Abstract:
Disclosed is a minimally invasive surgical instrument that may be used in hand-assisted laparoscopic surgeries. The device is a multifunctional surgical instrument that may be mounted directly on a surgeon&#39;s fingertip and inserted through an incision to allow the surgeon to manipulate tissue during a surgical procedure. Versions show a self-righting suture needle holder and a version with a dual pivoting jaw (e.g., grasper, cutter) that has an elongate neck to enhance the reach of the instrument. In addition, an elongate neck of an actuated fingertip instrument enhances the range reachable through a single incision.

Description:
CROSS REFERENCE TO RELATED APPLICATIONS 
       [0001]    The present application is related to and claims the benefit of two commonly-owned U.S. patent applications (a) Ser. No. 11/533,506, entitled “Dispensing Fingertip Surgical Instrument” to Voegele et al. filed on Sep. 20, 2006; and (b) U.S. patent application Ser. No. 10/777,324, “Fingertip Surgical Instruments” to Voegele et al., filed Feb. 12, 2004, published as U.S. patent application Publ. No. 2004/0193211 A1 on Sep. 30, 2004, the disclosures of which are hereby incorporated by reference in their entirety. 
         [0002]    The present application is further related to three U.S. patent applications: (1) U.S. patent application Ser. No. 10/777,740, “Fingertip Ultrasound Medical Instrument” to Voegele et al., filed Feb. 12, 2004, published Nov. 11, 2004 as U.S. patent application Publ. No. 2004/0225217 A1; (2) U.S. patent application Ser. No. 10/777,708, “Multifunctional Surgical Instrument” to Voegele et al., filed Feb. 12, 2004, published Oct. 7, 2004 as U.S. patent application Publ. No. 2004/0199204 A1; and (3) U.S. patent application Ser. No. 11/398,985 “A Multi-Port Insert For Use With A Laparoscopic Access Device” to Voegele et al., filed Apr. 5, 2006, which in turn claims the benefit of U.S. patent application Ser. No. 60/669,514 filed Apr. 8, 2005, the disclosures of all of which are hereby incorporated by reference in their entirety. 
     
    
     FIELD OF THE INVENTION 
       [0003]    The present invention relates, in general, to minimally invasive surgical instruments that may be used in hand-assisted laparoscopic surgeries where the instruments are mounted directly on a surgeon&#39;s fingertip and are then inserted through an incision, perhaps pneumatically sealed with a laparoscopic disk, to allow the surgeon to manipulate internal tissue during a surgical procedure. 
       BACKGROUND OF THE INVENTION 
       [0004]    Abdominal surgery typically involves an incision in the abdominal wall large enough to accommodate a surgeon&#39;s hands, multiple instruments, and illumination of the body cavity. While large incisions simplify access to the body cavity during a surgery, it also increases trauma, requires extended recovery time, and can result in unsightly scars. In response to these drawbacks, minimally invasive surgical methods have been developed. 
         [0005]    In minimally invasive abdominal surgery, or laparoscopic surgery, several smaller incisions are made into the abdominal wall. One of the openings is used to inflate the abdominal cavity with gas, which lifts the abdominal wall away from underlying organs and provides space to perform the desired surgery. This process is referred to as insufflation of the body cavity. Additional openings can be used to accommodate cannulas or trocars for illuminating and viewing the cavity, as well as instruments involved in actually performing the surgery, e.g., instruments to manipulate, cut, or resect organs and tissue. 
         [0006]    While minimally invasive surgical methods overcome certain drawbacks of traditional open surgical methods, there are still various disadvantages. In particular, there is limited tactile feedback from the manipulated tissue to the surgeon hands. In non-endoscopic surgery, a surgeon can easily verify the identification of structures or vessels within a conventional open surgery incision. In particular, the surgeon normally uses the sense of feel to verify the nature of visually identified operational fields. Further, in endoscopic surgery, tissue that is to be removed from the body cavity must be removed in pieces that are small enough to fit through one of the incisions. 
         [0007]    Recently, new surgical methods have been developed that combine the advantages of the traditional and minimally invasive methods. It is sometimes referred to as hand assisted laparoscopic surgery (“HALS”). In these new methods, small incisions are still used to inflate, illuminate, and view the body cavity, but in addition, an intermediate incision is made into the abdominal wall to accommodate the surgeon&#39;s hand. The intermediate incision must be properly retracted to provide a suitable-sized opening, and the perimeter of the opening is typically protected with a surgical drape to prevent bacterial infection. A sealing mechanism is also required to prevent the loss of insufflation gases while the surgeon&#39;s hand is either inserted into or removed from the body cavity though the retracted incision. 
         [0008]    While the hand provides a great deal of flexibility and retains the surgeon&#39;s sense of feel, fingers in themselves have limits as to their usefulness. Fingers lack the delicacy to pick up fine tissue. Fingers require making larger divisions when dissecting tissue. Fingers are subject to injury when holding tissue while energy modalities, such as ultrasound or RF, are used to treat the surgical site. Traditional instruments intended for conventional surgery, i.e. forceps and graspers, are too large for the limited body cavity environment. Traditional instruments also present the problem of being brought into and out of the laparoscopic site causing time-delaying deflation and re-insufflations of the body cavity. Laparoscopic equivalent instruments are delivered through a body wall port and have limited access to tissue. U.S. Pat. Nos. 6,149,642; and 5,925,064 disclose various aspects of laparoscopic surgery and fingertip devices for surgeon use. 
         [0009]    With the advance represented by HALS procedures, there is a need for improved fingertip surgical instrumentation that can take advantage of the increased freedom created by having a hand inside the body cavity. 
         [0010]    As an example, while suturing is often necessary in HALS procedures, generally known suturing instruments may prove difficult when repetitively gripping a curved suture needle and forming a stitch. 
         [0011]    As yet a further example, while instruments for HALS necessarily need to be of limited dimensions in order to be effective within the close confines of the insufflated abdomen, some additional range of motion is often desirable. 
         [0012]    Consequently, a significant need exists for an improved surgical instrument useful in HALS procedures. 
       BRIEF SUMMARY OF THE INVENTION 
       [0013]    The invention overcomes the above-noted and other deficiencies of the prior art by providing a fingertip surgical instrument that has an end effector that may be efficiently actuated with one hand within the close confines of an insufflated body cavity in order to manipulate internal tissue. 
         [0014]    In one aspect of the invention, a surgical instrument includes a fingertip mounting structure that is attachable to a fingertip of a surgeon so that his hand may be inserted through an incision to perform a hands assisted laparoscopy surgery (HALS) procedure, specifically suturing with an end effector having a pair of jaws with opposing generally convex and concave registering surfaces that tend to properly orient (i.e., self righting) a curved suture needle. 
