JP2004016662A

JP2004016662A - Surgery tool

Info

Publication number: JP2004016662A
Application number: JP2002178967A
Authority: JP
Inventors: Shuhei Iizuka; 飯塚　修平; Takahiro Ogasaka; 小賀坂　高宏
Original assignee: Olympus Corp
Current assignee: Olympus Corp
Priority date: 2002-06-19
Filing date: 2002-06-19
Publication date: 2004-01-22

Abstract

<P>PROBLEM TO BE SOLVED: To provide a surgery treatment tool whose operability is improved by increasing a rotation angle of a treatment part. <P>SOLUTION: One end of an insertion part 2 and an operation part 4 are formed so that mutually abutting surfaces form a prescribed angle with respect to an axial direction of the insertion part 2. Then, when the operation part 4 is rotated and operated to the maximum in a right and left direction, the one end of the insertion part 2 and the operation part 4 abut on each other on the mutually abutting surfaces and a rotation angle of the operation part 4 with respect to the axial direction of the insertion part 2 is regulated to regulate the rotation angle in the right and left direction of the treatment part 3. <P>COPYRIGHT: (C)2004,JPO

Description

【０００１】
【発明の属する技術分野】
この発明は、外科用処置具に関する。
【０００２】
【従来の技術】
例えば、特願２００１−１１９９０４号明細書には、２方向に回動可能な処置部２０３を有する外科用処置具２０１が示されている。図４１に示すように、この外科用処置具２０１の挿入部２０２は、細長い支持部２０８と、この支持部２０８に沿って２つの駆動棒２０６，２０７とが配設されている。これらの駆動棒２０６，２０７は、破損防止のため、操作部２０４を回動させて処置部を回動させたときにも互いに接触することなく配設されている。駆動棒２０６，２０７間の距離ａは、常に０よりも大きい。
【０００３】
また、この外科用処置具２０１の処置部２０３は、上下方向、すなわち、第１および第２の処置片２１２，２１４が互いに対して開閉する方向の上下方向の面内での最大回動角が約９０°である。この面に直交した左右方向の最大回動角は、水平状態に対して±５０°から±６０°程度となっている。
【０００４】
また、例えば内視鏡下で冠状動脈血行再建術（以下、ＣＡＢＧという）を行うには、把持鉗子２６８を用いている。図４２に示すように、鉗子２６８を用いて直径が２ないし３ｍｍ程度の血管２７０の縫合などを行う場合について説明する。この鉗子２６８では、湾曲針２７３の先端を斜めに切断した血管２７０の内壁側から外側に向けて貫通させるには、鉗子２６８を血管２７０の内部に入れて、湾曲針２７３の先端から外側に貫通させる。そして、一旦湾曲針２７３を離した後、湾曲針２７３の先端を再把持して上側に引っ張って湾曲針２７３の基端に接続された糸を血管２７０の内壁から外方に向かって通している。
【０００５】
【発明が解決しようとする課題】
このような鉗子２６８を用いて血管を縫合するには、鉗子２６８の先端が回動しないので、鉗子２６８を大きく傾けたり、上下方向に鉗子２６８全体を動かしたりして縫合を行う必要がある。このため、２ｍｍないし３ｍｍ程度の径が小さい血管２７０を縫合するなどの細かい処置を行うには不向きとなっている。また、上述のように鉗子２６８の先端は回動しないので、湾曲針２７３の湾曲度合に沿って鉗子２６８を微細に動かす必要があり、術者にとって大きな負担となっていた。このため、手術に時間がかかり、患者に対しても負担をかけることとなっていた。
【０００６】
また、図４１に示す特願２００１−１１９９０４号明細書に記載された外科用処置具２０１では、処置部を回動させることができるので図４２に示す鉗子２６８よりもスムーズにこのような処置を行うことができるが、最大回動角度が所望の角度よりも小さい。このため、多数回の湾曲針２７３の持ち替えなどの作業が必要で、血管を縫合するには時間がかかってしまう。
【０００７】
さらに、この外科用処置具２０１は処置部２０３の回動位置によって湾曲針２７３の把持力が変化する可能性がある。例えば心臓血管外科用などの繊細な湾曲針２７３を把持して処置を行うと、湾曲針が思わぬ方向に回転する可能性があり、使い勝手が悪かった。
【０００８】
この発明はこのような課題を解決するためになされたもので、操作性を向上させて手術時間を短縮することができる外科用処置具を提供することを目的としている。
【０００９】
【課題を解決するための手段】
