Patent Publication Number: US-2005119617-A1

Title: Multifunctional devices

Description:
The present application is a continuation-in-part of U.S. application Ser. No. 10/609,948 filed Jun. 30, 2003, which is a continuation of U.S. application Ser. No. 09/946,418, filed Sep. 5, 2001, now U.S. Pat. No. 6,620,129, which claims priority to U.S. Provisional Application Ser. No. 60/303,643, filed Jul. 9, 2001. All of these Applications and Patents are herein incorporated by reference. 
    
    
     FIELD OF THE INVENTION  
      The present invention relates generally to multifunctional devices for performing suction, irrigation, gas injection and extraction, and manipulation at an internal site in a subject, and more particularly to multifunctional devices with perforations that can be progressively exposed, or sealed-off, from the surgical cavity. The multifunctional devices of the present invention allow for improved suction, irrigation, and drainage of fluids from the surgical cavity.  
     BACKGROUND OF THE INVENTION  
      There are two fundamental types of surgery, conventional and endoscopic surgery. Conventional surgery generally involves a relatively large incision with direct visualization (e.g. the “naked eye”) of the area being operated upon. Examples of conventional surgery include heart and bowel surgeries. Endoscopic surgery involves indirect visualization of the operative field with a small camera. Endoscopic surgery is generally done by way of multiple small incisions through which a camera and instruments are inserted. The instruments perform their functions inside the body but are operated by use of their handles outside the body. Examples of endoscopic surgery include endoscopic appendix or gallbladder removal. Endoscopic surgery can also be done through existing, natural orifices (e.g. certain prostate surgeries).  
      A surgeon uses mechanical devices to assist in performing a variety of interventions within the surgical field during an operation. Three functions generally performed by such mechanical devices include direct tissue manipulation, irrigation, and suction. Direct tissue manipulation may include, but is not limited to, cutting, stitching, cauterizing, injecting, and scraping. Irrigation may include washing the surgical area with fluids (often directed with a tube and/or nozzle). Irrigation is employed as the area of interest within the operative field can become contaminated or can be obscured from visualization by blood or debris. Suction is employed as irrigation fluids and bodily fluids collect in the operative field and need to be removed. There are various devices that currently fulfill these functions. Their use is sometimes impeded, however, when malleable tissue such as fat or intestine surrounds the area of interest and obstructs visualization and/or operation of the device. Below are examples of the limitations of currently used devices.  
      Currently utilized direct tissue manipulation devices come in many different designs. These devices do not have a feature to intrinsically hold malleable tissue away from the tip of the instrument. This function is served by an assistant&#39;s hands or a separate device. This can make surgery particularly difficult during small incision conventional surgery or any endoscopic surgery.  
      Currently utilized suction devices contain a tube of fixed diameter (see, e.g.,  FIG. 1 ). These devices have an opening and/or perforations on the sides of the barrel through which fluid flows and is removed from the operative field. However, during endoscopic surgery (or other types of surgery), the ability to retract tissue out of the operative field is constrained by the limited number of introducer ports through which extra instruments can be placed. Thus, suction devices are frequently operated in close proximity to malleable tissue such as fat or intestine. This leads to frequent obstructions of the suction ports which require the surgeon to disengage the tissue from the device in order to resume suctioning of fluid. Disengaging the tissue from the suction device uses valuable operating room time and distracts from the primary tasks of the operation.  
      Currently utilized irrigation devices simply have a tube through which fluid is expelled into the operative field for cleansing or visualization purposes. Like the other two examples, malleable tissue can obstruct the end of the instrument.  
      What is needed are multifunctional devices capable of performing functions at an internal site in a subject (e.g. suction, irrigation, tissue manipulation) while avoiding obstruction from malleable tissue.  
     SUMMARY OF THE INVENTION  
      The present invention relates generally to multifunctional devices for performing suction (e.g. of liquid and/or gas), irrigation, gas injection, and manipulation at an internal site in a subject, and more particularly to multifunctional devices for performing such functions while avoiding obstruction during conventional and endoscopic surgery. Preferably, the multifunctional devices of the present invention have perforations that can be progressively exposed, or sealed-off, from the surgical cavity allowing improved suction, irrigation, and drainage of fluids from the surgical cavity. In certain embodiments, the multifunctional devices are enlargeable, while in other embodiments, the devices are not enlargeable. In some embodiments, the present invention provides multifunctional devices for gas injection and extraction during endoscopic surgery.  
      In some embodiments, the present invention provides multifunctional devices (e.g. for performing at least one function at an internal site in a subject), comprising; an elongate member with a plurality of openings defining an enlargeable section, wherein the enlargeable section comprises a plurality of walls, and wherein the enlargeable section is movable between a non-enlarged position, and an enlarged position. In preferred embodiments, the enlarged position creates a chamber in the elongate member. In particular embodiments, the enlarged position is any position of the enlargeable section that has a cross-sectional dimension greater than the enlarged section when in the non-enlarged position. In certain embodiments, the enlargeable section, when moved from the non-enlarged position to the enlarged position, is capable of pushing bodily tissue outward (e.g. the walls of the enlargeable section are capable of pushing bodily tissue away from the elongate member axis).  
      In other embodiments, the present invention provides multifunctional devices (e.g. for performing at least one function at an internal site in a subject comprising; a) an elongate member with a plurality of openings defining an enlargeable section, wherein the enlargeable section comprises a plurality of walls, and wherein the enlargeable section is movable between a non-enlarged position, and an enlarged position, wherein the enlarged position forms a chamber in the elongate member, and b) a sleeve member enclosing at least a portion of the elongate member, the sleeve member being moveable between a first position along the elongate member that fully encloses the enlargeable section, and a second position along the elongate member that at most partially encloses the enlargeable section. In particular embodiments, the sleeve member enclosing at least a portion of the elongate member may be pushed distally around the enlargeable section to transfer the location of maximal suction and/or irrigation forces toward the distal end of the device. In certain embodiments, the sleeve member encloses at least a portion of the elongate member such that an annulus space is formed between these two components (See, e.g.  FIG. 6 ). In further embodiments, the sleeve member comprises a sleeve member port (e.g. to allow gas to be injected into the annulus space, down into the surgical field). In further embodiments, the annulus space is at least partially enclosed by one or more annulus space seals (See, e.g.,  FIG. 6 ).  
      In certain embodiments, the present invention provides methods for constructing a multifunctional device, comprising; a) providing an elongate member, and b) generating a plurality of openings in the elongate member such that an enlargeable section is formed in the elongate member, the enlargeable section comprising a plurality of walls and being moveable between a non-enlarged position and an enlarged position. In preferred embodiments, the enlarged position creates a chamber in the elongate member.  
      In other embodiments, the present invention provides methods for constructing a multifunctional device, comprising; a) providing; i) an elongate member, and ii) a sleeve member configured for enclosing at least a portion of the elongate member; and b) generating a plurality of openings in the elongate member such that an enlargeable section is formed in the elongate member, the enlargeable section comprising a plurality of walls and being moveable between a non-enlarged position and an enlarged position, wherein the enlarged position creates a chamber in the elongate member; and c) inserting the elongate member into the sleeve member such that the sleeve member is moveable between a first position along the elongate member that fully encloses the enlargeable section, and a second position along the elongate member that at most partially encloses the enlargeable section.  
      In some embodiments, the present invention provides methods for performing at least one function at an internal site in a subject, comprising; a) providing; i) a multifunctional device comprising an elongate member with a plurality of openings defining an enlargeable section, wherein the enlargeable section comprises a plurality of walls, and wherein the enlargeable section is movable between a non-enlarged position, and an enlarged position, wherein the enlarged position creates a chamber in the elongate member, and ii) a subject comprising a body opening; and b) inserting the multifunctional device through the body opening into an internal site in the subject with the enlargeable section in the non-enlarged position. In preferred embodiments, the method further comprises step c) moving the enlargeable section from the non-enlarged position to the enlarged position. In certain embodiments, the methods of the present invention are part of an endoscopic surgery or endoscopic procedure. In some embodiments, the moving step is accomplished by pushing the distal end of the device against a solid surface in the subject (e.g. against tissue in the subject).  