         [0015]    In another aspect of the invention, a surgical instrument includes a fingertip mounting structure that is attachable to a fingertip of a surgeon so that his hand may be inserted through an incision to perform a hands assisted laparoscopy surgery (HALS) procedure. A pair of pivotal jaws are coupled by an elongate neck to the finger mounting portion so that an increased range of motion is achieved. A finger actuated member affects opening and closing the pair of pivotal jaws. 
         [0016]    These and other objects and advantages of the present invention shall be made apparent from the accompanying drawings and the description thereof. 
     
    
     
       BRIEF DESCRIPTION OF THE FIGURES 
         [0017]    The accompanying drawings, which are incorporated in and constitute a part of this specification, illustrate embodiments of the invention, and, together with the general description of the invention given above, and the detailed description of the embodiments given below, serve to explain the principles of the present invention. 
           [0018]      FIG. 1  is a cut-away perspective view of an exemplary use of a fingertip surgical instrument attached to a gloved finger of a surgeon&#39;s hand inserted through a laparoscopic disk into an insufflated abdomen of a patient undergoing Hand Assisted Laparoscopy Surgery (HALS). 
           [0019]      FIG. 2  is a left front perspective view of a self-righting needle holder, as a first illustrative version of the fingertip surgical instrument of  FIG. 1 . 
           [0020]      FIG. 3  is an exploded view of the self-righting needle holder of  FIG. 2  from a position above, left and in front. 
           [0021]      FIG. 4  is an exploded view of the self-righting needle holder of  FIG. 2  from a position below, left and in front. 
           [0022]      FIG. 5  is left side view taken in vertical longitudinal cross section through the self-righting needle holder of  FIG. 2  mounted on an index finger and having a thumb slide positioned distally to close and lock an upper jaw. 
           [0023]      FIG. 6  is left side view taken in vertical longitudinal cross section through the self-righting needle holder of  FIG. 2  mounted on an index finger and having a thumb slide positioned proximally to unlock and open the upper jaw. 
           [0024]      FIG. 7  is a left side view in vertical longitudinal cross section through an elongate grasper in an unactuated, closed position, as a second illustrative version of the fingertip surgical instrument of  FIG. 1 . 
           [0025]      FIG. 8  is a left side view in vertical cross section of the elongate grasper of  FIG. 7  in an actuated, open position. 
           [0026]      FIG. 9  is a left side view in elevation of yet an additional fingertip surgical instrument cut away to depict an extending inkpad for marking internal tissue actuated by pressure on an end effector nozzle. 
           [0027]      FIG. 10  is a left side view in elevation of yet another alternative fingertip instrument partially cut away to expose a roller ball that applies ink to internal tissue. 
           [0028]      FIG. 11  is a left side view in elevation of a further alternative fingertip surgical instrument partially cut away to expose a marking element extending from a finger mounted end effector tip that is unsheathed for use by distally advancing a thumb actuator. 
           [0029]      FIG. 12  is a left side view in elevation of an additional alternative fingertip surgical instrument partially cut away to expose a marking element distally extending from a thumb actuator that is extended out of a fingertip mounted end effector nozzle for use. 
           [0030]      FIG. 13  is a left side view in elevation of yet another alternative fingertip surgical instrument partially cut away to expose a marking solid element urged by a spring biased plunger into contact with a convex porous tip for marking internal tissue. 
           [0031]      FIG. 14  is a left side view in elevation of another alternative fingertip surgical instrument partially cut away to expose a thumb actuator that longitudinally compresses an ampoule for piercing and dispensing flowable material out of a nozzle tip. 
           [0032]      FIG. 15  is a left side view in elevation of yet a further alternative fingertip surgical instrument partially cut away to expose an upwardly pivoting thumb actuator that crushes an ampoule for dispensing flowable materials. 
           [0033]      FIG. 16  is a front view taken in cross section along lines  16 - 16  of  FIG. 15  of the further alternative fingertip surgical instrument of  FIG. 15 . 
           [0034]      FIG. 17  is a left side view in elevation of an additional alternative fingertip surgical instrument partially cut away to expose an upwardly pivoting thumb actuator that raises a linearly-moved actuator member to crush an ampoule and to dispense flowable material. 
           [0035]      FIG. 18  is a left side view in elevation of another alternative fingertip surgical instrument partially cut away to expose a thumb actuator in an initial position prior to dispensing. 
           [0036]      FIG. 19  is a left side view in elevation of the fingertip surgical instrument of  FIG. 18  partially cut away to expose the thumb actuator having been depressed to break an ampoule. 
           [0037]      FIG. 20  is a left side view in elevation of the fingertip surgical instrument of  FIG. 18  partially cut away to expose the thumb actuator after distal advancement followed by further upward depression to dispense in a controlled fashion the flowable liquid released from the ampoule. 
           [0038]      FIG. 21  is a left side view in elevation of an alternative fingertip surgical instrument for dispensing necked ampoules. 
           [0039]      FIG. 22  is a left side view in elevation of the alternative fingertip surgical instrument of  FIG. 21  mounted on an index finger and partially cut away to expose a two-compound necked ampoule prior to dispensing. 
           [0040]      FIG. 23  is a left side view in elevation of the alternative fingertip surgical instrument of  FIG. 22  partially cut away to expose the two-compound necked ampoule after dispensing. 
           [0041]      FIG. 24  is a left side view in longitudinal vertical cross section through the two-compound necked ampoule of  FIG. 22 . 
           [0042]      FIG. 25  is a left side view in longitudinal vertical cross section through an alternative single compound necked ampoule for the alternative fingertip surgical instrument of  FIG. 22 . 
           [0043]      FIG. 26  is a left side view of yet another alternative fingertip surgical instrument for dispensing a larger quantity of two flowable materials mixed during dispensing with an upper finger holder cut away. 
           [0044]      FIG. 27  is a top view of a distal portion of the fingertip surgical instrument in horizontal cross section along lines  27 - 27  through a longitudinal centerline. 
           [0045]      FIG. 28  is an aft view taken in cross section along lines  28 - 28  of the fingertip surgical instrument of  FIG. 27  through proximal cylindrical vessels, each containing one of the two flowable materials. 
           [0046]      FIG. 29  is an aft view taken in cross section along lines  29 - 29  of the fingertip surgical instrument of  FIG. 27  viewing manifolds and a central nozzle tube for mixing and dispensing the two flowable materials. 
           [0047]      FIG. 30  is a left side view in elevation of the fingertip surgical instrument of  FIG. 26  after actuation of the upper fingertip holder and opposing lower thumb actuator. 
           [0048]      FIG. 31  is a top view in cross section taken along lines  31 - 31  of the fingertip surgical instrument of  FIG. 30  after actuation and dispensing. 