上記課題を解決するために、この発明の、体内に挿入される細長い挿入部と、この挿入部の一端部に設けられ、少なくとも２つの軸を中心として回動可能かつ、開閉可能な処置部と、前記挿入部の他端部に設けられ、少なくとも２つの軸を中心として回動可能かつ、開閉可能な操作部と、この操作部と処置部とを連結し、操作部の操作力を処置部に伝達して処置部を動作させる第１のリンク棒とこの第１のリンク棒に平行に配置された第２のリンク棒とからなる駆動手段とを備え、前記処置部の開閉方向に沿った面内を回動する上下方向とこの上下方向に直交した面内を回動する左右方向との少なくとも２つの平面内で前記操作部および処置部が連動して回動可能な外科用処置具においては、前記挿入部の他端部と前記操作部とには、互いに当接する突き当て部が挿入部の軸方向に対して所定の角度をもって形成され、前記操作部を左右方向に最大に回動操作したときに、前記挿入部の他端部と前記操作部とが互いの突き当て部で当接されるとともに、前記挿入部の軸方向に対する操作部の回動角度が規定されて、前記処置部の左右方向の回動角度が規定されることを特徴とするものである。
【００１０】
また、体内に挿入される細長い挿入部と、この挿入部の一端部に設けられ、少なくとも２つの軸を中心として回動可能かつ、開閉可能な処置部と、前記挿入部の他端部に設けられ、少なくとも２つの軸を中心として回動可能かつ、開閉可能な操作部と、それぞれ両端部に枢軸対を有し、前記処置部を動作させる第１のリンク棒とこの第１のリンク棒に平行に配置された第２のリンク棒とからなり、前記操作部と処置部とを連結し、操作部の操作力を処置部に伝達する駆動手段とを備え、前記処置部の開閉方向に沿った面内を回動する上下方向とこの上下方向に直交した面内を回動する左右方向との少なくとも２つの平面内で前記操作部および処置部が連動して回動可能な外科用処置具においては、前記第１のリンク棒の両端部に設けられた前記枢軸対と、第２のリンク棒の両端部に設けられた前記枢軸対との少なくとも一方は、それぞれ第２のリンク棒と、第１のリンク棒とに近接する側に偏りをもって設けられ、前記第１および第２のリンク棒を互いに逆方向に進退させたときに、前記処置部の回動角度を増すようにしていることを特徴とするものである。
【００１１】
このような構成とすることによって、処置部の左右方向の回動角度が増して回動角度を大きくとることが必要な手技について操作性を向上させて手術時間の短縮が図れる。
【００１２】
【発明の実施の形態】
以下、図面を参照しながらこの発明の実施の形態について説明する。
【００１３】
［第１の実施の形態］
まず、第１の実施の形態について図１ないし図２５を用いて説明する。
【００１４】
（構成）
図１に示すように、この実施の形態にかかる外科用処置具１は、細長い挿入部２と、この挿入部２の先端に配設された処置部３と、挿入部２の基端に配設され、処置部３を操作する操作部４とを備えている。
【００１５】
挿入部２には、細長く、剛性を有する支持部８が配設されている。この支持部８の中央部は、細長の略平板状に形成されている。さらに、この支持部８の軸方向に沿って、開閉リンク機構を構成する第１の駆動棒５と、回動リンク機構を構成する第２および第３の駆動棒６，７（第１および第２のリンク棒）とが平行または略平行に設けられている。第１の駆動棒５は支持部８に対して図１中の下側に設けられている。また、第２および第３の駆動棒６，７は、支持部８に対して図１中の上側に設けられている。なお、第２および第３の駆動棒６，７は、挿入部２の長手方向中心軸に対して対称的に配置されるとともに、軸方向に独立して進退可能となっている。
【００１６】
図２ないし図４に示すように、支持部８の先端部にはすり割部８ａが設けられている。このすり割部８ａには、挿入部２の軸方向と直交する枢支軸９によって左右方向に回動可能な第１の回動板１０が連結されている。この第１の回動板１０には枢支軸９と直交する方向に第１の枢支ピン１１が固定されている。この第１の枢支ピン１１には第１の処置片１２の基端部が回動自在に枢支されている。また、第１の枢支ピン１１の近傍に位置する第１の処置片１２の部位は屈曲部１２ａとして形成されている。この屈曲部１２ａには後述する手段によって第２および第３の駆動棒６，７が連結されている。
【００１７】
第１の処置片１２の中間部には、第１の開閉枢支ピン１３によって第２の処置片１４が回動自在に連結されている。これにより、第１および第２の処置片１２，１４は、第１の開閉枢支ピン１３を支点として、互いに回動可能となっている。第２の処置片１４の基端部には、左右方向（挿入部２の軸方向と直交する方向）に延びる第１の連結ピン１５を介して、第１の連結部材１６の一端が回動自在に連結されている。第１の連結部材１６の他端は、挿入部２の軸方向と直交する第２の連結ピン１７を介して、第２の連結部材１８に連結されている。また、第２の連結部材１８の他端は、左右方向に延びる第３の連結ピン１９を介して、第１の駆動棒５の先端部に回動自在に連結されている。
【００１８】
また、第１の処置片１２の屈曲部１２ａには、左右方向に延びる第２の枢支ピン２０を介して、Ｔ字状の第２の回動板２１が連結されている。この第２の回動板２１の基端側は左右方向に幅広であり、第２の回動板２１の基端側には、挿入部２の軸方向と直交する第１の回動ピン（枢軸）２２と第２の回動ピン（枢軸）２３とが左右方向に離間して設けられている。また、この第２の回動板２１は、幅広部に対して直交して所定の軸方向に延びる直交部を有する。この直交部の先端には、上述した第２の枢支ピン２０が配設されている。そして、第１の回動ピン２２は第２の駆動棒６に連結され、第２の回動ピン２３は第３の駆動棒７に連結されている。
【００１９】
また、図４に示すように、第１の処置片１２は把持面１２ｂを有する。また、第２の処置片１４は把持面１４ｂを有する。この場合、第１および第２の処置片１２，１４が互いに閉じたときには、これらの把持面１２ｂ，１４ｂは、互いに略平行に対向して位置しており、協働して把持対象物を把持可能となっている。なお、これらの把持面１２ｂ，１４ｂには、必要に応じて例えば放電加工やエッチングなどにより微細な粗面が形成される凹凸加工が施されている。これにより、把持対象物である縫合針、縫合糸、生体組織等を確実に把持することができるようになっている。
