex artery (Cx), the obtuse marginal artery, and the ramus intermedius coronary artery. The RIMA is typically used for connection to all of the same target locations, as well as the right coronary artery (RCA) and the posterior descending artery. 
     Use of either IMA as a bypass graft first involves harvesting the IMA free from the inside chest wall. In conventional CABG approaches, access to the IMA is obtained through a sternotomy or major thoracotomy incision (involving sawing through one or more ribs) through the chest. Harvesting of the IMAs is accomplished with relative ease due to the working space made available by the sternotomy or major thoracotomy. 
     An IMA is detached from its connective tissue until there is sufficient slack in the IMA to allow the distal end thereof to be attached to an incision, generally in the left anterior descending coronary artery (LAD). In preparation for the in situ bypass graft, the sternotomy procedure provides the surgeon with ready access to the IMA since it is exposed by the spreading of the sternum. The IMA thus may be transected at its distal end and detached from the connective tissues in its native location in the sternum region, while still attached at its proximal end to its arterial supply, using the usual surgical instruments such as scalpels, scissors, forceps, etc. 
     The CABG procedure would be improved if surgeons could avoid the need for arresting the heart, thereby eliminating the need to connect the patient to a cardiopulmonary bypass machine to sustain the patient&#39;s life. To this end, recent developments lend themselves to CABG procedures using surgical techniques which enable surgeons to perform the procedure while the heart is beating. This eliminates the need for the lengthy and traumatic cardiopulmonary bypass procedure, cardioplegia is unnecessary, the overall surgery is much less invasive and traumatic, and patient recovery time and costs are reduced. 
     Recently, progress has been made in advancing minimally invasive surgical techniques, particularly in cardiothoracic surgery, which eliminates the need for a sternotomy or major thoracotomy. Access to the heart with these minimally invasive techniques is obtained through one very small surgical incision (minimal thoracotomy) or through several percutaneous cannulas known as trocar sleeves positioned intercostally in the thoracic cavity of the patient. Visualization of the operative area may be facilitated by thoracoscopes which typically consist of a video camera configured for introduction through a small incision or trocar sleeve to allow observation of the target area on a video monitor. 
     With the advent of these minimally invasive techniques, harvesting the IMA has become more complex and difficult due to a restricted work space and access, and to reduced visualization of the IMA. The in situ bypass graft procedure and thus the procedure of detaching the IMA likewise must be performed through the minimal thoracotomy. Surgeons presently perform the procedure of detaching the IMA from its native location with the aid of the usual instruments such as the scalpels, scissors and forceps of previous mention. These instruments are not specially designed for use in less invasive procedures and do not facilitate the desired gentle handling of the IMA as it is detached from the surrounding connective tissues to provide the bypass graft for the CABG procedure. The harvesting procedure itself may actually be lengthened and the trauma to the vessel potentially increased by the less invasive techniques, in part because a number of tools must be introduced and exchanged through the restricted incision(s). This is a concern as a high degree of precision is required when harvesting a bypass vessel to avoid injury (such as over cutting or cauterizing) to the vessel which may in turn lead to increased rates of occlusion in the vessel in the months and years after the procedure. 
     Although low-profile micro-surgical instruments are readily available for some procedures, such has not been the case for harvesting the IMA and other similarly situated arteries in minimally invasive CABG procedures. Surgical instruments designed for laparoscopic and other minimally invasive applications are not generally suitable for performing minimally invasive CABG. Most laparoscopic procedures, for example, target body structures which are quite large in comparison to coronary vessels, and do not require the high degree of precision required in a CABG procedure. Accordingly, laparoscopic instruments generally provide only limited angular orientation, making them unsuitable for harvesting of the IMA and other similarly situated arteries through a minimal thoracotomy or an intercostal puncture site. 
     Typically an electrosurgical tool (often called a “Bovie”) similar to that described in U.S. Pat. No. 5,013,312 is used to free a length of the IMA by incising the endothoracic fascia and severing the side branch vessels to free the IMA. The use of such electrosurgical devices is well known in the art and can be crucial in controlling bleeding during harvesting of the IMA. Such devices are typically in the form of scalpels, forceps, and scissors, and employ at least one conductive electrode connected thereto. 
