Patent ID: 12226088

DETAILED DESCRIPTION

As will be explained below, certain retractor embodiments described herein provide advantages over the prior art retractors comprising a set of blades and an actuator, such as a set of scissor arms. For example, the retractor of the illustrated embodiment allows a person to insert a relatively compact set of retractor blades into an incision having a short length. In some embodiments, the compact set of retractor blades (e.g., a first blade, a second blade, a third blade) are of such a size that they can be inserted within the incision so that they are snugly embraced by the side walls of the incision (e.g., a closed position).

Optionally, an actuator causes the first blade and the second blade to move apart (e.g., to an opened position) in a direction that can be essentially parallel to the length of the incision. This can cause the tissue to stretch in one direction (e.g., along the length of the incision), creating an opening having a length in that direction that is substantially longer than the incision. Once the retractor is opened in the first direction, the actuator may be locked open. Optionally, a rotation mechanism on the first and/or second blades may be manipulated to rotate the blades (e.g., to a rotated position), for example, pulling the incised tissue apart in one or more directions that are not parallel to the incision. Optionally, a pivot mechanism on the first and/or second blades can be manipulated to pivot the blades (e.g., to a pivoted position), pulling the incised tissue apart in one or more directions that are not parallel to the incision. Optionally, an adjuster on the first and/or second arms can be manipulated to slide or otherwise translate the arms (e.g., to a slid position), pulling the incised tissue apart in directions that are not parallel to the incision. Optionally, an adjuster on the third blade can be manipulated to slide or otherwise translate the third blade (e.g., to a slid position), pulling the incised tissue apart in directions that are not parallel to the incision. In some embodiments, these directions may be perpendicular, substantially perpendicular or oblique to the incision. In certain embodiments, the retractor can be used to open up an aperture that is substantially longer and/or wider than the incision, and is substantially larger than would be possible using a prior art device and/or in a manner that is easier to use and/or requiring less steps and/or less complicated steps. In certain arrangements in relative terms, the surgeon can use a smaller incision, and in some cases a much smaller incision, than would have been required with a prior art device. Moreover, in certain arrangements, removal of the retractor, e.g. by closing the blades, closing the arms and removing the blades from the incision, can allow the incision to relax back to a size that is much smaller than would have resulted from use of the prior art retractor. In addition, in certain arrangements, steps performed by the surgeon to retract the tissue can be simplified, easier to use and/or involve less steps as compared to prior art devices.

The illustrated embodiment will now be further described with reference to the appended drawings. InFIG.1there is shown a perspective view of a retractor10having a body26. The retractor10comprises a first arm12to which can be coupled a first blade assembly16comprising a first blade18. The first blade assembly16can include a first rotation mechanism20to rotate the first blade18. The first blade assembly16and the first arm12can also include a first pivot mechanism22to pivot the first blade18. The first arm12has a proximal end24opposite the first blade assembly16.

The retractor10can include a second arm32to which can be coupled a second blade assembly36comprising a second blade38. The second blade assembly36can include a second rotation mechanism40to rotate the second blade38. The second blade assembly36and the second arm32can include a second pivot mechanism42to pivot the second blade38. The second arm32has a proximal end44opposite the second blade assembly36. The first arm12and the second arm32can be coupled to a slide mechanism28to slide the first arm12and the second arm32relative to the body26. The first arm12and the second arm32can be coupled to a spread mechanism34to slide the first arm12and the second arm32relative to the body26.

In the illustrated embodiment ofFIG.2, the retractor can include a third blade46coupled to the third arm50. The third blade46can include a longitudinally extending slot48sized to accept a probe system500, described herein. In the illustrated embodiment, the probe system500can be configured to be inserted from the tip of the third blade46toward the body26. Other configurations are contemplated. The third arm50of the third blade46can be coupled with the slide mechanism30of the body26to slide the third blade46in relation to the body26. In the illustrated embodiment, the third blade46is configured to be inserted from underneath the body26. The third arm50can interlock to securely couple the third blade46to the body26. In some embodiments, the third arm50forms a snap fit. In some embodiments, the third arm50makes an audible noise when the third blade46is coupled to the body26. Other configurations for coupling these two components together are contemplated, such as, for example a male/female connection and/or permanently connecting the parts and/or forming the parts out of more or less components.

The first rotation mechanism20rotates the first blade18about a first axis52. The second rotation mechanism40rotates the second blade38about a second axis54. In the illustrated arrangement, the first axis52passes vertically or substantially vertically through the first blade18, and the second axis passes vertically or substantially vertically through second blade38. In some embodiments, the first and second axes52,54may be substantially coplanar with one another. Indeed in some embodiments, the first and second axes52,54are not only coplanar but also substantially parallel to one another. In particular embodiments, the first and second axes52,54are coplanar with, parallel to, or at some pre-determined skew angle with respect to one another. As will be described above, various embodiments will be described as “substantially” vertically, parallel, coplanar and/or perpendicular. In such embodiments, “substantially” can mean within plus or minus 25 degrees from the given orientation, in other embodiments, within plus or minus 10 degrees from the given orientation, and in other embodiments, within plus or minus 5 degrees from the given orientation.

In the illustrated embodiment, the first blade assembly16and the second blade assembly36can translate along a third axis56(see e.g.,FIG.3), e.g., spread. The first arm12and the second arm32can be coupled to a spread mechanism34to spread the first arm12and the second arm32relative to the body26. In the illustrated embodiment, the first blade assembly16and the second blade assembly36can move relative to one another along an arc. In the illustrated embodiment, their general direction of motion relative to one another, and the direction of motion can be along the common third axis56that is generally defined by a line passing through the first axis52and the second axis54. In other embodiments, the first blade assembly16and the second blade assembly36can rotate about different axes (e.g., axes that are parallel to each other or slightly skewed). In some examples, the third axis56is perpendicular or substantially perpendicular to the first axis52, the second axis54or both the first and second axes52,54. In particular embodiments, the third axis56is substantially perpendicular or perpendicular to both the first axis52and the second axis54. In some embodiments, the third axis56is substantially perpendicular or perpendicular to the first axis52, the second axis54or both the first and second axes52,54. In some embodiments, the third axis56is perpendicular or substantially perpendicular to both the first and second axes52,54. In some embodiments, the retractor10described herein possesses a mechanism (e.g., set screw, set pin, clamp, detent, ratchet mechanism etc.) for locking the first blade assembly16and the second blade assembly36in at least one predetermined position along the third axis56.

The first pivot mechanism22can pivot the first blade18about a fourth axis58. The second pivot mechanism42can pivot the second blade38about a fifth axis60. In some such embodiments, the fourth axis58and the fifth axis60may be substantially coplanar or coplanar with one another. Indeed in some embodiments, the fourth axis58and the fifth axis60are not only coplanar but also substantially parallel or parallel to one another. In particular embodiments, the fourth axis58and the fifth axis60are substantially coplanar with, coplanar with, substantially parallel to, parallel to, or at some pre-determined skew angle with respect to one another.

In the illustrated embodiment, the first blade assembly16and the second blade assembly36can slide along a sixth axis62(see e.g.,FIG.3). In the illustrated embodiment, the third blade46can slide along the sixth axis62. In some embodiments, the third blade46can slide independently of the first blade assembly16and the second blade assembly36. In the illustrated embodiment, the first blade assembly16and the second blade assembly36can move together in a proximal-distal direction. In other embodiments, the first blade assembly16and the second blade assembly36can slide about different axes (e.g., axes that are parallel to each other or slightly skewed). In some examples, the sixth axis62is perpendicular or substantially perpendicular to the first axis52, the second axis54, or the third axis56. In particular embodiments, the sixth axis62is substantially perpendicular or perpendicular to both the first axis52and the second axis54. In some embodiments, the sixth axis62is substantially parallel or parallel to the fourth axis58, the fifth axis60or both the fourth and fifth axes58,60. In some embodiments, the retractor10described herein possesses a mechanism (e.g., set screw, set pin, clamp, detent, ratchet mechanism etc.) for locking the first blade assembly16and the second blade assembly36in at least one predetermined position along the sixth axis62. In some embodiments, the retractor10described herein possesses a mechanism (e.g., set screw, set pin, clamp, detent, ratchet mechanism etc.) for locking the third blade46in at least one predetermined position along the sixth axis62. In some embodiments, through all the additional movements about the axes52,54,56,58,60,62the third blade46can remain stationary and fixed relative to the body26. In other words, during all movement of the first blade18and the second blade38the third blade26can remain immobile. In some embodiments, the third blade46can move relative to the first blade assembly16and the second blade assembly36through all the additional movements of the first blade assembly16and the second blade assembly36about the axes52,54,56,58,60,62. For example, the third blade46can move along the sixth axis62while the first blade18and the second blade38remain stationary. In another example, the third blade46can pivot relative to the first blade18and the second blade38. The third blade46can be hingedly connected to the body26and can pivot toward the proximal direction to help create an enlarged aperture in the incised tissue.

The blades18,38,46may have a variety of configurations. In some embodiments, at least one blade is substantially flat. In some embodiments (e.g., the illustrated embodiment ofFIGS.1-3), at least one blade is bent or beveled in order to enhance the ability of the blades to lie flat when the blades are in the closed position. This arrangement can allow the first and second blades18,38to exert force on the skin about an incision in opposing directions substantially perpendicular to the blade axes and perpendicular or oblique to a cord defined by the points at which the blade axes intersect the arms12,32of the retractor10. In some embodiments, one or more blades18,38,46can be fan shaped.

In some embodiments, two of the blades are of substantially different sizes in at least one dimension. In some embodiments, the at least two blades of different sizes are the first blade18and second blade38. In some embodiments, the at least two blades of different sizes are the first blade18and the third blade46. In some embodiments, the at least two blades of different sizes are the second blade38and the third blade46. In some embodiments, at least one of the blades18,38,46is a comb-shaped blade. In some embodiments, at least one of the blades18,38,46is a substantially flat blade. In some embodiments, the retractor10can include at least one removable blade. In some embodiments, the first blade18and the second blade38are removable. In some embodiments, the first blade assembly16and the second blade assembly36are removable. In some embodiments, the third blade46is removable. The first blade18can include a first bridge95and the second blade38can include a second bridge96. The blades18,38can have a variety of lengths of bridges95,96. The bridges95,96can allow the blade18,38to be smaller than the length of the retractor10.

The blade assemblies16,36can be removed from the arms12,32. In some arrangement, it can be convenient to remove the blade assemblies16,36in order to expedite sterilization of the blade assemblies16,36and/or in order to exchange one or both blade assemblies16,36for other blade assemblies (e.g. blade assemblies with different size blades, different configuration of blades, etc.) as discussed in more detail herein.

InFIGS.1-3, the retractor10is shown in the “closed position,” meaning that the first blade18, the second blade38, and the third blade46are aligned and relatively close to one another so as to provide a smaller cross-sectional area as compared to an “opened position”. While the application uses the phrase “the closed position,” it is understood that one or more positions may be described as closed. For instance, the blades18,38,46may be aligned, substantially aligned, stacked, substantially stacked, close together, relatively close together, the first blade18encloses the second blade38, the second blade encloses the third blade46, the first blade18encloses the third blade46, one or more blades18,38,46enclose the probe system500, or any other closed positions.

The first blade18, the second blade38, and the third blade46can be substantially parallel or parallel in the closed position. The longitudinal axes of the first blade18, the second blade38, and the third blade46can be aligned on substantially the same or the same plane in the closed position. The length of the three blades18,38,46in this configuration can be approximately equal to the length of one blade, such as the length of the first blade18. The first blade18, the second blade38, and the third blade46can have a stacked configuration. The first blade18can be in front (e.g., distal), the second blade38can be in the middle, and the third blade46can be in back (e.g., proximal).

