Patent Publication Number: US-2019167075-A1

Title: Device With A Working Channel Guiding Element

Description:
RELATED APPLICATION(S) 
     This application claims the benefit of European Patent Application No. 17205535.2, filed Dec. 5, 2017, the contents of which are incorporated herein by reference as if fully rewritten herein. 
     TECHNICAL FIELD 
     The invention relates to a device with an endoscope and an instrument guided by means of the endoscope. 
     BACKGROUND 
     Prior art has disclosed devices comprising an endoscope having a working channel through which extends an instrument beyond the distal end of the endoscope, wherein the instrument is guided in longitudinal direction in the working channel. Publication DE 103 34 100 A1, for example, describes an endoscope with a section of a working channel that can be bent for such a purpose. 
     An endoscope has been known from publication DE 10 2006 054 218 A1, wherein a guidewire extends through the endoscope&#39;s working channel, wherein an occluder is connected to a guidewire at the distal end in the guiding channel, said occluder being movable out of the guiding channel by means of the guidewire for closing an incision. 
     In other devices, the instrument is guided on the outside of the endoscope. 
     Referring to the device disclosed in publication EP 3 141 203 A1, an ablation instrument extends, for example, along the shaft of an instrument through a lumen of a sheath that provides another lumen for the endoscope. Furthermore, the ablation instrument extends through a fitting that is fastened to the distal end of the shaft of the endoscope. The ablation instrument can be moved in the lumen of the sheath and in the fitting along the shaft of the endoscope. 
     From publication DE 10 2010 020 220 A1 a guiding cuff has been known which can be fastened to a longitudinal side of the shaft of an endoscope in order to guide endoscopic instruments next to the endoscope through the guiding cuff. 
     Publication DE 20 2009 009 342 U1 describes an endoscope having a flexible endoscope shaft, in which case an inflatable tube is arranged on the longitudinal side of said flexible endoscope shaft. 
     It is the object of the present invention to state an improved device comprising an endoscope and to state an instrument guided by means of the endoscope. 
     SUMMARY 
     This object is achieved with a device as described herein. 
     The device according to one embodiment of the invention comprises an endoscope with a shaft, said shaft containing at least one working channel. The working channel ends on one side (outlet side) of the shaft, preferably on the front side of the endoscope on the distal end of said endoscope. Preferably, the shaft is flexible. The device comprises at least one instrument that is arranged so as to extend next to the shaft. The device is designed in such a manner that a distal end section of the instrument containing the working section of the instrument can be moved along the shaft beyond the side of the shaft where the working channel ends in order to move the working section of the instrument into a region opposite (in front of) the side of the shaft in order to work with the working section in this region during the endoscopic use of the device. The region can preferably be viewed with the aid of a means of the endoscope for image transmission. The instrument is in engagement with a guiding element in order to guide the working section of the instrument by means of the guiding element, while the end section is being moved beyond the side of the shaft into the region. For guiding the section of the instrument, the guiding element extends—while the distal end section is being moved—beyond the side of the shaft through the working channel. Preferably, the guiding element is guided so as to be longitudinally movable in the working channel in order to—with the shaft—form a telescopic guide for the working section of the instrument arranged along the longitudinal side of the shaft. 
     The fact that the instrument is guided by means of the guiding element comprises that the guiding element is movably coupled to the instrument in such a manner, that—during a movement of the guiding element that is movably guided in the working channel in a longitudinal direction—the guiding element is also moved, and/or that the guiding element—during a movement of the instrument along the shaft—is also moved with the instrument, in which case the guiding element guided in a longitudinally movable manner in the working channel—conveys to the instrument the guiding of the guiding element in the working channel. Alternatively or additionally, the feature that the instrument is guided according to one form of the invention by means of the guiding element may comprise that—on the guiding element—a guide for guiding the instrument outside the working channel is arranged, in which case the guide is arranged preferably opposite the side where the working channel leaves the shaft, and in which case the instrument is in engagement with the guide. 
     Compared to known devices, the device according to one form of the invention allows a more stable guiding of the instrument arranged outside the endoscope and thus, for example, a more smooth positioning and/or orientation of the working section of the instrument in the region in which the instrument is to be used, for example relative to the tissue to be treated and/or examined with the instrument. 
     The device according to some embodiments of the invention is preferably further developed to exhibit at least one of the features described hereinafter: 
     The device is preferably set up in such a manner that the guiding element can be moved forward along the working channel in distal direction and/or retracted in proximal direction, and/or that the guiding element can be rotated in the working channel, in which case the movement of the guiding element is transmitted to the instrument by a motion coupling of the guiding element with the instrument. In doing so, the guiding element can be operated, preferably outside the body of the patient for moving the instrument by means of the guiding element, while the distal end of the device with the working section is located inside the body. 
     Preferably, the instrument is movably coupled to the guiding element, so that a forward movement of the guiding element in the working channel in longitudinal extension direction of the working channel in the direction toward the outlet side is converted into a movement of the working section of the instrument away from the outlet side. Preferably, the forward movement is converted into a movement of the working section into longitudinal extension direction of the working channel away from the front side. Alternatively or additionally, the instrument is preferably coupled to the guiding element in such a manner that a retraction of the guiding element in the working channel in longitudinal extension direction of the working channel in the direction toward the proximal end of the device is converted into a movement of the working section of the instrument back, closer to the shaft. The working section can be shifted forward and/or pulled forward by introducing a force into the guiding element, preferably in distal direction. Additionally or alternatively, the working section can preferably be retracted and/or slid back in proximal direction by introducing a force into the guiding element. 
     The device is preferably set up in such a manner that the guiding element can be rotated in the working channel about the longitudinal axis of the guiding element, in which case the rotary motion is transmitted to the working section due to the coupling of the guiding element to the instrument, in order to move and/or pivot the working section about an axis. The working section of the instrument can preferably be driven via the guiding element to perform a rotation and/or a pivoting motion about the longitudinal axis of the guiding element. Alternatively or additionally, the instrument is movably coupled to the guiding element in such a manner that the working section of the instrument is pivoted when a section of the guiding element projecting from the outlet side and extending from the shaft is pivoted relative to the shaft opposite the front side about an axis transverse with respect to the longitudinal extension direction of the guiding element. 
     The guiding element may be a flexible guiding rod. A hollow space may extend through the guiding element along the guiding element. Accordingly, the guiding element may comprise, for example, a flexible tube and/or tubing. For example, the guiding element may comprise a wire or a cluster of wires. The wire or wires may extend along the working channel. Alternatively or additionally, the guiding element may comprise a wire coil, for example. For example, the guiding element may consist of plastic and/or metal. 
     At least one of the instruments guided by means of the guiding element may be a sampling instrument and/or an application instrument for the application of fluid, in particular gas and/or liquid, and/or solids to the tissue and/or into the tissue, a suction instrument and/or a surgical cutting and/or coagulation instrument. At least one instrument guided by means of the guiding element and arranged so as to extend next to the shaft, may be—alternatively or additionally—a measuring instrument for regulating, controlling, measuring or detecting tissue parameters. Alternatively or additionally, an instrument guided by means of the guiding element may be disposed for transmitting energy to the distal end of the device, for example. 