     Despite the use of an electrosurgical tool, because initial cauterization may be applied over too short a length of a vessel or side branch to be complete, it is common practice to apply sutures or surgical clips to control bleeding before complete coagulation is effected. Applying and removal of clips or sutures can be time-consuming. In addition, if clips are accidentally loosened and dropped inside the patient&#39;s body cavity, there can be serious complications and additional expenditure of time in the procedure. 
     When an electrosurgical tool is used in simultaneous conjunction with other instruments that are not electrically insulated, there is a serious risk of accidental electric short-circuiting or arcing due to contact or close proximity. This can lead to traumatic electric shock to the patient or the surgeon, damage to an instrument, disruption of the procedure, or over or under cutting or cauterization, which can adversely affect the control of bleeding or the integrity and patency of the graft vessel. 
     A bipolar electrosurgical instrument comprising a fork-shaped configuration is described in U.S. Pat. No. 4,671,274. This instrument combines the functions of tissue manipulation and electrocautery, and finds application for control of bleeding during the transection of blood vessels; however, it involves separate hinged jaws and cannot provide an adequate range of angular motion through a minimally invasive thoracotomy. 
     Accordingly, it would be highly desirable when performing a detachment, or “take-down” procedure on the IMA, to provide a specialized instrument which allows the surgeon a greater range of visibility and angular motion to harvest an intact and undamaged length of vessel more rapidly and gently with fewer instruments obstructing the operating field and with minimal risk of accidental electric shock, while the tissues and side branch vessels are being dissected with the aid of a surgical knife or scissors. It would further be desirable to reduce or eliminate the need for surgical clips or sutures in the IMA harvest procedure. 
     SUMMARY OF THE INVENTION 
     The present invention provides a specialized surgical instrument which overcomes the deficiencies of previous mention, that is, provides gentle handling of the IMA when performing the procedure of detaching the IMA from its native location during the less invasive CABG procedure using the comparatively small incision or thoracotomy in the chest. It potentially reduces the number of instruments obstructing the field and provides malleable instrument shafts, thereby allowing the surgeon a greater range of visibility and angular motion to harvest an intact and undamaged length of vessel more rapidly. It provides electrically insulated instruments and self-contained electrosurgical instruments that reduce the risk of accidental electric shock. It provides embodiments that potentially reduce the need for surgical clips or sutures to control bleeding. These advantages are also applicable to the dissection or harvesting of other vessels for use as a graft in a vascular surgical procedure. 
     More particularly, in selected embodiments the invention comprises an elongated slender rod, permanently attached to a handle of greater cross section configured for comfortable grasping by a surgeon. The slender rod may be formed of a material such as a firm plastic, but preferably is formed of stainless steel. The distal end of the rod is formed into a loop or coil, an arcuate segment or other preselected curved configuration which provides means for capturing the IMA, or other vessel, which is being detached, dissected or otherwise handled. The various embodiments contemplated by the invention include a full 360 degree loop configuration with the overlapped coil of the loop axially spaced apart, as well as partial loop and arcuate configurations. The distal, or working, end of the invention thus is configured and is of selected dimensions to allow a surgeon to capture a vessel at a distant location through small openings in a patient&#39;s body, and to then gently manipulate the vessel as necessary in the specific surgical procedure. Thus, the invention provides the advantage of remotely handling of a vessel with a minimum of trauma during minimally invasive surgical procedures. 
     In alternative embodiments, the invention includes an elongated tube coaxially attached to the handle, and a rod actuating means integral with the handle. In response to the rod actuating means, the rod and the integral working end is extended from the distal end of the tube as when in use, or may be retracted into the tube when not in use. 
     In further alternative embodiments, the invention includes a fork configuration that can engage and manipulate a vessel and connective tissue. These embodiments facilitate safe and rapid severing of the many side branches that must be separated from the main vessel, with minimal bleeding or damage to the harvested vessel. Described configurations protect the harvested vessel from accidental damage by an electrosurgical knife. Instruments according to the invention are coated with electrically insulating material to prevent accidental short-circuiting and arcing when used with electrosurgical tools. Other embodiments incorporate self-contained unipolar or bipolar electrosurgical capabilities, thereby eliminating the need for extra instruments, potentially reducing or eliminating the need for surgical clips or sutures to control bleeding, and improving the accuracy, speed, and safety of vascular graft dissection. 