【００２０】
次に、図５ないし図７を参照しながら、操作部４について説明する。
これらの図５ないし図７に示すように、挿入部２の基端部においても、第１の駆動棒５はその基端部が挿入部２の長手中心軸より下側に偏って配置されている。また、第２および第３の駆動棒６，７はその基端部が挿入部２の長手中心軸より上側で左右対称的に配置されている。そして、第１の駆動棒５は、後述する構成を介して、第３の連結部材４１に接続される（図６参照）。また、第２および第３の駆動棒６，７は、後述する構成を介して、第４の回動板４６に接続されている（図６参照）。
【００２１】
図５ないし図７に示すように、支持部８は、挿入部２の基端部では、後方（基端側）に向かって突出している。また、図６および図７に示すように、支持部８には、挿入部２の軸方向と直交する第２の枢支軸３２を有する第１の枢支部３３が設けられている。この第１の枢支部３３には、第２の枢支軸３２を中心に左右に回動可能な第３の回動板３４が設けられている。
【００２２】
この第３の回動板３４には、左右方向に延びる第３の枢支ピン３５を有する第２の枢支部３６が設けられている。この第２の枢支部３６には、第３の枢支ピン３５を中心に上下に回動可能な第１の操作部としての第１のハンドル３７が連結されている。
【００２３】
図１および図８に示すように、第１のハンドル３７には、第２の開閉枢支ピン３８によって、第２の操作部としての第２のハンドル３９が上下に回動自在に連結されている。
【００２４】
また、図６に示すように、第１の駆動棒５の基端部には、挿入部２の軸方向と直交する（上下方向に延びる）第４の連結ピン４２が設けられており、この第４の連結ピン４２には第３の連結部材４１が左右方向に回動可能に接続されている。この第３の連結部材４１は、第４の連結部材４３の一端に設けられた左右方向に延びる第５の連結ピン４０を介して第４の連結部材４３に連結されており、第５の連結ピン４０を中心に上下に回動できるようになっている。また、第４連結部材４３の他端には、左右方向に延びる第６の連結ピン４４を介して、第２のハンドル３９が上下に回動可能に接続されている。
【００２５】
第１のハンドル３７の第３の枢支ピン３５の近傍には、左右方向に延びる第４の枢支ピン４５が位置されている。この第４の枢支ピン４５は第４の回動板４６の一端に設けられており、この第４の枢支ピン４５には、第３の枢支ピン３５を中心に上下に回動する第１のハンドル３７が回動可能に連結している。第４の回動板４６の他端部には、挿入部２の軸方向と直交する（上下方向に延びる）第３および第４の回動ピン（枢軸）４７，４８が左右に離間して設けられている。そして、第３および第４の回動ピン４７，４８にはそれぞれ、互いに左右に位置する第２の駆動棒６の基端部および第３の駆動棒７の基端部が回動自在に連結されている（図７参照）。
【００２６】
さらに、図１に示すように、第１のハンドル３７には、術者が操作時に親指以外の指を用いて把持する第１のグリップ３７ａが設けられている。この第１のグリップ３７ａには、例えば中指で保持するラウンド部３７ｂが形成されている。さらに、この第１のグリップ３７ａの第２の開閉枢支ピン３８に対して遠位側には、手の腹部に当てる支柱１００が形成されている。この支柱１００の手の腹部に当たる部分は、好ましくは、球状の球部１００ａが形成されている。
【００２７】
また、第２のハンドル３９の第２の開閉枢支ピン３８の近位側は、親指の先端側の腹部を当てるように、平面状に形成されている。遠位側は、親指の腹部に沿って円弧状に親指置き部（膨部）３９ａが形成されている。さらに、この第２のハンドル３９の親指置き部３９ａには、第１のハンドル３７の内部の図示しない歯部に噛合わせられるラチェット８２が形成されている。このため、第１のハンドル３７に対する第２のハンドル３９の回動角度を所定の位置で留めることが可能となっている。
【００２８】
なお、ラチェット８２の噛合わせは、第１のハンドル３７のラウンド部３７ｂの近傍に設けたレバー８３で解除自在となっている。
【００２９】
図８（Ａ）および図９（Ａ）は、第１および第２のハンドル３７，３９をともに上下方向に最大に回動させた状態を示している。すなわち、第１の駆動棒５を処置部３側に押出した状態である。また、第２および第３の駆動棒６，７は、互いに平行に、かつ、進退していないニュートラル状態にある。この状態では、第２および第３の駆動棒６，７間の距離は、例えばａである。また、第１のハンドル３７には、第１の突き当て面６０が形成されている。この第１の突き当て面６０に対して、支持部８の長手方向は略直交している。
【００３０】
また、支持部８の後端部、すなわち、操作部４との連結部側には、２つの第２の突き当て面６１が形成されている。これらの第２の突き当て面６１の間の角度θは、支持部８の長手方向軸に沿って例えば４０°に形成されている。すなわち、ハンドル３７，３９は、左右方向にそれぞれ７０°ずつ回動可能となっている。
【００３１】
図９（Ｂ）は、図９（Ａ）の状態から第２の枢支軸３２を支点としてハンドル３７，３９を左右方向の一方向に最大（７０°）に回動させた状態を示している。すなわち、第１の駆動棒５を処置部３側に押出した状態である。さらに、第２の駆動棒６を操作部４側に引っ張り、第３の駆動棒７を処置部３側に押出した状態である。また、第２および第３の駆動棒６，７は、互いに平行な状態を維持しながら互いに対して当接した状態である。すなわち、上述した距離ａはゼロである。そして、第１の突き当て面６０と、一方の第２の突き当て面６１とは、互いに当接するようになっている。このとき、支持部８の軸方向に対する処置部３の回動角度は、７０°となる。すなわち、第２の回動板２１の幅広部の長手方向と支持部８の軸方向とのなす角は、２０°であり、幅広部と処置片１２，１４とのなす角度は９０°であるので、支持部８の軸方向と処置部３とがなす角度は７０°となる。このとき、第２の回動板２１の第２の枢支ピン２０が配設される直交部の先端部に対して遠位側の端部と、第１の突き当て面６０とは、互いに平行となっている。したがって、この実施の形態の外科用処置具１は、ハンドル３７，３９の回動量に比例して処置部３も回動する。