     At least one of the instruments guided by means of the guiding element may be a coagulation probe, a surgical fluid jet probe for lifting (elevation) tissue by introducing fluid, in particular liquid, under the tissue, a cryoprobe, for example a cryoprobe for freezing and taking a tissue sample, a sample excision forceps, an introduction cannula, a foreign body and/or stone catcher, a brush and/or a suction catheter. 
     The function of the guiding element may be restricted to providing a guide for the one or more instruments that are in engagement with the guiding element and/or to the transmission of movements to the one or several instruments that are in engagement with the guiding element. Alternatively, the guiding element is itself a medical instrument. In particular, the guiding element may comprise a working section intrinsic to the guiding element. For example a channel may extend through the guiding element for conducting fluid, in particular liquid and/or gas, and/or a solid. The channel extending through the guiding element may be determined for the evacuation of fluid, in particular liquid and/or gas, and/or solids from the distal end of the channel and/or for the transport of fluid, in particular liquid and/or gas, and/or a solid to the distal end and out of the distal end. 
     Preferably, the instrument comprises at least one functional element that extends next to the shaft of the endoscope up to the working section of the endoscope. The functional element is preferably disposed for guiding and/or moving the instrument, in particular its working section, and/or for actuating the instrument and/or for conveying media such as, for example, fluid, in particular liquid and/or gas, solids and/or electrical power to the working section and/or away from the working section. Preferably, the functional element is set up in such a manner that the user of the device can move and/or guide and/or use and/or supply the instrument by means of the functional element, wherein the handling and/or supply of the instrument by means of the functional element may preferably be done from outside the body of the patient, while the working section of the instrument is located in the body of the patient. 
     Preferably, in addition to the guiding function by means of the guiding element, there is arranged on the longitudinal side of the shaft a guide that is disposed for guiding the instrument along the longitudinal side of the shaft. The guide is in engagement with the instrument, preferably with the functional element of the instrument that extends up to the working section of the instrument along the shaft. Preferably, the functional element is guided on the shaft by means of at least one guide holder that is arranged so as to be effective at least between the longitudinal side of the shaft and the instrument. For example, a guide holder can be fastened to the shaft. Alternatively, for example, a guide holder is fastened to the functional element. For example, the guide holder may be a guide ring that is fastened to the shaft or the functional element and through which extend the shaft and/or the functional element. 
     Preferably, the guiding element has at least one engagement section for coupling the guiding element to an instrument. Preferably, the guiding element is disposed for coupling two or more instruments. Preferably, the guiding element has one engagement section each for two or more instruments. 
     Alternatively or additionally, an engagement element may be fastened to the guiding element, in which case the guiding element can be coupled by means of the engagement element to at least one instrument. 
     Preferably, the instrument is in engagement with engagement element and/or the engagement section in such a manner that the instrument can be shifted, relative to the engagement element and/or the engagement section, in the engagement element and/or the engagement section. Consequently, the engagement element preferably provides—by means of the engagement element and/or by means of the engagement section—a guide for the instrument outside the shaft opposite the outlet side, from where the guiding element moves out of the shaft. 
     Preferably, the engagement element and/or the engagement section has a form matching the outer form of the distal end of the shaft and/or a form matching the holding element arranged on the distal end of the shaft, so that the engagement element and/or the engagement section assume a specific orientation and/or a specific position relative to the distal end of the shaft and/or relative to the holding element when the matching form is in engagement with the outer form. For example, on the distal end of the shaft there is provided and/or formed a fitting for the engagement element and/or the engagement section, in which case the engagement element and/or the engagement section can be moved in axial direction into the fitting and in which case the rotatability of the engagement element and/or the engagement section in the fitting is restricted. Preferably, the device is designed in such a manner that the outer form and the matching form will automatically come into engagement when the engagement section and/or the engagement element are moved back in the direction toward the shaft. 
     The engagement between the guiding element and the instrument can preferably be released in a non-destructive manner. Particularly preferably, the device is designed in such a manner that the engagement between the guiding element and the instrument can be released from outside the body of the patient in a non-destructive manner and/or that a non-destructively releasable engagement between the guiding element and the instrument can be provided from outside the body of the patient, when the distal end of the device having the working section is located in the body of the patient. 
     Preferably, a guide holder is fastened to the distal end of the shaft, said guide holder providing a guide along the shaft for the instruments extending along the shaft. To do so, the guide holder preferably has receptacles in which respectively one instrument is guided so as to be slidable, preferably along the longitudinal extension of the distal end of the shaft. Preferably, the device is designed in such a manner that one or more instruments can be brought into engagement with the guiding element in order to move said instruments while at least another instrument arranged in its receptacle is out of engagement with the guiding element. 
     Preferably, the guiding element is designed for the accommodation of at least two instruments that extend next to the shaft in such a manner that the working section of at least one of the instruments can be shifted, guided by means of the guiding element, relative to the working section of another instrument. Alternatively or additionally, the guiding element is designed for the accommodation of at least two instruments that are arranged so as to extend next to the shaft in such a manner that the working section of at least one of the instruments can be rotated and/or pivoted relative to the working section of the other one of the instruments by means of the guiding element. Preferably, the device for using the guiding element for shifting, rotating and/or pivoting one of the instruments relative to the other instrument is set up from outside the body of the patient when the working sections of the instruments are located in the body of the patient. 
     In accordance with a form of the invention, there is also stated a guiding element that is disposed for the use in a device according to the invention as described herein, for example. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       Additional advantageous features of the device according to the invention can be inferred from the description, the figures and the dependent claims hereinafter. 
       They show schematically in 
         FIGS. 1 a  to 1 d   —partially perspective views of exemplary embodiments of the device according to the invention, 
         FIG. 1 e   —a partially perspective representation of another exemplary embodiment of the device according to the invention, 
         FIG. 2 a   —a partially perspective representation of another exemplary embodiment of the device according to the invention with a guide holder fastened to the endoscope with receptacles for the instruments, 
         FIG. 2 b   —a partially perspective representation of an exemplary embodiment of an arrangement of an endoscope and a guiding element of an exemplary device according to the invention, wherein the guiding element is used for indirectly moving at least two instruments via the guiding element relative to each other, 
         FIG. 2 c   —a partially perspective representation of an exemplary embodiment of the device according to the invention with a guiding element and an instrument that can be moved relative to said guiding instrument, 
         FIGS. 3   ai  to  3   d —perspective representations of various options of coupling the guiding element to the engagement element or the instrument, respectively, and 
         FIG. 4 —an exemplary handle for a device according to the invention. 
     