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS 
     FIGS. 1 and 2 are top and elevational views, respectively, of an embodiment of the present invention. 
     FIG. 3 is a perspective view illustrating a use of the invention in cooperation with surgical scissors when performing the procedure of detaching the IMA from its native location. 
     FIGS. 4 and 5 are elevational views of alternative embodiments of the invention. 
     FIGS. 6 and 7 are elevational views of a further alternative embodiment of the invention embodying a retractable distal working end. 
     FIG. 8 is a partial top view of the embodiment of FIGS. 6,  7 . 
     FIG. 9 is a cross-sectional view taken along section line  9 — 9  of FIG.  7 . 
     FIG. 10 shows an embodiment combining a loop with a fork configuration. 
     FIGS. 11A-11C illustrate fork configurations having fingers of unequal lengths. 
     FIG. 12 is a perspective view showing a use of the invention including a fork configuration to assist in detaching the IMA. 
     FIG. 13 is a perspective view illustrating the use of the invention including a fork configuration combined with a loop to assist in detaching the IMA. 
     FIG. 14 shows an embodiment of the invention comprising a fork having an articulating finger and equipped with electrosurgical capability. 
    
    
     DETAILED DESCRIPTION OF THE EMBODIMENTS 
     FIGS. 1 and 2 illustrate one embodiment  12  of a surgical instrument in accordance with the present invention, which includes a handle  14  at the proximal end securely attached to, or formed as part of, an elongated slender rod  16 . Rod  16  may have a circular, oval, rectangular, triangular or other cross-sectional shape over all or any portion of its length, and may be solid or hollow in whole or in part, containing one or a plurality of internal cavities. The distal end of the instrument, and particularly of rod  16 , is formed into a loop  18 . The loop  18  may be continued to form a complete circle as depicted in FIGS. 1 and 2, or may be of less than a full circle, such as exemplified by the arcuate embodiments depicted in FIGS. 4 and 5 below. Loop  18  has an inside diameter of the order of one-half to three-quarter inch, and the overlapping tip  19  of the loop is spaced from the body of the loop a distance, a, of the order of one-fourth to one-third inch. Preferably, the circumference of loop  18  does not lie in a single plane but is displaced helically to provide axial displacement between separate points on the loop. As depicted in the figures by way of example only, loop  18  is bent at an angle relative to rod  16  of approximately 10 degrees in the top view (FIG.  1 ), and at an angle of approximately 20 degrees in the elevational view (FIG.  2 ). Rod  16  and handle  14  may be formed in whole or in part of stainless steel, aluminum, or plastic, respectively. If a combination of materials is used, the rod is bonded or glued to the handle via a suitable axial bore in the handle. It may be preferable for use in electrosurgical procedures that the instrument be non-conductive electrically; accordingly, if rod  16  (and/or handle  14 ) is formed of stainless steel or other electrically conductive material, it may be coated with a non-conductive biocompatible material such as PTFE or polyamide polymer. Rod  16  and handle  14  also may be made of any of the other conventional biocompatible medical plastics having sufficient tensile and bending strength. 
     In a preferred embodiment, rod  16  is formed of a stainless steel material and thus is relatively resistant to force applied transversely to the rod length. However, a partial length  20  (FIG. 1) of rod  16  may be annealed to have a malleable property, whereby rod  16  can be deformed by the surgeon to tailor the precise curvature thereof depending on the nature of the procedure, the patient&#39;s anatomy, and the preferences of the surgeon. Loop  18  can likewise be annealed in whole or in part to have a malleable property. 