The first blade18can have a first rail64that aligns one side of the blades18,38,46. The first rail64can extend from the proximal surface of the first blade18toward the body26. The second blade38can have a second rail66that can extend from both distal surface and the proximal surface of the second blade38. When viewed from the distal end of the retractor10(as shown inFIG.1), the first rail64can extend on the left side of the first blade18and the second rail66can extend on the right side of the second blade38. This configuration permits the first blade18to slide relative to the second blade38without interference of the rails66,68. The rails66,68can have a width equal to the width of the stacked blades18,38,46.

InFIGS.4-9, the retractor10is shown in an “opened position,” meaning that the first blade18can be translated relative to the third blade46or the second blade38can be translated relative to the third blade46. The first blade18is moved apart from the second blade38, while the third blade46can remain stationary. The first blade18, the second blade38, and the third blade46can have an overlapped configuration in the opened position, as shown. While the application uses the phrase “the opened position,” it is understood that one or more positions may be described as opened. For instance, the blades18,38may be slightly spaced apart, greatly spaced apart, overlapping, not overlapping, adjacent, with a gap between, without a gap between, at any spaced apart location along the third axis56, wherein the total length in the opened position is greater than the incision length L, or any other opened positions.

The motion of the first blade18can be coupled to the motion of the second blade38such that actuation of a single actuator such as the spread mechanism34that moves both the first blade18and the second blade38along the third axis56. In other embodiments, each of the first blade18and the second blade38is separately actuated. The first blade18can be in front (e.g., distal), the second blade38can be in the middle, and the third blade46can be in back (e.g., proximal). The length L′ of the three blades18,38,46in this configuration is greater than the length L of one blade, such as the length of the first blade18. When viewed from the distal end of the retractor10(shown inFIG.4). The first blade18can translate a first distance to the left of the third blade46. The second blade38can translate a second distance to the right of the third blade46. The first distance can be equal to the second distance, but need not be. The configuration of the rails66,68permits the first blade18to translate relative to the second blade38without interference of the rails66,68.

FIG.5shows the top view of the retractor10. The retractor10can include an actuator302. The actuator302interacts with the arms12,32to spread the arms12,32. One embodiment of the actuator is shown inFIG.10. Rotation of the actuator302, in the direction of the arrow A inFIG.10results in the arms12,32and therefore the blade assemblies16,36moving apart along the directional arrows B and C, causing retractor10to assume the opened position depicted inFIG.5. In the illustrated embodiment, the third axis56forms an arc. The first blade18will follow an arced path away from the third blade46. The second blade38will follow an arced path away from the third blade46. The first blade18will follow an arced path in separating from the second blade38. In the illustrated embodiment, the third axis56can be substantially perpendicular or perpendicular to the first axis52and the second axis54. The third axis56can extend perpendicularly or substantially perpendicularly through the first axis52and the second axis54.

It is noted that in the embodiment depicted inFIG.5, the retractor10comprises a pair of arms12and32connected via a carriage264. Other embodiments of an actuator may be used. For example, scissor-like actuators are known in the clamp and retractor arts. In some such embodiments, the actuator comprises a pair of handles (not shown) coupled to the arms12and32. The handles can be roughly parallel and joined together at a pivot point. The handles can be crossed (e.g. scissor-like) handles and joined together at a pivot point. It is also to be understood that when the actuator is a scissor-like embodiment, the motion of blade assemblies16and36traverse an arc rather than a straight line upon opening of the retractor10. Nevertheless, the spatial relationship of the two blade assemblies16and36can be conceptualized as changing along a line described by arrows B and C, which for the purpose of brevity is referred to herein as an axis, and in particular the third axis56.

While the illustrated embodiment uses a mechanism for moving the first blade18and the second blade38comprising a pair of arms12,32joined to the carriage264, other configurations are contemplated. In some embodiments, the proximal ends24,44of the arms12,32can be joined in alternative ways to the body26such that the movement of the arms12,32is not a pivoting motion. For instance, arms12,32can be joined one to another by a cross member (not shown). The cross member holds the arms12,32in parallel and stabilizes the arms12,32. One or more arms12,32can be moved along the cross member in order to translate the first blade18away from the third blade46and to translate the second blade38away from the third blade46. In such configurations, the first arm12linearly translates relative to the second arm32along the third axis56. In this embodiment, the third axis56defines a geometric line passing through and joining the first axis52and the second axis54. The first blade18follows a straight path away from the second blade38.

In some embodiments, the retractor10described herein possesses a device for locking the first blade assembly16and the second blade assembly36in at least one predetermined position along the third axis56. The device for locking the blade assemblies16,36can be a ratchet (not shown). The device for locking the blade assemblies16,36can be a detent and recess configuration. The device for locking the blade assemblies16,36can be disposed on the pivot or the cross member (not shown).

Insertion of the blades18,38,46into an incision in the closed position (as inFIGS.1-3) and translating the first blade18and the second blade38to an opened position (such as inFIGS.4-5) results in a stretching of the incision along the third axis56. This stretching increases the length of the incision from a length approximately equal to the length L of a single blade (e.g., the first blade18) to a length L′ greater than the length L of a single blade (e.g., the first blade18). As can be seen inFIGS.4-5, the retractor10is in the opened position, meaning that the first blade18is relatively separated from the second blade38along the third axis56. As the blade assembly16moves along the directional arrow B and blade assembly36moves along the directional arrow C, they exert force in the direction of lines B and C, respectively.

InFIGS.6-7, the retractor10is shown in the “rotated position,” meaning that the first blade18is rotated relative to the third blade46and/or the second blade38is rotated relative to the third blade46. While the application uses the phrase “the rotated position,” it is understood that one or more positions may be described as rotated. For instance, the first blade18can be rotated at any angle relative to the third blade46greater than zero (e.g., 5°, 10°, 15°, 20°, 25°, 30°, 35°, 40°, 45°, 50°, 55°, 60°, 65°, 70°, 75°, 80°, 85°, 90°, 95°, 100°, 105°, 110°, 115°, 120°, 125°, 130°, 135°, 140°, 145°, 150°, 155°, 160°, 165°, 170°, 175°, 180°, between 10-40°, between 20-50°, between 30-60°, between 40-70°, between 50-80°, between 60-90°, between 70-100°, between 80-110°, etc.), the second blade38can be rotated at any angle relative to the third blade46greater than zero (e.g., 5°, 10°, 15°, 20°, 25°, 30°, 35°, 40°, 45°, 50°, 55°, 60°, 65°, 70°, 75°, 80°, 85°, 90°, 95°, 100°, 105°, 110°, 115°, 120°, 125°, 130°, 135°, 140°, 145°, 150°, 155°, 160°, 165°, 170°, 175°, 180°, between 10-40°, between 20-50°, between 30-60°, between 40-70°, between 50-80°, between 60-90°, between 70-100°, between 80-110°, etc.), the first blade18can be rotated approximately the same angle as the second blade38, the first blade18can be rotated a different angle as the second blade38, wherein the width W′ in the rotated position is greater than the incision width or the width of any of the blades18,38,46, or other rotated positions.

The width W′ of the three blades18,38,46in this configuration is greater than the width W of any one blade, such as the width of the first blade18and the rail64. The first blade18can rotate in a clockwise direction about the first axis52. The second blade38can rotate in a counterclockwise direction about the second axis54. The motion of the first blade18can be independent of the motion of the second blade38. In other embodiments, the motion of the first blade18can be coupled to the motion of the second blade38such that rotation is controlled by a single rotation mechanism.

In the illustrated embodiment, the first blade18is rotated by a first rotation mechanism20and the second blade38is rotated by a second rotation mechanism40. In some embodiments and methods of use, the first blade18can rotate in an opposite direction as the second blade38such that both blades open relative to the third blade46. The first rotation mechanism20can be identical, substantially similar, or a mirror image of the second rotation mechanism40. One embodiment of the first rotation mechanism20is shown inFIG.12-14. Other embodiments are contemplated for rotating the first and/or second blades (e.g., various linkages, hinges and/or cams).

Referring toFIG.7, turning the first rotation mechanism20about the first axis52in the direction of adjustment arrow D, results in rotation of the first blade18. Turning the second rotation mechanism40about the second axis54in the direction of adjustment arrow E, results in rotation of the second blade38, respectively. As shown inFIG.7, rotating the first blade18causes the first blade18to exert force in the direction of direction arrow F, while rotating the second blade38causes the second blade38to exert force in the direction of direction arrow G. In some such embodiments, the first axis52and second axis54may be substantially coplanar with one another. Indeed in some embodiments, the first axis52and second axis54are not only coplanar but also substantially parallel to one another. In particular embodiments, the first axis52and second axis54are coplanar with, parallel to, or at some pre-determined skew angle with respect to one another.

In the illustrated embodiment, the first blade18is rotated and/or the second blade38is rotated after the first blade18is translated relative to the third blade46and the second blade38is translated relative to the third blade46along the third axis56. Thus, after insertion in an incision of the blades18,38,46in the closed position, the retractor10is opened by the first blade18and the second blade38translating relative to the third blade46along the third axis56to achieve the opened position. Then the first blade18is rotated relative to the third blade46about the first axis52and/or the second blade38is rotated about the second axis54relative to the third blade46to achieve the rotated position. However, this depicts only some methods of use.

In some methods, the first blade18and/or the second blade38is rotated before the first blade18is translated relative to the third blade46and the second blade38is translated relative to the third blade46along the third axis56. Thus, after insertion in an incision of the blades18,38,46in the closed position, the first blade18is rotated about the first axis52relative to the third blade46and/or the second blade38is rotated the second axis54relative to the third blade46to achieve the rotated position. Then the retractor10is opened by the first blade18and the second blade38translating relative to the third blade46along the third axis56to achieve the opened position. Then, if needed, the first blade18and/or the second blade38is rotated again relative to the third blade46to achieve the rotated position (e.g., another rotated position within the broad definition of the “rotated position”).

The rotated position creates and maintains an aperture in the incised tissue that is wider W′ (i.e. dimensionally larger in a direction perpendicular or oblique to the direction of the incision) than the incision. If the first blade18and/or second blade38are rotated after the blades16,38have been translated relative to the third blade, then the retractor10creates and maintains an aperture in the incised tissue that is both longer L′ due to the translation (i.e. dimensionally larger in the direction of the incision,) and wider W′ due to the rotation (i.e. dimensionally larger in a direction perpendicular or oblique to the direction of the incision) than the incision.

It is to be understood that, while this description is especially apt where the incision is a straight line incision of about 0.1 to about 3 inches in length, it can apply to any shape of incision (e.g. an arc, a sinusoid, etc.) of any length. In particular embodiments, the contemplated size of the incision is about 0.5 to 2 inches in length and the blades18,38,46are appropriately sized so that when the retractor10is in the closed position the blades18,38,46fit lengthwise within the incision without requiring substantial stretching of the incised tissue prior to opening of the retractor10. Thus, in some embodiments, the blades18,38,46are sized to snugly fit within the incision when the retractor10is in the closed position.