      In other embodiments, the device further comprises a sleeve member, and the moving step is accomplished by moving the sleeve member to a position such that it does not enclose the enlargeable section. In other embodiments, the body opening is an incision in the body of the subject. In some embodiments, the body opening is a natural orifice in the body of the subject. In particular embodiments, the sleeve member enclosing at least a portion of the elongate member may be pushed downward around the enlargeable section to transfer the location of maximal suction and/or irrigation forces toward the distal end of the device.  
      In some embodiments, the present invention provides multifunctional devices, comprising; a) an outer elongate member, wherein the outer elongate member comprises; i) a plurality of openings defining a perforation section in the outer elongate member, and ii) a distal tip, wherein the distal tip is adjacent to the perforation section; and b) an inner elongate member enclosed by at least a portion of the outer elongate member, the inner elongate member being moveable between: i) a first position inside the outer elongate member that allows fluid movement through substantially all of the plurality of openings in the perforation section, and ii) a second position inside the outer elongate member that prevents fluid movement through substantially all of the plurality of openings in the perforation section.  
      In other embodiments, the perforation section is a non-enlargeable section. In certain embodiments, the device further comprises: an inner utility member, wherein the inner utility member comprises a proximal end and a distal end, and wherein the inner utility member is disposed inside the outer elongate member such that there is a gap between the inner utility member and the outer elongate member along the entire inner surface of the tube. In additional embodiments, the device further comprises a tissue manipulation tip comprising a proximal end and a distal end, wherein the proximal end of the tissue manipulation tip is attached to the distal end of the inner utility member.  
      In particular embodiments, the outer elongate member comprises an outer tube, and wherein the inner elongate member comprises an inner tube. In further embodiments, the diameter of the outer tube is between 4 mm and 10 mm. In certain embodiments, the perforation section is an enlargeable section, and wherein the enlargeable section is movable between a non-enlarged position, and an enlarged position, wherein the enlarged position forms a chamber in the elongate member. In some embodiments, the distal tip is adjacent to the perforation section, wherein the distal tip is attached to the perforation section, and wherein the distal tip is non-enlargeable.  
      In other embodiments, the device further comprises an operating rod, wherein the operating rod is attached to the inner elongate member. In particular embodiments, the device further comprises an operating lever, wherein the operating level is attached to the operating rod. In additional embodiments, the device further comprises an operating lever, wherein the inner elongate member is attached to the operating lever.  
      In some embodiments, the device further comprises a handle unit, wherein a portion of the outer elongate member installed in a stationary manner inside the handle unit. In other embodiments, a portion of the inner elongate member is installed in a stationary manner inside the handle unit. In particular embodiments, the inner elongate member comprises a rib protrusion and the outer elongate member comprises a rib groove, and wherein the rib protrusion is configured to fit into the rib grove in order to align the inner and outer elongate members. In certain embodiments, the inner elongate member comprises expandable tynes, wherein the expandable tynes are configured to expand outward unless constrained by the outer elongate member. In some embodiments, the inner elongate member comprises one or more openings. In other embodiments, the outer elongate member is substantially closed off at the distal end (see e.g.,  FIGS. 20   b  and  d ). In additional embodiments, the outer elongate member is substantially open at the distal end (see e.g.,  FIGS. 20   a  and  c ).  
      In some embodiments, the present invention provides multifunctional devices comprising; a) an elongate member, wherein the elongate member comprises i) a plurality of openings defining a perforation section in the elongate member, and ii) a distal tip, wherein the distal tip is adjacent to the perforation section; and b) a sleeve member enclosing at least a portion of the elongate member, the sleeve member being moveable between: i) a first position along the elongate member that allows fluid movement through substantially all of the plurality of openings in the perforation section, and ii) a second position along the elongate member that prevents fluid movement through substantially all of the plurality of openings in the perforation section.  
      In certain embodiments, the perforation section is a non-enlargeable section. In other embodiments, the device further comprises: an inner utility member, wherein the inner utility member comprises a proximal end and a distal end, and wherein the inner utility member is disposed inside the elongate member such that there is a gap between the inner utility member and the elongate member along the entire inner surface of the tube. In particular embodiments, the device further comprises: a tissue manipulation tip comprising a proximal end and a distal end, wherein the proximal end of the tissue manipulation tip is attached to the distal end of the inner utility member. In some embodiments, the elongate member comprises a tube. In other embodiments, the diameter of the tube is between 4 mm and 10 mm.  
      In additional embodiments, the perforation section is an enlargeable section, and wherein the enlargeable section is movable between a non-enlarged position, and an enlarged position, wherein the enlarged position forms a chamber in the elongate member. In other embodiments, the enlargeable section can only be in the non-enlarged position when the sleeve member is in the second position. In some embodiments, the enlargeable section is in the enlarged position when the sleeve member is in the first position. In other embodiments, the distal tip is adjacent to the perforation section, wherein the distal tip is attached to the perforation section, and wherein the distal tip is non-enlargeable.  
      In other embodiments, the device further comprises an operating rod, wherein at least a portion of the operating rod is enclosed by the elongate member. In particular embodiments, the operating rod is attached to a cross member, and wherein the cross member is not enclosed by the elongate member. In further embodiments, the operating rod is attached to an expandable unit, wherein the expandable unit is configured to expand outward unless constrained by the outer elongate member. In certain embodiments, the elongate member comprises tynes that extend from the distal tip, wherein the tynes are configured to expand outward unless constrained by the sleeve member. In particular embodiments, the elongate member is configured such that fluid transmitted through the elongate member contacts both the inner surface of the perforation section and the inner surface of the distal tip.  
      In some embodiments, the present invention provides multifunctional devices configured for performing at least one function at an internal site in a subject, comprising; a) an elongate member comprising; i) a plurality of openings defining an enlargeable section in the elongate member, wherein the enlargeable section is movable between a non-enlarged position, and an enlarged position, wherein the enlarged position forms a chamber in the elongate member, ii) a partial distal tip, wherein the partial distal tip is adjacent to the enlargeable section, and wherein the partial distal tip is attached to the enlargeable section; and b) an inner utility member, wherein at least a portion of the inner utility member is enclosed by the elongate member, and wherein the inner utility member comprises an operating rod and a cross member, and wherein the cross member is configured to combine with the partial distal tip to form a complete distal tip.  
      In certain embodiments, the elongate member is configured for transmitting fluid (e.g. into and/or out of a surgical site). In some embodiments of the present invention, the elongate member is configured for suctioning. In other embodiments, the elongate member is configured for irrigation. In further embodiments, the elongate member is configured for gas injection and/or gas suctioning. In some embodiments, the elongate member is configured for simultaneous tissue manipulations, suctioning, irrigation, and gas injection.  
      In particular embodiments, the elongate member comprises a tube (e.g. a cylindrical, hollow member with openings at both ends). In some embodiments, the tube comprises plastic (e.g., polyethylene, polypropylene, polystyrene, polyvinyl chloride, nylon, polyacetal, polyphenylene oxide, polytetrafluoethylene, polyethylene teraphthalate, polybutylene terephthalate, phenolic urea formaldehyde, melamine formaldehyde, polyester, and combinations thereof). In some embodiments, the elongate member is at least 1 centimeter in length (e.g. at least 1 centimeter, or at least 2 centimeters, or at least 3 centimeters). In certain embodiments, the elongate member is at least 5 centimeters in length (e.g. at least 5 centimeters, or at least 10 centimeters). In other embodiments, the elongate member is at least 12, or at least 15, or at least 18, or at least 20 centimeters in length. In particular embodiments, the elongate member is no more than 5 centimeters in length (e.g. no more than 5 centimeters, or no more than 3 centimeters, or no more than 2 centimeters).  
      In certain embodiments, the elongate member comprises an elongate member dividing wall. In some embodiments, the dividing wall creates separate channels within the elongate member (See, e.g.,  FIG. 7 ).  
      In some embodiments, the elongate member has a primary cross-sectional dimension (e.g., a cross-sectional dimension that is present throughout at least 50 percent of the length of the elongate member). In certain embodiments, the primary cross-sectional dimension is present throughout at least 60 percent, or at least 70 percent, or at least 80 percent, or at least 90 percent, or at least 95 percent, or at least 99 percent of the elongate member. In preferred embodiments, the cross-sectional dimension of the elongate member is uniform throughout its length. In certain embodiments, the primary cross-sectional dimension is a diameter value ranging between 2 millimeters and 15 millimeters (e.g., approximately 2 mm, 3 mm, 8 mm, 12 mm, or 14 mm). In other embodiments, the primary cross-sectional dimension is a diameter value ranging between 4 millimeters and 10 millimeters (e.g. approximately 4 mm, 6 mm, 8 mm or 10 mm).  