     FIG. 3 illustrates a manner of use of the invention employing the embodiment  12  of FIGS. 1 and 2. It is to be understood that any of the embodiments presented herein also may be used in similar fashion to perform the same function. To this end, surgical scissors  22  may be introduced by a surgeon through a thoracotomy  24  and used to initiate the severing of tissues from a vessel such as an IMA  26  to thus initiate detachment of a first segment of the IMA. In the following description, the IMA is used as the example, with the understanding that other vessels may be harvested using the devices and procedures of the invention. Upon slight detachment of the IMA, instrument  12  of the invention also is inserted through the thoracotomy  24  and the tip  19  of loop  18  is introduced past IMA  26 . A slight twist of instrument  12  causes loop  18  to encircle the IMA whereupon the surgeon has complete control of the direction in which force may be applied to urge the IMA gently from its native location. Scissors  22  simultaneously are used to dissect tissues and side branch vessels  25  from the IMA. The surgeon may continue the procedure of dissecting the connecting tissues and side branch vessels while pulling the IMA away from the endothoracic fascia with instrument  12  as depicted by arrow  27 , until a sufficient length of the IMA has been detached from the endothoracic fascia to allow performing a CABG procedure. The invention thus allows capturing the IMA and provides the surgeon thereafter with complete control of the artery to allow it to be manipulated gently in any direction during the detaching process. 
     FIG. 4 illustrates an alternative embodiment  28  of the invention, wherein the full loop  18  of the FIGS. 1 and 2 is defined by one or more arcuate segments, which comprise at least one arc  30  formed in the distal end of rod  16 . Arc  30  terminates in a tip  32  which is bent away from the arc configuration to extend generally coaxially with rod  16 . Tip  32  guides the introduction of arc  30  through the surrounding tissues and past the IMA, whereby arc  30  is used to manipulate the IMA while detaching it from the endothoracic fascia. 
     FIG. 5 illustrates a further alternative embodiment  34  of the invention, wherein the loop  18  of FIGS. 1 and 2 is defined by a slightly ovaled partial loop  36  of approximately three-fourths of a full oval or circle. This configuration provides a tip  38  which allows manipulating the IMA in various directions without completely encircling the artery as with loop  18 . As depicted in FIG. 5, rod  16  may be annealed along a length  20  as described in FIG. 1, to allow readily deforming the rod to tailor the contour of the instrument to meet the requirements of the procedure, the anatomy of the patient, and the preferences of the surgeon to facilitate the capture and manipulation of the IMA by loop  18 , arc  30  or partial loop  36 . 
     FIGS. 6-9 depict portions of alternative embodiments  40  of the invention employing a retractable distal working end of the instrument. Rod  16  and loop  18  (or arc  30  or partial loop  36 ) may be retracted into a protective housing when not in use, and extended to provide loop  18  when the instrument is to be used. Instrument  40  includes a hollow handle  42  having thus a lumen  44 . An elongated tube  46  is coaxially formed with the handle  42  and includes a lumen  48  extending the length of the tube  46  in communication with lumen  44 . A slender elongated rod  50  similar to rod  16  of FIGS. 1,  2 ,  4 , and  5  is dimensioned to fit in slidable relation within lumen  48  of tube  46 . Rod  50  is formed, for example, of a nickel-titanium alloy material having an inherent shapememory property. In this embodiment the distal working end of rod  50  is formed into a loop  52  similar to the loop  18  of FIGS. 1 and 2, which thus is the shape to which the shape-memory material, that is, the distal working end of rod  50 , will return. It is to be understood that the distal working end of rod  50  could be formed into the arcuate or partial loop configurations of FIGS. 4 or  5 , respectively, rather than the full loop configuration  18 ,  52 . FIG. 6 depicts instrument  40  with rod  50  extended to provide an exposed vessel capturing distal working end for use by a surgeon. 
     FIG. 7 depicts the instrument  40  with rod  50  retracted into tube  46 . As may be seen, the shape-memory material is sufficiently flexible that, when rod  50  is drawn into lumen  48  of tube  46 , loop  52  is forcibly deformed to assume the shape of the lumen, that is, loop  52  is straightened. Thus, the working end of the instrument may be fully retracted into the protective housing of tube  46 . When the instrument is to be used in a procedure of detaching a vessel such as the IMA from its connecting tissues, rod  50  is extended from tube  46 , whereupon due to the inherent shape-memory property of the nickel-titanium alloy material, loop  52  will automatically re-form into its memorized shape depicted in FIG.  6 . 