InFIGS.8-9, the retractor10is shown in the “pivoted position,” meaning that the first blade18is pivoted relative to the third blade46and/or the second blade38is pivoted relative to the third blade46. While the application uses the phrase “the pivoted position,” it is understood that one or more positions may be described as pivoted. For instance, the first blade18can be pivoted at any angle relative to the third blade46greater than zero (e.g., 5°, 10°, 15°, 20°, 25°, 30°, 35°, 40°, 45°, 50°, 55°, 60°, 65°, 70°, 75°, 80°, 85°, 90°, 95°, 100°, 105°, 110°, 115°, 120°, 125°, 130°, 135°, 140°, 145°, 150°, 155°, 160°, 165°, 170°, 175°, 180°, between 10-40°, between 20-50°, between 30-60°, between 40-70°, between 50-80°, between 60-90°, between 70-100°, between 80-110°, etc.), the second blade38can be pivoted at any angle relative to the third blade46greater than zero (e.g., 5°, 10°, 15°, 20°, 25°, 30°, 35°, 40°, 45°, 50°, 55°, 60°, 65°, 70°, 75°, 80°, 85°, 90°, 95°, 100°, 105°, 110°, 115°, 120°, 125°, 130°, 135°, 140°, 145°, 150°, 155°, 160°, 165°, 170°, 175°, 180°, between 10-40°, between 20-50°, between 30-60°, between 40-70°, between 50-80°, between 60-90°, between 70-100°, between 80-110°, etc.), the first blade18can be pivoted approximately the same angle as the second blade38, the first blade18can be pivoted a different angle as the second blade38, wherein the length L″ and/or the width W″ in the pivoted position is greater than the incision length or width or the length or width of any of the blades18,38,46, or other pivoted positions.

The width W″ of the three blades18,38,46in this configuration is greater than the width W of any one blade, such as the width of the first blade18and the rail64. The length L″ of the three blades18,38,46in this configuration is greater than the length L of any one blade, such as the length of the first blade18. The first blade18can pivot in a clockwise direction about the fourth axis58. The second blade38can pivot in a counterclockwise direction about the fifth axis60. The motion of the first blade18can be independent of the motion of the second blade38. In other embodiments, the motion of the first blade18can be coupled to the motion of the second blade38such that pivoting is controlled by a single pivot mechanism. The pivoted position creates and maintains an aperture in the incised tissue that is both longer L″ (i.e. dimensionally larger in the direction of the incision,) and wider W″ (i.e. dimensionally larger in a direction perpendicular or oblique to the direction of the incision) than the incision.

In the illustrated embodiment, the fourth axis58is perpendicular to the first axis52. The first blade18can rotate about the first axis52and pivot about the fourth axis58. This provides at least two degrees of freedom for the first blade18and allows the first blade18to be positioned in a variety of locations within the incision. In the illustrated embodiment, the fifth axis60is perpendicular to the second axis54. The second blade38can rotate about the second axis54and pivot about the fifth axis60. This provides at least two degrees of freedom for the second blade38and allows the second blade38to be positioned in a variety of locations within the incision. The fourth axis58and the fifth axis60are perpendicular to the third axis56. The movement along the third axis56provides an extra degree of freedom.

In the illustrated embodiment, the first blade18is pivoted by a first pivot mechanism22and the second blade38is pivoted by a second pivot mechanism42. The first blade18can pivot in an opposite direction as the second blade38such that both blades18,38open relative to the third blade46. The first pivot mechanism22can be identical, substantially similar, or a mirror image of the second pivot mechanism42. One embodiment of the first pivot mechanism22is shown in inFIGS.15-16. Other embodiments are contemplated for providing the described pivoting motions such as, for example, various linkages, cams and/or hinges.

Referring toFIG.9, pivoting the first pivot mechanism22about the fourth axis58in the direction of adjustment arrow H, results in rotation of the first blade18. Turning the second pivot mechanism42about the fifth axis60in the direction of adjustment arrow I, results in rotation of the second blade38, respectively. Pivoting the first blade18causes the first blade18to exert force in the direction of direction arrow J, while pivoting the second blade38causes the second blade38to exert force in the direction of direction arrow K.

In some examples, the first axis52is substantially perpendicular or perpendicular to the fourth axis58. In particular embodiments, the first axis52is at some pre-determined skew angle with respect to the fourth axis58. In some examples, the second axis54is substantially perpendicular or perpendicular to the fifth axis60. In particular embodiments, the second axis54is at some pre-determined skew angle with respect the fifth axis60. In some examples, the third axis56is substantially perpendicular or perpendicular to the fourth axis58, the fifth axis60or both the fourth axis58and the fifth axis60. In some embodiments, the third axis56is substantially perpendicular or perpendicular to both the fourth axis58and the fifth axis60. In some embodiments, the third axis56is perpendicular or substantially perpendicular to the fourth axis58, the fifth axis60or both the fourth axis58and the fifth axis60. In some embodiments, the third axis56is perpendicular or substantially perpendicular to both the fourth axis58and the fifth axis60.

In some embodiments, the third blade46can be pivoted about a seventh axis (not shown) that is parallel to the third axis56and extends from near the connection between the third blade46and the body26. In some embodiments, the third arm50can have a hinge that pivots the third blade46. The third blade46can be pivoted at any angle relative to the vertical plane greater than zero (e.g., 5°, 10°, 15°, 20°, 25°, 30°, 35°, 40°, 45°, 50°, 55°, 60°, 65°, 70°, 75°, 80°, 85°, 90°, 95°, 100°, 105°, 110°, 115°, 120°, 125°, 130°, 135°, 140°, 145°, 150°, 155°, 160°, 165°, 170°, 175°, 180°, between 10-40°, between 20-50°, between 30-60°, between 40-70°, between 50-80°, between 60-90°, between 70-100°, between 80-110°, etc.). The third blade46can be pivoted a same angle or a different angle as the first blade18and/or second blade38, wherein the length L″ and/or the width W″ in the pivoted position is greater than the incision length or width or the length or width of any of the blades18,38,46, or other pivoted positions. The seventh axis is described in some embodiments as substantially parallel or parallel to the third axis56. In other embodiments, the seventh axis can be at some pre-determined skew angle with respect to the third axis56.

The width W″ of the three blades18,38,46in this configuration is greater than the width W of any one blade, such as the width of the third blade46. The length L″ of the three blades18,38,46in this configuration is greater than the length L of any one blade, such as the length of the third blade46. The first blade18can pivot in a clockwise direction about the fourth axis58. The second blade38can pivot in a counterclockwise direction about the fifth axis60. The third blade46can pivot about the seventh axis toward the proximal direction. The motion of the third blade46can be independent of the motion of the first blade18and the second blade38. In other embodiments, the motion of the third blade46can be coupled to the motion of the first blade18and/or the second blade38such that pivoting is controlled by a single pivot mechanism. The pivoted position creates and maintains an aperture in the incised tissue that is both longer L″ (i.e. dimensionally larger in the direction of the incision,) and wider W″ (i.e. dimensionally larger in a direction perpendicular or oblique to the direction of the incision) than the incision.

The third blade46can be pivoted by a pivot mechanism that is identical or substantially similar to the pivot mechanism described herein for the first blade18and second blade38. Other embodiments are contemplated for providing the described pivoting motions such as, for example, various linkages, cams, hinges, gears and/or levers.

In the illustrated embodiment, the first blade18is pivoted and/or the second blade38is pivoted after the first blade18is rotated and/or the second blade38is rotated and after the first blade18is translated relative to the third blade46and the second blade38is translated relative to the third blade46. Thus, after insertion in an incision of the blades18,38,46in the closed position, the retractor10is opened by the first blade18and the second blade38translating along the third axis56relative to the third blade46to achieve the opened position. Then the first blade18is rotated about the first axis52relative to the third blade46and/or the second blade38is rotated about the second axis54relative to the third blade46to achieve the rotated position. Then the first blade18is pivoted about the fourth axis58relative to the third blade46and/or the second blade38is pivoted about the fifth axis60relative to the third blade46to achieve the pivoted position. In some embodiments, the third blade46is pivoted about the third axis56toward the proximal direction. However, this depicts only some methods of use.

In some methods, the first blade18is pivoted and/or the second blade38is pivoted and/or the third blade46is pivoted before the first blade18and/or the second blade38is rotated. In some methods, the first blade18is pivoted and/or the second blade38and/or the third blade46is pivoted is pivoted before the first blade18is translated relative to the third blade46and the second blade38is translated relative to the third blade46.

FIGS.10-16show embodiments of the various mechanisms of the retractor10.FIG.10shows the spread mechanism34. The spread mechanism34is a device for translating the first blade18and the second blade38about the third axis56.FIG.11shows the proximal end of the retractor10which includes the actuator for the spread mechanism34.FIGS.12-14show the rotation mechanism40. The rotation mechanism40is a device for rotating the second blade38about the second axis54. The rotation mechanism40can be identical, substantially similar or a mirror image of the rotation mechanism20shown inFIG.1. The rotation mechanism20is a device for rotating the first blade18about the first axis52.FIGS.15-16show the pivot mechanism22. The pivot mechanism22is a device for pivoting the first blade18about the fourth axis58. The pivot mechanism42can be identical, substantially similar or a mirror image of the pivot mechanism22. The pivot mechanism42is a device for pivoting the second blade38about the fifth axis60. Other configurations are possible for rotating the blades as described herein e.g., various levers, knobs, cams, etc.

FIG.10shows the spread mechanism34. The retractor10can include the carriage264. The carriage264can have a v-shaped configuration. The carriage264can have a first carriage arm288and a second carriage arm290. Each carriage arm288,290can form an angle alpha, beta with a longitudinal axis292of the body26. The angle alpha can be the same as the angle beta, or the angles alpha, beta can be different. Each carriage arm288,290can include a pin294,296. The pin294of the first carriage arm288can be connected to a slot298in the first arm12. The pin296of the second carriage arm290can be connected to a slot300in the second arm32. The pins294,296can be received within the slots298,300allowing the arms12,32to move about the pins294,296and allow the blade assemblies16,36to translate along the third axis56.

The retractor10can be in the “opened position,” meaning that the first arm12and the second arm32are displaced relative to the third blade46along the third axis56. While the application uses the phrase “opened position,” it is understood that one or more positions may be described as open. The carriage264can be mounted onto a screw304. The screw304can be located along the sixth axis62. The screw304can extend in the proximal-distal direction of the body26. The screw304can include external threads that engage complementary internal threads on the carriage264. The screw304can be configured to mate with a bearing (not shown) in the carriage264. The bearing allows the screw304to rotate without translation (e.g., rotate in place). In some configurations, the carriage264translates along the screw304as the screw304rotates.

The retractor10can include an actuator302. The actuator302interacts with the arms12,32to spread the arms12,32. In the illustrated embodiment, the actuator302rotates the screw304in the direction of arrow A. In some embodiments, the actuator302can include an inner engagement306that abuts a proximal end of the body26. The inner engagement306can include a plurality of flats designed to engage a driver. Other configurations are contemplated. In some embodiments, the actuator302is located within another actuator as shown inFIG.11.

Rotation of the actuator302causes the carriage264to translate from the proximal end of the body26toward the distal end of the body26. The carriage264is coupled to the pins294,296. As the carriage264translates forward, the pins294,296also translate forward. The slots298,300can be elongate channels that extend at an angle to the forward-aft direction of the movement of the pins294,296. The pins294,296can exert a force on the slots298,300of the arms12,32as the pins294,296move forward or aft. The angle of the slots298,300causes the arms12,32to spread. The arms12,32can pivot about their connection points to the carriage264. The shape of the slots298,300can cause the arms12,32to spread outward along the third axis56. One skilled in the art will recognize that the carriage264can spread the arms12,32in either direction.