【００３２】
また、図１０は、第２の回動板２１と、第２および第３の駆動棒６，７との位置関係を示している。図１０に示すように、例えば第３の駆動棒７の第２の回転ピン２３は、第３の駆動棒７の長手方向に対して直交した方向に対して第２の駆動棒６側に近接する側に配置されている。すなわち、図１０中の第３の駆動棒７の幅をＬとし、この第３の駆動棒７の外方から第２の回転ピン２３までの距離Ｌ１とし、第２の回転ピン２３から駆動棒７の内方までの距離Ｌ２とすると、
Ｌ＝Ｌ１＋Ｌ２
で、
Ｌ１−Ｌ２＞０
に形成されている。すなわち、第３の駆動棒７の距離Ｌ２を小さくすると、第２の回転ピン２３と第３の駆動棒７の側部との距離が近づけられる。このため、回動角度を大きくすることが可能となっている。そして、第３の駆動棒７は、第２の回転ピン２３を設けた部分の強度が弱くなるのを反対側の距離Ｌ１を大きくすることによって強度を保つようになっている。
なお、説明を省略するが、第２の駆動棒６についても第３の駆動棒７と同様に形成されていることが好ましい。
【００３３】
したがって、第２および第３の駆動棒６，７を進退させると、Ｌ１＝Ｌ２のときよりも第１および第２の回転ピン２２，２３と第３および第２の駆動棒７，６との間の距離が小さいので、第２の回動板２１の回動角が増す。このため、処置部３をより大きい角度に回動させることができるようになっている。
【００３４】
（作用）
次に、上述のように構成された外科用処置具１の動作について説明する。
【００３５】
図２および図３に示される状態から、第２および第３の駆動棒６，７を同時に前進させると、第２の回動板２１を介して第１の処置片１２の屈曲部１２ａが前方に押し出される。このため、第１の開閉枢支ピン１３を介して第１の処置片１２と連結する第２の処置片１４も、第１の処置片１２と同一の方向に回動する。その結果、第１および第２の処置片１２，１４は、挿入部２の長手中心軸と直交する第１の枢支ピン１１を中心として略水平まで回動する。
【００３６】
次に、第２の駆動棒６を後退させて第３の駆動棒７を前進させると、第１の枢支軸９を支点として第１の回動板１０が右方向（操作部４側から見て）に回動する。このため、第１および第２の処置片１２，１４（処置部３全体）が第１の枢支軸９を支点として右向に回動する。
【００３７】
逆に、第２の駆動棒６を前進させて第３の駆動棒７を後退させると、第１の枢支軸９を支点として第１の回動板１０が左方向（操作部４側から見て）に回動する。このため、第１および第２の処置片１２，１４（処置部３全体）が第１の枢支軸９を支点として左方向に回動する。
【００３８】
また、いずれの回動状態においても、第１の駆動棒５を前進させると、第１の連結部材１６および第２の連結部材１８を介して、第２の処置片１４の基端部が前方に押される。このため、第１の処置片１２に対して第２の処置片１４が第１の開閉枢支ピン１３を支点として回動される。これによって、処置部３が開く。逆に、この開放状態から第１の駆動棒５を後退させると、第１の連結部材１６および第２の連結部材１８を介して、第２の処置片１４の基端部が後方へ引き戻される。このため、第１の処置片１２に対して第２の処置片１４が第１の開閉枢支ピン１３を支点として回動される。これによって、処置部３が閉じる。
【００３９】
このように、この実施の形態によれば、開閉可能な第１および第２の処置片１２，１４を備えた処置部３全体を上下方向および左右方向に回動させることができる。このため、第１および第２の処置片１２，１４を目的部位に容易にアプローチすることができ、処置の自由度を向上させることができる。
【００４０】
実際の操作においては、まず、図１に示される操作部４の第１のハンドル３７の第１グリップ３７ａのラウンド部３７ｂに親指以外のいずれかの指で把持する（かける）。これとともに、第２のハンドル３９の第２のグリップ（親指置き部）３９ａに親指を添える。そして、図８（Ｂ）に示す水平状態から、操作部４の第１および第２のハンドル３７，３９を第３の枢支ピン３５を支点として同時に下方へ９０°回動させる。すると、第４の回動板４６を介して第２および第３の駆動棒６，７が同時に挿入部２に沿って後退する。これとともに、これに連動するように、第４の連結部材４３と第３の連結部材４１とを介して第１の駆動棒５が処置部３側に前進する。したがって、第１の駆動棒５に連結された処置部３側の第１の連結部材１６を介して第１の連結ピン１５が先端側へ突出されるとともに、第２の回動板２１を介して第１の処置片１２の屈曲部１２ａが後方に引き戻される。このため、第１および第２の処置片１２，１４は、相対的に回動することなく、閉じた状態を維持したまま、第１の枢支ピン１１を支点として９０°上向きになるまで回動する。その状態が図１および図８（Ａ）に示されている。
【００４１】
また、逆に、図１および図８（Ａ）に示す状態から、第１のハンドル３７および第２のハンドル３９を第３の枢支ピン３５を支点として上方へ回動させ、第１および第２のハンドル３７，３９を水平にする。すると、第４の連結部材４３と第３の連結部材４１とを介して第１の駆動棒５が操作部４側に後退するとともに、第４の回動板４６を介して第２および第３の駆動棒６，７が同時に挿入部２に沿って前進する。したがって、第１の駆動棒５に連結された処置部３側の第１の連結部材１６を介して第１の連結ピン１５が操作部４側に引き寄せられるとともに、第２の回動板２１を介して第１の処置片１２の屈曲部１２ａが前方に押し出される。このため、第１および第２の処置片１２，１４は、相対的に回動することなく、閉じた状態を維持したまま、第１の枢支ピン１１を支点として略水平まで回動する（真っ直ぐになる）（図８（Ｂ）参照）。
【００４２】
このように、この実施の形態の外科用処置具１では、操作部４側の第１および第２のハンドル３７，３９を第３の枢支ピン３５を支点として上下方向に回動することにより、処置部３を挿入部２の軸方向に沿って真っ直ぐに位置させたり、あるいは、挿入部２の軸方向に対して角度を持たせることができる。