      In some embodiments, the elongate member comprises an elongate member seal (e.g. to prevent gas and/or liquid from escaping from a surgical field). In other embodiments, the elongate member comprises an elongate member port (See, e.g.  FIG. 6 ).  
      In particular embodiments, the elongate member comprises a distal tip. In further embodiments, the enlargeable section of the elongate member has a bulging midsection shape. In other embodiments, the elongate member has a distal end and a proximal end. In certain embodiments, distal end of the elongate member is configured to be inserted in a body opening of a subject (e.g. during endoscopic surgery). In some embodiments, the proximal end of the elongate member is configured to remain outside the body (e.g., during endoscopic surgery such that the device may be manipulated by a user, such as a surgeon). In other embodiments, the enlargeable section is located in the distal end of the elongate member. In still other embodiments, the multifunctional device further comprises a handle. In particular embodiments, the handle is located in, or attached to, the proximal end of the elongate member.  
      In certain embodiments, the plurality of walls are separated by at least one of the plurality of openings (e.g. at least 1, 2, 3, 4, 5, 6, 7, 8, or 9 of the plurality of openings). In other embodiments, at least one of the plurality of walls is at least 1 millimeter in length (e.g., at least 1, 2, 3, 4, 5, or 6 millimeters in length).  
      In some embodiments, at least one of the plurality of openings in the elongate member is a longitudinal opening. In further embodiments, the at least one longitudinal opening is at least 1 millimeter in length (e.g. at least 1 mm, 2 mm, 3 mm, 4 mm, 5 mm, or 6 mm in length). In certain embodiments, the plurality of openings comprises at least three separate openings (e.g. at least 4, or 5, or 6, or 7, or 8, or 9, or 15, or 20 separate openings). The plurality of openings of the present invention may be of any shape or size. In some embodiments, the openings are longitudinal, diamond, zig-zag shape, regular or irregularly shaped, and allow adjustment of the chamber shape and/or volume.  
      In certain embodiments, the enlargeable section, when in the enlarged position, has a cross-sectional dimension at least 1.5 times larger than the enlarged section when in the non-enlarged position (e.g. at least 1.5 times larger, or at least 2 times larger, or at least 3 times larger, or at least 4 times larger). In some embodiments, the chamber has a volume of at least 5 cubic centimeters (e.g., at least 6 cc, 7 cc, 8 cc, 9 cc, or at least 10 cc).  
      In preferred embodiments, at least a portion of the enlargeable section is enclosed by media (e.g., an expandable membrane, such as GORE-TEX ePTFE membranes, made by W. L. Gore &amp; Associates, Inc., Elkton, Md.). In particularly preferred embodiments, the media is biocompatible. In other preferred embodiments, the media further comprises a therapeutic agent, including, but not limited to, antibiotics, anticoagulants, steroids, and combinations thereof. In some embodiments, the media is permeable to liquid. In other embodiments, the media (e.g. latex) is impermeable to liquid. In still other embodiments, the media is partially permeable to liquids. In other embodiments, the media comprises perforations (e.g. that allow fluid to pass).  
      In certain embodiments, the multifunctional device further comprises an adjustment device. In other embodiments, at least a portion of the adjustment device is within the elongate member. In some embodiments, the adjustment device is configured for changing the shape of the chamber. In preferred embodiments, the adjustment device is configured for moving the enlargeable section from the non-enlarged position to the enlarged position, or vice-versa. In other embodiments, the adjustment device comprises a handle component (e.g. such that user can operate the adjustment device from outside the body of a patient).  
      In some embodiments, the multifunctional devices of the present invention further comprise an inner utility member. In particular embodiments, the inner utility member comprises a rod or rod-like member. In certain embodiments, the inner utility member is configured for transmitting fluid (e.g. irrigation or suction, or both). In other embodiments, the inner utility member is configured for attachment to a tissue manipulator tip (or the distal end of the inner utility member forms a tissue manipulator tip). In some embodiments, the multifunctional device further comprises a tissue manipulator tip (e.g. connected to the inner utility member). In some embodiments, the inner utility member is configured for transmitting gas into and/or out of a surgical field (e.g. for insufflation procedures).  
      In certain embodiments, the enlargeable section of the elongate member comprises a spring member. In some embodiments, the spring member is configured to move the enlargeable section to the enlarged position. In other embodiments, the spring member is configured to move the enlargeable section to the non-enlarged position. In other embodiments, the enlargeable section has passive spring action (e.g. will move to the enlarged position unless constrained). In some embodiments, the plurality of walls of the enlargeable section have passive spring action (e.g. will move to the enlarged position unless constrained).  
      In some embodiments, the multifunctional devices of the present invention comprise a sleeve member. In certain embodiments, the sleeve member encloses at least a portion of the elongate member. In other embodiments, the sleeve member is moveable (e.g. adjustable) between a first position along the elongate member that fully encloses the enlargeable section, and a second position along the elongate member that at most partially encloses the enlargeable section (e.g. at most encloses 95%, 75%, 50%, 25%, 10% or 5% of the enlargeable section). In other embodiments, the enlargeable section is in the non-enlarged position when the sleeve member is in the first position. In particular embodiments, the enlargeable section is in an enlarged position when the sleeve member is in the second position.  
      In certain embodiments, the sleeve member comprises plastic (e.g., polyethylene, polypropylene, polystyrene, polyvinyl chloride, nylon, polyacetal, polyphenylene oxide, polytetrafluoethylene, polyethylene teraphthalate, polybutylene terephthalate, phenolic urea formaldehyde, melamine formaldehyde, polyester, and combinations thereof).  
      In other embodiments, the sleeve member is configured to be moved (e.g. adjusted) from outside of a subject&#39;s body (e.g. during endoscopic surgery). In some embodiments, the sleeve member comprises a proximal end, and the proximal end is connected to a handle.  
      In some embodiments, the present invention provides methods for constructing a multifunctional device, comprising; a) providing an elongate member, and b) generating a plurality of openings in the elongate member such that an enlargeable section is formed in the elongate member, wherein the enlargeable section comprises a plurality of walls. In other embodiments, after step b), the elongate member comprises a distal tip. In particular embodiments, the enlargeable section is moveable between a non-enlarged position and an enlarged position, wherein the enlarged position creates a chamber in the elongate member. In particular embodiments, the enlarged position is any position of the enlargeable section that has a cross-sectional dimension greater than the enlarged section when in the non-enlarged position. In certain embodiments, the generating comprises cutting a plurality of holes (e.g. slits) in the elongate member. In some embodiments, the present invention provides methods for constructing a multifunctional device, comprising; generating an elongate member that has a plurality of openings, wherein the plurality of openings form an enlargeable section comprising a plurality of walls. In some embodiments, the generating comprises blow-molding, or otherwise forming, the elongate member such that a plurality of openings are formed therein.  
      In other embodiments, the present invention provides kits, comprising an elongate member with a plurality of openings defining an enlargeable section, wherein the enlargeable section comprises a plurality of walls, and wherein the enlargeable section is movable between a non-enlarged position, and an enlarged position, wherein the enlarged position forms a chamber in the elongate member, and b) a sleeve member configured for enclosing at least a portion of the elongate member, the sleeve member being moveable between a first position along the elongate member that fully encloses the enlargeable section, and a second position along the elongate member that at most partially encloses the enlargeable section. In other embodiments, the kits of the present invention further comprise any of the additional components of the multifunctional devices mentioned above (e.g. media, inner utility member, adjustment device, elongate member with or without a distal tip, etc.). In certain embodiments, the kits of the present invention further comprise instructions for assembling and/or using the multifunctional devices of the present invention.  
      In other embodiments, the present invention provides systems, comprising an elongate member with a plurality of openings defining an enlargeable section, wherein the enlargeable section comprises a plurality of walls, and wherein the enlargeable section is movable between a non-enlarged position, and an enlarged position, wherein the enlarged position forms a chamber in the elongate member, and b) a sleeve member configured for enclosing at least a portion of the elongate member, the sleeve member being moveable between a first position along the elongate member that fully encloses the enlargeable section, and a second position along the elongate member that at most partially encloses the enlargeable section. In other embodiments, the systems of the present invention further comprise any of the additional components of the multifunctional devices mentioned above (e.g. media, inner utility member, adjustment device, elongate member with or without a distal tip, etc.). In certain embodiments, the systems of the present invention further comprise instructions for assembling and/or using the multifunctional devices of the present invention.  