The actuator302can translate the blades18,38along the third axis56irrespective of the location of the carriage264relative to the body26, as described herein with respect to the slide mechanism28. The rotation mechanisms20,40can rotate the blades18,38irrespective of the location of the carriage264relative to the body26. The pivot mechanisms22,42can pivot the blades18,38irrespective of the location of the carriage264relative to the body26.

FIGS.12-13are perspective views of the second blade38in the closed position and the rotated position, respectively.FIG.14is an exploded view of the rotation mechanism40. Referring back toFIGS.1,6-7, these figures depict an embodiment of a second blade assembly36, which comprises the second blade38. The second blade assembly36comprises a hub98. The hub98is coupled to the distal end of the second arm32. In the illustrated embodiment, the hub98houses the rotation mechanism40. Also shown in these views is the second axis54to achieve the rotated position. In some embodiments, the second blade38is adapted to rotate about the second axis54. In some embodiments, this added degree of freedom permit the second blade38to be rotated outward so that the second blade38is farther apart from the third blade46. The third blade46, in some embodiments, remains stationary.FIG.6shows a perspective view of the retractor10with the first blade18and the second blade38in a rotated position.FIG.7shows a top view ofFIG.6.

The hub98can have a first connecting hole100. The first connecting hole100can be non-threaded. The hub98is coupled to an inner barrel102. In the illustrated embodiment the inner barrel102is integrally formed with the second blade38. In other embodiments, the inner barrel102can be coupled with the second blade38. The second blade38can be connected to the second bridge96which can be connected to the inner barrel102. The inner barrel102can be sized to be accepted within the first connecting hole100of the hub98.

Referring toFIGS.12-14, the second rotation mechanism40can include a screw104. The second rotation mechanism40can include a collar106. The collar106can include a threaded bore108sized to receive the screw104. The screw104and the collar106are sized to be received in a lumen110of the inner barrel102. The inner barrel102can have a first slot112and a second slot114cut into the upper portion116of the inner barrel102. The first slot112can be offset 180 degrees from the second slot114. Specifically, the upper portion116of the inner barrel102is that portion of the inner barrel102above the highest point at which the second bridge96connects to the inner barrel102. The first slot112and second slot114can extend from near the top of the inner barrel102to the bottom of the inner barrel102. The slots112,114extend diagonally across the upper portion116. Although two slots112,114are shown, other configurations are contemplated (e.g., one slot, three slots, four slots, five slots). The one or more slots may have the same slope and extend in the same direction.

The inner barrel102can have an engagement groove118circumscribing the inner barrel102above the slots112,114. An appropriately sized retention member can be received within the groove118. The retention member allows the inner barrel102to rotate but not translate within the first connecting hole100.

The lumen110can have an engagement groove124circumscribing the lumen110above the slots112,114. The screw104can have a complementary engagement groove126circumscribing the head of the screw104. An appropriately sized retention member128such as an o-ring can be received within the grooves124,126. The retention member128allows the screw104to rotate but not translate within the inner barrel102.

FIGS.12-14further depict a first connector pin134and second connector pin136. The number of pins equals the number of slots. The connector pins134,136extend outward from the collar106. In the illustrated embodiment, the first connector pin134is offset 180 degrees from the second connector pin136. Other configurations are contemplated. The first connector pin134is sized to extend through the first slot112and the second connector pin136is sized to extend through the second slot114.

The screw104fits within the threaded bore108of the collar106, as depicted inFIGS.12-13. In this configuration, the first slot112forms a passage through which the first connector pin134fits. The second slot114forms a passage through which the second connector pin136fits. As depicted inFIG.12, the second blade38can be in the closed position when the first connector pin134is at the bottom of the first slot112and the second connector pin136is at the bottom of the second slot114. In this configuration, as shown inFIG.4it is seen that the second blade38, and the third blade46stack to form a substantially planar blade set.

One skilled in the art will recognize that rotating the screw104can cause the collar106to translate up and down. The retention member128prevents the screw104from translating. The connector pins134,136can be rigidly coupled to the collar106. At least one connector pin134or136can be retained in the channel122of the hub98, which prevents the collar106from rotating. Rotating the screw104will force the collar106to rise since the screw104cannot translate and the collar106cannot rotate. The connector pins134,136will similarly rise with the collar106. As the connector pins134,136rise, they act upon the slots112,114. Due to the shape of the slots112,114, the inner barrel102will rotate as the connector pins134,136rise. Rotation of the inner barrel102also rotates the second blade38. In other words, rotating the screw104forces the connector pins134,136to rise and act upon the slots112,114, thereby causing the inner barrel102to rotate, and also rotate the second blade38about the second axis54. One skilled in the art will understand that the first blade18can be rotated in the other direction (e.g., counterclockwise to close the first blade18). Starting with the connector pins134,136at the top of slots112,114, translating the collar106downward will force the connector pins134,136to move down the length of the screw104in the slots112,114, thereby causing the inner barrel102to rotate, thereby causing the second blade38to rotate about the second axis54.

As can be seen inFIG.14, the assembly of inner barrel102, the collar106, the screw104, and the connector pins134,136, fits through the first connecting hole100of the hub98. As can be seen inFIGS.6-7, the head of the screw104is visible through the hub98allowing the screw104to be manipulated. One of skill in the art will appreciate that the connector pins134,136engage the slots112,114, thereby permitting the inner barrel102to freely turn about the second axis54. The retention member (not shown) prevents the inner barrel102from moving up or down along the second axis54. The retention member128can prevent the screw104from moving up or down along the second axis54. Turning the screw104about the second axis54in one direction can cause the collar106to move upward along the second axis54, while turning the screw104in the opposite direction can cause the collar106to move downward along the second axis54. As explained above, movement of the collar106forces movement of the connector pins134,136up and down the second axis54. Movement of the connector pins134,136in one direction can create force in one direction on the slots112,114in the inner barrel102causing the inner barrel102to rotate. The screw104can be turned to rotate the second blade38toward or away from the third blade46. In the illustrated embodiment, the second blade38is connected to a second bridge96, which in turn is connected to the inner barrel102such that rotating the inner barrel102about second axis54clockwise can result in the second blade38also turning to clockwise.

The first blade assembly16can be substantially similar to the embodiment of the second blade assembly36described herein. For instance, the first blade assembly16can include an inner barrel similar to inner barrel102, screw similar to screw104, collar similar to collar106, and connecting pins similar to connecting pins134,136. In some embodiments, the first blade assembly16rotates clockwise about the first axis52away from the third blade46and the second blade assembly36rotates counterclockwise about the second axis54away from the third blade46. In this configuration, the inner barrel of the second blade assembly36can be a mirror image of the first blade assembly16. For instance, the first blade assembly16can have one slot which is the mirror image of first slot112and another slot which is the mirror image of second slot114. This slot configuration allows the first blade18to rotate clockwise, the opposite direction as the second blade38described herein. The function of the connector pins of the first blade assembly16and the method of rotation can be substantially similar.

FIG.15is a perspective view of the first blade assembly16in the pivoted position.FIG.16is an exploded view of the pivot mechanism22. Referring back toFIGS.8-9, these figures depict an embodiment of a first blade assembly16, which comprises the first blade18. The first blade assembly16comprises the hub97. The hub97can be similar, identical or a mirror image of the hub98described with respect toFIGS.12-14. The hubs97,98can interact with the arms12,32to pivot the hubs97,98. The hub97is coupled to the first arm12. In the illustrated embodiment, the hub97and the first arm12house the pivot mechanism22. The arm12can have a second connecting hole242and a third connecting hole244.

The hub97can include a post246. The post246can be integrally formed with the hub97. In some embodiments, the post246is a separate component from the hub97and the post246can be rigidly coupled to the hub97such that movement of the post246causes movement of the hub97. The post246can be accepted into a bore (not shown) of the first arm12. The post246can have a round cross-section but other shapes are contemplated. The post246can have a boss248extending along a portion of the length of the post246. The boss248can have a substantially semi-circular cross-section but other shapes are contemplated. The boss248can be rounded. The boss248can be integrally formed with the post246. The boss248can be rigidly coupled to the post246such that movement of the boss248causes movement of the post246.

The post246can have a groove250circumscribing post246. The groove250can be toward the proximal end of the post246that extends into the bore. The first arm12can include the second connecting hole242. The second connecting hole242can be sized to accept a pin252. The upper portion of the pin252can fit within the second connecting hole242. The lower portion of the pin242can fit within the groove250of the post246. The pin242facilitates alignment between the boss248and the screw256, described herein. The second connecting hole242can be non-threaded.

The first blade18can be pivoted by rotating a screw256. The second blade38can be pivoted by rotating a screw258. The screws256,258can be a hex screw. As shown inFIG.16, the first arm12can include the third connecting hole244. The third connecting hole244can be threaded. The screw256can be accepted into the third connecting hole244. The screw256can include a cutout260. The cutout260can have a complementary shape to the boss248extending from the post246. The boss248can be captured by the cutout260in the screw256. The boss248of the post246and the cutout260of the screw256can pivot the hub97relative to the first arm12.

One skilled in the art will recognize that rotating the screw256can cause the screw256to translate within the third connecting hole244. The translation of the screw256can exert a force on the boss248causing the boss248to rotate. The translation of the screw256can exert a force on the post246causing the post246to rotate. The force acting on the boss248and the post246can cause the hub97to pivot. As the hub97pivots, the pin252will follow the groove250of the post246. The pin252and the groove250maintain contact between the boss248and the screw256as the screw256is rotated. As the screw256is moved up and down, the boss248is moved up and down to rotate the hub97, which pivots the first blade18. The design benefits from direct drive of the post246(i.e., the screw256positively engages and rotates the post246in both directions) and may avoid fatigue of the pivot mechanism22, which can occur in other designs having springs, torsion bars, or other non-direct drive configurations in one or more directions. Fatigue can cause unintentional blade tilting.

Pivoting of the hub97can result in the pivoting of the inner barrel102received in the first connecting hole100. Pivoting the inner barrel102can also pivot the first blade18. In other words, rotating the screw256will cause the hub97to pivot, thereby pivoting the inner barrel102coupled to the first blade18and the first blade18. One skilled in the art will recognize that the first blade18can be pivoted in either direction based on the rotation of the screw256. The longitudinal axis of the post246can corresponds to the fourth axis58. The longitudinal axis of the post246can be offset from a longitudinal axis of the hub97.

The second blade assembly36can be similar to the embodiments described herein. For instance, the second blade assembly36can include a post similar to post246, a pin similar to pin252, and a screw258similar to screw256. In some embodiments, the first blade assembly16rotates counterclockwise about the post246and the second blade assembly36rotates clockwise about a similar post when viewed from the proximal end of the retractor10. In some configurations, the second blade assembly36can be a mirror image of the first blade assembly16. For instance, the screw258of the second assembly36can be threaded in the opposite direction as the screw256of the first assembly16. This configuration of the screws256,258allow the second blade38to pivot in the opposite direction as the first blade18described herein. The function of the screws, pins and the posts of the second blade assembly36and the method of rotation of the screw can be similar.

FIGS.17-18depict an embodiment of slide mechanisms28,30. The retractor10can be in the “slid position,” meaning that the first arm12and the second arm32are displaced in the proximal-distal direction relative to the third blade46along a sixth axis62. The retractor10can be in the “slid position,” meaning that the third blade46is displaced in the proximal-distal direction relative to the body26along a sixth axis62. While the application uses the phrase “the slid position,” it is understood that one or more positions may be described as slid. For instance, the first arm12can be slid at any position along the body26, the second arm32can be slid at any position along the body26, the third blade46can be slid at any position along the body26, the first arm12can be slid approximately the same distance as the second arm32, wherein the width in the slid position is greater than the incision width or the width of any of the blades18,38,46, or other slid positions.