【００４３】
また、第１の操作ハンドル３７と第２の操作ハンドル３９とを相対的に回動させれば、第１および第２の処置片１２，１４が相対的に回動して、処置部３を開くことができる。すなわち、第１のハンドル３７に対して第２のハンドル３９を第２の開閉枢支ピン３８を支点として回動させると（第１のハンドル３７と第２のハンドル３９とを開くと）、第４の連結部材４３および第３の連結部材４１を介して第１の駆動棒５が前後に進退する。したがって、第１の駆動棒５に連結された処置部３側の第１の連結部材１６を介して第１の連結ピン１５が前後に移動する。このため、第１の開閉枢支ピン１３を支点として第２の処置片１４が第１の処置片１２に対して回動し、処置部３が開閉する。
【００４４】
図９（Ｂ）は、第１および第２のハンドル３７，３９を共に左横方向（操作部４側から見て）に例えば７０°回動した状態を示している。この状態では、第１および第２のハンドル３７，３９の回動に伴って、第１および第２の処置片１２，１４も閉じた状態で右横方向へ７０°回動される。すなわち、第１のハンドル３７と第２のハンドル３９とを同時に第２の枢支軸３２を支点として左方向に回動すると、第４の回動板４６を介して第２の駆動棒６が後退し、第３の駆動棒７が前進する。したがって、処置部３における第１の回動ピン２２が後退し、第２の回動ピン２３が前進する。このため、第２の回動板２１を介して第１の処置片１２が第１の枢支軸９を支点として右方向に回動し、その結果、処置部３全体が右方向に回動する。
【００４５】
逆に、第１および第２のハンドル３７，３９を同時に第２の枢支軸３２を支点として右方向に回動すると、第４の回動板４６を介して第２の駆動棒６が前進し、第３の駆動棒７が後退する。したがって、処置部３における第１の回動ピン２２が前進し、第２の回動ピン２３が後退する。このため、第２の回動板２１を介して第１の処置片１２が枢支軸９を支点として左方向に回動する。その結果、処置部３全体が左方向に回動する。
【００４６】
このように、この実施の形態の外科用処置具１では、第１および第２のハンドル３７，３９の右方向の回動に連動して第１および第２の処置片１２，１４がハンドル３７，３９と略平行状態を保ったまま左方向に回動する。また、第１および第２のハンドル３７，３９の左方向の回動に連動して第１および第２の処置片１２，１４がハンドル３７，３９と略平行状態を保ったまま右方向に回動する。すなわち、第１および第２のハンドル３７，３９の上下左右の回動操作によって処置部３を任意の方向に向けることができる。
【００４７】
次に、このような作用を有する外科用処置具１を用いて例えばＣＡＢＧ手術を行う場合の手技について説明する。なお、この実施の形態では、右手で外科用処置具１を操作する場合について説明する。もちろん、左手で操作する場合には、以下に説明する操作を左右逆にして行えばよい。なお、この手術を行うには、例えば体外循環装置を使って心停止下で行っても良い。または、別のポートから血管吻合を行いたい部位の心拍動を部分的に止めるスタビライザ（例えば特開２０００−１１６６６３号公報参照）を挿入し、心拍動下で行っても良い。
【００４８】
図１１は、この実施の形態にかかる外科用処置具１の持ち方を示し、かつ、この外科用処置具１を体腔内に挿入して使用する様子を示している。また、図１１に示すように、内視鏡下のＣＡＢＧ手術においては、上下方向の回動角度を挿入部２に対して略直角に保持した状態で用いられることが多い。以下に説明するＣＡＢＧ手術では、略直角に保持した状態で使用される。
【００４９】
図１１に示すように、親指１１３は、第２のハンドル３９の親指置き部３９ａに載置される。人差指１１４は、挿入部２と操作部４との接続部付近を保持する。中指１１５は、第１のハンドル３７のラウンド部３７ｂを保持する。薬指１１６および小指１１７は、第１のハンドル３７の第２の開閉枢支ピン３８に対して遠位側、もしくは、支柱１００を支える。
【００５０】
図１２は、心臓がある部位の胸部を下側から見た断面図を示している。トロッカー１１８が挿入されると、胸腔内は陽圧となるので、肺６５は虚脱される。左前下行枝６４と称されている冠状動脈の真上にトロッカー１１８を介して硬性鏡６７を挿入する。すなわち、術部の真上から観察しながら手術を行う。また、硬性鏡６７が挿入されるトロッカー１１８に隣接した位置に２つの他のトロッカー１１８が挿入される。そして、このトロッカー１１８の一方には、図１１に示すように保持した状態で外科用処置具１の処置部３から体腔内に挿入する。また、トロッカー１１８の他方には、把持鉗子６８などの処置具を挿入する。
なお、この実施の形態で説明する左前下行枝６４や内胸動脈７０の血管径は、例えば２ｍｍないし３ｍｍ程度である。
【００５１】
図１３は、血管吻合を行う前段階が終了した状態を示している。図１３に示すように、内視鏡的に図示しない胸部側方に開けたポートを用いて、図１２に示す胸壁６６から内胸動脈７０が剥離されている。そして、左前下行枝６４内に狭窄を起こした部位の下流側にはさみ鉗子６９を用いて切開口７１を形成している。
【００５２】
図１４ないし図２５は、内視鏡下で行う血管吻合（縫合）手技の流れを順に示している。なお、径が２ｍｍないし３ｍｍ程度の血管を縫合することができる非常に微細な第１および第２の湾曲針７３，７４の先端は鋭利に形成され、適当な湾曲度合を持って湾曲されて、基端には両者を繋ぐ縫合糸７５が配設されている。
【００５３】
まず、第２の湾曲針７４の先端部が処置部３の右横側に配設されるように湾曲針７４の基端側を処置部３で把持しておく。そして、図１４（Ａ）に示すように、把持鉗子６８で胸壁６６から剥離させた内胸動脈７０を把持する。この状態で、湾曲針７４が内胸動脈７０の切断部（端部）近傍の内壁部に向かうように、ハンドル３７，３９を左横方向に回動操作する。処置部３は右横方向に回動して第２の湾曲針７４の先端部は内胸動脈７０に刺し入れられる。すなわち、内壁部から外側に向かって湾曲針７４の先端部を押し込む。ここで、図１８はこのような状態になるまでの内胸動脈７０に対する処置部３の一連の動きを図１４（Ａ）の１４Ａ−１４Ａ断面に沿って示している。
