Patent Publication Number: US-2020275970-A1

Title: Treatment device

Description:
This application is a continuation of International Application No. PCT/JP2017/044089, filed on Dec. 7, 2017, the entire contents of which are incorporated herein by reference. 
    
    
     BACKGROUND 
     The present disclosure relates to a treatment device. 
     In the related art, there has been known a treatment device that includes an energy applying structure applying energy to a living tissue, and performs treatment (joining (or anastomosis), incising, and the like) on the living tissue by application of the energy (for example, see JP 2012-165948 A). 
     The energy applying structure described in JP 2012-165948 A is disposed on each of facing surfaces of a pair of jaws (first and second holding members) for gripping a living tissue. In addition, the energy applying structure includes a treatment tool (first and second high-frequency electrodes) made of a conductive material, and a heating member (electric heating chip) that is disposed on the treatment tool and generates heat when energized. 
     The treatment tool is directly and electrically connected to a high-frequency lead wire (high-frequency electrode energizing line) constituting a cable connected to an external energy source. Then, by supplying high-frequency power from the energy source through each high-frequency lead wire to the treatment tool of each energy applying structure disposed on each of the pair of jaws, high-frequency energy is applied to the living tissue gripped by the pair of jaws. 
     The heating member is electrically connected to a flexible substrate. The flexible substrate is electrically connected to a heating lead wire constituting the cable described above. The heating member then generates heat by the power supplied from the energy source through the heating lead wire and the flexible substrate, thus heating the treatment tool. 
     SUMMARY 
     According to one aspect of the present disclosure, there is provided a treatment device including: a heater including a first surface serving as a front surface, a second surface serving as a back surface, and a heating pattern formed on the first surface and configured to generate heat when energized; a treatment tool bonded to the second surface and configured to apply high-frequency energy and thermal energy to a living tissue in contact with the treatment tool; and a flexible substrate disposed so as to face the treatment tool with the heating member interposed between the flexible substrate and the treatment tool, the flexible substrate including a first electrical conductor configured to supply high-frequency power to the treatment tool, a second electrical conductor configured to supply power to the heating pattern, and a pair of insulating layers facing each other with the first electrical conductor and the second electrical conductor interposed between the pair of insulating layers, wherein the first electrical conductor includes a first bonding portion exposed from the pair of insulating layers and bonded to the treatment tool, the second electrical conductor includes a second bonding portion exposed from the pair of insulating layers and bonded to the heating pattern, the treatment tool includes a projection configured to project toward the flexible substrate and surround the heater, and the first bonding portion is bonded to the projection. 
     The above and other features, advantages and technical and industrial significance of this disclosure will be better understood by reading the following detailed description of presently preferred embodiments of the disclosure, when considered in connection with the accompanying drawings. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  is a view schematically illustrating a treatment system according to an embodiment; 
         FIG. 2  is a view illustrating a gripping portion; 
         FIG. 3  is a view illustrating the gripping portion; 
         FIG. 4  is a view illustrating a first energy applying structure; 
         FIG. 5  is a view illustrating the first energy applying structure; 
         FIG. 6  is an exploded perspective view illustrating a first flexible substrate; 
         FIG. 7  is a partially enlarged view of the first flexible substrate; 
         FIG. 8A  is a view for explaining a method of manufacturing the first energy applying structure; 
         FIG. 8B  is a view for explaining the method of manufacturing the first energy applying structure; 
         FIG. 8C  is a view for explaining the method of manufacturing the first energy applying structure; 
         FIG. 9  is a view illustrating a first modification of the embodiment; 
         FIG. 10  is a view illustrating a second modification of the embodiment; 
         FIG. 11  is a view illustrating a third modification of the embodiment; 
         FIG. 12  is a view illustrating a fourth modification of the embodiment; 
         FIG. 13  is a view illustrating a fifth modification of the embodiment; 
         FIG. 14  is a view illustrating a sixth modification of the embodiment; 
         FIG. 15  is a view illustrating a seventh modification of the embodiment; and 
         FIG. 16  is a view illustrating an eighth modification of the embodiment. 
     
    
    
     DETAILED DESCRIPTION 
     Hereinafter, modes for carrying out the present disclosure (hereinafter, “embodiments”) will be described with reference to the drawings. The present disclosure is not limited by the embodiments to be described below. In addition, in the description of the drawings, the same portions are denoted by the same reference numerals. 
     Schematic Configuration of Treatment System 
       FIG. 1  is a view schematically illustrating a treatment system  1  according to the present embodiment. 
     The treatment system  1  applies high-frequency energy and thermal energy to a living tissue as a treatment target, thus performing treatment (joining (or anastomosis), incising, and the like) on the living tissue. As illustrated in  FIG. 1 , the treatment system  1  includes a treatment device  2 , a control device  3 , and a foot switch  4 . 
     Configuration of Treatment Device 
     The treatment device  2  is, for example, a linear surgical treatment device for performing treatment on a living tissue through an abdominal wall. As illustrated in  FIG. 1 , the treatment device  2  includes a handle  5 , a shaft  6 , and a gripping portion  7 . 
     The handle  5  is a portion that an operator holds by hand. The handle  5  includes an operation knob  51  as illustrated in  FIG. 1 . 
     As illustrated in  FIG. 1 , the shaft  6  has a substantially cylindrical shape and is connected to the handle  5  at one end (right end in  FIG. 1 ). In addition, the gripping portion  7  is attached to the other end (left end in  FIG. 1 ) of the shaft  6 . Inside the shaft  6 , an opening and closing mechanism (not illustrated) that opens and closes a first gripping member  8  and a second gripping member  9  ( FIG. 1 ) constituting the gripping portion  7  according to an operation of the operation knob  51  by the operator is disposed. Further, inside the shaft  6 , an electric cable C ( FIG. 1 ) connected to the control device  3  is extended from one end side (right end side in  FIG. 1 ) through the handle  5  to another end side (left end side in  FIG. 1 ). 