    
    
     DETAILED DESCRIPTION 
       FIGS. 1 a , 1 b    show a partially perspective representation of an exemplary embodiment of the device  10  according to the invention. The device  10  comprises an endoscope  11  with a flexible shaft  12 . The shaft  12  defines a distal direction  12  (sense of direction) along which the shaft  12  extends from its proximal end (not illustrated) to its distal end  14 . Conversely, the shaft  12  defines a proximal direction  15  from its distal end  14  along the shaft  12  up to its proximal end. On the distal end  14  on the front side  16  of the shaft  12 , there is arranged an illuminating unit  17  for illuminating a region  18  relative to the front side  16  of the shaft  12 . Extending through the shaft  12 , there is a means for transmission of an image up to an input  19  of the means in the front side  16 , where, for example, a lens system belonging to the means for image transmission may be arranged. The means for the transmission of an image of the region  18  to be examined and/or treated is provided opposite the front side  16  of the shaft  12  in order to be able to visually monitor the examination and/or treatment in the region  18  opposite the front side  16  by means of the endoscope  11  from outside the body of the patient. Additional lines for transmission in proximal direction and/or distal direction, for example of signals, electrical output, gases, in particular fluids and/or gas, or solids, may extend through the shaft  12  up to the front side  16 . In any event, at least one working channel  20  extends through the shaft  12  up to an opening  21  in the front side  16  of the shaft  12 . For example, in a known device  10 , it is possible to slide an instrument, for example, a tool, a gripper through such a working channel out of the front side  16  of the shaft  12  in order to use it to perform in this region—with the aid of the means for image transmission and visual control by the surgeon—examinations and/or treatments in the region  18 . 
     In the inventive device  10  (see in particular  FIG. 1 b   ), a longitudinal guiding element  25  extends through the working channel  20 , said guiding element being movably guided in longitudinal direction  26  of the working channel  20 . The guiding element  25  moves through the opening  21  in the front side (outlet side) out of the working channel  20 . The guiding element  25  extends in proximal direction  15  preferably up to a proximal end of the device  10  (not shown in  FIGS. 1 a , 1 b   ), from where the guiding element  25  can be actuated, in particular moved, by a surgeon. 
     The device  10  according to the invention comprises at least one instrument  30  that extends along the shaft  12  next to the shaft  12 . In the depicted exemplary embodiment, the inventive device  10  comprises a first instrument  30   a  and a second instrument  20   b , which each may be a coagulation probe having respectively one electrode for igniting a plasma, and a third instrument  30   c  which may be, for example a water jet probe. Each of the instruments  30   a ,  30   b ,  30   c  has respectively one distal end section  32   a - c  with a working section  34   a - c  on the distal ends of the instruments  30   a ,  30   b ,  30   c.    
     At least one functional element  36   a - c  per instrument  30   a ,  30   b ,  30   c  extends along the shaft  12  relative to the working section  34   a - c . The functional elements  36   a - c  extending next to the shaft can be used for guiding and/or moving the respective instrument  30   a - c  or the working section  34   a - c  and/or for actuating the instrument  30   a - c  and/or transmitting media to the working section  34   a - c  of the instrument  30   a - c  and/or of the working section  34   a - c , away from the distal end of the instrument  30   z - c . The user of the device  10  can move, guide, operate and/or supply the instrument  30   a - c  via the functional element  36   a - c , for example. If the first and the second instruments  30   a ,  30   b  are an APC probe, the first instrument  30   a  and the second instrument  30   b  being the functional element  36   a ,  36   b  may each comprise, for example a tubing through which extends an electrical line that is connected to the electrode, wherein argon gas can be conveyed to the working section  34   a ,  34   b  of the APC probe with its electrode in order to ignite an argon plasma in front of the distal end of the APC probe. If the third instrument  30   c , as in the depicted exemplary embodiment, is a liquid jet probe, this comprises as the functional element  36   c , for example a tubing that is connected to an outlet of the liquid jet probe in the working section  34   c  of the probe on its distal end and is disposed to supply a liquid to the outlet. 
     In the depicted exemplary embodiment, the functional elements  36   a - c  of the instruments  30   a - c  extend though a guiding cuff  40  fastened to the distal end  14  of the shaft  12 , said cuff forming a first guide holder  40  of the device  10  for guiding the instruments  30   a ,  30   b ,  30   c  on the outside of the shaft  12  in longitudinal direction  42 . In proximal direction  15  from the distal end  14  and the first guide holder  40 , there extend the functional elements  36   a - c  through the second guide holder  43  arranged on the longitudinal side  41  of the shaft  12 , said second guide holder  43  being disposed to guide the functional elements  36   a - c  on the longitudinal side  41  of the shaft  12 . The second guide holder  43  may be, for example, a ring that encloses the shaft  12  and/or the functional elements  36   a - c . The second guide holder  43  may be affixed to the shaft  12  against the axial movement along the shaft  12  or affixed to the functional element  36   a - c  against an axial movement of the second guide holder  43  relative to the functional element  36   a - c . In addition to the two guide holders  40 ,  43  depicted as examples for guiding the instrument(s)  30   a ,  30   b ,  30   c  extending laterally next to the shaft  12 , at least one other guide holder (not illustrated) may be provided outside on the shaft  12  for guiding the instrument(s)  30   a ,  30   b ,  30   c . Embodiments with only one guide holder effective between the longitudinal side  41  of the shaft  12  and the instrument(s)  30   a ,  30   b ,  30   c  is (are) possible for guiding the instruments  30   a ,  30   b    30   c  on the shaft along the longitudinal side  41  of the shaft  12 . 
     The first guide holder  40  arranged on the distal end  14  of the shaft  12  may form a sliding element via which the device  10  rests on the tissue section in order to facilitate the maintenance of a defined distance of the working section of at least one instrument  30   a ,  30   b ,  30   c  from the tissue. 
     Additionally or alternatively to the first and/or second guide holders  40 ,  43 , the device  10  may comprise a plastic tubing (not illustrated), in which case the shaft  12  and the functional elements  36   a - c  extend through the plastic tube, and in which case the plastic tube preferably provides a lumen for the shaft  12  and a separate lumen for the functional elements  36   a - c , and in which case the functional elements  36   a - c  are guided in the lumen for the functional elements  36   a - c  along the shaft  12  of the endoscope  11 . The plastic tubing may additionally be disposed for smoke evacuation. 
     The instruments  30   a - c  are coupled—on the distal end  44  of the device  10  comprising the guide element  25  that extends through the working channel  30 —to an engagement section of the guiding element  25  and/or to an engagement element  45  coupled to the guiding element  25  in such a manner that the instruments  30   a ,  30   b ,  30   c  are guided—during a movement of the working section  34   a - c -away from the front side  16  of the shaft  12  in the region opposite (relative to) the front side  16  and/or back to the front side  16  out of the region  18  by the guiding element  25 , guided during the movement in the working channel  20 . To do so, the section of the guiding element that projects distally from the front side  16  and into the working channel  20  is rigid or, preferably, flexible in order to guide the instruments  30   a ,  30   b ,  30   c.    