       
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
       [0049]    Referring now to  FIG. 1 , the environment for performing an endoscopic surgical procedure within an abdomen is illustrated, herein referred to as Hand Assisted Laparoscopic Surgery (HALS). A surgeon places a fingertip instrument  10  consistent with aspects of the present invention on his index finger  12  (although any finger can be used) of a gloved hand  14 . In particular, the fingertip instrument  10  includes an end effector (working element)  16  distally mounted on a finger tip attachment portion  18  with an actuator  20  movably attached thereto that is moved to actuate the end effector  16  to manipulate tissue  21  (e.g., dispense, mark, activate, pivot, scissor, grasp, etc.). A means for providing hand access, such as a lap disc  22 , for example, model LD111 available from Ethicon Endo-Surgery, Cincinnati, Ohio, is placed into an abdominal wall  23  to serve as a pressure seal. The surgeon inserts his arm and gloved hand  14  through the lap disc  22  and into an insufflated abdominal cavity  24 . 
         [0050]    Needle Holder. In the afore-mentioned U.S. patent application Publ. No. 2004/0193211 A1, a needle holder was disclosed as one illustrative working element. In  FIGS. 2-6  a version of the fingertip instrument  10  is depicted as a needle holder  100  advantageously including a lower jaw  112  and pivotally attached upper jaw  114  that advantageously form a self-righting grip to a curved suture needle  116  ( FIG. 2 ) having a flattened surface  118  on its concave side. The lower jaw  112  has a proximal cylindrical portion  120  with a vertically and proximally open slot  122  formed therein to receive a proximal rocker portion  124  of the upper jaw  114  that is pinned by a small horizontal pin  125  therein for pivotal opening and closing of a distal end  126  toward the lower jaw  112 . 
         [0051]    In particular, a distal end  127  of the lower jaw  112  has a cylindrical solid shape with an upper distal removed portion  128  to form a lower contact tray surface  130  into which a rectilinear ramped recess  132  is formed into which in turn a deeper but narrower rectilinear ramped recess  134  is formed. The distal end  126  of the upper jaw  114  has a width easily accommodated by the rectilinear ramped recess  132 . The distal end  126  of the upper jaw  114  has a downwardly projecting longitudinal squared off ridge  136  that has a width easily accommodated within the deeper but narrower rectilinear ramped recess  134 . Thus, the distal end  126  of the upper jaw  114  has a T-shape in transverse cross section that interacts with the recess  132  in the lower jaw  112  to tend to roll a loosely gripped suture needle  116  toward an upright position with an increased grip. This capability facilitates efficient suturing within the close confines of a HALS procedure. It should be appreciated that the recesses  132 ,  134  and the ridge  136  may be curved surfaces rather than squared off. Any shape that allows a downwardly projecting portion to be within a recessed area would serve to orient a suture needle  16 . 
         [0052]    A wing or band  138  of adhesive tape (e.g., cloth surgical tape) or hook loop material (e.g., VELCRO) provides a finger tip attachment portion to secure a curved upper, proximal surface  140  of a sled-shaped finger holder  142  to an undersurface and fingertip of the last digit of the index finger  12 . It should be appreciated that the wing or band  138  may be formed from various types of adjustable attachment means that would be acceptable for surgical use and that may securely grip the finger  12 . With particular reference to  FIGS. 3-4 , In addition to being attachable to the finger  12  for movement, the finger holder  142  supports components that are moveably attached for closing the jaws  112 ,  114  and for locking the jaws  112 ,  114  closed. A distal snout  144  includes left and right distal mounting arms  146 ,  148  separated by a vertical slot  150  that widens into a longitudinal, distally open cylindrical recess  152  that receives the proximal cylindrical portion  120  of the lower jaw  112 , secured by pin  125  received respectively through five holes  154 - 158  formed in the left distal mounting arm  146 , a left arm  160  of the proximal cylindrical portion  120 , the proximal rocker portion  124  of the upper jaw  114 , a right arm  162  of the proximal cylindrical portion  120 , and the right distal mounting arm  148 . 
         [0053]    The proximal rocker portion  124  of the upper jaw  114  rotates up and down along with an upper end  164  of a closure link  166  pinned for pivoting movement on the right with an upper pin  168  through right and left holes  170 ,  172  respectively. A lower end  174  of the closure link  166  pivots within a front vertical slot  176  formed in a curved underslung actuating member  178  received within an elongate recess  180  formed in the undersurface of the sled shaped finger holder  142 . Left and right front horizontal through holes  182 ,  184  formed in the actuating member  178  communicate with the front vertical slot  176  to receive a front horizontal pin  186  that also passes through a bottom hole  188  in the lower end  174  of the closure link  166 . An aft end  190  of the underslung actuating member  178  has a proximal horizontal through hole  192  that is aligned with left and right proximal holes  194 ,  196  ( FIG. 4 ) to pivotally receive a proximal horizontal pin  198 , the holes  194 ,  196  formed in a U-shaped bracket  200  attached to a proximal underside of the sled shaped finger holder  142 . 
         [0054]    A downwardly open spring recess  202  ( FIG. 4 ) formed in the elongate recess  180  in the sled-shaped finger holder  142  is aligned with an upwardly open spring recess  204  ( FIG. 3 ) formed in the curved underslung actuating member  178  to receive a compression spring  206  that urges the actuating member  178  away from the finger holder  142  when allowed, drawing the closure link  166  to open the upper jaw  114  ( FIG. 6 ). Closure and locking of the upper jaw  114  is effected by distal movement of a thumb slide  208 . In particular, the thumb slide  208  has a lower thumb slide button portion  210  attached to an upward arm  212  having a locking tip  214  extending distally from a top end. A shallow rectangular recess  216  ( FIG. 4 ) is sized to contact an upper surface of the low thumb slide button portion  210  allowing some longitudinal sliding. A rightwardly open aperture  218  longitudinally centered in the shallow rectangular recess  216  is sized to allow the upward arm  212  to move a like amount fore and aft with the locking tip  214  received within a downwardly open locking recess  220  formed within the elongate recess  180  in the sled-shaped finger holder  142 . A locking ramp  222  across a front portion of the locking recess  220  guides the locking tip  214  into locking engagement with the sled shaped finger holder  142  when distally positioned ( FIG. 5 ) to close and lock the upper jaw  114 . The locking tip  214  is released when the thumb slide  208  is proximally positioned ( FIG. 6 ). 
         [0055]    It should be appreciated that the locking features may be reversed such that drawing the thumb slide aft effects closing and locking or that the upper jaw is locked open in addition to or as an alternative to locking closed. As another alternative, the jaws may be coupled to a lever to both pivot toward the other. As yet another alternative, the lever may translated one of the jaws toward the other with neither jaw being pivotally attached to the other, allowing for parallel orientation of the jaws. 