     Configuration of Gripping Portion 
       FIG. 2  and  FIG. 3  are views illustrating the gripping portion  7 . Specifically,  FIG. 2  is a perspective view of the gripping portion  7 .  FIG. 3  is a cross-sectional view of the gripping portion  7  obtained by cutting the gripping portion  7  along a plane orthogonal to a longitudinal direction from a distal end to a proximal end of the gripping portion  7 . 
     The gripping portion  7  is a portion that grips a living tissue LT ( FIG. 3 ) such as a blood vessel and treats the living tissue LT. The gripping portion  7  includes the first gripping member  8  and the second gripping member  9  as illustrated in  FIGS. 1 to 3 . 
     The first gripping member  8  and the second gripping member  9  are supported by the other end (left end in  FIG. 1  and  FIG. 2 ) of the shaft  6  so as to be openable and closable in a direction of an arrow R 1  ( FIG. 2 ), and can grip the living tissue LT according to an operation of the operation knob  51  by an operator. 
     Configuration of First Gripping Member 
     Note that “distal end side” to be described below is the distal end side of the gripping portion  7  and means the left side in  FIG. 1  and  FIG. 2 . In addition, “proximal end side” to be described below is the side of the shaft  6  of the gripping portion  7  and means the right side in  FIG. 1  and  FIG. 2 . 
     The first gripping member  8  is disposed above the second gripping member  9  in  FIGS. 1 to 3 . As illustrated in  FIG. 2  or  FIG. 3 , the first gripping member  8  includes a first jaw  10  and a first energy applying structure  11 . 
     The first jaw  10  has an elongated shape extending in the longitudinal direction of the gripping portion  7 . The first jaw  10  is rotatably supported at the proximal end side with respect to the shaft  6  to rotate, thus opening and closing with respect to the second gripping member  9 . 
     In the present embodiment, it is configured that the second gripping member  9  is fixed to the shaft  6  and the first gripping member  8  is rotatably supported by the shaft  6 , but the present disclosure is not limited thereto. For example, it may be configured that both the first gripping member  8  and the second gripping member  9  are rotatably supported by the shaft  6  to rotate, thus opening and closing. Alternatively, for example, it may be configured that the first gripping member  8  is fixed to the shaft  6 , and the second gripping member  9  is rotatably supported by the shaft  6  to rotate, thus opening and closing with respect to the first gripping member  8 . 
       FIG. 4  and  FIG. 5  are views illustrating the first energy applying structure  11 . Specifically,  FIG. 4  is a perspective view of the first energy applying structure  11  as viewed from above in  FIGS. 1 to 3 .  FIG. 5  is an exploded perspective view of the first energy applying structure  11  illustrated in  FIG. 4 . 
     The first energy applying structure  11  generates high-frequency energy and thermal energy under the control of the control device  3 . As illustrated in  FIG. 4  or  FIG. 5 , the first energy applying structure  11  includes a treatment tool  12 , a heating member  13 , and a first flexible substrate  14 . 
     The treatment tool  12  is made of, for example, a conductive material such as copper. In addition, as illustrated in  FIG. 4  or  FIG. 5 , the treatment tool  12  is formed of a plate that extends in an elongated shape (elongated shape extending in longitudinal direction of gripping portion  7  (left-right direction in  FIG. 4  and  FIG. 5 )) and has a recess  121  on one plate surface. 
     The recess  121  is located at the center of the treatment tool  12  in a width direction, and extends along the longitudinal direction of the treatment tool  12 . Further, among side walls constituting the recess  121 , the proximal end side does not include the side wall. The treatment tool  12  supports the members  13  and  14  in the recess  121 , and is attached to the first jaw  10  in a posture that the recess  121  faces upward with respect to the lower surface of the first jaw  10  in  FIGS. 2 and 3 . 
     Here, in the treatment tool  12 , the side wall constituting the recess  121  extends along an outer edge of the treatment tool  12 , surrounds the heating member  13 , and corresponds to a projection  122  ( FIGS. 3 to 5 ) according to the present disclosure. As illustrated in  FIG. 4  or  FIG. 5 , a bonding groove  1221  to which a high-frequency pad  1441  of the first flexible substrate  14  is bonded is formed on a distal end side of a projecting end of the projection  122 . Further, in the treatment tool  12 , the plate surface on which the recess  121  is not formed is constituted by a flat surface orthogonal to a thickness direction of the treatment tool  12  (vertical direction in  FIGS. 3 to 5 ), and functions as a first gripping surface  123  gripping the living tissue LT with the second gripping member  9 . 
     The heating member  13  has an outer size slightly smaller than the inner size of the recess  121  and is bonded to a bottom surface of the recess  121 . The heating member  13  has a resistance pattern  162  that generates heat when energized, and heats the treatment tool  12  by the heat of the resistance pattern  162 . As illustrated in  FIG. 5 , the heating member  13  includes an insulating member  15 , a heating pattern  16 , and a cover layer  17 . 
     The insulating member  15  is made of, for example, an insulating material having high thermal conductivity, such as alumina or aluminum nitride, and transmits the heat of the resistance pattern  162  to the treatment tool  12 . Further, as illustrated in  FIG. 5 , the insulating member  15  is formed of an elongated plate extending in the longitudinal direction of the gripping portion  7 . 
     Here, in the insulating member  15 , one plate surface (upper plate surface in  FIG. 5 ) corresponds to a first surface PS 1  ( FIG. 5 ) according to the present disclosure. Further, in the insulating member  15 , the other plate surface (lower plate surface in  FIG. 5 ) corresponds to a second surface PS 2  ( FIG. 5 ) according to the present disclosure. The heating member  13  has the second surface PS 2  bonded to the bottom surface of the recess  121 . 