     The device  10  is constructed in such a manner that the counter-constraint forces are discharged into the shaft  12 —due to the guiding of the instruments  30   a ,  30   b ,  30   c  via the guiding element  25 —through the wall surface delimiting the channel  20  and enclosing the channel  20 . Therefore, the guiding element  25  may brace itself within the working channel  20  against the shaft  12  and thus convey to the instrument  30   a ,  30   b ,  30   c  arranged next to the shaft  12  the guiding motion of the guiding element  25  in the working channel  20 . This means that the instrument is indirectly guided opposite the outlet side  16  outside the working channel  20  via the guiding element  25  with the working channel  20 . The shaft  12  and the guiding element  25  thus form a telescopic guide for the working section  34   a - c  of the instruments  30   a ,  30   b ,  30   c  extending along the longitudinal side  41  of the shaft  12 . Inasmuch as, in the device  10  according to the invention, the working channel  20  is used indirectly via the guiding element  25  for guiding the working sections  34   a - c  relative to the outlet side  16 , the working sections  34   a - c  can be guided in front of the outlet side  16  in a more stable manner and thus in a safer and smother manner than in known devices. 
     The device  10  according to the invention is preferably set up in such a manner that the user is able to transmit the force in the direction of movement for moving the working sections  34   a - c  of the instruments  30   a ,  30   b ,  30   c  into the region  18  opposite the front side  16  and/or out of the region  18  to the working sections  34   a - c  via the guiding element  25 . Preferably, the device  10  is set up in such a manner that the user can control the guiding element  25  on the grip (not shown in  FIGS. 1 a , 1 b   ; see, e.g.,  FIG. 4 ) in order to transmit a force for moving the working sections  34   a - c  into the region  18  and/or out of the region  18 , along the guiding element  25  toward the instruments  30   a ,  30   b ,  30   c . The device  10  is set up in such a manner that the user can control the guiding element  25  from outside the body of the patient in order to introduce the force for pushing and/or pulling the instruments  30   a ,  30   b ,  30   c —back out of the region  18  and/or forward into the region  18 —via the guiding element  25 . While pushing and/or pulling the instruments  30   a ,  30   b ,  30   c  via the guiding element  25 , it may be necessary to push the functional elements  36   a - c  (lines) of the instruments  30   a ,  30   b ,  30   c  from outside the body of the patient further forward or to retract them. 
     In order to achieve a direct transmission of a pushing movement of the actuated section  48  of the guiding element  25 , e.g., on the handle, toward one or several instruments  30   a ,  30   b ,  30   c , the guiding element  25  is preferably pressure-resistant and is coupled—preferably in a pressure-resistant manner—to the working section  34   a - c  of the instrument  30   a ,  30   b ,  30   c . Furthermore, the guiding element  25  that acts as a pushing member is guided in the working channel  20 , preferably in a rigid manner. 
     In order to achieve a direct transmission of a pulling movement of the guiding element  25  on the handle to the instrument  30   a ,  30   b ,  30   c , the guiding element  25  preferably displays tensile stiffness and preferably is coupled to the working section  34   a ,  34   b ,  34   c  of the instrument  30   a ,  30   b  in manner displaying tensile stiffness. 
     The end section  20   a  of the working channel  20  at the opening  21  in the front side  16  specifies—with its longitudinal extension direction—a guiding direction  50  for the guiding element  25  and thus the working sections  34   a ,  34   b    34   c  of the instruments  30   a ,  30   b ,  30   c , along which the guiding element  25  and, moreover, also the working sections  34   a ,  34   b ,  34   c  of the instruments, away from the front side  16  into region  18  and back. The distal end sections  32   a - c  of the instruments  30   a ,  30   b ,  30   c , as shown by  FIG. 1 b   , can be moved in guiding direction  50  along the longitudinal extension direction of the distal end section of the working channel  20 —by introducing a force into the guiding element  25 —away from the distal end  14  of the shaft  12  (can be pushed forward and/or pulled forward) and/or can be moved back toward the distal end  14  of the shaft  12  (can be pushed back and/or pulled back). 
     Alternatively or additionally to the introduction of force into the guiding element  25  for moving the instruments  30   a ,  30   b ,  30   c  extending next to the longitudinal side  41  of the shaft  12 , the device  10  may be set up in such a manner that a force is transmitted in the guiding direction  50  for moving the instrument along the longitudinal extension direction of the end section of the working channel  20  toward the working sections  34   a - c  of the instruments  30   a ,  30   b ,  30   c —completely or partially via at least one of the functional elements  36   a - c . In such cases, the user can, for example, slide the functional elements  36   a - c  along the shaft  12  in distal direction  13  in order to move the sections  32   a - c  of the instruments  30   a ,  30   b ,  30   c  having the working sections  34   a ,  34   b ,  34   c  beyond the front section  16  in the direction toward the region  18  in which an operation is to be performed with the working sections  34   a - c.    
       FIG. 1 c    shows an exemplary embodiment of the device  10  according to the invention that, in accordance with the example, is set up in such a manner that the working sections  34   a - c  can be rotated and/or pivoted relative to the shaft  12  about an axis through the guiding element  25  extending along the longitudinal extension direction  52  of the guiding element  25 , as is indicated by the double arrow  55 . This also includes a rotation and/or a pivoting at an angle of rotation and/or a pivoting angle between a starting position and an end position, said angle being smaller than 360°. The device  10  is preferably configured in such a manner that the torque for rotation and/or pivoting can be transmitted to the working sections  34   a ,  34   b ,  34   c , via the guiding element  25 . Preferably, the guiding element  25  can be controlled for the rotation of the working sections  34   a ,  34   b ,  34   c  and/or for pivoting these outside the body of the patient, when the distal end  44  of the device  10  is located in a lumen of the body. To do so, the guiding element  25  is preferably torsion-proof at least in one direction of rotation—restricted to one direction of rotation or in both directions of rotation—in order to achieve a direct transmission of a movement of rotation of the guiding element  25  to the instruments  30   a ,  30   b ,  30   c.    