     Various mechanical devices may be employed with handle  42  to provide rod  50  with working end  18 ,  30 ,  36  operated by an actuating means  54 . By way of example only, actuating means  54  herein includes a reciprocatable slide  56  formed with a cylindrical member  58  slidably fitted within lumen  44  of handle  42 . Cylindrical member  58  is integrally formed with a radially-extending flat yoke  60  which, in turn, has a thumb-engaging member  62  secured thereto. Flat yoke  60  reciprocates within a slot  64  formed in the side wall of handle  42  in communication with lumen  44 , and thumb-engaging member  62  is positioned exterior of slot  64  and outer cylindrical surface of handle  42  for access by the surgeon&#39;s thumb or fingers. Rod  50  is coaxially secured to cylindrical member  58  and thus any reciprocation of thumb-engaging member  62  imparts similar reciprocation to rod  50 . 
     Although slidable actuating means  54  is illustrated herein, other mechanisms may be used. For example, the proximal end of rod  50  may be provided with external helical threads, wherein a coaxial circular dial with internal matching helical threads is disposed within the distal portion of handle  42  with the internal threads engaging the external threads. Selective rotation of the dial thus reciprocally translates rod  50  to extend or retract the rod and working end of instrument  40 . 
     An alternative preferred embodiment of the invention comprising a fork configuration at the distal working end of rod  16  is illustrated in FIGS. 10,  11 A- 11 C,  12 ,  13 , and  14 . The fork configuration may be combined with loop  18  as depicted in FIGS. 10 and 13 or with arcuate configuration  30  or partial loop configuration  36  shown in FIGS. 4 and 5 respectively; alternatively a fork configuration may be used in place of loop  18  or equivalents at the distal working end of rod  16 . It is to be understood that a fork configuration may be combined with malleable rod section  20 , handle  14 , retractable rod  50 , hollow handle  42 , actuating means  54 , or any other element described herein. 
     Proceeding, FIG. 10 illustrates an embodiment  100  in which fork configuration  102  and loop  18  are combined at the distal working end of rod  16 . Fork configuration  102  comprises a plurality of fingers  104  projecting from the distal end of the fork configuration. For purposes of illustration a finger  104  is formed into an arcuate or circular configuration, such as loop  18 , terminating in tip  19 . The diameter of the loop portion  18  of finger  104  may be slightly tapered from its proximal connection point to tip  19 . Preferably, loop  18  is between about 270° and 360°. Tip  19  and the tips of fingers  104  preferably end in a bulbous configuration or have a tear drop shape. Fork  102  may comprise at least two and up to any greater number of fingers  104 , one or more of which may be formed into a loop or equivalent, depending on the detailed design of embodiment  100 . Likewise the lengths, widths, and spacings of fingers  104  may be chosen to be equal or unequal in any order at the discretion of the instrument designer. Fingers  104  may be straight, bent, curved, or adjustably shaped at the discretion of the designer. 
     FIGS. 11A-11C illustrate fork configurations at the distal working end of rods  16  having fingers of unequal lengths. FIG. 11 A shows a fork  110  having inner finger  114  shorter than outer fingers  112  and  116 . FIG. 11B shows a fork  120  in which left-hand outer finger  112  is shortest, inner finger  114  is intermediate in length, and right-hand outer finger  116  is longest. FIG. 11C shows a fork  130  having inner finger  114  longer than outer fingers  112  and  116 . Preferably, any two adjacent fingers define a rounded “V”-shape groove to accommodate vessels of varying diameters for scraping or dissecting tissue away from a vessel. 
     FIG. 12 illustrates a manner of use of the invention employing an embodiment  140  comprising a fork configuration  142 . In the illustrated embodiment a fork  142  is connected to the distal working end of rod  16 , which is fastened to handle  14 . Fork  142  comprises fingers  144 , which terminate at their distal ends in enlarged hemispherical or rounded tips  146 . Tips  146  are configured to make gentle atraumatic contact with a patient&#39;s tissue. In the illustrated procedure fork  142  gently captures, retracts, and stabilizes IMA segment  26  or other tubular organ away from its connective tissue. The IMA and/or separated and clipped side branch and tissue  25  may be captured and woven between fingers  144  to provide additional control and stability. Combination of a malleable rod  20  (FIG. 1) and adjustable finger shapes provide the surgeon with a wide range of angular motion through a small minimally invasive incision. An electrosurgical knife  148 , such as a “Bovie” or such as that described in U.S. Pat. No. 5,013,312, may then be employed by the surgeon to coagulate and cut off side branch  25  from IMA  26 . Fingers  144  provide a sliding guide surface for knife  148  to cut off side branch  25  cleanly and accurately, and protect IMA  26  from accidental injury by the knife. Instrument  140  positions, stabilizes, and protects IMA  26  during the described dissection procedure, reducing the time and risk of the procedure. 