     The heating pattern  16  is obtained by processing a platinum thin film, and includes a pair of heating connectors  161  and the resistance pattern  162  as illustrated in  FIG. 5 . The heating pattern  16  is formed by patterning a platinum thin film that is formed on the first surface PS 1  by vapor deposition, sputtering, or the like using photolithography. 
     The material of the heating pattern  16  is not limited to the platinum thin film, and may be a conductive thin film material such as nickel or titanium. The heating pattern  16  is not limited to the configuration in which a thin film is patterned on the first surface PS 1 , and a configuration in which a thick film paste material such as ruthenium oxide is formed on the first surface PS 1  by a printing technique may be employed. 
     The pair of heating connectors  161  have a layer structure of an adhesion layer inserted between the insulating members  15  and the heating connector  161  as needed, an adhesion layer added to a surface side, and a protective layer. Further, as illustrated in  FIG. 5 , the pair of heating connectors  161  are located at diagonal positions on the first surface PS 1 , that is, at corner portions on the distal end side (left end side in  FIG. 5 ) and the proximal end side (right end side in  FIG. 5 ). Then, a pair of heating conductive lines  145  constituting the first flexible substrate  14  are bonded (connected) to the pair of heating connectors  161 , respectively. 
     The resistance pattern  162  is connected (conductive) to the heating connector  161  on the proximal end side at one end, extends while meandering in a wave shape toward the distal end side, and is connected (conductive) to the heating connector  161  on the distal end side at the other end. Then, the resistance pattern  162  generates heat when a voltage is applied (energized) to the pair of heating connectors  161  through the pair of heating conductive lines  145  under the control of the control device  3 . 
     The cover layer  17  is made of, for example, an insulating material such as polyimide having high thermal conductivity. The cover layer  17  is formed of an elongated plate (elongated plate extending in longitudinal direction of gripping portion  7 ) having the same width and length dimensions as the insulating member  15 . The cover layer  17  has one plate surface (lower plate surface in  FIG. 5 ) bonded to the first surface PS 1  to cover the heating pattern  16 . The cover layer  17  includes apertures  171  ( FIG. 5 ) that pass the cover layer  17  and expose the pair of heating connectors  161  to outside at positions facing the pair of heating connectors  161 . 
     In the present embodiment, it is desirable that the thermal resistance of the cover layer  17  is higher than the thermal resistance of the insulating member  15 . The cover layer  17  may be made of the same material as the insulating member  15 . In this case, if the thickness dimension of the cover layer  17  is made larger than the thickness dimension of the insulating member  15 , the thermal resistance of the cover layer  17  can be made larger than the thermal resistance of the insulating member  15 . By making the thermal resistance of the cover layer  17  larger than the thermal resistance of the insulating member  15  as described above, more heat generated in the resistance pattern  162  can be transmitted to a side of the insulating member  15 . 
       FIG. 6  is an exploded perspective view illustrating the first flexible substrate  14 .  FIG. 7  is a partially enlarged view of the first flexible substrate  14 . 
     The first flexible substrate  14  corresponds to a flexible substrate according to the present disclosure. The first flexible substrate  14  is electrically connected to the electric cable C extended from one end side to the other end side of the shaft  6 , the treatment tool  12 , and the heating member  13 , respectively, and relays the electric cable C to the treatment tool  12  and the heating member  13 . The first flexible substrate  14  is disposed so as to face the first surface PS 1 . The first flexible substrate  14  includes a first insulating layer  141 , a conductive layer  142 , and a second insulating layer  143 , as illustrated in  FIGS. 4 to 6 . 
     The first insulating layer  141  corresponds to an insulating layer according to the present disclosure. The first insulating layer  141  is an elongated sheet (elongated sheet extending in longitudinal direction of the gripping portion  7 ) made of an insulating material such as polyimide, and has a width dimension slightly smaller than the width dimension of the recess  121  and a length dimension larger than the length dimension of the recess  121  in the longitudinal direction. 
     The conductive layer  142  is made of a rolled copper foil, and is formed on one surface (upper surface in FIG.  6 ) of the first insulating layer  141 . As illustrated in  FIGS. 4 to 6 , the conductive layer  142  includes a high-frequency conductive line  144  and a pair of heating conductive lines  145 . 
     The high-frequency conductive line  144  corresponds to a first electrical conductor according to the present disclosure. As illustrated in  FIGS. 4 to 6 , the high-frequency conductive line  144  is located at the center in the width direction on one surface of the first insulating layer  141 , and extends linearly from its proximal end to its distal end. A first high-frequency lead wire (not illustrated) constituting the electric cable C is connected (bonded) to an end of the high-frequency conductive line  144  on the proximal end side. In addition, as illustrated in  FIGS. 4 to 6 , the high-frequency pad  1441  that has a rectangular shape in a planar view, projects from an outer edge of the first insulating layer  141  to the distal end side, and is bonded to the treatment tool  12  (bonding groove  1221 ) is disposed at the distal end of the high-frequency conductive line  144 . The high-frequency pad  1441  corresponds to a first bonding portion according to the present disclosure. 
     The pair of heating conductive lines  145  each correspond to a second electrical conductor according to the present disclosure. As illustrated in  FIGS. 4 to 6 , the pair of heating conductive lines  145  are located on both sides in the width direction on one surface of the first insulating layer  141  with the high-frequency conductive line  144  interposed therebetween. Each of the pair of heating conductive lines  145  extends from the proximal end to the position facing each of the pair of heating connectors  161 . A pair of heating lead wires (not illustrated) constituting the electric cable C are respectively connected (bonded) to the ends of the pair of heating conductive lines  145  on the proximal end side. As illustrated in  FIGS. 4 to 6 , a heating pad  1451  that has a rectangular shape in a planar view and is bonded to each of the pair of heating connectors  161  is disposed at each of the distal ends of the pair of heating conductive lines  145 . Each heating pad  1451  corresponds to a second bonding portion according to the present disclosure. 