     As can be inferred from  FIG. 1 c    based on the double arrow  56  and the dashed line representation of the section of the guiding element  25  projecting from the opening  21 , the engagement element  45  and the instruments  30   a ,  30   b ,  30   c  in a pivoted position, the working sections  34   a ,  34   b ,  34   c  arranged opposite the front side  16  are—in the exemplary embodiment according to the invention—pivotable relative to the distal end  14  of the shaft around an axis extending in transverse direction, for example perpendicular direction, with respect to the guiding element  25  in order to change the orientation of the working sections  34   a ,  34   b ,  34   c  arranged opposite the front side  16 . The device  10  is preferably configured in such a manner that the torque for pivoting toward the instruments  30   a ,  30   b ,  30   c  can be transmitted via the guiding element  25 . For example, the guiding element  25  may comprise one or more wires (not illustrated) coupled to the distal end  57  of the guiding element  25 , said wires extending through a handling section of the device, for example on the grip of the device, so that the user of the device  10  can control the wires from outside the body of the patient, when the distal end  44  of the device  10  is located inside the lumen of a body of the patient. For example, the guiding element  25  may consist of a highly flexible tube, in which case the wires can extend from the proximal end of the device  10  to the distal end  57  of the guiding element  25  through the tube. 
       FIG. 1 d    shows another exemplary embodiment of the device  10  according to the invention with an engagement element  45  coupled to the guiding element  25  that may have at least one receptacle  60  for an instrument in order to couple the instrument to the guiding element  25  via the engagement element  45  in such a manner that a force introduced into the guiding element  25  in longitudinal extension direction of the guiding element  25  is transmitted to the instrument (which is not depicted here for the sake of clarity). The engagement element  45  has a receptacle  61  for another instrument  30 , said receptacle being disposed to guide the other instrument  30  in a sliding manner, preferably along the longitudinal extension direction  52  of the section of the guiding element  25  projecting distally from the opening, in the engagement element  45  opposite the front side  16  relative to the guiding element  25 . As an alternative to an engagement element  45  coupled to the guiding element  25 , it is also possible for an engagement section of the guiding element  25  to have such a receptacle for an additional instrument  30 . The guiding element  25  forms a guide arm projecting beyond the front side  16  held in the working channel  20  for the additional instrument  30  that can be moved relative to the guiding element  25  and provides, with the engagement element  45  or the engagement section, a guide for the additional instrument  30  that can be positioned relative to (in front of) the front side  16 . The guiding element  25  is guided in the working channel  20  along the longitudinal extension direction of the working channel  20  in such a manner that the distance of the engagement element  45  or the engagement section—and thus the distance of the guide for the additional instrument  30 —can be changed relative to the front side  16 . The device  10  can be set up in such a manner that the force for sliding the working section  34  of the additional instrument  30  relative to the guiding element  25  toward the working section  34  via the functional element  36  of the instrument  30  can be introduced. To do so, the functional element  36  may be guided next to the longitudinal side of the shaft through a guide holder  40 . The additional instrument  30  may be a liquid jet probe, for example. Such a probe can be configured to introduce liquid under a tissue layer in order to elevate it. In doing so, the distal end of the liquid jet probe is placed on the tissue. With the use of the exemplary embodiment of the device according to the invention, the distal end of the liquid jet probe may be placed on the tissue at a distance from the engagement element  45  and the front side  16 . It is also possible to move forward into tight lumens of the body of the patient with the application of the distal working section  34  of the additional instrument  30  beyond the distal end of the guiding element  25 , away from the distal end  57  of the guiding element  25 . 
       FIG. 1 e    is a partial perspective representation of another exemplary embodiment of the device  10  according to the invention, with a view onto the distal end  44  of the device  10 . A holding element  65  having a positive-locking section  65   a  is mounted to the distal end  14  of the shaft  12 . The positive-locking section  65   a  has a form that is complementary to a form-locking section  45   a  of the engagement element  45 .  FIG. 1 e    shows the engagement element  45  in retracted position arranged on the shaft  12 , so that the positive-locking section  45   a  of the engagement element  45  is in engagement with the positive-locking section  65   a  of the holding element  65 . The form-locking feature has the effect that the engagement element  45  is arranged about the shaft  12  in a torque-proof manner on the holding element  65 , and that the engagement element  45  can no longer be moved back in proximal direction  15  relative to the distal end  14  of the shaft  15 . Thus the holding element  65  defines a specific orientation and position of the engagement element  45  on the shaft  12  in the retracted position. At the same time, the holding element  65  may act as a guide for the instruments  30   a ,  30   b  on the shaft. For example, the holding element  65  may be a first guide holder  40  with at least two separate receptacles  40   i ,  40   ii  for one instrument  30   a ,  30   b , respectively. For example, the instrument  30   a  may have a working section  34   a  with a gripper. For example, the instrument  30   b  may be an APC probe with a working section  34   b  with an electrode in order to generate an argon plasma. 
     Preferably, guiding and counter-guiding surfaces (not shown) are provided on the holding element  65  and the engagement element  45 , said surfaces coming into engagement with each other on the shaft  12  when the engagement element  45  is retracted in such a manner that the positive-locking section  45   a  of the engagement element  45  automatically enters into positive-locking mode with the positive-locking section  65   a  of the holding element  65  mounted to the distal end  14  of the shaft  12 . In this manner, it is possible to automatically adjust the position and the orientation of the engagement element  45  on the shaft  12  by means of the holding element  65  when the engagement element  45  is moved back out of a specified position opposite the front side  16 . 
       FIG. 2 a    shows, in a sectional perspective view, an exemplary embodiment of the device  10  according to the invention with a guide holder  40  mounted to the distal end  14  of the shaft  12 , said guide holder having receptacles  40   i ,  40   ii ,  40   iii  in which one instrument  30   a ,  30   b ,  30   c , respectively, is arranged in a guided manner. The instruments  30   a ,  30   b ,  30   c  are slidably guided in the receptacles  40   i ,  40   ii ,  40   iii , preferably along the longitudinal extension direction of the distal end section of the working channel  20 . The guiding element  25  extending through the working channel  20  has an engagement section  70 . The device  10  is configured so that the guiding element  25  can be selectively coupled—via its engagement section  70 —to at least two of the instruments  30   a ,  30   b ,  30   c  in order to guide the instrument  30   a  that is respectively coupled to the guiding element  25  into the region  18  opposite the front side  18  where the instrument  30   a  is to be operated, and/or to move the instrument  30   a  back out of the region  18  toward the front side  16 . The device  10  is preferably set up such that the force is transmitted along the longitudinal extension direction  52  of the guiding element  25  for moving the instrument  30   a ,  30   b ,  30   c  into the region  18 ; and/or the force along the longitudinal extension direction  52  of the guiding element  25  for moving out of the region  18  is transmitted to the instrument  30 ,  30   b ,  30   c , via the guiding element  25 . Preferably, the device  10  is set up in such a manner that the coupling of an instrument  30   a ,  30   b ,  30   c  to the guiding element  25  and/or the uncoupling of an instrument  3   a ,  30   b ,  30   c  from the guiding element  25  preferably can be controlled outside the body of the patient, while the distal end  44  of the device  10  with the working sections  34   a - c  of the instruments  30   a ,  30   b ,  30   c  is located inside the body of the patient. 