【００５４】
図１８（Ａ）に示すように、ハンドル３７，３９を右横方向に最大（例えば、＋７０°）に回動させて、処置部３の左右方向の回動角度を左横方向に最大（例えば、＋７０°）に回動させる。この状態で湾曲針７４の先端を内胸動脈７０内に刺す。
次に、図１８（Ｂ）に示すように、ハンドル３７，３９を右横方向の最大回動位置から左横方向に略中央の位置まで回動させる。つまり、ハンドル３７，３９を略ニュートラル状態に戻す。すると、処置部３の回動角度が小さくなる方向、すなわち、処置部３が右横方向に向かって略中央のニュートラル位置まで回動し、湾曲針７４の先端部を内胸動脈７０の内壁部の任意の位置に刺し入れる。そして、この状態で一旦、湾曲針７４を放す。
そして、図１８（Ｃ）に示すように、ハンドル３７，３９を左横方向の適当な角度に回動させて処置部３を右横方向に適当な角度に回動させた状態にする。この後、湾曲針７４の先端部が処置部３の右横側を向くように湾曲針７４の先端側を処置部３で再把持する。
さらに、ハンドル３７，３９を左横方向に最大に回動操作（例えば、−７０°）して、処置部３を図１８（Ａ）に示す方向に対して反対側の右横方向に最大（例えば、−７０°）に回動させる。このようにして、湾曲針７４の基端部を湾曲針７４の湾曲度合にほぼ沿わせながら内胸動脈７０から抜き取る。すなわち、図１８（Ｄ）に示すように、第２の湾曲針７４を把持した状態で内胸動脈７０に縫合糸７５を通す。
【００５５】
そして、第２の湾曲針７４の先端部が処置部３の左横側に配設されるように湾曲針７４の基端側を処置部３で再把持しておく。この状態で、図１４（Ｂ）に示すように、湾曲針７４の先端部が左前下行枝６４の切開口７１近傍の外壁部に向かうように、ハンドル３７，３９を右横方向に回動操作する。処置部３は左横方向に回動して第２の湾曲針７４の先端部は左前下行枝６４の外壁部から内側に向かって刺し入れられる。すなわち、処置部３の回動によって左前下行枝６４の外壁部から内側に向かって湾曲針７４の先端部を引っ掛ける。ここで、図１９はこのような状態になるまでの左前下行枝６４に対する処置部３の一連の動きを図１４（Ｂ）に示す１４Ｂ−１４Ｂ断面に沿って示している。
【００５６】
図１９（Ａ）に示すように、ハンドル３７，３９を左横方向に最大に回動させて、処置部３の左右方向の回動角度を右横方向に最大に回動させる。この状態で湾曲針７４の先端を左前下行枝６４の外壁部の任意の位置に刺す。
次に、図１９（Ｂ）に示すように、ハンドル３７，３９を左横方向の最大回動位置から右横方向に向かって回動させる。つまり、ハンドル３７，３９をニュートラル方向に戻す。すると、処置部３の回動角度が小さくなる方向、すなわち、処置部３が左横方向に向かって回動し、湾曲針７４の先端部を左前下行枝６４の外壁部に刺し入れる。そして、この状態で一旦、湾曲針７４を放す。
そして、図１９（Ｃ）に示すように、ハンドル３７，３９を右横方向の適当な角度に回動させて処置部３を左横方向に適当な角度に回動させた状態にする。この後、湾曲針７４の先端部が処置部３の左横側を向くように湾曲針７４の先端側を処置部３で再把持する。
さらに、ハンドル３７，３９を右横方向に最大に回動操作して、処置部３を図１９（Ａ）に示す方向に対して反対側の左横方向に最大に回動させる。このようにして、湾曲針７４の基端部を湾曲針７４の湾曲度合にほぼ沿わせながら左前下行枝６４から抜き取る。すなわち、図１９（Ｄ）に示すように、第２の湾曲針７４を把持した状態で左前下行枝６４に縫合糸７５を通す。
【００５７】
この状態では、湾曲針７４の先端部は、内胸動脈７０と左前下行枝６４とを貫通している。すなわち、縫合糸７５は、内胸動脈７０と左前下行枝６４とを通っている。
【００５８】
次に、第２の湾曲針７４の先端部が処置部３の右横側に配設されるように湾曲針７４の基端側を処置部３で再把持しておく。この状態で、図１４（Ｃ）に示すように、湾曲針７４の先端部が内胸動脈７０の端部の内壁部に向かうように、ハンドル３７，３９を左横方向に回動操作する。処置部３は右横方向に回動して第２の湾曲針７４の先端部は内胸動脈７０の内壁部から外側に向かって刺し入れられる。すなわち、内壁部から外側に向かって湾曲針７４の先端部を押し込む。ここで、図２０はこのような状態になるまでの内胸動脈７０に対する処置部３の一連の動きを図１４（Ｃ）に示す１４Ｃ−１４Ｃ断面に沿って示している。
【００５９】
図２０（Ａ）に示すように、ハンドル３７，３９を右横方向に最大に回動させて、処置部３の左右方向の回動角度を左横方向に最大に回動させる。この状態で湾曲針７４の先端部を内胸動脈７０の内壁に刺す。
図２０（Ｂ）に示すように、ハンドル３７，３９を右横方向の最大回動位置から左横方向に向かって回動させる。つまり、ハンドル３７，３９をニュートラル方向に戻す。すると、処置部３の回動角度が小さくなる方向、すなわち、処置部３が右横方向に向かって回動し、湾曲針７４の先端部を内胸動脈７０の内壁部に刺し入れる。そして、この状態で一旦、湾曲針７４を放す。
そして、図２０（Ｃ）に示すように、ハンドル３７，３９を左横方向の適当な角度に回動させて処置部３を右横方向に適当な角度に回動させた状態にする。この後、湾曲針７４の先端部が処置部３の右横側を向くように湾曲針７４の先端側を処置部３で再把持する。
さらに、ハンドル３７，３９を左横方向に最大に回動操作して、処置部３を図２０（Ａ）に示す方向に対して反対側の右横方向に最大に回動させる。このようにして、湾曲針７４の基端部を湾曲針７４の湾曲度合にほぼ沿わせながら内胸動脈７０から抜き取る。すなわち、図２０（Ｄ）に示すように、第２の湾曲針７４を把持した状態で内胸動脈７０に縫合糸７５を通す。
【００６０】