     The second insulating layer  143  corresponds to an insulating layer according to the present disclosure. The second insulating layer  143  is a sheet made of the same material as the first insulating layer  141  and having the same shape. The second insulating layer  143  is bonded to one surface of the first insulating layer  141  and covers the conductive layer  142 . 
     Cut-away portions  1411 ,  1431  that respectively pass the first and second insulating layers  141 ,  143  and expose parts of the pair of heating pads  1451  to the outside are formed at positions facing the pair of heating pads  1451  on the first and second insulating layers  141 ,  143 , as illustrated in  FIGS. 5 to 7 . More specifically, the cut-away portions  1411 ,  1431  have a rectangular shape in a planar view. As illustrated in  FIG. 7 , the pair of heating pads  1451  are exposed to the outside via the cut-away portions  1411 ,  1431  such that among four sides of the rectangular shape in a planar view, only one side on an outer edge side is located in the cut-away portions  1411 ,  1431 , and the other three sides are sandwiched between the first insulating layer  141  and the second insulating layer  143 . The cut-away portions  1411 ,  1431  each correspond to an exposing aperture according to the present disclosure. 
     Method of Manufacturing First Energy Applying Structure 
       FIGS. 8A to 8C  are views for explaining a method of manufacturing the first energy applying structure  11 . 
     Next, the method of manufacturing the first energy applying structure  11  described above (method of manufacturing treatment device according to the present disclosure) will be described with reference to  FIGS. 8A to 8C . 
     First, as illustrated in  FIG. 8A , a worker disposes a bonding material Bo on the bottom surface of the recess  121 , and houses the heating member  13  in the recess  121  in a posture that the second surface PS 2  faces the bottom surface. At this time, in order to increase the positional accuracy between the treatment tool  12  and the heating member  13 , it is desirable to use a positioning jig or to form a positioning marker, a positioning groove, and a displacement prevention groove in the treatment tool  12  in advance. Then, the worker cures the bonding material Bo while applying an appropriate load between the treatment tool  12  and the heating member  13 , and bonds the treatment tool  12  to the heating member  13  (first bonding step). 
     Examples of the bonding material Bo include bonding materials having high thermal conductivity such as a solder, a conductive paste, and a high thermal conductive adhesive sheet. 
     Next, as illustrated in  FIG. 8B , the worker causes the first flexible substrate  14  to face the treatment tool  12  with the heating member  13  interposed therebetween, and stacks the bonding groove  1221  and the high-frequency pad  1441 , and the pair of heating connectors  161  and the pair of heating pads  1451  in a thickness direction of the first flexible substrate  14  (vertical direction in  FIG. 8B ). At this time, the positional accuracy between the treatment tool  12  and the heating member  13  is achieved at the first bonding step, the heating pattern  16  is formed by a photolithographic technique and thus has high shape accuracy, and the high-frequency pad  1441  and the pair of heating pads  1451  are formed on the single first flexible substrate  14  and thus the position accuracy required for manufacturing the first flexible substrate  14  is achieved. Consequently, the positioning of the bonding groove  1221  and the high-frequency pad  1441 , and of the pair of heating connectors  161  and the pair of heating pads  1451  can be easily performed. 
     Next, the worker brings a probe Pr ( FIG. 8C ) of a resistance welding machine or an ultrasonic welding machine into contact with the high-frequency pad  1441  from a side of the first flexible substrate  14 , applies bonding energy from the probe Pr to perform spot welding. As a result, the high-frequency pad  1441  is bonded to the bonding groove  1221  (second bonding step). Similarly, the worker sequentially brings the probe Pr into contact with the pair of heating pads  1451  from the side of the first flexible substrate  14 , and applies the bonding energy from the probe Pr to perform spot welding. As a result, the pair of heating pads  1451  are sequentially bonded to the pair of heating connectors  161  (third bonding step). 
     With the first to third bonding steps described above, the first energy applying structure  11  is manufactured. 
     Configuration of Second Gripping Member 
     As illustrated in  FIG. 2  or  FIG. 3 , the second gripping member  9  includes a second jaw  18  and a second energy applying structure  19 . 
     The second jaw  18  is a portion obtained by extending a part of the shaft  6  toward the distal end side, and is formed in an elongated shape extending in the longitudinal direction of the gripping portion  7 . 
     The second energy applying structure  19  generates high-frequency energy under the control of the control device  3 . As illustrated in  FIG. 2  or  FIG. 3 , the second energy applying structure  19  includes a counter electrode  20 , a second flexible substrate  21 , and a counter member  22 . 
     The counter electrode  20  is made of, for example, a conductive material such as copper. Further, the counter electrode  20  is formed of an elongated plate (elongated plate extending in longitudinal direction of gripping portion  7 ) having recesses  201 ,  202  ( FIG. 3 ) on both plate surfaces. 
     The recess  201  is located at the center in the width direction on the upper plate surface of the counter electrode  20  in  FIG. 2  and  FIG. 3 , and extends along a longitudinal direction of the counter electrode  20 . 
     Further, among side walls constituting the recess  201 , the distal end side and the proximal end side do not include the side wall. 
     The recess  202  is located at the center in the width direction on the lower plate surface of the counter electrode  20  in  FIG. 2  and  FIG. 3 , and extends along the longitudinal direction of the counter electrode  20 . 
     Further, among side walls constituting the recess  202 , the proximal end side does not include the side wall. 