       FIG. 2 b    shows a sectional perspective representation of an exemplary embodiment of an endoscope  11  of the inventive device  10  with a guiding element  25  that can be moved in longitudinal direction in its working channel  20 . The guiding element  25  has two engagement sections  70   a ,  70   b  that each can couple to at least one instrument that extends along the shaft  12  in order guide it opposite its front side  16  of the shaft  12 . For reasons of clarity, the instruments are not shown in  FIG. 2 b   . The guiding element  25  is configured in such a manner that the working section  34   a ,  34   b  of each of the instruments coupled to the engagement sections  70   a ,  70   b —as indicated by the double arrows  71   a ,  71   b —can be moved relative to the working section of the other instrument in longitudinal extension direction  52  of the guiding element  25 . Furthermore, the working sections of the instrument coupled to the engagement sections  70   a ,  70   b  can be pivoted relative to each other by rotating and/or pivoting the engagement sections  70   a ,  70   b  about an axis extending along the longitudinal extension direction  52  of the guiding element, and/or be rotated about the axis extending along the longitudinal extension direction  52 . In addition, the device  10  is configured such that the guiding element  25  can be slid forward and be retracted as an entity along its longitudinal axis guided in the working channel and be rotated about its longitudinal axis—as indicated by the double arrows  72   a, b —in order to be able to move the working sections of both instruments accordingly. The force for moving the working sections relative to each other and/or the force for moving the guiding element  25  as an entity can preferably be introduced into the guiding element  25  from outside the body of the patient, while the distal end  14  of the shaft  12  is located in the body of the patient. In doing so, the position of the working section of an instrument relative to the other working section can be changed from outside the body of the patient, while the distal end  44  of the device  10  with the working sections is located inside the body of the patient. 
       FIG. 2 c    shows an exemplary embodiment of the device  10  according to the invention with a guiding element  25  that extends through the working channel  20  of the shaft  12  of the endoscope, in which case the guiding element  25  may have a curved end section, for example, where the engagement section  70  of the guiding element  25  is provided. In the engagement section  70 , the distal end section  32  of the instrument  30  is guided in a movable manner along a guiding direction  50  that is specified by the engagement section  70 . The guiding direction  50  is bent from the longitudinal extension direction of the distal end section of the working channel  20  in order to lead the working section  34  of the instrument  30  in one region away from the imaginary parallel extension of the center axis of the distal end section of the working channel  20 . 
       FIGS. 3   ai  to  3   d  show various exemplary embodiments of mounting the guiding element  25  to the engagement element  45 . The mounts are suitable for the transmission of force from the guiding element  25  to the instruments  30   a ,  30   b  in order to move the working sections  34   a ,  34   b  of the instruments  30   a ,  30   b  mounted to the engagement element  45 , due to the introduction of force into the guiding element  25 , away from the outlet side, and/or to move the working sections  34   a ,  34   b  of the instruments  30   z ,  30   b  back to the outlet side  16 .  FIGS. 3   ai  and  3   aii  show a snap connection for a positive lock between the engagement element  45  and the guiding element  25  transversely with respect to the longitudinal extension direction  52  of the guiding elements  25 . The positive lock between the engagement element  45  and the guiding element  25  in longitudinal extension direction  52  of the guiding element is produced in that the section of one connecting part (here: the engagement element  45 ) with the at least one snap element  75  extends around the other connecting part (here: the guiding element  25 ) with the snap connection established between opposing positive-locking surfaces  76 , said surfaces being provided on the other connecting part, in which case the positive-locking surfaces  76  prevent a movement of one connecting part relative to the other connecting part in the direction  52  of the longitudinal extension of the guiding element  25 . Considering the exemplary embodiment according to  FIG. 3 b   , a positive-locking connection is produced transversely with respect to the longitudinal extension direction  52  of the guiding element  25  and in the longitudinal extension direction  52  of the guiding element  25  by a spherical body  77  on the engagement element  45  that is enclosed by two opposing snap tabs  75  when the connection is established.  FIG. 3 c    shows an exemplary embodiment, in which the positive lock is provided in the direction of movement only when the engagement element  45  is slid by means of the guiding element  25  away from the outlet side  16 . If, however, the guiding element  25  is retracted, the guiding element  25  can be pulled out of the receptacle in the engagement element  45 , in order to disconnect the instruments  30   a ,  30   b  from the guiding element  25 . In the embodiment according to  FIG. 3 d   , a positive lock is produced in the direction of movement of the guiding element  25  in that a distal end section  57  of the guiding element  25 , said end section having a greater dimension relative to an inside dimension of a recess in the engagement element  45 , is arranged in the recess. Independent of the specific embodiment, the connection between the instrument  30   a ,  30   b  and the guiding element  25  can preferably be disconnected on the distal end of the device in order to allow an instrument change, without necessitating the removal of the instrument  30   a ,  30   b  from the device  10 . 
       FIG. 4  shows an exemplary handle  80  of a device  10  according to the invention, said handle being arranged on the proximal end  81  of the device  10 . The handle  80  is connected to the shaft  12  of the endoscope  11 . Around the shaft  12  there is arranged a guide holder  82 , adjacent to the handle  80 , through which guide holder the functional elements  36   a ,  36   b ,  36   c  extend from the instruments  30   z ,  30   b ,  30   c  up to the working sections  34   z ,  34   b ,  34   c  of the instruments  30   a ,  30   b ,  30   c  on the distal end  44  of the device  10 . The handle  80  has a control part  83  for controlling the endoscope  11 . For example, the control part  83  may comprise articulating wheels  84   a ,  84   b  for the targeted bending of the distal end  14  of the endoscope  11  and control elements  85  for the air and/or water supply, for example, to the distal end  14  of the shaft  12 . An inlet  86  into the handle  80  is arranged on the handle  80  which is connected to the working channel  20  through the shaft  12  and through which the guiding element  25  extends into the working channel  20  of the endoscope  11 . Fastened to the guiding element  25 , there is