FIG.16depicts an embodiment of a slide mechanism262that provides an additionally degree of freedom. The slide mechanism262can include the carriage264. The first arm12and the second arm32can be coupled to the carriage264via pins294,296, as described herein. The first arm12, the second arm32, and the carriage264can move as a unit relative to the body26.

The carriage264can be attached to the body26via a track266. In some embodiments, the track266can be linear and/or parallel to the width of the blades18,38,46. The track266can extend from the proximal end of body26to the distal end of the body26, or over a portion therewithin. The track266can define the sixth axis62. A screw274can extend along the track266. The screw274can be configured to mate with a bearing (not shown). The bearing allows the screw274to rotate without translation (e.g., rotate in place).

The slide mechanism262can include an outer cylinder270. The outer cylinder270can include a threaded bore272. The threaded bore272can couple with the screw274. The outer cylinder270can be coupled to the carriage264such that translation of the outer cylinder270causes translation of the carriage264. In some configurations, the outer cylinder270and the carriage264translate along the screw274as the screw274rotates.

The slide mechanism262can include an actuator268that permits the carriage264, the first arm12, and the second arm32to slide along the screw274. The rotation of the actuator268can cause the outer cylinder270to translate along the screw274. The translation of the outer cylinder270can cause the carriage264, the first arm12, and the second arm32to translate along the screw274. The translation of the actuator268can cause the carriage264, the first arm12, and the second arm32to translate along the sixth axis62.

Referring back toFIG.11, the proximal end of the body26can include the actuator268. In some embodiments, the actuator268can include an outer engagement276that abuts a proximal end of the body26. The outer engagement276can include a plurality of flats designed to engage a driver. Other configurations are contemplated. Rotation of the outer engagement276causes the carriage264to translate from the proximal end of the body26toward the distal end of the body26along the sixth axis62.

The slide mechanism262permits the arms12,32to extend a greater distance from the distal end of the body26. The slide mechanism262permits the first blade18and the second blade38to slide relative to the third blade46. In the illustrated embodiment, the third blade46is not coupled to the slide mechanism262. This permits the first blade18and the second blade38to slide relative to the third blade46. The slide mechanism262permits the incision to be stretched along the width of the incision to create an opening width greater than width W″. One skilled in the art will recognize that the carriage264can translate in either direction.

FIGS.16also depicts an embodiment of a slide mechanism278that provides an additionally degree of freedom. The third blade46can be coupled to slide mechanism278. The third blade46can be coupled to the slide mechanism278via the third arm50. The third blade46and the third arm50can move as a unit relative to the body26.

The third blade46can be attached to the body26via a track280. In some embodiments, the track280can be linear and/or parallel to the width of the blades18,38,46. The track280can extend from the proximal end of body26to the distal end of the body26, or over a portion therewithin. A screw286can extend along the track280. The screw286can be configured to mate with a bearing (not shown). The bearing allows the screw286to rotate without translation (e.g., rotate in place). The track280can define the sixth axis62.

The slide mechanism278can include an outer cylinder282. The outer cylinder282can include a threaded bore284. The threaded bore284can mate with a screw286. The outer cylinder282can be coupled to the third arm50. In some configurations, the outer cylinder282, the third arm50, and the third blade46translates along the screw286as the screw286rotates.

The slide mechanism278can include an actuator288that permits the third arm50and the third blade46to slide along the screw286. The rotation of the actuator288can cause the outer cylinder282to translate along the screw286. The translation of the outer cylinder282can cause the third arm50and the third blade46to translate along the screw286. In embodiments where the track280is along the sixth axis62, the translation of the outer cylinder282can cause the third arm50and the third blade46to translate along the sixth axis62.

Referring back toFIG.11, the proximal end of the body26can include the actuator388. In some embodiments, the actuator388] can include an outer engagement390that abuts a proximal end of the body26. The outer engagement390can include a plurality of flats designed to engage a driver. Other configurations are contemplated. Rotation of the outer engagement390causes the third arm50and the third blade46to translate from the proximal end of the body26toward the distal end of the body26along the sixth axis62.

The slide mechanism278permits the third blade46to extend a greater distance from the distal end of the body26. The slide mechanism278permits the third blade46to slide relative to the first blade18and the second blade38. In the illustrated embodiment, the first blade18and the second blade38are not coupled to the slide mechanism278. This permits the third blade46to slide relative to the first blade18and the second blade38. The slide mechanism278permits the incision to be stretched along the width of the incision to create an opening width greater than width W″. One skilled in the art will recognize that the third blade46can translate in either direction.

FIG.19illustrates a quick release mechanism200. The first blade assembly16and the second blade assembly36can be removed from the retractor10. The quick release mechanism200can include a first tab202associated with the first blade assembly16and a second tab204associated with the second blade assembly36. The tabs202,204can be located on the hubs97,98. The tabs202,204can be located on the arms12,32. The tabs202,204can be depressed thereby releasing the blade assemblies16,36. In some embodiments, the tabs202,204can be independently actuated.

Referring back toFIGS.12-13, the inner barrel102can have an engagement groove118circumscribing the inner barrel102above the slots112,114. The tab202can have an appropriately sized retention member206such as a flange which can be received within the groove118. The retention member206allows the inner barrel102to rotate but not translate within the first connecting hole100.

The tab202can be biased by a spring208. The tab202can be retracted toward the body26to allow the inner barrel102to be inserted within the first connecting hole100. The tab202can be released to engage the retention member206with the groove118. The spring208can bias the retention member206toward the distal direction and into engagement with the groove118. The blade assemblies16,36can be inserted into the hubs97,98from underneath the hubs97,98.

The first blade assembly16can include a first post210designed to be coupled to the first tab202. The first post210can be an alignment post. The first post210can help facilitate alignment between the retention member206and the groove118.

The arms12,32may be removed from the body26. For instance, in the illustrated embodiment, the pins294,296can be removed to remove the arms12,32from the body26. This may occur at any time, e.g. prior to or during sterilization of the retractor10or during a surgical procedure once the retractor10has been opened. Removal of the body26during surgery may afford a member of the surgical team greater freedom of motion, an improved field of view or both.

The third blade46may be removed from the third arm50. For instance, in the illustrated embodiment, the third arm50can have a mating configuration such as a snap fit with the third blade46. The third blade46may be removed at any time, e.g. prior to or during sterilization of the retractor10or during a surgical procedure once the retractor10has been opened. Removal of the third blade46during surgery may afford a member of the surgical team greater freedom of motion, an improved field of view or both.

Some embodiments contemplate kits comprising a retractor10. In some embodiments, the kit comprises a plurality of removable and exchangeable blade assemblies16,36and/or blades18,38,46. Each kit may comprise a different actuator, a different rotation mechanism, a different pivot mechanism, a different spread mechanism, and/or a different slide mechanisms. Each blade assembly may comprise a different blade. In some embodiments, the kit comprises at least three blade assemblies having amongst the three blade assemblies at least two distinct blade configurations. In other embodiments, the kit comprises from 3 to 12 blade assemblies having amongst the several blade assemblies from 2 to 12 distinct blade configurations. In some embodiments, the kit comprises at least two pairs of identical, substantially similar, or mirror image blade assemblies. In some embodiments, the kit comprises at least two pairs of mirror image blade assemblies. In other embodiments, the kit comprises from 2 to 10, especially about 2 to 5 such pairs of blade assemblies.

In some embodiments, the retractor10may be provided to a surgeon or surgical personnel in the form of a kit comprising additional surgical articles and optionally instructions for the use and handling of the retractor. Such additional surgical articles may include one or more of: scalpels, suture needles, pedicle screws, suture material, spinal implant material, spinal fusion rods, biocompatible adhesive and closure staples.

In some embodiments, the blades18,38,46are removable. In some embodiments, the blades18,38,46may take on a variety of shapes and sizes. In some embodiments, a kit is provided comprising a plurality of retractors having blades of various sizes, shapes or both. In some embodiments, a kit is provided comprising one or more arms and two or more blade assemblies (optionally of varying blade sizes and/or shapes). In some embodiments, a kit is provided comprising a retractor, optionally more than two blades assemblies, at least two of which differ from one another in size, shape or both, and one or more pedicle screws for performing lumbar surgery. Thus, a variety of surgical kits for performing surgery, especially back surgery, are contemplated and methods of using the retractor to perform surgery, especially back surgery, are contemplated.

The retractor10described herein can allow the blades18,38,46to pivot and swing open as described herein. The movement of the blades18,38,46can cause less trauma to the tissue by gently pushing the tissue apart. The blades18,38,46can have a low profile configuration that can cause less trauma upon insertion. The blades18,38,46can be moved about a variety of axes to reduce trauma. The blades18,38,46can be independently actuated to reduce trauma.

FIG.20illustrates the attachment mechanism15. The attachment mechanism15can be located on the body26. The attachment mechanism15couples the body26to a fixture (not shown). The fixture can be a support arm. The fixture can be located within the operating arena. The fixture can support the body26during the procedure.

The attachment mechanism15can include features to enable coupling to the fixture. The attachment mechanism15can be threaded. The attachment mechanism15can include a serrated plate to limit rotation. The attachment mechanism15can include any features to ensure a stable connection between the fixture and the body26.

On the market retractor systems typically have two attachment points. A first attachment point allows the outer blades to move relative to the first attachment point. A second attachment point allows another blade, for instance, a middle blade to move relative to the second attachment point. With the on the market retractor systems, the retractor can lose the surgical site when changing attachment points. The retractor can shift when removed from the attachment point and switched to another attachment point.

FIG.20illustrates a single attachment point located at the attachment mechanism15for the body26. The first blade18and the second blade38can move relative to the one attachment point. For instance, the first blade18and the second blade38can pivot with the pivot mechanisms22,42relative to the attachment point. The first blade18and the second blade38can rotate with the rotation mechanism20,40relative to the attachment point. The first blade18and the second blade38can spread with the spread mechanism34relative to the attachment point. The first blade18and the second blade38can slide with the slide mechanism28relative to the attachment point.

The third blade46can also move relative to the one attachment point. The third blade46can slide with the slide mechanism30relative to the attachment point. The third blade46can pivot relative to the attachment point. Each of the blades18,38,46can move independently of the attachment point. Each of the blades18,38,46can move independently of the body26.

The one attachment point located at the attachment mechanism15can provide more stability and accuracy during retraction. The one attachment point can maintain the position of the retractor10during the procedure. The surgeon does not need to switch between attachment points to allow operation of the blades. Each blade can be manipulated when the body26is coupled to the fixture via the attachment mechanism15. In some methods of use, the body26is not removed from the attachment mechanism during the course of the procedure. In some methods of use, there is no need to find the surgical site or reposition the retractor after switching attachment points.

FIG.21A-21Eillustrates a probe system500and a method for its use in conjunction with the retractor10. The probe system500can include one or more probes. The probe system500can include one probe, two probes, three probes, four probes, etc. InFIG.21A, the probe system500includes an anterior probe505and a posterior probe510. The probes505,510can form a shape having a smooth perimeter. The smooth perimeter can form a generally flat shape such as a shape having two or more generally flat sides. In some embodiments, each probe505,510forms an equal half of the perimeter. In some embodiments, the posterior probe510forms greater than half of the perimeter. The anterior probe505faces toward the front of the system (e.g., distal end when coupled to the retractor10) and the posterior probe510faces toward the rear of the system (e.g., proximal end when coupled to the retractor10).