     The counter electrode  20  is attached to the upper surface of the second jaw  18  in  FIG. 2  and  FIG. 3  in a posture that the recess  201  faces upward. 
     The second flexible substrate  21  is fixed to a bottom surface of the recess  202  at its distal end side, electrically connected to a second high-frequency lead wire (not illustrated) of the electric cable C extended from one end side to the other end side of the shaft  6  and the counter electrode  20 , and relays the second high-frequency lead wire to the counter electrode  20 . 
     The counter member  22  is made of an insulating material. The counter member  22  has an outer size that is substantially the same as the inner size of the recess  201 , and is fitted into the recess  201 . In the counter member  22 , the upper surface in  FIG. 2  and  FIG. 3  projects upward toward the center in the width direction, and the counter member  22  thus has a substantially mountain-like shape whose projecting end is formed in a flat shape orthogonal to a thickness direction (vertical direction in  FIG. 3 ) of the counter member  22 . 
     In the second energy applying structure  19 , the upper surface in  FIG. 2  and  FIG. 3  functions as a second gripping surface  191  that grips the living tissue LT with the first gripping surface  123 . 
     Configuration of Control Device and Foot Switch 
     The foot switch  4  is a portion operated by an operator with his foot. In response to the operation on the foot switch  4 , the control device  3  switches on and off the power supply to the treatment device  2 . 
     The means for switching on and off is not limited to the foot switch  4 , and a switch operated by hand or the like may be used. 
     The control device  3  is configured by including a CPU (Central Processing Unit) and the like, and totally controls the operation of the treatment device  2  according to a predetermined control program. More specifically, the control device  3  supplies high-frequency power to the treatment tool  12  and the counter electrode  20  through the electric cable C (first and second high-frequency lead wires), the high-frequency conductive line  144 , and the second flexible substrate  21 , in response to the operation of the foot switch  4  by the operator (operation of turning on power). In addition, the control device  3  applies a voltage (supplies power) to the pair of heating connectors  161  through the electric cable C (a pair of heating lead wires) and the pair of heating conductive lines  145 . 
     Operation of Treatment System 
     Next, an operation of the treatment system  1  described above will be described. 
     An operator holds the treatment device  2  by hand and inserts the distal end portion (gripping portion  7  and part of shaft  6 ) of the treatment device  2  into an abdominal cavity through an abdominal wall using, for example, a trocar. The operator then operates the operation knob  51  and grips the living tissue LT as a treatment target at the gripping portion  7  (with first gripping surface  123  and second gripping surface  191 ). 
     Next, the operator operates the foot switch  4  to switch on the power supply from the control device  3  to the treatment device  2 . When the power supply is switched on, the control device  3  supplies high-frequency power to the treatment tool  12  and the counter electrode  20  through the electric cable C (first and second high-frequency lead wires), the high-frequency conductive line  144 , and the second flexible substrate  21 . That is, high-frequency energy is applied to the living tissue LT gripped by the first gripping surface  123  and the second gripping surface  191  and degeneration occurs with the high-frequency energy. The living tissues LT are then joined to each other. Further, the control device  3  applies a voltage to the pair of heating connectors  161  through the electric cable C (a pair of heating lead wires) and the pair of heating conductive lines  145  to heat the resistance pattern  162 . The heat from the resistance pattern  162  is transmitted to the treatment tool  12  through the insulating member  15  and the bonding material Bo. The temperature of the living tissue LT that is in contact with the treatment tool  12  (first gripping surface  123 ) increases due to the heat (application of thermal energy) of the treatment tool  12 , and the living tissue LT is incised by both effects of extreme degeneration due to the temperature increase and pressing by the gripping portion  7 . 
     In the above description, a case where high-frequency energy is used to join the living tissues LT and thermal energy is used to incise the living tissue LT has been described. However, by appropriately adjusting the thermal energy, the thermal energy can cooperate with the high-frequency energy to achieve stronger joining and faster incision. 
     The present embodiment described above achieves the following effects. 
     The first energy applying structure  11  according to the present embodiment is manufactured by the first to third bonding steps described above. That is, since the high-frequency wire (high-frequency conductive line  144 ) and the heating wire (heating conductive line  145 ) are disposed on the same first flexible substrate  14 , the wiring is compact and the positioning of each wire and a bonding target (bonding groove  1221  and heating connector  161 ) is easily performed. As a result, the bonding steps (second and third bonding steps) of the respective wires can be simplified and the assemblability of the first energy applying structure  11  (treatment device  2 ) can be improved. 
     Further, it is not necessary to have a space for preventing interference between the wires. In particular, by forming the wires as the conductive layer  142  disposed on the first flexible substrate  14 , the thickness of the first energy applying structure  11  can be reduced as compared with a case where wiring is performed with lead wires. For this reason, the first energy applying structure  11  (treatment device  2 ) can be made compact. 
     As described above, the method of manufacturing the treatment device  2  and the treatment device  2  according to the present embodiment achieve the effect that the assemblability is improved while compactness is achieved. 
     In the first energy applying structure  11  according to the present embodiment, the high-frequency conductive line  144  has the high-frequency pad  1441  projecting from the outer edges of the first and second insulating layers  141 ,  143 . At the second bonding step, the first flexible substrate  14  faces the treatment tool  12  with the heating member  13  interposed therebetween, and the high-frequency pad  1441  and the bonding groove  1221  are stacked in the thickness direction of the first flexible substrate  14 . In such a state, spot welding is performed from the side of the first flexible substrate  14 , so that the high-frequency pad  1441  and the bonding groove  1221  are bonded to each other. That is, the bonding area of the high-frequency pad  1441  and the bonding groove  1221  can be made into a small area subjected to spot welding in order to cope with the compactness of the first energy applying structure  11  (treatment device  2 ), and at the same time, bonding can be performed with high strength. Further, since the high-frequency pad  1441  projects from the outer edges of the first and second insulating layers  141 ,  143 , the bonding energy can be directly applied from the probe Pr to the high-frequency pad  1441 , and the high-frequency pad  1441  can be stably bonded to the bonding groove  1221 . 