a guiding element grip  87  arranged on the handle  80 , via which the guiding element  25  can be further moved forward in the direction  13  toward the distal end  14  of the shaft  12  and/or the guiding element  25  can be slightly retracted from the inlet  86 —as indicated by the double arrow  88 . Furthermore, the guiding element grip  87  can be rotated (double arrow  89 ) in order to rotate the guiding element  25  about the longitudinal axis of the guiding element  25 . Thus the engagement section  70 ,  70   a ,  70   b  of the guiding element  25  and/or the engagement element  45  coupled to the guiding element  25  can be moved, positioned and/or oriented relative to the front side  16  opposite the distal front side  16  of the shaft from outside the body of the patient, when the working section  34   a - c  of the instrument  30   a ,  30   b  coupled to the guiding element  25  via its engagement section  70 ,  70   a ,  70   b  and/or via the engagement element  45  is located inside the body of the patient. The guiding element grip  87  itself may optionally be mounted to the handle  80 —directly or indirectly via the inlet  86  to the working channel  20 —for example by means of a Luer lock connection, in which case the mounted guiding element grip  87  preferably moves along the double arrow  88  for the forward and reverse movements of the instrument  30   a ,  30   b ,  30   c  that is coupled to the guiding element  25 , and/or, as indicated by the double arrow  89 , can be rotated about a longitudinal axis in order to rotate or pivot the instrument  30   a ,  30   b ,  30   c  that is coupled to the guiding element  25 . By mounting the guiding element grip  87 , the working channel  20  may be sealed. In the event of an indirect mounting, an adapter is used for mounting to the endoscope  11  and for sealing the working channel  20 . 
     The guiding element  25  may be hollow for guiding fluid, in particular liquid and/or gas, solids and/or an instrument inside the guiding element  25 . For example, an opening  90  may be provided on the guiding element grip  87  through which the fluid, in particular liquid and/or gas, and/or solid can be evacuated from the distal end  44  of the device  10  through the guiding element  25  up to the opening  90 , and/or the fluid, in particular liquid and/or gas, and/or solid can be brought into the region  18  in front of the front side  16  of the endoscope  11 . Alternatively or additionally, an instrument  91  can be slid through the opening  90  by the guiding element  25  into the region  18  in front of the front surface  16  and/or be retracted again from the region  18 . The instrument may be, for example, a flexible water jet probe or a liquid jet probe. 
     The guiding element  25  may be electrically conductive, in which case an electrical power source may be connected to the guiding element  25  outside the body of the patient, said guiding element being configured to supply at least one of the instruments  30   a - c  that are guided next to the shaft  12  of the endoscope  11 . 
     The device  10  according to the invention can be used to operate as follows: Initially, the instruments  30   a ,  30   b ,  30   c  may be arranged in the position as shown by  FIG. 1 a   , in which the guiding element  25  is in a maximum-retracted position in the working channel  20 . The user guides the distal end  14  of the endoscope  11  into the body of the patient. In doing so, the user can adapt the curvature of the distal end  14  of the shaft  12 , for example by means of the articulating wheels  84   a ,  84   b  on the handle  80 . Having arrived at the target, the user can change the position and/or the orientation of the working sections  34   a - c  of the instruments  30   a - 30   c  relative to the distal end  14  of the shaft  12  by introducing a force into the guiding element  25 . For example, the user can move the working sections  34   a - 34   c  of the instruments  30   a - 30   c  in a direction transverse to the front side  16  away from the front side  16 , for example in a direction perpendicular away from the front side, by controlling the guiding element  25  from outside the body of the patient, in that the user pushes the guiding element  25  through the working channel  20  further in the direction toward the distal end  14  of the shaft  12 . As a result of this, the working sections  34   z - c  can be arranged, for example, in a position relative to the distal end  14  of the shaft  12 , as shown by  FIG. 1 b   . Before and during the treatment or examination in the region  18  in which the working sections  34   a - c  are located, the user can move the working sections  34   a - c  by introducing a force into the guiding element  25  in order to adapt the position of the working section  34   a - c . To do so, the user can rotate, by rotating the guiding element  25  about its own axis, the working sections  34   z - c  about this axis. By actuating the guiding element  25 , the user can pivot the working sections  34   a - c  preferably about an axis transversely—in particular perpendicularly—to the longitudinal extension direction of the guiding element  25  in which the guiding element  25  extends outside the working channel. By adapting the position and/or orientation of the working sections  34   a - c  relative to the distal end  14  of the shaft  12  by means of the guiding element  25 , the treatment and/or examination in the region  18  by means of the device  10  can take place preferably under the visual control of the user who can view the region  18  from outside the body of the patient by virtue of the means for image transfer. 
     The device  10  according to the invention comprises an endoscope shaft  12  through which extends a working channel ending at an outlet side  16  of the shaft  12 . A guiding element  25  extends through the working channel  20 , said guiding element being preferably guided in longitudinal direction in the working channel  20  along the working channel  20 . The device  10  is set up in such a manner that the distal end section  32   a - c  of an instrument  30 ,  30   a - c  extending in longitudinal direction next to the shaft  12  can be moved alongside the shaft  12  beyond the outlet side  16  in order to move the working section  34 ,  34   a - c  of the instrument  30 ,  30   a - c  away from the outlet side  16  so as to lengthen the distal end section of the device  10 . The instrument  30 ,  30   a - c  is coupled to the guiding element  25  in order to guide the working section  34 ,  34   a - c  of the instrument  30 ,  30   a - 30   c  in a direction transverse to the outlet side  16 , for example perpendicular to the outlet side  16 , away from the outlet side  16  in a region  18  opposite—this also includes obliquely opposite—the outlet side  16  in order to work with the instrument  30 ,  30   a - c  in the region  18 . Due to the guiding element  25  that is held and/or guided in the working channel  20 , the instrument  30 ,  30   a - 30   c  is indirectly held by the shaft  12  and/or guided by means of the working channel  20  via the guiding element opposite the outlet side  16 . Preferably, the device  10  is set up in such a manner that the working sections  34 ,  34   a - d  of the instruments  30 ,  30   a - c  are shifted and/or pulled away from the outlet side  16  when the working sections  34 ,  34   a - c  are moved and/or shifted and/or pulled back to the shaft  12  guided along the longitudinal extension direction of the distal end section  20   a  of the working channel  20 . As a result of this, a particularly stable arrangement of the instrument  30 ,  30   a - c  projecting beyond the shaft  12  next to the shaft  12  and/or a particularly stable guiding of the instrument  30 ,  30   a - c  beyond the shaft  12  are achieved, said guiding allowing a precise and smooth positioning of the working section  34 ,  34   a - c  of the instrument  30 ,  30   a - c . 
     