In some embodiments, the anterior probe505includes an anterior electrode515. In some embodiments, the posterior probe510includes a posterior electrode520. The electrodes515,520can be on an exterior surface of the probes505,510. The electrodes515,520can be on a distal surface of the probes505,510. The electrodes515,520can face outward from the probes505,510. The electrodes515,520can be positioned at any radial distance (e.g., 90 degrees apart, 100 degrees apart, 110 degrees apart, 120 degrees apart, 130 degrees apart, 140 degrees apart, 150 degrees apart, 160 degrees apart, 170 degrees apart, 180 degrees apart, etc.). In some embodiments, the electrodes515,520are on opposed surfaces. The anterior electrode515can monitor the anterior side of the probes505,510and the posterior electrode520can monitor the posterior side of the probes505,510.

The posterior probe510can include a mating configuration with the anterior probe505. The mating configuration can be a tongue and groove configuration. In some embodiments, the posterior probe510can include a groove530and the anterior probe505can include a tongue525. The proximal end of the posterior probe510can accept the anterior probe505. In some methods of use, the anterior probe505is aligned with the posterior probe510. In some methods of use, the anterior probe505is slid down the length of the posterior probe510from a first end550of the posterior probe510toward a second end555of the posterior probe. In some methods of use, the anterior probe505is slid until the anterior electrode515aligns with the posterior electrode520. The structure of the probes505,510when coupled together can facilitate its passage through tissues of a patient (e.g., psoas muscles) which can run parallel to the flat surfaces of the probes505,510. For example, the generally flat shape of the probes505,510can dissect and/or dilate the tissues of a patient by separating the psoas muscle along the muscle fibers in a lateral approach to the spine. The flat surfaces of the probes505,510can be oriented parallel to (i.e., aligned with) the lengths of the muscle fibers, which helps to minimize trauma to the muscle tissue as the probes are inserted through the psoas muscle.

The posterior probe510can include a retention configuration with the anterior probe505. The retention configuration can maintain the position of the anterior probe505relative to the posterior probe505. In some embodiments, the retention configuration is a stop coupled to the posterior probe510. The anterior probe505abuts the stop thereby limiting further distal movement. In some methods of use, the anterior probe505is slid down the length of the posterior probe510until the anterior probe505abuts a stop.

The mating configuration can couple other components of the probe system500with the probes505,510. The probe system500can include a shim535. In some embodiments, the posterior probe510can include the groove530and the shim535can include a tongue540. The first end550of the posterior probe510can accept the shim535. In some methods of use, the shim535is aligned with the posterior probe510. In some methods of use, the shim535is slid down the length of the posterior probe510from the first end550of the posterior probe510toward the second end555of the posterior probe510. In some embodiments, the shim535is configured to couple with the third blade46instead of, or in addition to the posterior probe510.

In some embodiments, the third blade46can include the slot48. The slot48is sized to accept one or more probes505,510. In some embodiments, the slot48is sized to accept the anterior probe505coupled to the posterior probe510. The slot48is sized to accept the shim535. As described herein, the posterior probe510can form greater than half of the perimeter of the assembled probes505,510. The slot48can limit motion of the posterior probe510in directions other than translation. The slot48can limit motion of the posterior probe510after the anterior probe505is removed. The slot48can limit motion of the posterior probe510after the shim535is inserted.

The probes505,510can be inserted underneath the third blade46. The third blade46can be inserted underneath the third arm50. In some methods of use, the probes505,510are aligned with the third blade46. In some methods of use, the third blade46is slid down the length of the probes505,510from the first end550of the probes505,510. The slot48of the third blade46can fit substantially closely around the probes505,510.

The retractor10can include a retention configuration with the shim535. The retention configuration can maintain the position of the retractor10relative to the shim535. In some embodiments, the retention configuration is one or more notches540located on the third blade46. The shim535includes a corresponding detent545that engages one or more notches540thereby limiting further movement of the shim535. In some methods of use, the shim535is slid down the length of the third blade46engaging and disengaging the one or more notches540on the third blade46. The one or more notches540can be in discrete positions along the third blade46. In some embodiments, the engagement between the detent545and the notches540provides feedback such as an audible click or tactile feedback for the user. Other retention configurations are also contemplated, such as ratcheting hooks, releasable clamps, and the like.

In some embodiments, the shim535is shorter than one or more probes505,510. In some methods of use, the shim535retains the retractor10at the anchorable location instead of the probes505,510. The shorter length of the shim535as compared to the probes505,510can provide clearance around the retractor10for the user to work. In some methods of use, the shim535is held by the third blade46during use.

Each probe505,510can have a probe body extending between the first end550and the second end555. The second end555can include a tip565for insertion within the anchorable location. In some embodiments, the second end555can include a distal shoulder570. The distal shoulder570can limit penetration of the probe505,510. In modified embodiments, the probe505,510can have a distal end of a different shape. For example, the probe505,510can be formed without the shoulder570and/or without the tip565and/or one of both elements can be modified in shape.

In some embodiments, probe505,510coupled together can be rectangular in horizontal cross section (i.e., the plane bisecting the probe505,510perpendicular to the axis formed by the first end550and the second end555). In other embodiments, the probe505,510coupled together can be circular in horizontal cross section or oval in horizontal cross section. Some representative cross sectional shape the probes505,510coupled together can include: a circle; an oval; a triangle; a flattened oval; a thin flattened oval; a rounded rectangle; a thin rounded; a rectangle; and a thin rectangle. Each probe505,510can form a portion of the cross section, for instance half of the cross section. In yet other embodiments, the probe505,510can be any other appropriate shape, including but not limited to square, triangular, and ellipsoid. A rectangular cross-sectional shape can include a shape in which the corners of the device are rounded and/or arrangements in which the adjacent sides are not exactly perpendicular (e.g., plus or minus 10 degrees, 5 degrees, 1 degrees or 0.1 degrees from perpendicular) and/or when the sides of the probe have ridges, bends that deviate 10%, 5%, 1% or 0.1% from the width or length of a side.FIG.21A-21Dillustrate the probes505,510which together form an oval cross section.

In some embodiments, the probes505,510can be constructed out of a biocompatible metal, such as but not limited to stainless steel, titanium, and cobalt chrome moly. In other embodiments, the probes505,510can be constructed out of a biocompatible ceramic. In still other embodiments, the probes505,510can be constructed out of any stiff, biocompatible material, including such classes of materials as metals, ceramics, and polymers, or any combinations thereof. In some embodiments, the probes505,510can be constructed out of non-biocompatible material and coated with a biocompatible material.

In some embodiments, the probes505,510can have a vertical dimension (i.e., between ends550,555) in the range of about 5-50 cm, about 6-40 cm, about 7-30 cm, about 7-20 cm and about 8-10 cm or any other range which is appropriate to allow the probes505,510to function as desired. In some embodiments, the probes505,510can have a width in its largest, non-vertical dimension, in the range of about 5 mm-5 cm, about 6 mm-4 cm, about 7 mm-3 cm, and about 8 mm-2 cm, including about 1.5 cm.

In some embodiments, the shoulders570can extend horizontally in from the edges of the probes505,510in the range of about 0.1-5 mm, about 0.2-4 mm, about 0.3-3 mm, about 0.4-2 mm, about 0.5-1 mm, and about 0.6-0.8 mm. In some embodiments, the external corners where the shoulders570meet the vertical edges of the probes505,510can be squared. In other embodiments, the external corners where the shoulders570meet the vertical edges of the probes505,510can be rounded or smoothed. In some embodiments, the shoulder570can be machined flat on the bottom (particularly in such embodiments in which the probe400is a shape other than rectangular). In other embodiments, the shoulder570can be sharpened across their entire length to form a blade along their entire length. In other embodiments, the shoulders570can be are sharpened across only a portion of their length to form a blade along only a portion of their length. For example, in some embodiments, only half of each shoulder570is sharpened (e.g., either the half of the shoulders570abutting the tip565or the half of the shoulders570abutting the edges of the probes505,510).

In some embodiments, the tip565can extend downward from the probes505,510. In some embodiments, the tip565can be substantially triangular. In other embodiments, the tip565can be substantially parabolic. In other embodiments, the tip565can be a small cylindrical member, such as a trocar. In yet other embodiments, the tip565can be any shape which allows anchoring of the probes505,510in tissue. In some embodiments, the edges of the tip565can be machined to be substantially smooth. In other embodiments, the edges of the anchor tip565can be sharpened to form a blade.

In some embodiments, at least a portion of the vertical edges of the probes505,510can be sharpened. In some of these embodiments, the portion of the edges of the probes505,510which are sharpened can be disposed near the second end555of the probes505,510. As a representative example, 1-5 cm of the edges of the probes505,510extending up from the second end555and distal shoulders570can be sharpened to form a blade to facilitate insertion of the probes505,510into corporeal tissue of a patient.

The probe system500illustrated inFIG.21Ais a thin, blade like probe having a flat cross-section. The flat cross-section may limit the probes505,510ability to be rotated within the anchorable location to detect nerve signals. In some embodiments, each probe505,510includes an electrode515,520to detect nerve signals. The electrodes515,520can be positioned to detect nerve activity at locations approximately 180 degrees apart. The structure of the probes505,510can facilitate its passage through tissues of a patient (e.g., psoas muscles) which can run parallel to the flat surfaces of the probe.

In operation, a physician can select a location in which he desires to use a retractor10to form an operative channel in the tissues of the patient (the spine will be used in this example for illustration purposes only). A location is preferably selected that provides adequate access to an intervertebral disc space, yet minimizes the risk of injury to the nerves extending from the intervertebral foramen. After the surgeon selects the location for retractor10placement, he can make an incision in the skin and insert one or more of the probes505,510by placing the tip565against the surface of the patient. In some methods of use, the probes505,510are coupled prior to insertion. The surgeon applies pressure to the first end550of one or more probes505,510. The physician can then continue to apply pressure, thereby pushing the one or more of the probes505,510through the tissue of the patient, until the probes505,510are fully in place. In some embodiments, an imaging modality can be used during the insertion of the one or more probes505,510. As a representative, non-limiting example, X-ray fluoroscopy can be used during insertion of the one or more probes505,510to ensure correct placement. Any appropriate imaging modality can be used to monitor the placement of the one or more probes505,510. In some embodiments, a surgeon can make an incision with another instrument, such as a scalpel, prior to the insertion of the one or more probes505,510, into which the one or more probes505,510is inserted. In some embodiments, a K-wire (i.e., guide wire) can first be anchored at the location for retractor10placement. One or more probes505,510can have a passage extending through its longitudinal length to receive the K-wire when the one or more probes505,510are inserted at the surgical location. The K-wire advantageously provides improved accuracy in placement of the one or more probes505,510and can also help stabilize the one or more probes505,510during insertion through the patient tissue.

FIG.21Billustrates the probes505,510fully in place in a patient. The probes505,510have been inserted into the side of the spinal column (here defined by a first vertebra440, a second vertebra450, and the disc460between them).FIG.21Billustrates the placement of the probe400in a location in which the tip565can anchor the probes505,510. As shown inFIG.21B, the probes505,510have been inserted into the patient until the tip565has sunk at least some distance into the disc460between the first vertebra440and second vertebra450. The tip565has sunk into the disc460up until the shoulders570of the probes505,510. The shoulders570serve in this example to limit the possible insertion depth of the tip565of the probe570.