     FIG. 13 illustrates a manner of use of the invention employing an embodiment  150  comprising a fork configuration  152  combined with loop  18  at the distal working end of rod  16  affixed to handle  14 . In the illustrated procedure loop  18  captures and gently stabilizes IMA  26 . Fingers  154  of fork  152  are curved to engage and retract IMA  26  and to separate side branch  25  between fingers  154 . The surface defined by adjacent fingers  154  protects IMA  26  and provides a sliding support to guide electrosurgical knife  148  to coagulate and cut off side branch  25  quickly, accurately, and safely, reducing the time and risk of the procedure. Embodiment  150  illustrates the cooperative action between fork  152  and loop  18 , wherein the loop controls IMA  26 , while the fork captures side branch  25  and guides knife  148 . This functionality potentially reduces the need for extra instruments in the small operating field. 
     FIG. 14 depicts an embodiment  160  of the invention comprising a fork  162  having an articulating finger  166 . In the illustration of FIG. 14 inner finger  166  is pivotally connected to fork  162  by means of pivot bearing  168  and toggles either right or left to engage an outer stationary finger  164 . Alternatively outer fingers may pivot to engage an inner finger. For purposes of illustration only, articulating finger  166  may be actuated by cable mechanism  170 . Pulling on the right-hand cable as illustrated by the arrows  171  pivots articulating finger  166  to the right, and pulling on the left-hand cable pivots articulating finger  166  to the left. Other actuating mechanisms, such as push rods, may alternatively be employed. Fingers  164  and  166  may include cutting blade edges, clamping jaws, or grasping surfaces. Embodiment  160  may comprise only mechanical elements, or may provide for unipolar or bipolar electrosurgery by means of electrical leads  172  connected to a suitable energy source. For example articulating finger  166  may be electrically insulated from stationary fingers  164  and connected to a unipolar electrical energy source by means of electrical leads  172 , or articulating finger  166  may be electrically insulated from stationary fingers  164  with fingers  166  and  164  connected respectively to opposite poles of a bipolar electrical energy source by means of electrical leads  172 . Those skilled in the art will recognize that alternative electrode arrangements may be used with the present invention. 
     Embodiment  160  can function as an electrosurgical fork  162  with all mechanically stationary fingers  164 . One or more fingers  164  may be configured with cutting edges and connected to unipolar or bipolar energy sources. In this configuration the electrically active fingers may serve as electrosurgical cutting or coagulating (“Bovie”) knives. In a configuration comprising one or more articulating fingers  166 , embodiment  160  can function as electrosurgical scissors, wherein the knife edge of one finger engages another finger. 
     In operation embodiment  160  may be used to capture, engage, manipulate, clamp, coagulate, and cut vessels such as the IMA and side branches, tubular body organs, and related tissue. Use of embodiment  160  to coagulate and cut potentially eliminates the need for a separate electrosurgical knife, thereby reducing the number of instruments in the minimal operating field and thus increasing visibility and freedom of motion therein. When used alone or in combination with electrically insulated instruments embodiment  160  reduces the risk of accidental electrical shock or unwanted electrosurgical effects. Use of embodiment  160  further potentially reduces the need to apply mechanical surgical clips to side branches, thereby reducing the time for a procedure involving application and removal of mechanical clips, and reducing the risk of misplaced or lost mechanical surgical clips within the patient&#39;s body. A vessel or side branch can be woven and captured through the spaces between fingers  164  and  166 , thereby exposing a greater length of vessel or side branch to coagulating energy, and insuring complete cauterization prior to cutting. 
     Although the invention has been described herein relative to specific embodiments, various additional features and advantages will be apparent from the description and drawings, and thus the scope of the invention is defined by the following claims and their equivalents.