Abstract:
In a surgical method, a hollow needle is inserted into a hollow internal organ of a patient through a natural body opening. A wireless scanning apparatus is operated externally of the patient to obtain data as to internal structures of the patient on a side of a wall of the organ opposite the body cavity. A distal tip or free end of the needle is passed through the wall of the organ only upon detecting, via the wireless scanning apparatus, an absence of internal organic tissues of the patient in contact with the wall of the organ on the side of the organ opposite the body cavity. Upon the passing of the distal tip or free end of the needle through the wall of the organ, pressurized CO2 gas is conveyed through the needle into the patient on the side of the wall opposite the body cavity. The needle may be connected to the distal end of an elongate flexible hollow shaft and an endoscope may be optionally used to view the needle deployment procedure.

Description:
CROSS-REFERENCE TO RELATED APPLICATION 
     This application claims the benefit of U.S. Provisional Patent Application No. 60/670,514 filed Apr. 12, 2005. 
    
    
     BACKGROUND OF THE INVENTION 
     This invention relates to medical procedures carried out without the formation of an incision in a skin surface of the patient. 
     Such procedures are described in U.S. Pat. Nos. 5,297,536 and 5,458,131. 
     As described in those patents, a method for use in intra-abdominal surgery comprises the steps of (a) inserting an incising instrument with an elongate shaft through a natural body opening into a natural body cavity of a patient, (b) manipulating the incising instrument from outside the patient to form a perforation in an internal wall of the natural internal body cavity, and (c) inserting a distal end of an elongate surgical instrument through the natural body opening, the natural body cavity and the perforation into an abdominal cavity of the patient upon formation of the perforation. Further steps of the method include (d) inserting a distal end of an endoscope into the abdominal cavity, (e) operating the surgical instrument to perform a surgical operation on an organ in the abdominal cavity, (f) viewing the surgical operation via the endoscope, (g) withdrawing the surgical instrument and the endoscope from the abdominal cavity upon completion of the surgical operation, and (h) closing the perforation. 
     Visual feedback may be obtained as to position of a distal end of the incising instrument prior to the manipulating thereof to form the perforation. That visual feedback may be obtained via the endoscope or, alternatively, via radiographic or X-ray equipment. 
     The abdominal cavity may be insufflated prior to the insertion of the distal end of the endoscope into the abdominal cavity. Insufflation may be implemented via a Veress needle inserted through the abdominal wall or through another perforation in the internal wall of the natural body cavity. That other perforation is formed by the Veress needle itself. U.S. Pat. No. 5,209,721 discloses a Veress needle that utilizes ultrasound to detect the presence of an organ along an inner surface of the abdominal wall. 
     A method in accordance with the disclosures of U.S. Pat. Nos. 5,297,536 and 5,458,131 comprises the steps of (i) inserting an endoscope through a natural body opening into a natural body cavity of a patient, (ii) inserting an endoscopic type incising instrument through the natural body opening into the natural body cavity, (iii) manipulating the incising instrument from outside the patient to form a perforation in an internal wall of the natural internal body cavity, (iv) moving a distal end of the endoscope through the perforation, (v) using the endoscope to visually inspect internal body tissues in an abdominal cavity of the patient, (vi) inserting a distal end of an elongate surgical instrument into the abdominal cavity of the patient, (vii) executing a surgical operation on the internal body tissues by manipulating the surgical instrument from outside the patient, (viii) upon completion of the surgical operation, withdrawing the surgical instrument and the endoscope from the abdominal cavity, (ix) closing the perforation, and (x) withdrawing the endoscope from the natural body cavity. 
     The surgical procedures of U.S. Pat. Nos. 5,297,536 and 5,458,131 reduce trauma to the individual even more than laparoscopic procedures. Hospital convalescence stays are even shorter. 
     OBJECTS OF THE INVENTION 
     It is an object of the present invention to provide improvements on the afore-described surgical procedures. 
     It is another object of the present invention to provide a method and/or an associated device for use particularly in the insufflation portion of the procedures. 
     These and other objects of the present invention will be apparent from the drawings and detailed descriptions herein. While every object of the invention is believed to be attained in at least one embodiment of the invention, there is not necessarily any single embodiment that achieves all of the objects of the invention. 