      In other embodiments, the present invention provides multifunctional devices that permit the removal of bodily and irrigation fluids, the injection of gas and/or irrigation liquids, or the manipulation of tissue (e.g. cautery, cutting, scraping, etc.), comprising an elongate member (e.g. suction and/or irrigation tube) that is connected to, or preferably integral with, an enlargeable section that is configured to provide access down into a surgical field (e.g. for removal or injection of fluids), the enlargeable section defining a chamber volume having an area measured across the elongate member axis similar to the cross-sectional area of the elongate member when the enlarged section is non-deployed (e.g. in a non-enlarged position), and having an area measured across the elongate member axis greater than the cross-sectional area of the elongate member, and thereby an increased chamber volume, when the enlargeable section is deployed (e.g. in an enlarged position).  
      In some embodiments, the enlargeable section comprises walls. In further embodiments, the wall are perforated. In certain embodiments, the wall of the enlargeable section, when deployed, are capable of pushing bodily tissue outward from the elongate member axis to form an enlarged chamber volume free of bodily tissue (e.g. such that fluids may be collected for removal). In certain embodiments, the enlargeable section in combination with injection of gas allow bodily tissue to be pushed outward from the elongate member (e.g. during endoscopic surgery).  
      In certain embodiments, the elongate member has a plurality of openings that form the enlargeable area. The openings may be of any shape or size. In some embodiments, the openings are longitudinal, diamond, zig-zag shape, regular, or irregular in shape, and allow adjustment of the chamber shape and volume.  
      In particular embodiments, the walls of the enlargeable section have passive spring action that opens the enlargeable section to its deployed shape and size. In other embodiments, the walls of the enlargeable section have passive spring action that returns the enlargeable section to its non-deployed (e.g. non-enlarged) shape and size when deployment forces are released or counteracted, whereby the chamber length can be reduced and the chamber width and volume can be increased by pushing on the tube and enlargeable section.  
      In some embodiments, the multifunctional device further comprises a tissue manipulation tip (including, but not limited to, a cautery tip, scalpel tip, scissors tip, scraping tip, and stitching tip) which can operate both within the enlargeable section and beyond the tip of the enlargeable section.  
      In further embodiments, the multifunctional device further comprises an adjustment device that connects to the enlargeable section and is operable from the top of the elongate member. In certain embodiments, the adjustment device may be used to change the change length, width and volume (e.g., change the enlargeable section from a non-enlarged position to an enlarged position, or vice versa).  
      In some embodiments, the multifunctional device of the present invention further comprises a sleeve member around the elongate member, through which the elongate member (e.g. tube) and enlargeable section can move. In certain embodiments, the sleeve member may be used to insert into or withdraw from the surgical area the elongate member (e.g. suction/irrigation tube), with the enlargeable section in a non-deployed (e.g. non-enlarged), or partially deployed condition. In particular embodiments, the sleeve member enclosing at least a portion of the elongate member may be pushed downward around the enlargeable section to transfer the location of maximal suction and/or irrigation forces toward the proximal end of the device.  
      In certain embodiments, the walls of the enlargeable section comprise tynes. In some embodiments, when the tynes are spread apart form openings between them for fluid movement. In particular embodiments, the tynes have outward or inward passive spring action to create deployment or non-deployment forces.  
      In some embodiments, the multifunctional device of the present invention comprises flexible media material surrounding and/or conforming to at least a portion of the enlargeable section. In certain embodiments, the flexible media serves to control movement of materials into the chamber. In other embodiments, the media is fluid permeable or impermeable, or perforated, in specific areas, thus restricting bodily tissue from entering the chamber.  
      In additional embodiments, the multifunctional device further comprises an inner utility member (e.g. suction and/or irrigation and/or gas injection or extraction tube) inside of the elongate member. The inner suction/irrigation tube may be employed to additionally remove bodily or irrigation fluids or inject irrigation fluids. In other embodiments, the insertion depth of the inner suction/irrigation tube determines the zone from which fluids are removed or to which fluids are injected within the chamber. 
    
    
     DESCRIPTION OF THE FIGURES  
       FIG. 1  shows a cutaway perspective view of a prior art endoscopic surgery suction device.  
       FIG. 2  shows one embodiment of the multifunctional device of the present invention.  
       FIG. 3  shows another embodiment of the multifunctional device of the present invention.  
       FIG. 4  shows an additional embodiment of the multifunctional device of the present invention.  
       FIG. 5  shows a further embodiment of the multifunctional device of the present invention.  
       FIG. 6  shows yet another embodiment of the multifunctional device of the present invention.  
       FIGS. 7   a  and  7 B show an additional embodiment of the multifunctional device of the present invention.  
       FIG. 8  shows one embodiment of the device of the present invention with an enlargeable section, sleeve, and suction/irrigation tube.  
       FIG. 9  shows one embodiments of the device of the present invention with a partial distil tip ( 9 B) and an inner utility member with a cross member that combines with the partial distil tip to form a complete distal tip ( 9 A).  
       FIG. 10  shows a head-on view of one embodiment of the device of the present invention with tynes at the distal end of the elongate member expanded and non-expanded.  
       FIG. 11  shows a side view of one embodiment of the present invention with tynes at the distal end of the elongate member.  
       FIG. 12  shows an elongate member partially enclosing an inner utility member composed of a control rod and cross-member.  
       FIG. 13  shows one embodiment of the present invention with an inner elongate member partially enclosed by an outer elongate member, where the inner elongate member is attached to an operating rod.  
       FIG. 14  shows one embodiments of the present invention with an elongate member partially enclosing an operating rod with an expandable distal end.  
       FIG. 15  shows one embodiment of the present invention with an inner elongate member partially enclosed by an outer elongate member, where the inner elongate member is attached to an operating rod, and wherein said inner elongate member has expandable typnes.  
       FIG. 16  shows exemplary shapes for perforations in a perforation section.  
       FIG. 17  shows various distances of perforations from the distal end of the elongate member.  
       FIG. 18  shows an elongate member with a perforation section (different perforation shapes are shown in A, B, C, and D) and a sleeve member.  
       FIG. 19  shows an inner elongate member inside an outer elongate member, where the inner elongate member is moveable between a position that prevents fluid movement through substantially all of the openings ( 19 A), a position that allows fluid movement through about half of the openings ( 19 B), and a position that allows fluid movement through substantially all of the openings ( 19 C).  
       FIG. 20  shows certain embodiments where the distal end of the elongate member is either open ( 20 A and  20 C) or closed ( 20 B and  20 D).  
       FIG. 21  shows an inner elongate member substantially enclosed by an outer elongate member, where the outer elongate member is stationary inside a handle unit.  
       FIG. 22  shows an inner elongate member substantially enclosed by an outer elongate member, where the inner elongate member is stationary inside a handle unit.  
       FIG. 23  shows a cross section through one embodiment of the inner and outer elongate members of the present invention. 
    
    
     DEFINITIONS  
      To facilitate an understanding of the invention, a number of terms are defined below.  
      As used herein, the terms “subject” and “patient” refer to any animal, such as a mammal like livestock, pets, and preferably a human. Specific examples of “subjects” and “patients” include, but are not limited to, individuals requiring surgery, and in particular, requiring endoscopic surgery for diagnostic or therapeutic purposes.  
      As used herein, the phrase “perforation section” refers to the area along the length of an elongate member that contains a plurality of openings, and in particular a perforation section is defined by the area along the elongate member that contains at least 90% of all the openings found along the length of the elongate member (distal and proximal end openings in the elongate member excluded). In preferred embodiments, the perforation section contains at least 95-100% of all the openings found along the length of the elongate member. In certain embodiments, the configuration of the openings in this region allow the perforation section to function as an expandable section (thereby allowing the elongate member to expand in this area forming a chamber in the elongate member). In other embodiments, the configuration of the openings in the perforation section do not allow the elongate member to expand in this area.  
      As used herein, the phrase “substantially all” used in reference to the plurality of openings that make up a perforation section, means at least 90% and preferably 95% of all the openings in the perforation section.  