         [0056]    In  FIGS. 7-8 , an alternative fingertip surgical instrument (“extended end effector fingertip surgical instrument”)  300  is depicted as having a grasper or scissor end effector  302  that is actuated at a desired distance from the index finger  12  via an elongate neck  304 . The index finger  12  is placed upon a finger holder  306  that is then held in place by a wing or band  308 . It should be appreciated that the wing or band  308  may be formed from various types of adjustable attachment means that would be acceptable for surgical use and that securely grip the finger  12 . A distally projecting neck cannula  310  extends from the finger holder  306 . An outer sheath  311  with inwardly beveled outer edges is attached to a distal opening of the neck cannula  310  and defines a distal bore  312  that communicates and is longitudinally aligned through a narrow neck opening  314  at a proximal end of the outer sheath  311 . The narrow neck opening  314  communicates and is longitudinally aligned with a proximal cylindrical spring cavity  316  defined by the neck cannula  310 . A lower longitudinal actuator slot  318  passes through the neck cannula  310  to communicate with the cylindrical spring cavity  316 . 
         [0057]    An upper jaw  320  and lower jaw  322 , which may have gripping, cutting, scissoring or other surfaces, rotate about a shared jaw axle  324  to form an end effector  326  sized to fit at least partially within the distal bore  312 . A U-shaped clip spring  328  passes around the axle  324  and has an upper distal end attached to the upper jaw  320  and a lower distal end attached to the lower jaw  322  to bias the jaws  320 ,  322  to an open position ( FIG. 8 ). A thumb slide actuator  330  has a thumb gripping portion  332  that underlies the finger holder  306  that is attached to a connecting portion  334  that moves within the lower longitudinal actuator slot  318  to a cylindrical portion  336  that is sized for movement within the proximal cylindrical spring cavity  316 . A reciprocating shaft  338  is shaped with a bullet-shaped distal end  340  recessed on each side of an axle hole  342  to receive the jaws  320 ,  322  and to proximally ground against narrow neck opening  314  with a narrower rod  344  extending back through the cylindrical spring cavity  316  terminating in a screw portion  346  that is threaded into a threaded screw hole  348  in the cylindrical portion  336  of the thumb slide actuator  330 . A compression spring  350  encompasses the narrower rod  344  and grounds against a proximal side of the narrow neck opening  314  and a distal side of the cylindrical portion  336  of the thumb slide actuator  330 , creating a proximal bias on the end effector  326 . When the bias withdraws the end effector  326  into the outer sheath, the opening bias on the end effector  326  is overcome and the jaws  320 ,  322  close ( FIG. 7 ). The outer sheath  311  is assembled last to retain this spring  350 . Distal movement of the thumb slide actuator  330  overcomes this bias to extend the end effector  326  out of the distal bore  312  to allow the end effector  326  to open ( FIG. 8 ). Thus, coordinated movement of the entire fingertip surgical instrument  300  and the thumb slide actuator  330  allows manipulation or severing of internal tissue. 
         [0058]    It should be appreciated that the configuration of the alternative fingertip surgical instrument  300  is illustrative and that applications consistent with the present invention may be biased open in the unactuated position. In addition, rather than both jaws actuating, one jaw may be fixed. Further, rather than relying upon a spring bias to pivot the jaws in one direction relative to each other, applications consistent with the present invention may include affirmative coupling with an actuator to transfer actuating motion to both open and to close the end effector. It should be appreciated that for clarity a straight and vertically aligned end effector is depicted, but the orientation of the end effector in applications consistent with the invention may include curved, longitudinal rotary and/or articulating structures for positioning prior to insertion or to remotely position the end effector after insertion. Further, for simplicity a fixed length elongated neck is depicted, but it should be appreciated that an adjustable (e.g., telescoping) portion of the elongate neck may be incorporated to adjust either prior to insertion or after insertion to a desired distance from the fingertip. It should be appreciated that the trigger may instead be a pivoting actuator whose motion is converted to a longitudinal reciprocating motion. As yet another alternative, the actuator may be slid an outer sheath over a fixed grasping portion rather than moving the grasping portion. 
         [0059]    Internal Liquid Dispensers: Markers. Applications of an internal liquid dispensing instrument suitable for a HALS procedure are numerous. For instance, a fingertip ink marker may be used as a training tool to mark anatomic features. Another example is use as a planning tool to show where to make incisions, the path to follow, to establish orientation, and to cut profiles for feature alignment. As yet another example is use as a landmark identifier to avoid having to spend time relocating a structure. In addition to dispensing a marking liquid, other significant applications exist for the precise application of liquids as part of a HALS procedure, such fluid dispensers principally for but not limited to adhesives and sealants, with the dispensing of any fluid or gel chemistry for the additional purpose of drug delivery, barrier/scaffolding/buttress, or sclerosing/necrosing of tissue, with the application being of a permanent or temporary (time limited) nature. Dispersants may be self-contained or used with external activation sources such as moisture, oxygen (air) or lack of heat, light, etc. Applications may be surface, tissue to tissue or tissue to device in nature. Adhesives may be activated by moisture, peel-liner, or other delivery approaches. Absorbability of an ink, adhesive or physical marker conveyed as flowable material may be advantageous in certain applications. Mechanical forms may include a biocompatible collagen that has a tissue adhering adhesive. 
         [0060]    Versions of a fingertip surgical instrument described hereafter thus include a fingertip mounting structure to which is attached a fluid containing structure that is selectively actuated to expose a fluid, liquid or gel (e.g., marking, adhesive, therapeutic compound) that is biocompatible and efficacious for application to internal tissue in a HALS procedure. 
         [0061]    Returning to the drawings, in  FIG. 9 , yet an additional alternative fingertip surgical instrument (“extending inkpad fingertip instrument”)  400  includes a porous cylindrical ink dispensing component  402  held within a distal bore  404  of an end effector nozzle  406  formed in a finger holder  408 . A proximal, finger portion  410  encompasses a lower and distal portion of the index finger  12 , retained therein by a wing or band  412  attached to an upward, proximal surface  414  of the finger portion  410 . It should be appreciated that the wing or band  412  may be formed from various types of adjustable attachment means that would be acceptable for surgical use and that securely grip the finger  12 . A cylindrical diaphragm  416  is attached across a wider cavity  418  defined inside of the end effector nozzle  406  proximal to and communicating with the distal bore  404 . A plunger  420  has a proximal shaft  422  sized to closely fit for translation within the distal bore  404  and has a rounded head  424  that contacts the diaphragm  416  from the distal side. A compression spring  426  larger than the diameter of the distal bore  404  encompasses the proximal shaft  422 , urging the rounded head  424  proximally to position the diaphragm  416  into contact with the fingertip of the index finger  12 . A small diameter plug attachment rod  428  extends distally from the proximal shaft  422  terminating in a flathead  430  embedded within the porous cylindrical ink dispensing component  402 . Thus, when the end effector nozzle  406  is pressed against tissue, the fingertip of the index finger  12  depresses against the diaphragm  416 , distally advancing the plunger  420  while compressing the compression spring  426 , which in turn distally extends the porous cylindrical ink dispensing component  402  into contact with the internal tissue to impart a marking, adhesive and/or therapeutic effect, depending upon a flowable material absorbed by the ink dispensing component  402 . 