     SUMMARY OF THE INVENTION 
     A surgical method in accordance with the present invention comprises inserting a hollow needle into a hollow internal organ of a patient, the organ communicating with the ambient environment via a natural body opening, the organ defining an internal body cavity. The needle is inserted into the organ through the natural body opening. The method further comprises (a) operating a wireless scanning apparatus externally of the patient to obtain data as to internal structures of the patient on a side of a wall of the organ opposite the body cavity and (b) passing a distal tip or free end of the needle through the wall of the organ only upon detecting, via the wireless scanning apparatus, an absence of internal organic tissues of the patient in contact with the wall of the organ on the side of the organ opposite the body cavity. Upon the passing of the distal tip or free end of the needle through the wall of the organ, a pressurized fluid is conveyed through the needle into the patient on the side of the wall opposite the body cavity. The pressurized fluid is typically carbon dioxide gas. 
     The wireless scanning apparatus may utilize any type of waveform energy suitable for obtaining image data of structures internal to a patient&#39;s body. Thus, the wireless scanning apparatus may take the form of a magnetic resonance imaging apparatus, an X-ray machine, a CAT scanner, or an ultrasound apparatus. In the case of an ultrasound apparatus, the method additionally comprises transmitting ultrasonic pressure waves into the patient and sensing echo waveforms reflected from internal tissues of the patient. 
     The needle may be located at a distal end of an elongate flexible shaft member. In that event, the method additionally comprises inserting the needle into the patient along a nonlinear path having at least one bend or turn. A distal end portion of an endoscope insertion member may be inserted into the hollow internal organ and used to view the wall of the hollow internal organ from the body cavity. Where the endoscope has a sheath with a longitudinally extending channel, the needle may be inserted into the body cavity via the channel. 
     Pursuant to an optional feature of the present invention, the method also comprises inserting a distal end portion of an endoscope insertion member into the hollow internal organ and using the endoscope to view the wall of the hollow internal organ from the body cavity. 
     Pursuant to another feature of the present invention, the passing of the distal tip or free end of the needle through the organ wall results in a perforation in the wall. The method may further comprise removing the needle from the wall, inserting a port element in a collapsed configuration into the body cavity, deploying the port element in the organ wall so that parts of the port element are disposed on opposing sides of the wall, and after the deploying of the port element, expanding the parts of the port element into expanded configurations so that the wall is sandwiched between the expanded port element parts. 
     A surgical method comprises, in accordance with a particular embodiment of the present invention, inserting a hollow needle into a hollow internal organ of a patient, where the organ communicates with the ambient environment via a natural body opening and the organ defines an internal body cavity, the needle being inserted into the organ through the natural body opening and the needle being located at a distal end of an elongate flexible shaft member. The inserting of the needle into the patient includes passing the needle and a distal end portion of the shaft member along a nonlinear path having at least one bend or turn. A distal or free end of the needle is inserted through a wall of the organ and thereafter a pressurized fluid is conveyed through the needle into the patient on the side of the wall opposite the body cavity. 
     The method may further comprise inserting a distal end portion of an endoscope insertion member into the hollow internal organ and using the endoscope to view the wall of the hollow internal organ from the body cavity. Where the endoscope has a sheath with a longitudinally extending channel, the needle may be inserted into the body cavity via the channel. Typically, the needle is housed in a delivery tube that is inserted through the channel in the endoscope sheath. The distal end of the tube thus serves as a shield preventing the needle from penetrating and perforating the wall of the channel. 
     Alternatively, instead of being inserted through the sheath channel after the deployment of the endoscope insertion member inside the hollow internal organ of the patient, the needle instrument may be stored inside the channel at manufacture and inserted together with the endoscope into the internal organ through the natural body opening. The distal end portion of the channel may be provided with a liner of a smooth hard material to encapsulate and isolate the needle during the insertion procedure, thereby protecting the soft tissues of the natural body opening during the deployment procedure. 
     Where the passing of the distal tip or free end of the needle through the organ wall results in a perforation in the wall, the method of this embodiment may further comprise removing the needle from the wall, inserting a port element in a collapsed configuration into the body cavity, deploying the port element in the organ wall so that parts of the port element are disposed on opposing sides of the wall, and after the deploying of the port element, expanding the parts of the port element into expanded configurations so that the wall is sandwiched between the expanded port element parts. 