     In the first energy applying structure  11  according to the present embodiment, the first insulating layer  141  and the second insulating layer  143  includes the cut-away portions  1411  and  1431  that expose the heating pads  1451  to the outside, respectively. At the third bonding step, the first flexible substrate  14  faces the treatment tool  12  with the heating member  13  interposed therebetween, and the heating pad  1451  and the heating connector  161  are stacked in the thickness direction of the first flexible substrate  14 . In such a state, spot welding is performed from the side of the first flexible substrate  14 , so that the heating pad  1451  and the heating connector  161  are bonded to each other. That is, the bonding area of the heating pad  1451  and the heating connector  161  can be made into a small area subjected to spot welding in order to cope with the compactness of the first energy applying structure  11  (treatment device  2 ), and at the same time, bonding can be performed with high strength. Further, since the heating pad  1451  is exposed to the outside through the cut-away portions  1411 ,  1431 , the bonding energy can be directly applied from the probe Pr to the heating pad  1451 , and the heating pad  1451  can be stably bonded to the heating connector  161 . 
     Furthermore, at the second and third bonding steps, the directions that the probe Pr is brought into contact with the high-frequency pad  1441  and the heating pad  1451  are the same. For this reason, the second and third bonding steps can be simplified, and the assemblability can be further improved. 
     Meanwhile, in the heating member  13 , the resistance pattern  162  contributes to actual heating, and the pair of heating connectors  161  are non-heating portions that do not generate heat. In the present embodiment, the pair of heating connectors  161  are located at diagonal positions on the first surface PS 1 , that is, at corner portions on the distal end side and the proximal end side. That is, as the pair of heating connectors  161  that are non-heating portions are disposed to be separated from each other, the thermal uniformity of the heating member  13  can be improved. 
     In addition, in order to stably bond the heating pad  1451  to the heating connector  161  with high strength, it is necessary for the heating connector  161  to have a certain area. In the present embodiment, the pair of heating connectors  161  are disposed on the first surface PS 1  so as to be separated from each other in the longitudinal direction. Consequently, the area of the heating connector  161  can be set to be larger than that in a configuration in which the pair of heating connectors  161  are arranged in the width direction. 
     In the first energy applying structure  11  according to the present embodiment, the heating pad  1451  is exposed to the outside via the cut-away portions  1411 ,  1431  such that among four sides of the rectangular shape in a planar view, only one side is located in the cut-away portions  1411 ,  1431 , and the other three sides are sandwiched between the first insulating layer  141  and the second insulating layer  143 . That is, by supporting many sides of the heating pad  1451 , the strength of the heating pad  1451  can be improved. 
     OTHER EMBODIMENTS 
     The mode for carrying out the present disclosure has been described above, but the present disclosure should not be limited only by the embodiment described above. 
       FIG. 9  is a view illustrating a first modification of the present embodiment. 
     In the embodiment described above, a first energy applying structure  11 A according to the present first modification illustrated in  FIG. 9  may be used instead of the first energy applying structure  11 . 
     As illustrated in  FIG. 9 , the first energy applying structure  11 A is different from the first energy applying structure  11  described in the above embodiment in that an insulating resin member Re is added. 
     Specifically, the first energy applying structure  11 A is manufactured by sealing the pair of heating pads  1451  exposed to outside with the resin member Re so as to cover the pair of heating pads  1451  (sealing step) after the first to third bonding steps described in the above embodiment. 
     Here, it is desirable to not only apply the resin member Re on a surface of the first flexible substrate  14  but also cause the resin member Re to permeate a side surface of the first flexible substrate  14  and an interface between the first flexible substrate  14  and the heating member  13 , in order to completely seal the pair of heating pads  1451 . Consequently, a resin member having a relatively low viscosity before curing may be used as the resin member Re so as to easily permeate the interface. Alternatively, two types of resin members may be used as the resin member Re. For example, a low-viscosity resin member may be used for the interface and a high-viscosity resin member may be used for the surface and side surface of the first flexible substrate  14  so as to prevent sagging. Examples of such a resin member include a silicone resin, an epoxy resin, and a polyimide resin. 
     According to the first modification described above, in addition to effects similar to those of the embodiment described above, the pair of heating pads  1451  can be reliably insulated and the power for heating can be prevented from leaking to the outside. 
       FIG. 10  is a view illustrating a second modification of the present embodiment. 
     In the embodiment described above, a first energy applying structure  11 B according to the present second modification illustrated in  FIG. 10  may be used instead of the first energy applying structure  11 . 
     As illustrated in  FIG. 10 , the first energy applying structure  11 B is different from the first energy applying structure  11  described in the above embodiment in that a treatment tool  12 B and a first flexible substrate  14 B are used instead of the treatment tool  12  and the first flexible substrate  14 . 
     As illustrated in  FIG. 10 , the treatment tool  12 B is different from the treatment tool  12  described in the above embodiment in that the projection  122  is not formed. 
     As illustrated in  FIG. 10 , the first flexible substrate  14 B is different from the first flexible substrate  14  described in the above embodiment in that a high-frequency pad  1441 B having a shape different from that of the high-frequency pad  1441  is used. 
     As illustrated in  FIG. 10 , the high-frequency pad  1441 B includes a connecting portion  1442  projecting from outer edges of the first and second insulating layers  141 ,  143  to a side of the treatment tool  12  and a bonding portion main body  1443  bent substantially at a right angle from the connecting portion  1442  along a back surface of the first gripping surface  123  in the treatment tool  12 B. Similarly to the second bonding step described in the above embodiment, bonding energy is applied from the probe Pr to the bonding portion main body  1443 , and the high-frequency pad  1441 B is bonded to the back surface of the first gripping surface  123  in the treatment tool  12 B by spot welding. 