         [0062]    In  FIG. 10 , yet another alternative fingertip surgical instrument (“rollerball fingertip instrument”)  500  has a roller ball end effector  502  that includes a cylindrical reservoir  504  with a roller ball or disk  506  held for rotation and exposing a distal portion  508  to paint flowable material  510  drawn from the reservoir onto internal tissue (not shown). A finger mounting portion  512  is proximally attached to the cylindrical reservoir  504  to contact at least an undersurface and fingertip of the index finger  12 , while a band or wing  514  attached to a proximal upward surface  516  of the finger mounting portion  512  retains the finger  12  in contact, accommodating a range of finger sizes. It should be appreciated that the wing or band  514  may be formed from various types of adjustable attachment means that would be acceptable for surgical use and that securely grip the finger  12 . Thus, swiping contact with tissue causes the roller ball  506  to deposit flowable liquid  510  onto internal tissue. If a roller disk  506  is selected, a castor attachment may allow the roller disk  506  to readily align with the direction of swiping contact. 
         [0063]    In  FIG. 11 , yet a further alternative fingertip surgical instrument (“sheathed marking fingertip instrument”)  600  has a marking element (e.g., ink soaked porous elongate rod)  602  partially embedded into a cylindrical end effector tip  604  attached to a finger mounting structure  606  that partially encompasses an index finger  12 . It should be appreciated that the amount of flowable material may be augmented by a reservoir that communicates with the marking element  602  or may be limited to the quantity that the marking element  602  may absorb. A wing or band  608  attached to an upward, proximal surface  610  of the finger mounting structure  606  grips the finger  12 . It should be appreciated that the wing or band  608  may be formed from various types of adjustable attachment means that would be acceptable for surgical use and that securely grip the finger  12 . A horizontal gear axle  612  is attached to the finger mounting structure  606  below the cylindrical end effector tip  604  to support a vertically aligned spur gear  614 . An outer cylindrical sleeve  616  encompasses the cylindrical end effector tip  604 , longitudinally translating between a distal position encompassing the marking element  602  as shown and a proximal position exposing the marking element  602  depicted in phantom. A lower rack portion  618  formed on an exterior of the outer cylindrical sleeve  616  is in gear engagement to the spur gear  614 , which in turn is in gear engagement to an upwardly presented gear rack portion  620  formed on a distal portion of a thumb slide  622 , coupled for longitudinal translation to the finger mounting structure  606 . Thus, distal movement of the thumb slide  622  causes the marking element  602  to be exposed for use. It should be appreciated that other mechanizations that tend to extend the marking element  602  or to withdraw a shielding component may be used consistent with aspects of the invention, to include but are not limited to a lever, flattening an arcuate member, etc. 
         [0064]    In  FIG. 12 , an additional alternative fingertip surgical instrument (“direct coupled sheath marking fingertip instrument”)  700  has a marking element  702  partially embedded into a distally open cylindrical receptacle  704  of a thumb actuator  706 . The marking element  702  may be manually drawn out of the receptacle  704  prior to use to expose a suitable portion, adjusting for the available longitudinal length of the marking element  702 , especially for a marking element  702  that is mechanically rubbed off or dissolved by fluid. Alternatively, the marking element may comprise a porous structure that allows a flowable material retained therein to dispense upon contact. The cylindrical receptacle  704  translates within a distally open cylindrical end effector nozzle  708  that is attached to a finger mounting structure  710  that partially encompasses an index finger  12 . A wing or band  712  attached to an upward, proximal surface  714  of the finger mounting structure  710  grips the finger  12 . It should be appreciated that the wing or band  712  may be formed from various types of adjustable attachment means that would be acceptable for surgical use and that securely grip the finger  12 . A lower longitudinal slot  716  along at least a proximal portion of the end effector nozzle  708  allows longitudinal movement of a connecting arm  718  that connects the receptacle  704  to a thumb contacting surface  720 , forming the actuator  706 . Distal movement of the actuator  706  exposes the marking element  702  for use distal to the end effector nozzle  708  (shown in phantom) and proximal movement of the actuator  706  hides the marking element  702  as depicted. 
         [0065]    In  FIG. 13 , yet another alternative fingertip surgical instrument (“convex porous tip dispensing fingertip instrument”)  800  has a marking element  802  containing flowable material which is enclosed within a dispensing end effector  804 . In particular, an outer cap  806  of the end effector  804  has a convex porous portion  808 , which in the illustrative version is composed of a resilient material for deflection under a force exerted by a fingertip, and is presented centrally on an otherwise flat circular end  810 , which in turn is attached to a distal cylindrical side wall  812  that transitions to a slightly smaller diameter proximal cylindrical side wall  814 , presenting an internal locking lip  816  at the transition. A distally open cylindrical bore  818  of the end effector  804  has a diameter to closely fit within the proximal cylindrical side wall  814  and presents an outer locking lip  820  at its distal end that locks inside distal to the internal locking lip  816 . A finger holder  822  is proximally attached to the distally open cylindrical bore  818  and partially encompasses an index finger  12 . A wing or band  824 , attached to an upward, proximal surface  826  of the finger holder  822 , grips the finger  12 . It should be appreciated that the wing or band  824  may be formed from various types of adjustable attachment means that would be acceptable for surgical use and that securely grip the finger  12 . A spring post  828  extends distally from the finger holder  822  centered within the distally open cylindrical bore  818 . A plunger  830  has a cylindrical side wall  832  sized to closely fit but translate within the distally open cylindrical bore  818  and spanned by a transverse seat disk  834  defining a shallow distal recess  836  that receives a smaller diameter base  838  of the marking element  802  that is otherwise sized to translate within the distally open cylindrical bore  818 . The transverse seat disk  834  of the plunger  830  also defines a deeper proximal spring cavity  840  that receives a distal end of a compression spring  842  whose proximal end is received around the spring post  828 . The spring biased plunger  830  maintains the marking element  802  in contact with an inner surface of the convex porous portion  808  of the outer cap  806  so that under cooperative deflection of the convex porous portion  808  that flowable material is forced out for application to internal tissue. 
         [0066]    Internal Liquid Dispensing: Encapsulated Liquids. Some flowable materials to be dispensed may advantageously be encapsulated in ampoules or similar structures to preserve their properties until dispensing (e.g., a moisture or oxygen activated or two-part adhesive). An illustrative list of adhesives is contained in U.S. patent application Ser. No. 10/359,699 “Applicators, Dispensers And Methods For Dispensing And Applying Adhesive Material” to Goodman et al., filed 7 Feb. 2003, now published as U.S.2004/0190975A1 on 30 Sep. 2004, the disclosure of which is hereby incorporated by reference in its entirety. 