     A surgical device in accordance with the present invention comprises an elongate flexible hollow shaft or tube, a hollow needle connected to one end of the shaft or tube, and a coupling element at an opposite end of the shaft or tube for operatively connecting the shaft or tube and concomitantly the needle to a source of pressurized carbon dioxide gas. The shaft or tube may be insertable though a working channel associated with a flexible endoscope. 
     A surgical kit comprises, in accordance with the present invention, a surgical instrument having an elongate flexible hollow shaft and a hollow needle disposed at a distal end of the shaft. The kit further comprises a port element with parts disposable on opposite sides of a body organ wall, the port element having an aperture enabling passage of a distal end portion of an elongate medical instrument into a body cavity through the body organ wall. 
     The port element may have a collapsed insertion configuration and an expanded use configuration. 
     The surgical kit may additionally comprise the medical instrument, where the medical instrument has an elongate flexible shaft and an operative tip at a distal end thereof, the operative tip being different from a needle. 
     The shaft may be adapted for insertion though a working channel associated with a flexible endoscope, i.e., a biopsy channel provided in the endoscope insertion shaft or a working channel in an endoscope sheath used with the endoscope. 
     The shaft of the needle instrument is preferably provided at a proximal end with a coupling element for operatively connecting the shaft and concomitantly the needle to a source of pressurized carbon dioxide gas. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWING 
         FIG. 1  is a schematic partial longitudinal cross-section of a human patient, showing an abdomen-insufflation step in a trans-organ surgical procedure in accordance with the present invention. 
         FIG. 2  is a schematic cross-sectional view of a hollow internal organ of a patient, showing a step in a modified abdomen-insufflation step of a trans-organ surgical procedure in accordance with the present invention. 
         FIG. 3A  is a schematic partial cross-sectional view of the organ of  FIG. 2 , showing a step in the deployment of a trans-organ port. 
         FIG. 3B  is a schematic partial cross-sectional view similar to  FIG. 3A , showing a subsequent step in the deployment of the trans-organ port of  FIG. 3A . 
     
    
    
     DETAILED DESCRIPTION 
     As illustrated in  FIG. 1 , a method for insufflating a patient&#39;s abdominal cavity AC during a trans-organ surgical procedure as described in U.S. Pat. Nos. 5,297,536 and 5,458,131 (both incorporated by reference herein) includes inserting a distal end portion of an insufflation instrument  12  into a hollow internal organ IO of the patient via a natural body opening NBO of the patient. Internal organ IO, which defines an internal body cavity IC, may be the stomach, the urinary bladder, the colon, or the vagina, while the natural body opening NBO is the mouth, the urethral orifice, the anus, or the vaginal orifice. 
     Instrument  12  includes a hollow needle  14  at a distal end of a tubular flexible shaft member  16 . The inserting of needle  14  into the patient may include passing the needle and a distal end portion of the shaft member  16  along a nonlinear path (not separately designated) having at least one bend or turn  18 ,  20 . A distal or free end  22  of needle  14  is inserted through a wall  24  of the organ IO and thereafter a pressurized fluid is conveyed through shaft  16  and needle  14  into the patient&#39;s abdominal cavity AC on the side of wall  24  opposite the internal body cavity IC. 
     Shaft  16  may be coupled at a proximal end to a handpiece  26  provided with one or more steering control or actuator knobs  28  and a port  30  connected to a source  32  of pressurized carbon dioxide gas. 
     Needle  14  and the distal end portion of shaft  16  may be inserted into the patient and particularly into organ IO through a tubular working channel  34  of an endoscope sheath  36 . Needle  14  may be disposed inside channel  34  at the time of manufacture and thus inserted into the patient together with an endoscope  38 . Endoscope  38  is connected to a video monitor  40  for enabling a surgeon to view the insertion path and the inner surface of wall  24  during the perforation or penetration of the organ wall by needle  14 . 
     If needle  14  is inserted into cavity IC together with endoscope  38  and sheath  36 , channel  34  may be formed with an inner lining that is made of a hard, puncture resistant material. Alternatively, needle  14  may be housed in a dedicated deployment tube (not illustrated) that may be inserted into channel  34  after the insertion of endoscope  38  and sheath  36  into the patient. 