      As used herein, the terms “endoscopic surgery” and “endoscopic procedures,” and like terms, refer to what is generally known as laproscopic or endoscopic surgery, which generally involves indirect visualization of the operative field with a small camera (e.g. specialized fiberoptic telescopes measuring less than a half inch in diameter that are attached to high resolution television cameras). Endoscopic surgery is generally done by way of multiple small incisions through which a camera and instruments are inserted. The instruments perform their functions inside the body but are operated by use of their handles outside the body. Examples of endoscopic surgery include endoscopic appendix or gallbladder removal.  
      As used herein, the term “primary cross-sectional dimension” when used in reference to the elongate member, refers the cross sectional dimension (i.e. area of the internal opening) in the elongate member that is present throughout at least 50% of the length of elongate member (i.e. at least 50% of the length of the elongate member has a cross-sectional dimension that is the same value, referred herein as the primary cross-sectional dimension). In some embodiments, the primary cross-sectional dimension is present throughout at least 60%, or at least 70%, or at least 80%, or at least 90%, or at least 95% of the elongate member. In preferred embodiments, the primary cross-sectional dimension is present throughout about 100% of the elongate member (e.g. a tube of approximately uniform diameter is employed).  
      As used herein, the term “distal tip” when used in reference to a portion of the elongate member, refers to the area of the elongate member that is distal of the perforation section (e.g. which may be an enlargeable section or a non-enlargeable section) of the elongate member. In some embodiments, the distal tip has approximately the same cross-sectional dimension as the primary cross-sectional dimension of the elongate member. In other embodiments, the distal tip is non-enlargeable.  
     GENERAL DESCRIPTION OF THE INVENTION  
      The present invention relates generally to multifunctional devices for performing suction (e.g. suctioning of solids material, liquid and/or gas), irrigation, gas injection, and manipulation at an internal site in a subject, and more particularly to enlargeable multifunctional devices for performing such functions while avoiding obstruction during conventional and endoscopic surgery. The present invention also provides multifunctional devices which have perforations that can be progressively exposed, or sealed-off, from the surgical cavity allowing improved suction, irrigation, and drainage of fluids from the surgical cavity. In certain embodiments, the multifunctional devices are expandable, while in other embodiments, the devices are not expandable.  
      The present invention eliminates many of the problems associated with malleable tissue obstruction or impeding suction catheters, irrigation catheters, and other surgical instruments. The present invention permits conventional utilization of suction, irrigation, and other functions, but also provides the ability to deploy and retract a guard (e.g. enlargeable section) to create an area (e.g. chamber) free of tissue interference. The tissue guard (enlargeable section) may be activated (e.g. go from non-enlarged position to an enlarged position), for example, by direct pressure of the device tip against tissue (or other firm surface). The tissue guard (enlargeable section) may also be activated, for example, by a mechanism on the device handle or passive spring action. When the enlargeable section is deployed (e.g. in an enlarged position), it forms a barrier preventing tissue from coming into direct contact with any functioning portion of the device (e.g. suction, irrigation, or tissue manipulation part of the device).  
      In preferred embodiments, the multifunctional devices of the present invention comprise an elongate member (e.g. a hollow tube) with longitudinal slits or other perforations/openings that run to nearly the end of the elongate member (e.g. a plurality of openings are formed near the distal end of the elongate member forming an enlargeable section adjacent to the distal tip of the elongate member). In other embodiments, the multifunctional devices of the present invention comprise an elongate member (e.g. hollow tube) with longitudinal or other perforations/opening that run to the end of the elongate member (e.g. a plurality of openings are formed at the distal end of the elongate member forming an enlargeable section at the end of the elongate member).  
      Also in preferred embodiments, when the tip (e.g. very end) of the elongate member is forced against an object or is pulled proximally toward the top of the elongate member (e.g. toward the handle), the openings (e.g. slits, perforations, etc) allow the sides of the elongate member (e.g. the walls of the enlargeable section of the elongate member) to bow out. This creates a cavity (e.g. chamber) that is protected from tissue encroachment by the bowed-out walls. In certain embodiments, the multifunctional devices have a suctioning function, and the formation of the chamber (e.g. when the enlargeable section is in the enlarged position) causes the suction interface to shift from the area just beyond the distal tip of the elongate member, to the an area within the enlargeable section, or just above the enlargeable section.  
      Since, in some embodiments, the multifunctional devices of the present invention may be moved between a non-enlarged position and an enlarged position (e.g. the enlargeable section of the elongate member may be in enlarged and non-enlarged positions), the device may be inserted through openings otherwise too small to accommodate a device with bowed out chambers. In this regard, the devices of the present invention may be used in a conventional manner, or passed through introducer ports (e.g. for endoscopic type surgery), by reversing the bowing process, thus causing the cross-sectional dimension of the enlargeable section to return to “normal” (e.g., return to a position such that the enlargeable section has approximately the same cross-sectional dimension as the primary cross-sectional dimension of the elongate member).  
      Another important advantage of the multifunctional devices of the present invention is the ability to inject gas into, or extract gas from, a surgical field. Generally, during endoscopic surgery (e.g. in the abdomen) a surgeon will inject gas (e.g. carbon dioxide) into the abdomen such that the abdominal wall is raised up, off of the underlying tissues and organs. This process is generally referred to as “insufflation.” One of the problems associated with insufflation involves removing smoke generated during cauterization procedures. For example, as air is suctioned out of the abdomen to get rid of the smoke, the gas pressure in the abdomen decreases and the abdominal wall sags down onto the operative field. This necessitates stopping the surgery and the insertion of a separate instrument that re-injects gas to build up pressure again. This problem is overcome by the multifunctional devices of the present invention. For example, the present invention permits simultaneous cauterization, suctioning of smoke, and gas injection. This permits tissue manipulation at the same time as suctioning of smoke to improve visualization and gas injection to maintain pressure in the body cavity.  
      A further advantage of the multifunctional devices of the present invention is that, in certain embodiments, the multifunctional devices have perforations that can be progressively exposed, or sealed-off, from the surgical cavity allowing improved suction, irrigation, and drainage of fluids from the surgical cavity. For example, in certain embodiments, an inner elongate member may be moved inside an outer elongate member (containing a plurality of perforations) such that the perforations can be exposed or blocked, thereby allowing or preventing fluid movement through the openings. Also for example, in other embodiments, an elongate member is partially enclosed by a sleeve member that may be moved along the elongate member such that perforations in the elongate member are exposed or blocked, thereby allowing or preventing fluid movement through the openings. In certain embodiments, such multifunctional devices are expandable, while in other embodiments, such devices are not expandable.  
     DETAILED DESCRIPTION OF THE INVENTION  
      The multifunction devices of the present invention have advantages over previous prior art devices.  FIG. 1  shows a prior art suction device, and  FIGS. 2-7  show various preferred embodiments of the multifunctional devices of the present invention.  FIGS. 8-23  show additional embodiments, including embodiments with perforations that can be progressively exposed, or sealed-off, from the surgical cavity.  
      Referring to  FIG. 1 , a prior art suction device  10  penetrates the body wall  11  of a subject through an introducer  12  down to the surgical field  13  where bodily and irrigation fluids  14  accumulate. Tube  20  transmits fluids during surgery through hole  21  (not shown, and not always present) in the tube  20  end, and holes  22  in the tube  20  sides from the surgical area inside the body  14  to outside the body  23 .  
      Referring generally to  FIGS. 2, 3 ,  4 , and  5 , elongate member  20  (e.g. suction/irrigation tube) is connected to, or preferably integral with, an enlargeable section  30  (i.e. elongate member  20  has an enlargeable section  30 ). Elongate member  20  allows removal/suctioning of bodily liquids/fluids or air, as well as gases and irrigation/liquids fluids during surgical operations inside the bodies of subjects (e.g. humans and other animals, such as cows, pigs, horses, dogs, cats, and other mammals). The suctioning and irrigation may be accomplished, for example, with the elongate member  20  itself or through internal utility member  49 . The enlargeable section  30  may be in a non-enlarged (non-deployed) position or an enlarged (deployed) position.  FIGS. 2, 3 ,  4  and  5  show the enlargeable section  30  in an enlarged position. Generally, the enlargeable section  30 , when in the non-deployed position, is of similar cross-sectional dimension  31  as elongate member  20 , but when in a deployed position, is of a cross-sectional dimension, such as  32 , that is larger than the cross-sectional dimension  31  of elongate member  20 .  