         [0067]    In  FIG. 14 , another alternative fingertip surgical instrument (“pushed ampoule dispensing fingertip instrument”)  900  has an ampoule  902  with distal scorings  904  whose proximal end is received within a distal recess  906  in a cylindrical pusher  908  of a thumb actuator  910 . The cylindrical pusher  908  translates within a cylindrical end effector tube  912  that is attached to a finger holder  914  that partially encompasses an index finger  12 . A wing or band  916  attached to an upward, proximal surface  918  of the finger holder  914  grips the finger  12 . It should be appreciated that the wing or band  916  may be formed from various types of adjustable attachment means that would be acceptable for surgical use and that securely grip the finger  12 . A lower longitudinal slot  920  along at least a proximal portion of the end effector tube  912  allows longitudinal movement of a connecting arm  922  that connects the pusher  908  to a thumb contacting surface  924 , forming an actuator  926 . A nozzle cap  928  has a wide diameter proximal ring  930  that fits over a distal portion of the end effector tube  912 . The nozzle cap  928  includes a central bulbous portion  932  distally attached to the wide diameter proximal ring  930  and is sized to have an internal cavity  934  that continues the diameter of the end effector tube  912 . A converging nozzle tip  936  is distally attached to the central bulbous portion  932 . A spike member  938  internally received in the nozzle tip  936  extends an upper piercing arm  940  and a slightly shorter lower piercing arm  942  proximally toward the ampoule  902  in the internal cavity  934 . It should be appreciated that the spike member  938  allows a longitudinal flow between the internal cavity  934  and an external orifice  944  of the nozzle tip  936 . Distal movement of the actuator  926  impales the ampoule  902  upon the piercing arms  940 ,  942  of the spike member  938 , filling the internal cavity  934  distal to the ampoule  902 . Continued distal movement (shown in phantom) of the actuator  926  reduces the volume of the internal cavity  934 , expelling the flowable material contents out of the external orifice  944  onto internal tissue. 
         [0068]    In  FIGS. 15-16 , yet a further alternative fingertip surgical instrument (“bottom ampoule crushing dispensing fingertip instrument”)  1000  has an ampoule  2  with an outer frangible elongate shell  1004  containing a flowable material  1006 . The ampoule  1002  is contained within an elongate nozzle bulb  1008  have a converging nozzle orifice  1010  distally oriented. A finger holder  1012  receives and encompasses a distal and lower surface of an index finger  12 , retained therein by a wing or band  1014  that is attached to a proximal upward surface  1016  of the finger holder  1012 . It should be appreciated that the wing or band  1014  may be formed from various types of adjustable attachment means that would be acceptable for surgical use and that securely grip the finger  12 . An end effector support portion  1018 , having a uniform inverted U-shaped transverse cross section ( FIG. 16 ) extends distally from the finger holder  1012  to encompass each side of the elongate nozzle bulb  1008  except distally and underneath. A U-shaped bracket  1020  extends below a proximal end of the finger holder  1012  to receive a proximal pivoting end  1022  of an actuator  1026  horizontally pinned therein by a pin  1024 . A central portion  1028  of the actuator  1026  has a lower contour shaped for a thumb to rotate the actuator  1026  upwardly, resisted by a vertical compression spring  1030  whose top end is received in a downwardly open spring receptacle  1032  formed in the finger holder  1012  and an aligned upwardly open spring receptacle  1034  formed in the central portion  1028  of the actuator  1026 . A distal portion  1036  of the actuator  1026  has a generally triangular vertical cross section ( FIG. 15 ) and is laterally sized to closely fit for upward translation within the end effector support portion  1018 . A top, proximal corner  1038  of a ramped surface  1040  of the distal portion  1036  initially makes nondeforming contact at an aft lower point on the elongate nozzle bulb  1008 . Left, center and right upward bumps  1042 ,  1043 ,  1044  ( FIG. 16 ) formed on the ramped surface  1040  initially make nondeforming contact to a longitudinal midpoint underneath the elongate nozzle bulb  8  respectively on a left, center and right side. It should be appreciated that upward actuation of the actuator  1026  causes the bumps  1042 - 1044  to fracture the elongate shell  1004  of the ampoule  1002  as the ramped surface  1040  progressively collapses a proximal portion of the elongate nozzle bulb  1008  to expel the flowable material  1006  out of the converging nozzle orifice  1010  until proximity with the end effector support portion  1018  and finger holder  1012  arrests further actuation. 
         [0069]    In  FIG. 17 , yet an additional alternative fingertip surgical instrument (“rocker bottom ampoule crushing dispensing fingertip instrument”)  1100  has an ampoule  1102  with a frangible elongate shell  1104  containing a flowable material  1106 . The ampoule  1102  is contained within an elongate nozzle bulb  1108  have a converging nozzle orifice  1110  distally oriented. A finger holder  1112  receives and encompasses a distal and lower surface of an index finger  12 , retained therein by a wing or band  1114  that is attached to a proximal upward surface  1116  of the finger holder  1112 . It should be appreciated that the wing or band  1114  may be formed from various types of adjustable attachment means that would be acceptable for surgical use and that securely grip the finger  12 . An end effector support portion  1118 , having a uniform inverted U-shaped transverse cross section extends distally from the finger holder  1112  to encompass each side of the elongate nozzle bulb  1108  except distally and underneath. A U-shaped bracket  1120  extends below a proximal end of the finger holder  1112  to receive a proximal pivoting end  1122  of an actuator  1126  horizontally pinned therein by a pin  1124 . A central portion  1128  of the actuator  1126  has a lower contour shaped for a thumb to rotate the actuator  1126  upwardly, resisted by a vertical compression spring  1130  whose top end is received in a downwardly open spring receptacle  1132  formed in the finger holder  1112  and an aligned upwardly open spring receptacle  1134  formed in the central portion  1128  of the actuator  1126 . A distal portion of the actuator  1126  is a curved upward bar portion  1136  laterally sized to closely fit for upward translation within the end effector support portion  1118 . A linearly-moved contact member  1137  has a rectangular plate surface  1140  whose midpoint rests upon the bar portion  1136  of the actuator  1126 . A downturned flange  1144  at a top, proximal corner  1138  of the rectangular plate surface  1140  abuts a distal vertical, transverse surface of the downwardly open spring receptacle  1132  of the finger holder  1112 . One or more upward bumps  1143  laterally arrayed across a longitudinal midpoint of the rectangular plate surface  1140  of the linearly-moved contact member  1137  are initially in nondeforming contact with a midpoint of an undersurface of the elongate nozzle bulb  1108 . It should be appreciated that upward actuation of the actuator  1126  causes the linearly-moved contact member  1137  to move upwardly, maintaining a slight downward cant of its distal edge, causing bump(s)  1143  to fracture the elongate shell  1104  of the ampoule  1102  as the rectangular plate surface  1140  progressively collapses a proximal portion of the elongate nozzle bulb  1108  to expel the flowable material  1106  out of the converging nozzle orifice  1110  until proximity with the end effector support portion  1118  and finger holder  1112  arrests further actuation. Thus, the contact member  1137  linearly guided by the structure of the finger holder  1112  converts the rotation movement from the distal end  1136  of the actuator  1126  so that an optimized orientation of breaking and compressive contact may be imparted to the elongate nozzle bulb  1108  and ampoule  1102  throughout a desired distance of translation, even for a distal end  1136  that substantially changes its angular orientation. 