     As an alternative or additional method for the monitoring of organ IO and needle  14  prior to and during the penetration of wall  24  by the needle, a wireless scanning apparatus such as an ultrasound scanner  42  may be used to view internal organ IO and other structures inside the patient on a display or monitor  44 . Ultrasound scanner  42  may particularly include a transducer carrier  46  placed in contact with the patient, an ultrasonic waveform generator  48  operatively connected to the carrier for energizing the transducers (e.g., piezoelectric crystals, not shown) thereof, and a computer  50  functioning as an ultrasound signal analyzer operatively connected to the carrier for receiving therefrom signals encoding ultrasonic waves reflected from internal structures. 
     An entirely electronic (no moving parts) ultrasound scanner suitable for the present purposes is disclosed in the following patents: U.S. Pat. No. 5,871,446, U.S. Pat. No. 6,023,032, U.S. Pat. No. 6,319,201, U.S. Pat. No. 6,106,463, and U.S. Pat. No. 6,306,090. Other kinds of ultrasound scanning devices, as well as magnetic resonance imaging, X-ray machines, and CAT scanners, may also be suitable for present purposes, i.e., for monitoring the shapes and relative positions of organ IO and other internal tissue structures. 
     Ultrasound scanner  42  is operated and display or monitor  44  viewed in order to determine whether a selected location along organ wall  24  is free and clear of other intra-abdominal organs or whether organ wall  24  at a selected location lies against another organ AO or the patient. This determination is made prior to the penetration of wall  24  by needle  14 , to ensure that needle  14  does not enter another organ AO and conduct insufflation fluid into that other organ. Instead, the point of penetration of needle  14  through wall  24  is selected to avoid adjacent organ structures AO, so that needle  14  subsequently conducts carbon dioxide gas into abdominal cavity AC. 
       FIG. 2  depicts an alternative abdomen inflation method wherein the detection of an adjacent organ structure AOS inside the patient is accomplished via an ultrasound probe  52  that is inserted into a hollow body organ HB via a natural body opening or aperture NBA together with an insufflation needle  54 . Probe  52  may specifically include one or more ultrasound transducers  56  disposed in the end of an elongate flexible tubular member  58  from which needle  54  is ejected into a natural body cavity NC defined by a wall  60  of organ HB. Needle  54  is coupled to the distal end of an elongate flexible tubular shaft (not shown) such as shaft  16  in  FIG. 1 . Such an elongate flexible tubular shaft is insertable through a lumen or channel inside tubular member  58 . That lumen or channel may be lined at a distal end with a layer of a hard low-friction material such as polytetrafluoroethylene, to facilitate the ejection of needle  54 . 
     Probe  52  may include a handpiece  62  connected to a proximal end of tubular member  58 , the handpiece being provided with steering controls  64  and a port  66  for coupling to a source or reservoir  68  of pressurized carbon dioxide gas (possibly in liquid form). Handpiece  62  is also provided with a connector  70  for forming an electrically conductive link to an ultrasound electronics apparatus and display  72 . This electrically conductive link enables the transmission of ultrasound pressure waves and the sensing of incoming reflected waveforms by  56  under the control of ultrasound electronics apparatus  72 . 
     Probe  52  and needle  54  may be inserted into cavity NC through a collapsible tubular channel element  74  of an endoscope sheath  76  attached to and surrounding an endoscope  78 . Endoscope  78  has optical elements  80  and a handpiece  82 . Sheath  76  may be provided with a second tubular channel  84  through which an instrument  86  is inserted into cavity NC of organ HB for deploying a port element  88  ( FIG. 3B ) in organ wall  60 . At the time of insertion, instrument  86  includes port element  88  in a collapsed or folded insertion configuration  90  and an elongate flexible tubular shaft  92 . At a proximal end, shaft  92  includes a port or connector schematically represented at  94  for coupling the shaft to a source  96  of pressurized fluid such as saline solution. 
     Upon the insertion of needle  54  and probe  52  into cavity NC of organ HB and the subsequent placement of transducer elements  56  into contact with a proximal surface  98  ( FIGS. 3A and 3B ) of organ wall  60 , ultrasound electronics  72  are operated to scan through the organ wall for the presence of an adjacent organ structure AOS in contact with or proximate to a distal surface  100  ( FIGS. 3A and 3B ) of wall  60 . If an adjacent organ structure AOS is detected, probe  52  is manipulated from outside the patient to reposition the probe head (not separately enumerated) including transducer elements  56  at another location along proximal surface  8  of organ wall  60 . Upon failing to detect an adjacent organ structure AOS alongside distal surface  100  of organ wall  60 , the operating surgeon moves needle  54  in a distal direction to penetrate through wall  60 . Upon completed penetration, carbon dioxide gas from source or reservoir  68  through the flexible shaft or tube (not shown) and into the abdominal cavity AC via needle  54 . 