      In particularly preferred embodiments, the walls  35  of deployed enlargeable section  30  are capable of pushing bodily tissue  36  (e.g. malleable tissue) outward away from the elongate member  20  axis  37 , and form a chamber  38 . In certain embodiments, the enlargeable section contains a plurality of openings  39 .  FIGS. 2 and 5  show “slit” type openings  39   a , between walls  35 . In some embodiments, the slit openings are longitudinal (e.g.  39   a ), horizontal, angled, or combinations thereof.  FIGS. 2 and 5  also show an alternative embodiments with openings  39   b  (e.g. perforations) cut in a zig-zag pattern (e.g. to form an expanding mesh). In certain embodiments with perforations  39   b , the perforations may be any type of opening, including, but not limited to, longitudinal, diamond, regular or irregular shaped openings. Openings  39  (e.g.  39   a  and  39   b ) may allow adjustment of the chamber shape and volume.  
      The chamber  38  shape and volume may be varied by adjusting its length  40  and width  32 . The chamber  38  length  40  can be decreased and the chamber  38  width  32  can be increased, for example, by pushing elongate member  20  downward against the surgical field  13 . This motion may also act to bring the point of maximum suction  47  closer to the surgical field  13 .  
      The walls  35 , in some embodiments, have inward passive spring action that returns the enlargeable section  30  to its non-deployed (non-enlarged) shape and size when deployment forces are released or counteracted. In alternative embodiments, the plurality of walls  35  have outward passive spring action that opens the enlargeable section  30  to its deployed shape and size of variable length  40  and width  32 .  
      Adjustment device  45 , which connects to the bottom of enlargeable section  30  and is operable from the top of elongate member  20 , can be used to change the chamber  38  length  40  and width  32 . Adjustment device  45  can be used to increase or decrease the volume of chamber  38 .  
      Sleeve member  46 , which surrounds elongate member  20 , can be used for many purposes. For example, for device insertion purposes, with enlargeable section  30  non-deployed and retracted within sleeve member  46 , the enlargeable section  30  and elongate member  20  can be inserted into the surgical area. After insertion, sleeve member  46  can be partially pulled back such that walls  35 , when including outward passive spring action, will open to form enlarged chamber dimension  32 . In another example of employing sleeve member  46 , for device removal purposes, sleeve member  46  can be used to reduce the enlargeable section  30  width  32  to the same cross-sectional area  31  of elongate member  20  for removal of enlargeable section  30  and elongate member  20  through sleeve  46 . In a further example, for controlled suction and irrigation purposes, sleeve member  46  can be pushed toward the surgical field  13 . Through this downward movement, sleeve member  46  compresses the walls  35  inward from the larger dimension  32  to the smaller dimension  31 , blocks increasing percentages of the openings  39 , and thereby transfers the location of maximal suction or irrigation forces  47  downward toward the surgical field  13 .  
      Media  48  may surround part or all of enlargeable section  30  to control movement of materials into chamber  38 . Media  48  is flexible to conform to the variable shape of walls  35 . Specific areas of media  48  may be permeable or impermeable to fluids, and may further contain perforations. Media  48  restricts bodily tissue from entering chamber  38  (e.g. restricts bodily tissue from entering openings  39 ).  
      Inner utility member  49  (e.g. suction/irrigation tube or tissue manipulation support), inserts into elongate member  20  and chamber  38  as an additional or alternative means for removal of bodily and irrigation fluids, or as a tissue manipulation support (e.g. for attaching a tissue manipulator tip). Inner utility member  49  may also be used to inject gas (e.g. into the abdomen of a surgical subject) or to remove gas from the surgical field (e.g. smoke from cauterizing procedures). Generally, for liquid removal, the depth of insertion determines the zone from which fluids are removed. As insertion depth increases and dimension  50  therefore decreases, fluid levels are lowered closer to surgical field  13 . Tissue manipulator tip  62  may be attached to, or integral with, inner utility member  49  (e.g. in order to perform surgical maneuvers, such as cutting, cauterizing, knot tying, scraping, and stitching).  
      Referring now to  FIGS. 2 and 3  specifically, both of these figures show the enlargeable section  30  in an enlarged position such that a ‘bulging midsection’ is formed (i.e. enlargeable section  30  is narrower at either end, and larger in the middle). In preferred embodiments, the cross-sectional dimension adjacent to both ends of the enlargeable section  30  is approximately the same (e.g. approximately the same cross-sectional dimension as the primary cross-sectional dimension of the elongate member  20 ).  FIG. 2  specifically shows a distal tip  51  of elongate member  20  adjacent to the enlargeable section  30  that has approximately the same cross-sectional dimension as elongate member  20 .  FIG. 2  also shows a tissue manipulation tip  62  at the end of inner utility member  49 .  
      Referring now to  FIGS. 4 and 5  specifically, both of these figures show the enlargeable section  30  in an enlarged position such that a ‘cone configuration’ is formed (i.e. enlargeable section  30  is narrower at one end (approximately the same cross sectional dimension as elongate member  20 ), and the other end is the widest part of the enlargeable section  30 .  FIG. 5  also shows a tissue manipulation tip  62  at the end of inner utility member  49 .  
      Referring now to  FIG. 6 , an elongate member seal  70  at the top of elongate member  20  permits suction, irrigation or gas injection into or extraction out of the surgical body cavity through the inside of elongate member  20  or a channel within elongate member  20 . Elongate member seal  70  may, in some embodiments, have self-sealing perforations to permit insertion of objects such as adjustment device  45  and/or inner utility member  49 . Elongate member port  71  permits suctioning of liquid or gas out of the surgical body cavity and/or irrigation of liquid into the surgical body cavity. There can be, in some embodiments, multiple elongate member ports  71  to perform separate functions. Annulus space  80  between elongate member  20  and sleeve member  46  conveys gas from sleeve member port  82  to the surgical body cavity. Annulus space seals  81  and  83  between elongate member  20  and sleeve member  46  prevent, in some embodiments, gas escape from annulus space  80 . Seals  81  and  83  may be integral with or separate from elongate member  20  and sleeve member  46 . Sleeve member port  82  permits gas injection into the surgical body cavity through annulus space  80 . The distance  84  from the bottom of sleeve member  46  to annulus space seal  83 , in some embodiments, can be varied to permit various numbers and locations of gas discharge perforations  85 . Gap  86  at the bottom of sleeve member  46  permits gas discharge if, for example, seal  83  were omitted.  
      Referring now to  FIG. 7 , elongate member dividing wall  100  inside of elongate member  20  creates separate channels  101  and  102 . In some embodiments, multiple such dividing walls create-varying numbers of such channels. Elongate member dividing wall  100  can, in particular embodiments, run the entire length of elongate member  20  or some portion of that length. In some embodiments, channel  101  may be used for functions including but not limited to tissue manipulation, cauterization, suctioning, and irrigation. In particular embodiments, channel  102  may be used for functions including but not limited to gas injection.  
      Referring generally to  FIGS. 8, 9 ,  10 ,  11 ,  12 ,  13 ,  14 ,  15 ,  16 ,  17 ,  18 ,  19 , and  20 , the outer elongate member  10 - 1 ,  11 - 1 ,  12 - 1 ,  13 - 1 ,  14 - 1 ,  15 - 1 ,  16 - 1 ,  17 - 1 ,  18 - 1 ,  19 - 1 , and  20 - 1  transmits fluid from its distal end to its proximal end for suction or removal from the surgical cavity or from it proximal end to its distal end for irrigation of the surgical cavity. In certain preferred embodiments illustrated by  FIGS. 8, 9 ,  11 , and  18 , the sleeve member  10 - 2 ,  11 - 2 , and  18 - 2  may be included in some applications and not included in other applications, depending upon the need and circumstances. In preferred embodiments illustrated by  FIGS. 11, 12 ,  13 ,  15 ,  16 ,  17 ,  18 ,  19 , and  20 , a perforation section is included that contains a plurality openings (perforations) labeled  11 - 4 ,  12 - 2 ,  13 - 2 ,  15 - 2 ,  16 - 2 ,  17 - 2 ,  18 - 3 ,  19 - 2 , and  20 - 2  which may be of any shape and configuration. The shape or configuration may be similar to that shown by  FIG. 16  illustration A, B, C, or D, or of a different shape or configuration.  