次に、第２の湾曲針７４の先端部が処置部３の右横側に配設されるように湾曲針７４の基端側を処置部３で再把持しておく。この状態で、図１５（Ａ）に示すように、湾曲針７４の先端部が左前下行枝６４の切開口７１近傍の外壁部に向かうように、ハンドル３７，３９を右横方向に回動操作する。処置部３は左横方向に回動して第２の湾曲針７４の先端部は左前下行枝６４の外壁部から内側に向かって刺し入れられる。すなわち、外壁部から内側に向かって湾曲針７４の先端部を引っ掛ける。ここで、図２１はこのような状態になるまでの左前下行枝６４に対する処置部３の一連の動きを図１５（Ａ）に示す１５Ａ−１５Ａ断面に沿って示している。
【００６１】
図２１（Ａ）に示すように、ハンドル３７，３９を右横方向に最大に回動させて、処置部３の左右方向の回動角度を左横方向に最大に回動させる。この状態で湾曲針７４の先端部を左前下行枝６４の外壁に刺す。
図２１（Ｂ）に示すように、ハンドル３７，３９を右横方向の最大回動位置から左横方向に向かって回動させる。つまり、ハンドル３７，３９をニュートラル方向に戻す。すると、処置部３の回動角度が小さくなる方向、すなわち、処置部３が右横方向に向かって回動し、湾曲針７４の先端部を左前下行枝６４の外壁部に刺し入れる。そして、この状態で一旦、湾曲針７４を放す。
そして、図２１（Ｃ）に示すように、ハンドル３７，３９を左横方向の適当な角度に回動させて処置部３を右横方向に適当な角度に回動させた状態にする。この後、湾曲針７４の先端部が処置部３の右横側を向くように湾曲針７４の先端側を処置部３で再把持する。
さらに、ハンドル３７，３９を左横方向に最大に回動操作して、処置部３を図２１（Ａ）に示す方向に対して反対側の右横方向に最大に回動させる。このようにして、湾曲針７４の基端部を左前下行枝６４の切開口７１から抜き取る。すなわち、図２１（Ｄ）に示すように、第２の湾曲針７４を把持した状態で左前下行枝６４に縫合糸７５を通す。
【００６２】
そして、図１５（Ｂ）に示すように、左前下行枝６４を術者が見たときに反時計回り方向に１２時方向から９時方向付近まで、内胸動脈７０に対して時計回り方向に同様にして順次縫合する。この後、左前下行枝６４および内胸動脈７０の両血管の１／４程度を縫合した時点で、図１５（Ｃ）に示すように、縫合糸７５を引っ張って血管６４，７０同士の吻合位置を規定する。
【００６３】
次に、第２の湾曲針７４が一端に取り付けられた縫合糸７５の他端に配設された第１の湾曲針７３を用いて縫合を開始する。すなわち、図１６（Ａ）に示すように、図１４（Ａ）ないし図１４（Ｃ）、並びに図１５（Ａ）および図１５（Ｂ）に示した位置から左前下行枝６４の長手方向に対して対称的な方向に縫合を行う。第１の湾曲針７３の先端部が処置部３の右横側に配設されるように湾曲針７３の基端側を処置部３で把持しておく。また、把持鉗子６８で内胸動脈７０を把持しておく。この状態で、湾曲針７３の先端部が内胸動脈７０の外壁側から左前下行枝６４の内壁側に向かって刺し入れられる。ここで、図２２および図２３はこのような状態になるまでの左前下行枝６４および内胸動脈７０に対する処置部３の一連の動きを図１６（Ａ）の１６Ａ−１６Ａ断面に沿って示している。
【００６４】
図２２（Ａ）に示すように、ハンドル３７，３９を右横方向に最大に回動させて、処置部３の左右方向の回動角度を左横方向に最大に回動させる。この状態で湾曲針７３の先端部を内胸動脈７０の外壁部に刺す。
図２２（Ｂ）に示すように、ハンドル３７，３９を右横方向の最大回動位置から左横方向に向かって回動させる。つまり、ハンドル３７，３９をニュートラル方向に戻す。すると、処置部３の回動角度が小さくなる方向、すなわち、処置部３が右横方向に向かって回動し、湾曲針７３の先端部を内胸動脈７０の外壁部に刺し入れる。
さらに、図２２（Ｃ）に示すように、この状態で、湾曲針７３の先端部を左前下行枝６４の内壁部から外側に向かって刺し入れる。すなわち、湾曲針７３の先端は、内胸動脈７０と左前下行枝６４とが接触した状態で、両者７０，６４に貫通する。そして、この状態で一旦、湾曲針７３を放す。
なお、図２２（Ｂ）および図２２（Ｃ）で示すように、内胸動脈７０と左前下行枝６４とを縫合するには、２回の回動操作を行っているが、１回の回動操作のみで済む場合もあり得る。すなわち、１回の回動操作で２つの血管７０，６４に湾曲針７３を貫通させてもよい。
【００６５】
そして、図２３（Ａ）に示すように、ハンドル３７，３９を略ニュートラル位置に回動させて処置部３を略ニュートラル位置にする。この後、湾曲針７３の先端部が処置部３の右横側を向くように湾曲針７３の先端側を処置部３で再把持する。
さらに、ハンドル３７，３９を左横方向に最大に回動操作して、処置部３を図２２（Ａ）に示す方向に対して反対側の右横方向に最大に回動させる。このようにして、湾曲針７３の基端部を内胸動脈７０および左前下行枝６４から抜き取る。すなわち、図２３（Ｂ）に示すように、第１の湾曲針７３を把持した状態で内胸動脈７０および左前下行枝６４に縫合糸７５を通す。
【００６６】
そして、図１６（Ｂ）に示すように、左前下行枝６４を術者が見たときに時計回り方向に１２時方向から３時方向付近まで内胸動脈７０および左前下行枝６４を順次縫合する。
【００６７】
次に、第１の湾曲針７３の先端部が処置部３の左横側に配設されるように湾曲針７３の基端側を処置部３で再把持しておく。この状態で、図１６（Ｃ）に示すように、湾曲針７３の先端部が内胸動脈７０の外壁側から左前下行枝６４の内壁側に向かって刺し入れられる。ここで、図２４および図２５はこのような状態になるまでの左前下行枝６４および内胸動脈７０に対する処置部３の一連の動きを図２２および図２３とは反対側から図１６（Ｃ）の１６Ｃ−１６Ｃ断面に沿って示している。
【００６８】
図２４（Ａ）に示すように、ハンドル３７，３９を左横方向に最大に回動させて、処置部３の左右方向の回動角度を右横方向に最大に回動させる。この状態で湾曲針７３の先端部を内胸動脈７０の外壁に刺す。
図２４（Ｂ）に示すように、ハンドル３７，３９を左横方向の最大回動位置から右横方向に向かって回動させる。つまり、ハンドル３７，３９をニュートラル方向に戻す。すると、処置部３の回動角度が小さくなる方向、すなわち、処置部３が左横方向に向かって回動し、湾曲針７４の先端部を内胸動脈７０の外壁部に刺し入れる。