         [0070]    In  FIGS. 18-20 , another alternative fingertip surgical instrument (“two-step ampoule crushing dispensing fingertip instrument”)  1200  has an ampoule  1202  with a frangible elongate shell  1204  containing a flowable material  1206 . The ampoule  1202  is contained within an elongate nozzle bulb  1208  having a converging nozzle orifice  1210  distally oriented. A finger holder  1212  receives and encompasses a distal and lower surface of an index finger  12 , retained therein by a wing or band  1214  that is attached to a proximal upward surface  1216  of the finger holder  1212 . It should be appreciated that the wing or band  1214  may be formed from various types of adjustable attachment means that would be acceptable for surgical use and that securely grip the finger  12 . An end effector support portion  1218 , having a uniform inverted U-shaped transverse cross section extends distally from the finger holder  1212  to encompass each side of the elongate nozzle bulb  1208  except distally and underneath. A U-shaped bracket  1220  extends below a proximal end of the finger holder  1212  to receive a proximal rod-shaped pivoting end  1222  of an actuator  1226 . A central portion  1228  of the actuator  1226  has a lower contour shaped for a thumb to rotate the actuator  1226  upwardly ( FIG. 18 ), then distally ( FIG. 19 ), followed by more upward motion ( FIG. 20 ) to sequentially rupture the ampoule and then to dispense the flowable material  1206  in a controlled rate. An angled compression spring  1230  has a top end attached to the finger holder  1212  proximal to a downward grounding flange  1232  extending from a finger shaped portion  1233  of the finger holder  1212 . An upwardly and distally angled spring post  1234  formed in the central portion  1228  of the actuator  1226  receives a bottom end of the compression spring  1230  and aims toward the attachment of the top end of the compression spring  1230 . A distal portion  1236  of the actuator  1226  has a vertical foot shape laterally sized to closely fit for upward translation within the end effector support portion  1218  and a slightly downwardly canted upper surface  1235 . A crush detent step  1239  is formed on an upper transition between the distal portion  1236  and the central portion  1228  of the actuator  1226 . A linearly-moved actuator member  1237  has a rectangular plate surface  1240  whose midpoint rests upon the bar portion  1236  of the actuator  1226 . A downturned proximal flange  1244  at a top, proximal corner of the rectangular plate surface  1240  abuts a distal vertical, transverse surface presented by the downward grounding flange  1232  of the finger holder  1212 . Thus, the structure of the finger holder  1212  guides the actuator member  1237  for linear movement to present an optimized breaking and contact surface to the nozzle bulb  1208  and ampoule  1202  through the rotational movement of the distal portion  1136  of the actuator  1126 . A downturned distal flange  1245  from a top, distal corner of the rectangular plate surface  1240  resides in front of the distal portion  1236  of the actuator  1226 . One or more upward bumps  1243  laterally arrayed across a longitudinal midpoint of the rectangular plate surface  1240  of the linearly-moved actuator member  1237  are initially in nondeforming contact with a midpoint of an undersurface of the elongate nozzle bulb  1208  ( FIG. 18 ). Upward actuation of the actuator  1226  causes the linearly-moved actuator member  1237  to move upwardly, causing bump(s)  1243  to fracture the elongate shell  1204  of the ampoule  1202 . The downturned grounding flange  1232  then contacts the crush detent step  1239 , preventing any significant reduction in the volume of the elongate nozzle bulb  1208  ( FIG. 19 ). When dispensing is then desired in the ensuing moments, the actuator  1226  may be distally moved slightly and then upwardly depressed to progressively collapse the elongate nozzle bulb  1208  to expel the flowable material  1206  out of the converging nozzle orifice  1210  ( FIG. 20 ). 
         [0071]    In  FIGS. 21-24 , an alternative fingertip surgical instrument (“necked ampoule applier”)  1300  receives a necked ampoule  1302  ( FIG. 24 ) having a nozzle neck  1304  surrounded by a thick walled distal disk  1306  attached to an elongate capsule wall  1308  to form a reservoir  1310 . For a dual chemical flowable material, in  FIG. 24 , the reservoir  1310  has a neck plug  1312  that seals off the nozzle neck  1304  and a fragile bifurcating barrier  1314  that separates a first flowable material  1316  from a second flowable material  1318 . For a single chemical/mixture  1320 , in  FIG. 25 , a necked ampoule  1302 ′ has a reservoir  1310 ′ filled with a single fragile neck barrier  1322 ′ plugging a nozzle neck  1304 ′, such as at a distal orifice end  1324 ′. 
         [0072]    In  FIGS. 21-23 , an ampoule cavity  1326  sized for the necked ampoule  1302  is formed within an end effector block  1328 . The ampoule cavity  1326  provides a distal circular nozzle surface  1330  against which the thick walled distal disk  1306  of the necked ampoule  1302  grounds and provides a centered nozzle hole  1332  in the nozzle surface  1330  through which the nozzle neck  1304  of the necked ampoule  1302  extends. A plunger passage  1334  communicates horizontally from a proximal direction through the end effector block  1328  to communicate with the ampoule cavity  1326 . A rod plunger  1336  having a distal plunger end  1338  extends through the plunger passage  1334 , initially in nondeforming contact with a proximal end of the necked ampoule  1302 . A proximal plunger end  1340  of the rod plunger  1336  extends proximally out of the plunger passage  1334  of the end effector block  1328  a distance at least the longitudinal width of the necked ampoule  1302  ( FIGS. 21-22 ). Both a lower end  1342  of an upper scissor link  1344  and an upper end  1346  of a lower scissor link  1348  are pivotally attached by a center rivet  1350  to the proximal plunger end  1340 . An upper end  1352  of the upper scissor link  1344  is pivotally attached to a midpoint of an upper finger holder  1354  by an upper rivet  1356 . A lower end  1358  of the lower scissor link  1348  is pivotally attached at a midpoint to a lower thumb actuator  1360  by a lower rivet  1362 . Proximal ends  1364 ,  1366  of the upper finger holder  1354  and the lower thumb actuator  1360  are pivotally attached at about a longitudinal midpoint of the end effector block  1328  by a horizontal axle attachment  1368  ( FIG. 21 ), forming an acute angle with one another bisected by the rod plunger  1336 . Actuation of the upper finger holder  1354  and the lower thumb actuator  1360 , as depicted in  FIG. 23 , causes the scissor links  1344 ,  1348  to rotate more toward the horizontal, translating the rod plunger  1336  distally, compressing the ampoule  1302  in a fashion to rupture the neck plug  1312  that seals off the nozzle neck  1304  and the fragile bifurcating barrier  1314  and to expel the flowable materials  1316 ,  1318  from the reservoir  1310  of  FIG. 24  or to open the distal orifice end  1324 ′ of the necked ampoule  1302 ′ of  FIG. 25 . 