      Referring to  FIGS. 8-10 , various features are illustrated, including enlargeable section  10 - 3  and enlargeable section openings  10 - 4  are shown. Fluids may enter from the surgical cavity into enlargeable section  10 - 3  through openings  10 - 4 . Suction-irrigation tube  10 - 5  allows for suction of fluids from enlargeable section  10 - 3 . Suction-irrigation tube  10 - 5  can be moved longitudinally to control the depth to which fluids are removed. As the suction-irrigation tube is advanced farther to the distal end of enlargeable section  10 - 3  and dimension  10 - 6  is thereby reduced, increasing amounts of fluids are removed from the enlargeable section. Inner utility member  10 - 7  comprises an operating rod and a cross member, where the cross member is configured to hold the partial distal tip distal (e.g. ends of enlargeable section  10 - 3 ) pieces together to form a complete distal tip when in the position shown by  FIG. 9A . In  FIG. 9B , inner utility member  10 - 7  is disengaged from the distal tip and retracted from the enlargeable section. In the arrangement shown in  FIG. 9B , the enlargeable section pieces can deflect outward away from the axis of the enlargeable section so there is no distal tip that confines openings  10 - 4 . Figures A and B each show cross sections A-A and B-B which are non-enlarged and enlarged conditions for the enlargeable section  10 - 3 . When the enlargeable section is comprised of a smaller number of pieces  10 - 8 , the distance between adjacent pieces is larger as shown by View A, Section B-B, versus when comprised of a larger number of pieces  10 - 9 , the distance between adjacent pieces is smaller as shown by View B, Section B-B. Each of these two cases provides a different “filtering” effect for fluid entering through openings  10 - 4  into enlargeable section  10 - 3 .  
      Referring to  FIG. 11 , various features are illustrated by Views A, B, and C. Tynes  11 - 3  at the distal end of elongate member  11 - 1  may, in some embodiments, have passive spring action configured to move the tynes outward away from their axis unless confined by sleeve member  11 - 2 . As sleeve member  11 - 2  is moved toward the proximal end of elongate member  11 - 1 , the tynes may passively move and deflect bodily tissue outward away from the suction area of elongate member  11 - 1  and sleeve member  11 - 2  as shown by Views B and C, allowing fluid but not tissue to enter. Suction-irrigation tube  11 - 5  allows for suction of fluids from the tyne area beyond the distal tip of elongate member  11 - 1  and sleeve member  11 - 2 . Suction-irrigation tube  11 - 5  can be moved longitudinally to control the depth to which fluids are removed. As the suction-irrigation tube is advanced farther away from the proximal end and dimension  11 - 6  is thereby reduced, increasing amounts of fluids are removed.  
      Referring to  FIG. 12 , various features are illustrated by Views A and B. Operating rod  12 - 3  has a cross member  12 - 4  at its distal end. By extending operating rod  12 - 3 , the cross member  12 - 4  is moved farther away from the distal end of elongate member  12 - 1  and dimension  12 - 5  is thereby increased. As cross member  12 - 4  is moved away from the distal end of elongate member  12 - 1 , bodily tissue is deflected and fluid can more easily flow into elongate member  12 - 1  without entry of bodily tissue. Fluid may enter elongate member  12 - 1  through its distal end if open and/or perforations  12 - 2 .  
      Referring to  FIG. 13 , various features are illustrated by Views A and B. Operating rod  13 - 3  has an inner elongate member  13 - 4  and cap member  13 - 5  at its distal end. By extending operating rod  13 - 3 , inner elongate member  13 - 4  and cap member  13 - 5  move farther away from the distal end of outer elongate member  13 - 1  and dimension  13 - 7  is thereby increased. As cap member  13 - 5  is moved away from the distal end of outer elongate member  13 - 1 , bodily tissue is deflected away and fluid can more easily flow into outer elongate member  13 - 1  without entry of bodily tissue. Fluid may enter outer elongate member  13 - 1  through its perforations  13 - 2 . Openings  13 - 6  in inner elongate member  13 - 4  allow fluid to flow through perforations  13 - 2 , into the inner chamber of inner elongate member  13 - 4 , through the open proximal end of inner elongate member  13 - 4 , and ultimately into outer elongate member  13 - 1 .  
      Referring to  FIG. 14 , various features are illustrated by Views A, B, C, D, and E. Operating rod  14 - 2  has an expandable cross member  14 - 3  at its distal tip. As operating rod  14 - 2  is moved toward the distal end of elongate member  14 - 1 , cross member  14 - 3  exits the distal end of elongate member  14 - 1  and expands. With further movement of operating rod  14 - 2 , dimension  14 - 4  increases. As dimension  14 - 4  increases, cross member  14 - 3  deflects bodily tissue away from elongate member  14 - 1  and allows fluid to flow more easily into elongate member  14 - 1 , without entry of bodily tissue.  
      Referring to  FIG. 15 , various features are illustrated by Views A, B, and C. Operating rod  15 - 3  is attached to inner elongate member  15 - 4  at its distal end. By extending operating rod  15 - 3 , inner elongate member  15 - 4  advances out the distal end of outer elongate member  15 - 1  and dimension  15 - 6  increases. Passive spring action of tynes  15 - 5  causes the tynes to spread away from their axis as a result of not being confined by outer elongate member  15 - 1 . The tynes deflect bodily tissue away from the distal end of outer elongate member  15 - 1  so fluid can more easily flow into outer elongate member  15 - 1  through perforations  15 - 2  and/or openings through the distal and proximal ends of inner elongate member  15 - 4 .  
      Referring to  FIG. 16 , various features are illustrated by Views A, B, C, and D. These four views show perforation section with different shapes and configurations of the  16 - 2  perforations that allow fluid to flow into elongate member  16 - 1 . The shapes or configurations may be similar to that shown by  FIG. 16  or of different shapes or configurations. One feature of certain perforation arrangements employs an increasing total perforation opening area while progressing from the distal end of tube  16 - 1  to the proximal end.  
      Referring to  FIG. 17 , various features are illustrated by Views A, B, C, and D. These four views show exemplary alternative positions of the  17 - 2  perforations that allow fluid to flow into elongate member  17 - 1 . The perforation locations may be closer to the distal end of elongate member  17 - 2  as shown by View A or farther from the distal end as shown by Views B or C. As dimension  17 - 3  is increased, the length of distal tip beyond the perforations increases. The longer distal tip dimensions provide for more deflection of bodily tissue upon insertion of elongate member  17 - 1  into the surgical cavity and through that greater tissue deflection the improved flow of fluid into elongate member  17 - 1 .  
      Referring to  FIG. 18 , the position of sleeve member  18 - 2  along the length of elongate member  18 - 1  can be varied during the duration of surgery. For example, initially, sleeve member  18 - 2  can be moved toward the distal tip of elongate member  18 - 1  so that only a small percentage of the perforations are exposed and capable of drawing fluid from the surgical cavity into elongate member  18 - 1 . Later, for example, sleeve member  18 - 2  can progressively be moved away from the distal tip of elongate member  18 - 1  thereby increasing percentages of the perforations exposed and capable of drawing fluid from the surgical cavity into elongate member  18 - 1 . Another benefit of progressively exposing a greater number of perforations is in case the initial perforations become clogged and therefore additional perforations are needed. A benefit of this embodiment is that the point of maximum suction which is at the distal tip of sleeve member  18 - 2  is always at the location of the most recently exposed and open perforations.  
      Referring to  FIG. 19 , the position of inner elongate member  19 - 3  along the length of outer elongate member  19 - 1  can be varied (e.g. during the duration of surgery). For example, initially, inner elongate member  19 - 3  can be moved toward the distal tip of outer elongate member  19 - 1  so that only a small percentage of the perforations are exposed and capable of drawing fluid from the surgical cavity into tube  19 - 1 . Later, inner elongate member  19 - 3  can progressively be moved away from the distal tip of outer elongate member  19 - 1  so increasing percentages of the perforations are exposed and capable of drawing fluid from the surgical cavity into outer elongate member  19 - 1 . Another benefit of progressively exposing a greater number of perforations is in case the initial perforations become clogged and therefore additional perforations are needed. A benefit of this embodiment is that the point of maximum suction which is at the distal tip of inner elongate member  19 - 3  is always at the location of the most recently exposed and open perforations.  