       FIG. 11  is a view illustrating a third modification of the present embodiment. 
     In the embodiment described above, a first energy applying structure  11 C according to the present third modification illustrated in  FIG. 11  may be used instead of the first energy applying structure  11 . 
     As illustrated in  FIG. 11 , the first energy applying structure  11 C is different from the first energy applying structure  11  described in the above embodiment in that a treatment tool  12 C is used instead of the treatment tool  12 . 
     The treatment tool  12 C does not have the projection  122  as in the treatment tool  12 B described in the second modification. In the treatment tool  12 C, a projection  122 C projecting toward the first flexible substrate  14  is disposed at a position facing the high-frequency pad  1441  on a back surface of the first gripping surface  123 . Similarly to the second bonding step described in the above embodiment, bonding energy is applied from the probe Pr to the high-frequency pad  1441 , and the high-frequency pad  1441  is bonded to the projection  122 C by spot welding. 
     According to the second and third modifications described above, in addition to effects similar to those of the embodiment described above, it is possible to improve the degree of freedom of the shape of the treatment tools  12 B,  12 C. 
       FIG. 12  is a view illustrating a fourth modification of the present embodiment. 
     In the embodiment described above, a first energy applying structure  11 D according to the present fourth modification illustrated in  FIG. 12  may be used instead of the first energy applying structure  11 . 
     As illustrated in  FIG. 12 , the first energy applying structure  11 D is different from the first energy applying structure  11  described in the above embodiment in positions where the pair of heating pads  1451  (a pair of cut-away portions  1411 ,  1431  and a pair of heating connectors  161 ) are formed. 
     Specifically, in the first energy applying structure  11 D according to the fourth modification, the pair of heating pads  1451  (a pair of cut-away portions  1411 ,  1431  and a pair of heating connectors  161 ) are disposed so as to face to each other in a width direction at a substantially central position in the longitudinal direction of the heating member  13 , as illustrated in  FIG. 12 . 
     The fourth modification described above achieves the following effect in addition to effects similar to those of the embodiment described above. 
     Meanwhile, when the resistance pattern  162  is formed over the entire first surface PS 1 , the temperature distribution of the first surface PS 1  tends to be high at the central position and low at the outer edge. In the present fourth modification, the pair of heating connectors  161  are disposed at a substantially central position in the longitudinal direction of the heating member  13  (first surface PS 1 ). That is, by setting the pair of heating connectors  161  that are non-heating portions at the position where the temperature is highest in the temperature distribution described above, the temperature distribution described above can be smoothed and the thermal uniformity of the heating member  13  can be improved. 
     Further, it is assumed in the fourth modification that the pair of heating pads  1451  are sealed with the resin member Re at the sealing step as described in the first modification. In this case, since the pair of heating pads  1451  are disposed close to each other, the pair of heating pads  1451  can be sealed at the same time and the sealing step can be simplified. 
       FIG. 13  is a view illustrating a fifth modification of the present embodiment. Specifically,  FIG. 13  is a view corresponding to  FIG. 7 . 
     In the embodiment described above, a heating pad  1451 E (heating conductive line  145 E, conductive layer  142 E, and first flexible substrate  14 E) according to the fifth modification illustrated in  FIG. 13  may be used instead of the heating pad  1451 . 
     Specifically, as illustrated in  FIG. 13 , the heating pad  1451 E is exposed to outside via the cut-away portions  1411 ,  1431  such that among four sides of the rectangular shape in a planar view, three sides are located in the cut-away portions  1411 ,  1431 , and the remaining one side is sandwiched between the first insulating layer  141  and the second insulating layer  143 . That is, the heating pad  1451 E can be elastically deformed in a thickness direction of the first flexible substrate  14 E (direction orthogonal to plane of  FIG. 13 ) with the edges of the cut-away portions  1411 ,  1431  as fulcrums. 
     The fifth modification described above achieves the following effect in addition to effects similar to those of the embodiment described above. 
     Meanwhile, there is a gap corresponding to the thickness of the cover layer  17  and the first insulating layer  141  between the heating pad  1451 E and the heating connector  161 . For this reason, when the heating pad  1451 E is bonded to the heating connector  161 , it is necessary to forcibly deform the heating pad  1451 E so as to fill the gap. In the fifth modification, the heating pad  1451 E can be elastically deformed in the thickness direction of the first flexible substrate  14 E. Consequently, the heating pad  1451 E is deformed so as to fill the gap described above, so that the heating pad  1451 E can be easily bonded to the heating connector  161 . 
     The shape of the heating pad  1451 E is not limited to a rectangular shape in a planar view. Any other shape may be possible if the heating pad  1451 E can be elastically deformed in the thickness direction of the first flexible substrate  14 E with the edges of the cut-away portions  1411 ,  1431  as fulcrums. 
       FIG. 14  is a view illustrating a sixth modification of the present embodiment. In  FIG. 14 , the second insulating layer  143  is omitted for convenience of description. 
     In the embodiment described above, a first flexible substrate  14 F according to the present sixth modification illustrated in  FIG. 14  may be used instead of the first flexible substrate  14 . 
     Specifically, as illustrated in  FIG. 14 , the first flexible substrate  14 F is different from the first flexible substrate  14  described above in that a ground conductive line  146  is disposed on one surface of the first insulating layer  141  so as to partition the space between the high-frequency conductive line  144  and each of the pair of heating conductive lines  145 . A ground line (not illustrated) constituting the electric cable C is connected (bonded) to an end of each of the pair of ground conductive lines  146  on a proximal end side. 