FIG.21Cillustrates the third blade46of the retractor10(as disclosed herein) and a placed probes505,510. The third blade46can include a longitudinally extending slot48sized to accept the probes505,510. The third blade46can fit substantially closely around the probes505,510. The third blade46can be any type of blade as described above, including but not limited to a substantially flat blade. An incision I having a length L is made in a suitable tissue, such as the skin overlying or in proximity to the lumbar region of the spine.

FIG.21Dillustrates the shim535and the placed third blade46of the retractor10and placed probes505,510. The third blade46can include the slot48sized to accept the shim535after the anterior probe505is removed. The third blade46can fit substantially closely around the shim535and the posterior probe510.

FIG.21Eillustrates the first blade18and the second blade38of the retractor10in their closed configuration placed near the third blade46. The blades18,38,46will be in their stacked configuration when coupled. The blades18,38,46are in the closed position and aligned relatively parallel to one another. The third arm50of the third blade46can couple with the body26.FIG.21Eshows the retractor10still in the closed position.

In some methods, the retractor10ofFIG.21Eis manipulated to achieve the opened position, as shown and described inFIGS.4-5and10. In the opened position, the incision can be stretched along the length of the incision to pull open the incision. In some methods of use, translation about the third axis56results in the retractor10opening: i.e. the first blade18and the second blade38move apart from one another in the general directions of directional arrows B, C, respectively. The incision can be stretched open in the direction of the directional arrows B and C so that it obtains a length L′ greater than length L of the incision.

In some methods, the retractor10ofFIG.21Eis manipulated to achieve the rotated position, as shown and described inFIGS.6-7and12-14. In the rotated position, the incision can be stretched along the width of the incision. Turning the rotation mechanism20,40in the direction of the arrows D and E about the first axis52and the second axis54, respectively results in the rotating of the first blade18and the second blade38respectively, resulting in the widening of the incision. The aperture can be opened to a width W′. If the retractor is previously opened as shown inFIG.4-5, then the aperture would provide an access area of dimensions L′ by W′ for surgical personnel to view the operating field, to pass instruments, sutures, implants and other surgical materials through the aperture.

In some methods, the retractor10ofFIG.21Eis manipulated to achieve the pivoted position, as shown and described inFIGS.8-9and15-16. In the pivoted position, the incision can be stretched along the width and/or length of the incision. Turning the pivot mechanism22,42pivots the first blade assembly16and second blade assembly36in the direction of the arrows H and I about the fourth axis58and the fifth axis60, respectively results in the pivoting of the first blade18and the second blade38, further stretching the incision. The aperture can be opened to a length L″ and a width W″. The aperture can provide an access area of dimensions L″ by W″ for surgical personnel to view the operating field, to pass instruments, sutures, implants and other surgical materials through the aperture.

In some methods, the retractor10ofFIG.21Eis manipulated to achieve the slid position, as shown and described inFIGS.17-18. In the slid position, the incision can be stretched along the width of the incision. Moving the slide mechanism262results in the translation of the arms12,32, and therefore the translation of the blades18,38, causing the incision to open. Moving the slide mechanism278results in the translation of the third blade46, causing the incision to open. The aperture A can be opened to a width wider than width W″.

Reversal of the steps described above results in a final incision having substantially the same length L and essentially no width, like the original incision. By way of comparison, in order for a prior art device having a pair of blades to create such an aperture, the incision would have to have a length L′ or L″ and the blades would have to have a width of W′ or W″. The present retractor10permits the use of a much smaller incision to create the aperture. The present retractor10permits less invasive surgical methods, quicker and more comfortable recovery from surgery and potentially cost savings for the medical coverage provider.

The probes505,510can be removed prior to any of these steps or left in place during the procedure. The probes505,510can allow a surgeon to easily and quickly insert a retractor10without cutting an incision all the way to the surgery site prior to inserting the retractor10into the desired location to access the surgery site. Rather, the surgeon can quickly and easily insert the probes505,510into the desired location, anchor the probes505,510using the tip565in the desired location, slip the third blade46of the retractor10around one or more of the probes505,510, and then simply slip the retractor10into place. From this position, the first blade18and/or the second blade38can be moved in any of the ways described herein. From this position, the first arm12and the second arm32can be moved in any of the ways described herein.

In some embodiments, the probes505,510comprise at least one electrode515,520, wherein the at least one electrode515,520is capable of stimulating a nerve to provoke an electromyographic response in the nerve. The probes505,510can sense nerve activity as a probe and anchor the retractor10at an anchorable location. In some embodiments, the first end550of the probes505,510can be broken off once the second end555of the probes505,510is implanted. The probes505,510can have one or more break points along the length of the probes505,510to facilitate this break. The break points can provide clearance around the retractor10for the user to work.

In some embodiments, only one electrode is used. In other embodiments, a plurality of electrodes can be used, including about 1-10 electrodes, about 2-8 electrodes, about 3-6 electrodes and about 4-5 electrodes. In some embodiments, at least one electrode can be disposed on the tip565. In some embodiments, at least one electrode can be disposed on the probes505,510. The electrode515,520can be included in any of the embodiments described herein.

In some embodiments, the probe system500comprises an endoscope499, wherein the endoscope499can comprise an imaging element432at the distal end412of the endoscope499. In some of these embodiments, the endoscope499can be configured to both allow a surgeon to visualize the placement of the probe system500as well as allow a surgeon to slide a retractor10down over the probe system500and into place as described herein to create an operative channel. In some embodiments, the endoscope499can include a tip. Such an endoscope can be applied to any of the embodiments described herein.

The method of use can include any step described herein. In some methods of use, the probe system500can facilitate placement of the retractor10relative to an anatomical feature of the patient. The probe system500can be used on a portion of the spine including a first vertebra440, a second vertebra450, and a disc460disposed between the first vertebra440and the second vertebra450, as shown inFIGS.21A-21B.FIG.21Aillustrates the probes505,510being inserted into a patient (not fully shown) toward the spine (only a first vertebra440, second vertebra450, and disc460are illustrated in this representative example). In some methods of use, an incision is made on the patient. In some methods of use, the anterior probe505and the posterior probe510are inserted into a patient, preferably into an anchorable location, such as a collagenous tissue, bone, or vertebral disc. In some methods of use, the posterior probe510and the anterior probe505are coupled with the mating configuration prior to insertion within the patient. The probes505,510are inserted while assembled together. In some methods of use, the posterior probe510is inserted first. The anterior probe505is slid along the length of the posterior probe510toward the anchorable location.

In some methods of use, one or more probes505,510includes an electrode515,520to monitor the patient. In some embodiment, each probe505,510includes an electrode515,520. In some methods of use, each electrode515,520monitors nerve activity. In some methods of use, the electrodes515,520monitor nerve activity in opposite directions. In some methods of use, the electrodes515,520monitor nerve activity in directions 180 degrees apart.

In some methods of use, the probes505,510are secured to the disc460. In some methods of use, a K-wire is inserted and attached to the disc460. In some embodiments, a K-wire (i.e., guide wire) can first be anchored at the location for retractor10placement. One or more of the probes505,510can have a passage extending through its longitudinal length to receive the K-wire when the probes505,510are inserted at the surgical location. The K-wire advantageously provides improved accuracy in placement of the probes505,510and can also help stabilize the probes505,510during insertion of the retractor blades through the patient tissue.

In some methods of use, one or more blades of the retractor10are inserted over the probes505,510. In some methods of use, one or more blades of the retractor10are inserted over the probes505,510after the probes505,510are secured to the anatomy. In some methods of use, the third blade46of the retractor10is slid around the probes505,510. The third blade46can be slid from the first end550of the probes505,510toward the second end555of the probes505,510. In some methods of use, the first blade18and the second blade38of the retractor10are placed in their closed configuration. The third blade46can be coupled to the third arm50underneath the body26. The blades18,38,46will be in their stacked configuration when coupled.

In some methods of use, the anterior probe505is removed from the anchorable location. In some methods of use, the anterior probe505is removed after the retractor10is inserted over the probes505,510. In some methods of use, the anterior probe505is slid toward the first end550of the posterior probe510. In some methods of use, the retractor10remains coupled to the posterior probe510after the anterior probe505is removed.

In some methods, the shim535is inserted into the anchorable location. In some methods of use, the shim535is inserted after the anterior probe505is removed. In some methods of use, the shim535is slid along the length of the posterior probe510toward the anchorable location. In some embodiments, the shim535engages the mating configuration of the posterior probe510. In some methods of use, the shim535engages the third blade46. In some methods of use, the detent345of the shim535engages one or more notches340of the third blade46. In some methods of use, the notches340retain the shim535in a desired position relative to the third blade46.

In some methods of use, the posterior probe510is removed from the anchorable location. In some methods of use, the posterior probe510is removed after the shim535is inserted into the anchorable location. In some methods of use, the K-wire or other securing device is removed from the anchorable location. In some methods of use, the K-wire or other securing device is removed after the shim535is inserted into the anchorable location.

In some methods of use, the third blade46remains coupled to the shim535during use. In some methods of use, the third blade46remains at the anchorable location during use.

The shim535can allow a surgeon to easily and quickly insert a retractor10without cutting an incision all the way to the surgery site prior to inserting the retractor10into the desired location to access the surgery site. Rather, after the third blade46is inserted over the probes505,510, the surgeon can quickly and easily insert the shim535onto the third blade46of the retractor10into the desired location, and then simply slip the first blade18and second blade38of the retractor10into place. From this position, the first blade18and/or the second blade38can be moved in any of the ways described herein. From this position, the first arm12and the second arm32can be moved in any of the ways described herein. The probes505,510can be removed prior to any of these steps or left in place during the procedure.

The probe system500can be more accurate than other systems in maintaining the position of the surgical site. The probe system500can have small tolerances between components of the probe system500. The posterior probe510is inserted at an anchorable location, as described herein. The probes505,510find and monitor the surgical site with one or more electrodes515,520. The K-wire secures the surgical site. The posterior probe510can include a lumen to accept a K-wire therethrough. The inner diameter of the lumen can closely match the outer diameter of the K-wire to limit movement between the K-wire and the posterior probe510. The probes505,510can have a mating configuration. The mating configuration can limit movement between the anterior probe505and the posterior probe510in directions other than translation. The combination of the K-wire and one or more probes505,510can maintain the position of the surgical site.

The interaction between the slot48of the third blade46and the posterior probe510can maintain the position of the surgical site. There is little movement between the probes505,510and the slot48. The posterior probe510can be greater than half of the perimeter of the slot48. The inner diameter of the slot48can closely match the outer diameter of the posterior probe510to limit movement between the slot48and the posterior probe510in a direction other than translation. The inner diameter of the slot48can closely match the outer diameter of the posterior probe510, alone or when mated with the anterior probe505or the shim535.

As described herein, there is little movement between the K-wire and the probes505,510. As described herein, there is little movement between the posterior probe510and the slot48. As described herein, there is little movement between the probes505,510and the slot48. As described herein, there is little movement between the posterior probe510coupled to the shim535and the slot48. This limitation of movement can limit the shifting of the retractor10from the surgical site.

While certain embodiments have been shown and described herein, it will be obvious to those skilled in the art that such embodiments are provided by way of example only. Numerous variations, changes, and substitutions will now occur to those skilled in the art without departing from the invention. It should be understood that various alternatives to the embodiments described herein may be employed. It is intended that the following claims define the scope of the invention and that methods and structures within the scope of these claims and their equivalents be covered thereby.