       
         
           
               
             
               
                   
               
               
                 List of Reference Signs: 
               
               
                   
               
             
            
               
                   
               
            
           
           
               
               
               
            
               
                   
                 10 
                 Device 
               
               
                   
                 11 
                 Endoscope 
               
               
                   
                 12 
                 Shaft 
               
               
                   
                 13 
                 Distal direction 
               
               
                   
                 14 
                 Distal end 
               
               
                   
                 15 
                 Proximal direction 
               
               
                   
                 16 
                 Outlet side, Front side 
               
               
                   
                 17 
                 Illuminating unit 
               
               
                   
                 18 
                 Region 
               
               
                   
                 19 
                 Input of the means for image transmission 
               
               
                   
                 20 
                 Working channel 
               
               
                   
                 20a 
                 End section of the working channel 
               
               
                   
                 21 
                 Opening 
               
               
                   
                 25 
                 Guiding element 
               
               
                   
                 26 
                 Longitudinal direction 
               
               
                   
                 30 
                 Instrument 
               
               
                   
                 30a 
                 First Instrument 
               
               
                   
                 30b 
                 Second Instrument 
               
               
                   
                 30c 
                 Third Instrument 
               
               
                   
                 32 
                 Distal End 
               
               
                   
                 32a-c 
                 Distal end sections 
               
               
                   
                 34 
                 Working section 
               
               
                   
                 34a-c 
                 Working sections 
               
               
                   
                 36 
                 Functional element 
               
               
                   
                 36a-c 
                 Functional elements 
               
               
                   
                 40 
                 Guide cuff, first guide holder 
               
               
                   
                 40i, 40ii, 40iii 
                 Receptacles 
               
               
                   
                 41 
                 Outside, longitudinal side 
               
               
                   
                 42 
                 Longitudinal extension direction 
               
               
                   
                 43 
                 Second guide holder 
               
               
                   
                 44 
                 Distal end of the device 
               
               
                   
                 45 
                 Engagement element 
               
               
                   
                 45a 
                 Positive-locking section 
               
               
                   
                 48 
                 Section 
               
               
                   
                 50 
                 Guiding direction 
               
               
                   
                 52 
                 Longitudinal extension direction 
               
               
                   
                 55 
                 Double arrow 
               
               
                   
                 56 
                 Double arrow 
               
               
                   
                 57 
                 Distal end of the guiding element 
               
               
                   
                 60 
                 Receptacle 
               
               
                   
                 61 
                 Receptacle 
               
               
                   
                 65 
                 Holding element 
               
               
                   
                 65a 
                 Positive-locking section 
               
               
                   
                 70 
                 Engagement section 
               
               
                   
                 70a, 70b 
                 Engagement sections 
               
               
                   
                 71a, 71b 
                 Double arrows 
               
               
                   
                 72a, b 
                 Double arrows 
               
               
                   
                 75 
                 Snap element, snap tab 
               
               
                   
                 76 
                 Positive-locking surfaces 
               
               
                   
                 77 
                 Body 
               
               
                   
                 80 
                 Handle 
               
               
                   
                 81 
                 Proximal end 
               
               
                   
                 82 
                 Guide holder 
               
               
                   
                 83 
                 Control part 
               
               
                   
                 84a, 84b 
                 Articulating wheels 
               
               
                   
                 85 
                 Control elements 
               
               
                   
                 86 
                 Inlet, input 
               
               
                   
                 87 
                 Guiding element grip 
               
               
                   
                 88 
                 Double arrow 
               
               
                   
                 89 
                 Double arrow 
               
               
                   
                 90 
                 Opening 
               
               
                   
                 91 
                 Instrument