      Referring to  FIG. 20 , the distal end  20 - 3  of elongate member  20 - 1  may be, for example, either open as shown by Views A and C or closed as shown by Views B and D. Elongate member  20 - 1  may either be used without a tissue manipulation tip as shown by Views A and B or with a tissue manipulation tip  20 - 4  as shown by Views C and D. For View D, the tissue manipulation tip  20 - 4  penetrates through a hole in distal end  20 - 3 .  
      Referring to  FIGS. 21 and 22 , the embodiments of, for example,  FIGS. 8 through 20  are assembled with other surgical instrument devices. Referring to  FIG. 21 , outer elongate member  21 - 1  is installed in a stationary manner inside handle unit  21 - 3 . Inner elongate member  21 - 2  slides inside outer elongate member  21 - 1  and inside handle  21 - 3 . For Views A and B, inner elongate member  21 - 2  has an operating lever  21 - 4  connected to it. For Views C and D, an operating rod  21 - 5  connects handle  21 - 4  to inner elongate member  21 - 2  at point  21 - 6 . In View C, operating rod  21 - 5  connects to the proximal end of inner elongate member  21 - 2 . In View D, operating rod  21 - 5  connects to the distal tip of inner elongate member  21 - 2 . In View A, the proximal end of inner elongate member  21 - 2  has a fixed lever  21 - 4  attached. In Views B, C, and D, the proximal end of inner elongate member  21 - 2  has a pivoting lever  21 - 4  attached. By moving lever  21 - 4 , inner elongate member  21 - 2  is also moved.  
      Referring to  FIG. 22 , inner elongate member  22 - 2  is installed in a stationary manner inside handle unit  22 - 3  as shown by Views A and B. In Views B and C, inner elongate member  22 - 2  is connected to a stationary point inside handle unit  22 - 3  with operating rod  22 - 5 . Outer elongate member  22 - 1  slides outside inner elongate member  22 - 2  and inside handle  22 - 3 . For Views A, B, C, and D, outer elongate member  22 - 1  has an operating lever  22 - 4  connected to it. For Views C and D, an operating rod  22 - 5  connects to inner elongate member  22 - 2  at point  22 - 6 . In View C, operating rod  22 - 5  connects to the proximal end of inner elongate member  22 - 2 . In View D, operating rod  22 - 5  connects to the distal tip of inner elongate member  22 - 2 . In View A, the proximal end of outer elongate member  22 - 1  has a fixed lever  22 - 4  attached. In Views B, C, and D, the proximal end of outer elongate member  22 - 1  has a pivoting lever  22 - 4  attached. By moving lever  22 - 4 , outer elongate member  22 - 1  is also moved.  
       FIG. 23 , illustrates cross sections through the elongate member of embodiments shown by  FIGS. 8-22 .  FIG. 23  illustrates the inclusion of a cautery hook or utility member numbered  23 - 3 . Inner elongate member  23 - 1  is inside outer elongate member  23 - 2 . The wall thickness of outer elongate member  23 - 2  varies as necessary to contain cautery hook or utility member  23 - 3 . Views A and B also show a rib protrusion  23 - 4  that guides the movement between the two elongate members and keep them in alignment. Rib protrusion  23 - 4  is integral with inner elongate member  23 - 1  and slides in rib groove  23 - 2  in outer elongate member  23 - 2 .  
      The multifunctional devices of the present invention have many advantages. For example, in certain embodiments, the enlargeable section may be constructed by cutting holes (e.g. longitudinal slits) in an existing elongate member, instead of attaching a separate enlargeable member to an elongate member. In this regard, the devices of the present invention are reliable (e.g. few parts) and easy to produce (e.g. no extra steps to create and attach a separate enlargeable member). Another advantage of the devices of the present invention is that, in many embodiments, there are no tynes (or other potentially dangerous protuberances) that stick out that could damage tissue (e.g. embodiments with a “bulging midsection” do not have tynes sticking out that might damage tissue). Furthermore, in some embodiments, the walls of the enlargeable section and/or the media (membrane) surrounding the enlargeable section, prevents tissue from being blocking the ability of the multifunctional devices to provide a suction, irrigation, or tissue manipulation function.  
      The enlargeable section of the present invention can be continuously enlarged to different sizes or can have various predetermined sizes in the deployed (expanded position). The walls of the enlargeable section can have various predetermined or preformed configurations or shapes in the expanded position in accordance with procedural use including various shapes for holding back or manipulating tissue and defining or circumscribing various working or operating spaces. Some configurations for the enlargeable section that are particularly advantageous include, but are not limited to, “bulging midsection” configurations, “cone-shaped” configurations”, triangular, oval, single or multiple ball-shaped, etc. Any shape that that creates space during surgery, or allows irrigation or suction to occur without blockage are useful in the present invention.  
      As described above, a further advantage of the multifunctional devices of the present invention is that, in certain embodiments, the multifunctional devices have perforations that can be progressively exposed, or sealed-off, from the surgical cavity allowing improved suction, irrigation, and drainage of fluids from the surgical cavity. For example, in certain embodiments, an inner elongate member may be moved inside an outer elongate member (containing a plurality of perforations) such that the perforations can be exposed or blocked, thereby allowing or preventing fluid movement through the openings. Also for example, in other embodiments, the elongate member is partially enclosed by a sleeve member that may be moved along the elongate member such that perforations in the elongate member are exposed or blocked, thereby allowing or preventing fluid movement through the openings. The use of inner elongate member and/or sleeve members to control the opening and closing of perforations allows for maintenance of maximum suction at the most recently exposed and freshly opened perforations. This provision results in continually available and open perforations during the duration of surgical procedures.  
      In certain embodiments, such multifunctional devices are expandable, while in other embodiments, such devices are not expandable. These improvements facilitate improved surgical suctioning and/or irrigation, as well as chronic drainage from a wound after surgical procedures (e.g. drained abscesses, thoracotomy tubes, etc.). Control over the number and timing of when the perforations in the elongate member provides for additional control of the fluid environment during surgery.  
      The multifunctional devices of the present invention are useful for performing conventional surgery. Examples of conventional surgery include, but are not limited to, abdominal surgeries, urologic surgeries, gynecologic surgeries, thoracic surgeries, cardiac surgeries, and vascular surgeries. The multifunctional devices are also useful for conventional microsurgeries (e.g. of the hand), peripheral vascular surgeries, neurosurgery (e.g. peripheral, spinal cord, and intracranial), and otolaryngological (ENT) surgeries.  
      The multifunctional devices of the present invention are particularly useful for endoscopic type procedures. Examples of procedures in which the devices of the present invention may be employed include, but are not limited to, laparoscopic cholecystectomy, laparoscopic treatment of gastroesophageal reflux and hiatal hernia, laparoscopic cardiomyotomy (Heller Myotomy), laparoscopic gastrostomy, laparoscopic vagotomy, laparoscopic plication of perforated ulcer, gastric resections, laparoscopic bariatris surgery, small bowel resections, enterolysis, enteroenterostomy, placement of jejunostomy tube, laparoscopic appendectomy, laparoscopic colostomy, laporoscopic segmental colectomies, anterior resections, abdominopereneal resection, laparoscopic-assisted proctocolectomy, distal pancreatectomy, laparoscopic cholecystojejunostomy, laporoscopic gastrojejunostomy, laporoscopic splenectomy, lymph node biopsy, laparoscopic adrenalectomy, laproscopic inguinal hernia repair, laproscopic repair of ventral hernia, upper gastrointestinal endoscopy, small bowel enteroscopy, endoscopic retrograde cholangiopancreatography, choledochostomy, flexible sigmoidoscopy, colonoscopy, and pediatric endoscopy. These and other techniques and methods suitable for use with the multifunctional devices of the present invention are described in “The Sages Manual, Fundamentals of Laparoscopy and GI Endoscopy”, edited by Carol E. H. Scott-Conner, Spinger Pub., 1999, herein specifically incorporated by reference.  
      All publications and patents mentioned in the above specification are herein incorporated by reference. Various modifications and variations of the described devices, compositions, methods, systems, and kits of the invention will be apparent to those skilled in the art without departing from the scope and spirit of the invention. Although the invention has been described in connection with specific preferred embodiments, it should be understood that the invention as claimed should not be unduly limited to such specific embodiments. Indeed, various modifications of the described modes for carrying out the invention which are obvious to those skilled in art are intended to be within the scope of the following claims.