     Upon an insufflation of the abdominal cavity by this method, needle  54  is withdrawn from organ wall  60 . Then instrument  86  in moved forward so that the collapsed form  90  of port element  88  may be pushed partially through organ wall  60  at the former site of needle penetration (see  FIG. 3A ). Subsequently, a disk  102  or balloon  104  on the distal side of port element  88  is expanded from the collapsed configuration  90  of the port element, as shown in  FIG. 3B , while a balloon or bladder element  106  on the proximal side of the port element is inflated to an expanded configuration. 
     Disk  102  is made of a flexible sheet material. Disk  102  (or balloon  104 ) and balloon  106  define respective apertures (not shown) that are aligned with one another to define a hole for the passage of a medical instrument (not shown) through the port element  88 . Balloon  106  is attached to disk  102  and has an inflation tube  108  for enabling an introduction of a pressurizing fluid into the balloon to expand the balloon from a collapsed insertion configuration to an inflated use configuration. (In the case of balloon  104  in place of disk  102 , balloons  104  and  106  communicate with one another to enable an inflating of both balloons via saline or other fluid conveying through tube  108 .) 
     At least one valve element in the form of a self-sealing membrane or film (not shown) may be provided on port element  88  for forming a seal about the shaft of a medical instrument inserted through the port element into abdominal cavity AC during a trans-organ procedure as described in U.S. Pat. Nos. 5,297,536 and 5,458,131. The valve element or self-sealing membrane may be realized as a resilient annular flange or film material about at least one of the apertures in the disk  102  and the balloon  106 . 
     Another elongate tube  110  may be attached to port element  88 , traversing the port element, for the introduction of gas (e.g., carbon dioxide) to maintain pneumoperitoneum in abdominal cavity AC during a trans-organ procedure as described in U.S. Pat. Nos. 5,297,536 and 5,458,131. 
     Disk  102  may be provided along an edge or periphery with a ring (not shown) of a resilient material stiffer than the flexible sheet material of the disk. The ring assists in spreading disk  102  during a deployment procedure, after a passing of disk  102  in a collapsed form through the artificial aperture AA formed in organ wall  60 , for instance, by needle  54  or an incising instrument (not shown). Alternatively, where the ring is omitted, disk  102  is held in an opened configuration by the higher gas pressure in the abdominal cavity AC. 
     In a trans-organ surgical procedure as described in U.S. Pat. Nos. 5,297,536 and 5,458,131, port element  88  is connected to wall  60  and disposed in artificial aperture AA to keep that aperture open during a surgical procedure conducted via organ HB and natural body cavity NC, as described in U.S. Pat. Nos. 5,297,536 and 5,458,131. Upon completed deployment of port element  88 , disk  102  (or balloon  104 ) and balloon  106  sandwich organ wall  60  and maintain access to abdominal cavity AC via aperture AA. 
     Port element  88  may be used upon completion of the insufflation operation discussed above with reference to  FIG. 1 . Needle  54  may be inserted into the patient along a nonlinear path having at least one bend or turn. Alternatively, in some cases, the needle  54  may be inserted into the patient along a linear path. 
     Insufflation instrument  12 ,  52 , etc., may be marketed as a component of a kit including port element  88  and/or one or more surgical instruments having elongate flexible shafts provided at proximal ends with handle or actuators and at distal ends with operative tips such as scalpel blades, scissors, forceps, cauterizers, retrieval pouches, snares, etc. The instruments of the kit may vary in accordance with different kinds of procedures that may be performed via trans-organ access as described above. Thus, a tubal ligation would require a clip applier. A bladder removal procedure could utilize a cutting and cauterization tool, a graspers and a tissue removal instrument (none shown in particular). The kit may further include sheath  36 , which may include more than two working channels should more than one instrument be required simultaneously during a contemplated procedure. 
     Although the invention has been described in terms of particular embodiments and applications, one of ordinary skill in the art, in light of this teaching, can generate additional embodiments and modifications without departing from the spirit of or exceeding the scope of the claimed invention. Accordingly, it is to be understood that the drawings and descriptions herein are proffered by way of example to facilitate comprehension of the invention and should not be construed to limit the scope thereof.