         [0073]    In  FIGS. 26-31 , yet another alternative fingertip surgical instrument (“two-component fingertip adhesive dispenser”)  1400  includes an end effector dispenser  1402  that internally mixes a portion of a first flowable material  1404  with a portion of a second flowable material  1406  for extended dispensing ( FIG. 27 ). With particular reference to  FIG. 26 , dispensing is effected by squeezing an upper finger holder  1408  toward a lower thumb actuator  1410 , both being distally, pivotally attached to the end effector dispenser  1402  (not shown). The motion is transferred to left and right rod plungers  1412 ,  1413  ( FIG. 27 ) that extend proximally out of the end effector dispenser  1402 . In particular, an upper end  1414  of an upper scissor link  1416  is pivotally attached to a midpoint of the upper finger holder  1408  by an upper rivet  1418 . A lower end  1420  of the upper scissor link  1416  is pivotally attached to proximal ends  1422 ,  1423  of the left and right rod plungers  1412 ,  1413  by a center elongate rivet  1424 . An upper end  1426  of a lower scissor link  1428  is also pivotally attached to the proximal ends  1422 ,  1423  of the rod plungers  1412 ,  1413  by the center elongate rivet  1424 . A lower end  1430  of the lower scissor link  1428  is pivotally attached at a midpoint of the lower thumb actuator  1410  by a lower rivet  1432 . 
         [0074]    With particular reference to  FIGS. 27-29 , the first flowable material  1404  is contained within a left collapsible, generally cylindrical bladder  1434  sized to fit within a first cylindrical cavity  1436  formed within a left proximal cylindrical vessel  1438  of the end effector dispenser  1402 . A left proximal solid portion  1440  of the left proximal cylindrical vessel  1438  includes a left rod passage  1442  which is longitudinally defined and receives the left rod plunger  1412  and has a left distal opening  1444  also longitudinally defined. A left cylindrical disk plunger  1446 , laterally sized for the diameter of the first cylindrical cavity  1436 , is retained within a proximal end  1448  aft of accordion sidewalls  1450  of the collapsible, generally cylindrical bladder  1434 . A left generally cylindrical spike  1452  is attached to a longitudinal center of a distal surface  1454  of the left cylindrical disk plunger  1444  with a left sharp tip  1456  distally aimed longitudinally toward the left distal opening  1444  to pierce a distal wall  1458  of the bladder  1434 . Three longitudinal aligned, radially spaced channel recesses  1460  ( FIG. 29 ) formed along the length of the left generally cylindrical spike  1452  allow fluid material  1404  to flow out of the left cylindrical vessel  1438  into a left distal manifold chamber  1462  ( FIG. 31 ). 
         [0075]    The second flowable material  1406  is contained within a right collapsible, generally cylindrical bladder  1464  sized to fit within a second cylindrical cavity  1466  formed within a right proximal cylindrical vessel  1468  of the end effector dispenser  1402 . A right proximal solid portion  1470  of the right proximal cylindrical vessel  1468  includes a right rod passage  1472  that is longitudinally defined and receives the right rod plunger  1413  and has a right distal opening  1474  also longitudinally defined. A right cylindrical disk plunger  1476 , laterally sized for the diameter of the second cylindrical cavity  1466 , is retained within a proximal end  1478  aft of accordion sidewalls  1480  of the collapsible, generally cylindrical bladder  1464 . A right generally cylindrical spike  1482  is attached to a longitudinal center of a distal surface  1484  of the right cylindrical disk plunger  1476  with a right sharp tip  1486  distally aimed longitudinally toward the right distal opening  1474  to pierce a distal wall  1488  of the bladder  1464 . Three longitudinal aligned, radially spaced channel recesses  1490  ( FIG. 29 ) formed along the length of the right generally cylindrical spike  1482  allow fluid material  1406  to flow out of the right cylindrical vessel  1468  into a right distal manifold chamber  1492  ( FIG. 31 ). 
         [0076]    When the upper finger holder  1408  and lower thumb actuator  1410  are depressed toward each other as depicted in  FIG. 30 , the first fluid material  1404  is pushed out of the left distal manifold chamber  1462  through left inward holes  1494  into a central nozzle cavity  1496  and the second fluid material  1406  is pushed out of the left distal manifold chamber  1492  through right inward holes  1498  into the central nozzle cavity  1496 . As the fluid materials  1404 ,  1406  are pushed toward a nozzle orifice  1500 , a nozzle tube  1502  that defines the central nozzle cavity  1496  narrows. A proximal horizontal pin  1504 , then a proximal vertical pin  1506 , then a distal horizontal pin  1508 , and finally a distal vertical pin  1510  pass through a longitudinal centerline of the nozzle tube  1502 , longitudinally spaced from one another proximal to distal and alternatingly perpendicular to adjacent pins, to enhance turbulent, mixing interaction between the flowable materials  1404 ,  1406 . 
         [0077]    It should be appreciated that any patent, publication, or other disclosure material, in whole or in part, that is said to be incorporated by reference herein is incorporated herein only to the extent that the incorporated material does not conflict with existing definitions, statements, or other disclosure material set forth in this disclosure. As such, and to the extent necessary, the disclosure as explicitly set forth herein supersedes any conflicting material incorporated herein by reference. Any material, or portion thereof, that is said to be incorporated by reference herein, but which conflicts with existing definitions, statements, or other disclosure material set forth herein will only be incorporated to the extent that no conflict arises between that incorporated material and the existing disclosure material. 
         [0078]    While the present invention has been illustrated by description of several embodiments and while the illustrative embodiments have been described in considerable detail, it is not the intention of the applicants to restrict or in any way limit the scope of the appended claims to such detail. Additional advantages and modifications may readily appear to those skilled in the art. 
         [0079]    For example, in addition to a roller ball or porous dispensing component or swab, liquid dispensing may be enhanced by adding other types of applicator tips (e.g., polymer loop, a spatula, a rolling ball, a grate, and a brush.