     The sixth modification described above achieves the following effect in addition to effects similar to those of the embodiment described above. 
     Meanwhile, it is assumed that high-frequency power as power for heating is supplied to the pair of heating connectors  161  (a pair of heating conductive lines  145 ). In this case, since the high-frequency conductive line  144  and the pair of heating conductive lines  145  are arranged side by side, interference may occur between the high-frequency conductive line  144  and each of the pair of heating conductive lines  145 . In the present sixth modification, the ground conductive line  146  is disposed so as to partition the space between the high-frequency conductive line  144  and each of the pair of heating conductive lines  145 . For this reason, in the case described above, it is possible to reduce the interference generated between the high-frequency conductive line  144  and each of the pair of heating conductive lines  145 . 
     When the first flexible substrate  14 F is formed of a multilayer substrate, the high-frequency conductive line  144  and the pair of heating conductive lines  145  may be disposed on separate layers, and the ground conductive line  146  may be disposed as a solid pattern between the layer of the high-frequency conductive line  144  and the layer of the pair of heating conductive lines  145 . 
       FIG. 15  is a view illustrating a seventh modification of the present embodiment. 
     In the embodiment described above, a first energy applying structure  11 G according to the present seventh modification illustrated in  FIG. 15  may be used instead of the first energy applying structure  11 . 
     As illustrated in  FIG. 15 , the first energy applying structure  11 G is different from the first energy applying structure  11  described in the above embodiment in that a flexible substrate  14 G that includes first and second insulating layers  141 G,  143 G having a width dimension narrower than that of the first and second insulating layers  141 ,  143  is used instead of the first flexible substrate  14 . 
     Specifically, the first and second insulating layers  141 G,  143 G have a shape in which both end portions of the first and second insulating layers  141 ,  143  described in the above embodiment in the width direction are omitted. As a result, the pair of heating pads  1451  project outward in the width direction from outer edges of the first insulating layer  141  and the second insulating layer  143 . 
       FIG. 16  is a view illustrating an eighth modification of the present embodiment. 
     In the embodiment described above, a first energy applying structure  11 H according to the present eighth modification illustrated in  FIG. 16  may be used instead of the first energy applying structure  11 . 
     As illustrated in  FIG. 16 , the first energy applying structure  11 H is different from the first energy applying structure  11  described in the above embodiment in that a flexible substrate  14 H and a treatment tool  12 H are used instead of the flexible substrate  14  and the treatment tool  12 . 
     As illustrated in  FIG. 16 , the flexible substrate  14 H is different from the flexible substrate  14  described in the above embodiment in that first and second insulating layers  141 H,  143 H having a longitudinal length dimension longer than that of the first and second insulating layers  141 ,  143  are used. 
     Specifically, in the first and second insulating layers  141 H,  143 H, ends on a distal end side substantially match the end of the high-frequency pad  1441  on the distal end side. Cut-away portions that respectively pass the first and second insulating layers  141 H,  143 H and expose a part of the high-frequency pad  1441  to outside are formed at positions facing the high-frequency pad  1441  on the first and second insulating layers  141 H,  143 H.  FIG. 16  illustrates only a cut-away portion  1432  formed in the second insulating layer  143 H among the cut-away portions formed in the first and second insulating layers  141 H,  143 H, respectively. The cut-away portions (cut-away portion  1432  in second insulating layer  143 H) formed in the first and second insulating layers  141 H,  143 H, respectively correspond to an exposing aperture according to the present disclosure. 
     As illustrated in  FIG. 16 , the treatment tool  12 H is different from the treatment tool  12  described in the above embodiment in that a bonding groove  1221 H having a width dimension larger than that of the bonding groove  1221  is formed. 
     Specifically, the bonding groove  1221 H cooperates with the change of the first and second insulating layers  141 H,  143 H described above. That is, the bonding groove  1221 H has a width dimension slightly larger than the width dimension of the first and second insulating layers  141 H,  143 H, and allows the distal end side of the flexible substrate  14 H to be disposed. 
     While the treatment device  2  according to the embodiment described above and the first to eighth modifications is configured to apply thermal energy and high-frequency energy to the living tissue LT, the present disclosure is not limited thereto. A configuration of further applying ultrasonic energy may be adopted. 
     In the treatment device  2  according to the embodiment described above and the first to eighth modifications, the first gripping surface  123  is configured as a flat surface, but the present disclosure is not limited thereto. For example, the first gripping surface  123  may be configured to have a projecting cross-sectional shape, a recessed cross-sectional shape, or a mountain-like cross-sectional shape. Similarly, the shape of the second gripping surface  191  is not limited to a mountain-like shape, and other shapes may be adopted. 
     In the embodiment described above and the first to eighth modifications, only the first gripping member  8  of the first gripping member  8  and the second gripping member  9  has a heating function. However, both the first and second gripping members  8  and  9  may have the heating function. 
     While the first energy applying structure  11  ( 11 A to  11 D) and the second energy applying structure  19  are electrically connected to the control device  3  by the electric cable C in the embodiment described above and the first to eighth modifications, the present disclosure is not limited thereto. For example, only the first flexible substrate  14  ( 14 B,  14 D to  14 F) and the second flexible substrate  21  may electrically connect the first energy applying structure  11  ( 11 A to  11 D) and the second energy applying structure  19  to the control device  3 . 
     The method of manufacturing a treatment device and the treatment device  2  according to the present embodiment achieve the effect that the assemblability is improved while compactness is achieved. 
     Additional advantages and modifications will readily occur to those skilled in the art. Therefore, the disclosure in its broader aspects is not limited to the specific details and representative embodiments shown and described herein. Accordingly, various modifications may be made without departing from the spirit or scope of the general inventive concept as defined by the appended claims and their equivalents.