Further features of this disclosure are given in the following numbered clauses:Clause 1. A retractor comprising:a first blade,a first rotation mechanism that rotates the first blade about a first axis,a second rotation mechanism that rotates the second blade about a second axis,a first pivot mechanism that pivots the first blade about a fourth axis, wherein the fourth axis is skewed to the first axis;a second pivot mechanism that pivots the second blade about a fifth axis, wherein the fifth axis is skewed to the second axis.Clause 2. The retractor of clause 1, wherein the first and second axes are substantially coplanar with one another.Clause 3. The retractor of clause 2, wherein the first and second axes are coplanar with one another.Clause 4. The retractor of clause 1, further comprising an actuator that translates the first blade and second blade about a third axis.Clause 5. The retractor of clause 4, wherein the third axis is substantially perpendicular to the first axis, the second axis or both the first and second axes.Clause 6. The retractor of clause 4, wherein the third axis is substantially perpendicular to both the first axis and the second axis.Clause 7. The retractor of clause 4, wherein the third axis is perpendicular to the first axis, the second axis or both the first and second axes.Clause 8. The retractor of clause 4, wherein the third axis is perpendicular to both the first and second axes.Clause 9. The retractor of clause 4, further comprising a device for locking the first and second blades in at least one predetermined position along the third axis.Clause 10. The retractor of clause 1, further comprising an actuator that slides the first blade and second blade about a sixth axis.Clause 11. The retractor of clause 10, wherein the sixth axis is substantially perpendicular to the first axis, the second axis or both the first and second axes.Clause 12. The retractor of clause 10, wherein the sixth axis is substantially perpendicular to both the first axis and the second axis.Clause 13. The retractor of clause 10, wherein the sixth axis is perpendicular to the first axis, the second axis or both the first and second axes.Clause 14. The retractor of clause 10, wherein the sixth axis is perpendicular to both the first axis and the second axis.Clause 15. The retractor of clause 10, wherein the sixth axis is substantially parallel to the fourth axis, the fifth axis or both the fourth and fifth axes.Clause 16. The retractor of clause 10, wherein the sixth axis is substantially parallel to both the first axis and the second axis.Clause 17. The retractor of clause 10, wherein the sixth axis is parallel to the fourth axis, the fifth axis or both the fourth and fifth axes.Clause 18. The retractor of clause 10, wherein the sixth axis is parallel to both the first axis and the second axis.Clause 19. The retractor of clause 10, further comprising a device for locking the first and second blades in at least one predetermined position along the sixth axis.Clause 20. The retractor of clause 1, further comprising an actuator that translates the first blade and second blade about a third axis and an actuator that slides the first blade and second blade about a sixth axis.Clause 21. The retractor of clause 20, wherein the sixth axis is substantially perpendicular to the third axis.Clause 22. The retractor of clause 20, wherein the sixth axis is perpendicular to the third axis.Clause 23. The retractor of clause 20, further comprising a device for locking the first and second blades in at least one predetermined position along the sixth axis.Clause 24. The retractor of clause 1, further comprising a third blade that remains stationary during movement of the first blade and the second blade.Clause 25. The retractor of clause 24, wherein the first and third blades are of different sizes in at least one dimension.Clause 26. The retractor of clause 24, wherein at least one of the first, second and third blades is a flat blade.Clause 27. The retractor of clause 1, further comprising a third blade and a third pivot mechanism that pivots the third blade about a seventh axis, wherein the seventh axis is skewed to the fourth axis.Clause 28. The retractor of clause 1, wherein at least one blade is removable.Clause 29. The retractor of clause 1, wherein the first and second blades are removable.Clause 30. A retractor blade assembly, comprising:a first blade having attached thereto a first barrel, the first barrel having a wall and defining a first lumen, a first slot in the wall having a first slope,a first screw having an axis, the first screw fitting within the first lumen of the first barrela collar having an inner surface configured to mate with the outer surface of the first screw, the collar having a hole that aligns with the first slot in the wall of the first barrel;a connecting pin fitting through the hole and the slot such that movement of the collar along the axis causes the first barrel to rotate in a first direction; anda hub comprising a first connecting hole, wherein the first barrel fits within the first connecting hole.Clause 31. The blade assembly of clause 30, wherein the hub is adapted to be removably affixed to an arm of a retractor.Clause 32. The blade assembly of clause 30, wherein the hub comprises a second connecting hole and a third connecting hole, wherein the retractor blade assembly further comprises a second screw configured to be received within the third connecting hole, a pin configured to be received within the second connecting hole, wherein movement of the second screw causes the hub to rotate about a post.Clause 33. A retractor blade assembly, comprising:a first blade having attached thereto a first barrel,a hub having a second connecting hole and a third connecting hole,a second screw configured to be received within the third connecting hole;a pin configured to be received within the second connecting hole; anda post extending into the hub, the post comprising a groove configured to accept the pin;wherein movement of the screw causes the hub to rotate about the post.Clause 34. The blade assembly of clause 33, wherein the hub is adapted to be removably affixed to an arm of a retractor.Clause 35. The blade assembly of clause 33, wherein the hub comprises a first connecting hole, wherein the first barrel fits within the first connecting hole, the first barrel having a wall and defining a first lumen, a first slot in the wall having a first slope, a first screw having an axis, the first screw fitting within the first lumen of the first barrel, a collar having an inner surface configured to mate with the outer surface of the first screw, the collar having a hole that aligns with the first slot in the wall of the first barrel, and a connecting pin fitting through the hole and the slot such that movement of the collar along the axis causes the first barrel to rotate in a first direction.Clause 36. A retractor, comprising:a first arm having a distal end and a proximal end;a second arm having a distal end and a proximal end;a first blade coupled near the distal end of the first arm;a first rotation mechanism that rotates the first blade about a first axis;a second blade coupled near the distal end of the second arm rotatable about a second axis;a second rotation mechanism that rotates the second blade about the second axis, wherein the first axis is substantially parallel to the second axis;a first pivot mechanism in mechanical communication with the first blade and adapted to pivot the first blade about a fourth axis, wherein the first axis is skewed to the fourth axis; anda second pivot mechanism in mechanical communication with the second blade and adapted to pivot the second blade about a fifth axis, wherein the second axis is skewed to the fifth axis.Clause 37. The retractor of clause 36, further comprising a third blade and a third pivot mechanism in mechanical communication with the third blade and adapted to pivot the third blade about a seventh axis, wherein the seventh axis is skewed to the fourth axis.Clause 38. A retractor, comprising:a first arm having a distal end and a proximal end;a second arm having a distal end and a proximal end, at least the distal end of the first arm and the distal end of the second arm being movable toward and away from each other;a first blade attached near the distal end of the first arm and a device for moving the first blade about a first axis to adopt at least an opened position and a closed position;a second blade attached near the distal end of the second arm and a device for moving the second blade relative a second axis different from the first axis to adopt at least an opened position and a closed position; anda device for moving at least the distal end of the first arm and the distal end of the second arm relative to one another along a third axis that is not parallel to the first and second axes.Clause 39. A retractor blade assembly, comprising:a first arm having a distal end and a proximal end;a second arm having a distal end and a proximal end, at least the distal end of the first arm and the distal end of the second arm being movable toward and away from each other;a first blade attached near the distal end of the first arm and a device for pivoting the first blade about a fourth axis;a second blade attached near the distal end of the second arm and a device for pivoting the second blade relative a fifth axis different from the fourth axis; anda device for moving at least the distal end of the first arm and the distal end of the second arm relative to one another along a third axis that is not parallel to the fourth and fifth axes.Clause 40. A method of using a retractor, comprising:rotating a first blade of a retractor about a first axis;rotating a second blade of a retractor about a second axis, wherein the first axis is substantially parallel to the second axis;translating the first blade and the second blade about a third axispivoting the first blade about a fourth axis, wherein the fourth axis is skewed to the first axis; andpivoting the second blade about a fifth axis, wherein the fourth axis is skewed to the second axis.Clause 41. A method of using a retractor, comprising:making an incision in a tissue of a body;providing a retractor;rotating a first blade of a retractor about a first axis;rotating a second blade about a second axis, wherein the first axis is substantially parallel to the second axis;pivoting the first blade about a fourth axis, wherein the fourth axis is skewed to the first axis; andpivoting the second blade about a fifth axis, wherein the fifth axis is skewed to the second axis.Clause 42. The method of Clause 41, further comprising positioning the first and second blades substantially parallel to each other to form a first closed blade assembly.Clause 43. The method of Clause 41, further comprising positioning a third blade substantially parallel to the first and second blades in a closed position.Clause 44. The method of Clause 43, further comprising pivoting the third blade about a seventh axis, wherein the seventh axis is skewed to the fourth axis.Clause 45. The method of Clause 43, further comprising inserting the first blade, the second blade, and a third blade within the incision.Clause 46. The method of Clause 41, further comprising actuating the retractor such that the first blade and second blade are moved apart from one another along a third axis and the incision is stretched along the length of the incision to create an opening longer than the incision.Clause 47. The method of Clause 41, further comprising actuating the retractor such that the first blade and second blade are slid together along a sixth axis and the incision is stretched along the width of the incision to create an opening wider than the incision.Clause 48. The method of Clause 41, further comprising creating an aperture in the tissue that is longer and wider than the incision.Clause 49. A retractor comprising:a first blade,a first rotation mechanism that rotates the first blade about a first axis,a second blade,a second rotation mechanism that rotates the second blade about a second axis,a first pivot mechanism that pivots the first blade about a fourth axis, wherein the fourth axis is skewed to the first axis;a second pivot mechanism that pivots the second blade about a fifth axis, wherein the fifth axis is skewed to the second axis.Clause 50. The retractor of clause 49, further comprising an actuator that translates the first blade and second blade about a third axis.Clause 51. The retractor of clause 50, wherein the third axis is perpendicular to the first axis, the second axis or both the first and second axes.Clause 52. The retractor of clause 49, further comprising an actuator that slides the first blade and second blade about a sixth axis.Clause 53. The retractor of clause 52, wherein the sixth axis is perpendicular to the first axis, the second axis or both the first and second axes.Clause 54. The retractor of clause 49, further comprising a third blade.Clause 55. The retractor of clause 54, wherein at least one of the first, second and third blades is a flat blade.Clause 56. The retractor of clause 54, wherein at least one blade is removable.Clause 57. The retractor of clause 54, further comprising a third pivot mechanism that pivots the third blade about a seventh axis, wherein the seventh axis is skewed to the fourth axis.Clause 58. A method of using a retractor, comprising:making an incision in a tissue of a body;providing a retractor;rotating a first blade of a retractor about a first axis;rotating a second blade about a second axis, wherein the first axis is substantially parallel to the second axis;pivoting the first blade about a fourth axis, wherein the fourth axis is skewed to the first axis; andpivoting the second blade about a fifth axis, wherein the fifth axis is skewed to the second axis.Clause 59. The method of clause 58, further comprising positioning the first and second blades substantially parallel to each other to form a first closed blade assembly.Clause 60. The method of clause 58, further comprising positioning a third blade substantially parallel to the first and second blades in a closed position.Clause 61. The method of clause 60, further comprising pivoting the third blade about a seventh axis, wherein the seventh axis is skewed to the fourth axis.Clause 62. The method of clause 60, further comprising inserting the first blade, the second blade, and a third blade within the incision.Clause 63. The method of clause 58, further comprising actuating the retractor such that the first blade and second blade are moved apart from one another along a third axis and the incision is stretched along the length of the incision to create an opening longer than the incision.Clause 64. The method of clause 58, further comprising actuating the retractor such that the first blade and second blade are slid together along a sixth axis and the incision is stretched along the width of the incision to create an opening wider than the incision.Clause 65. The method of clause 58, further comprising creating an aperture in the tissue that is longer and wider than the incision.