さらに、図２４（Ｃ）に示すように、この状態で、湾曲針７３の先端部を左前下行枝６４の内壁部から外側に向かって刺し入れる。すなわち、湾曲針７３の先端は、内胸動脈７０と左前下行枝６４とが接触した状態で、両者７０，６４に貫通する。そして、この状態で一旦、湾曲針７４を放す。
そして、図２５（Ａ）に示すように、ハンドル３７，３９を略ニュートラル位置に回動させて処置部３を略ニュートラル位置にする。この後、湾曲針７３の先端部が処置部３の左横側を向くように湾曲針７４の先端側を処置部３で再把持する。
さらに、ハンドル３７，３９を右横方向に最大に回動操作して、処置部３を図２４（Ａ）に示す方向に対して反対側の左横方向に最大に回動させる。このようにして、湾曲針７３の基端部を内胸動脈７０および左前下行枝６４から抜き取る。すなわち、図２５（Ｂ）に示すように、第１の湾曲針７３を把持した状態で内胸動脈７０および左前下行枝６４に縫合糸７５を通す。
【００６９】
そして、図１６（Ｄ）に示すように、左前下行枝６４の切開口７１を術者が見たときに時計回り方向に３時方向から６時方向まで順次縫合する。
【００７０】
次に、第１の湾曲針７３の先端部が処置部３の左横側に配設されるように湾曲針７３の基端側を処置部３で再把持しておく。この状態で、図１７（Ａ）に示すように、湾曲針７３の先端部が内胸動脈７０の外壁側から左前下行枝６４の内壁側に向かって刺し入れられる。このようにして、左前下行枝６４の切開口７１を術者が見たときに時計回り方向に６時方向から９時方向まで順次縫合する。すなわち、左前下行枝６４の切開口７１に対する内胸動脈７０の端部の全周に渡る縫合（吻合）を終了する。
【００７１】
そして、図１７（Ｂ）に示すように、処置部３を操作して縫合糸７５を任意の位置で結んで、数回結び目を形成して縫合糸７５を留める。
その後、図１７（Ｃ）に示すように、縫合糸７５の結び目近くで縫合糸７５を切り、湾曲針７３，７４を体外に取り出す。
【００７２】
（効果）
以上説明したように、この実施の形態にかかる外科用処置具１は、処置部３の回動角度を±７０°程度など、従来の外科用処置具の処置部の回動角度よりも大きくすることができる。このため、ＣＡＢＧ手術時には、湾曲針７３，７４の湾曲度合に応じて処置部３を回動させることができる。このため、径が２ｍｍないし３ｍｍ程度の左前下行枝６４や内胸動脈７０などの血管に無理な力を与え難くして縫合することができる。また、内胸動脈７０などの移植血管と左前下行枝６４などの冠状動脈などからなる被移植血管とを一度の回動操作によっても湾曲針の先端部を刺し入れることができる。このため、外科用処置具１の操作部４を持ち替える回数や回動させる回数を減らすことができる。また、この外科用処置具１を上下動させる回数を減らすことができる。このため、手術時間の大幅な短縮を図ることができる。
【００７３】
すなわち、処置部３の回動角度を±７０°など、従来の技術にかかる外科用処置具の処置部の回動角度よりも大きくすることができるので、ＣＡＢＧにおける複雑な運針操作（押し込み、引っ掛け、反時計回り、時計回りの回動操作）に対して持ち替えなしで対応することができる。このため、手術時間の短縮を図ることができ、患者に対する侵襲の低下、手術室のランニングコストの削減など、様々に寄与することができる。
【００７４】
なお、この実施の形態では、外科用処置具１の左右方向の回動角度は、ハンドル３７，３９を±７０°、処置部３を±７０°としたが、このような角度は一例であって、他の角度であってももちろん構わない。
【００７５】
また、冠状動脈としての左前下行枝６４や、胸壁から剥離させた内胸動脈７０は一例であって、他の血管同士を縫合（吻合）させるときにも適用しても構わない。
【００７６】
［第２の実施の形態］
次に、図２６ないし図３５を用いて第２の実施の形態について説明する。この実施の形態は、第１の実施の形態の変形例であって、同一の部材には同一の符号を付し、詳しい説明を省略する。
【００７７】
（構成）
図２６に示すように、支持部８に沿って設けられた第２および第３の駆動棒６ａ，７ａは、それぞれ第２の回動板２１および第４の回動板４６の近傍で支持部８の内方に向かってＬ字状に屈曲した屈曲部が形成されている。すなわち、第２のおよび第３の駆動棒６ａ，７ａの両端部は、それぞれの端部で同一の方向に向かってＬ字状に屈曲されている。
【００７８】
また、支持部８の後端部側、すなわち、支持部８の操作部４側の第２の枢支軸３２の近傍は、支持部８の中央部よりも細く、かつ、互いに対して平行な第２の突き当て面６１ａが形成されている。
【００７９】
また、第２の回動板２１の第２の枢支ピン２０が配設される直交部の先端部に対して遠位側の端部と、この端部から第１および第２の回転ピン２２，２３中心との間の距離をＬ３とする。また、第４の回動板４６の第１の突き当て面６０側の端部と、この端部から第３および第４の回動ピン（枢軸）４７，４８中心との間の距離もＬ３に形成されている。
【００８０】
第２の駆動棒６ａの中央部の側部と、第１の回転ピン２２、第３の回動ピン４７を結ぶ線との間の距離をＬ４とする。同様に、第３の駆動棒７ａの中央部の側部と、第２の回転ピン２３、第４の回動ピン４８を結ぶ線との間の距離もＬ４に形成されている。このとき、
Ｌ４−Ｌ３≧０
に形成されている。第２および第３の駆動棒６ａ，７ａと、第２および第４の回動板２１，４６とは干渉し難くなっている。すなわち、第１の突き当て面６０と第２の突き当て面６１とが当接した状態で、第２および第３の駆動棒６ａ，７ａと第２および第４の回動板２１，４６とが当接もしくは離れた状態となる。このため、ハンドル３７，３９および処置部３は直角になるまで回動可能となっている。
【００８１】
図２６（Ａ）は、上下方向に最大に回動させた状態を示している。すなわち、第１の駆動棒５を処置部３側に押し込んだ状態である。また、第２および第３の駆動棒６ａ，７ａは、互いに平行に、かつ、進退していないニュートラル状態にある。また、第１の突き当て面６０に対して、支持部８の長手方向は略直交している。
【００８２】
図２６（Ｂ）は、図２６（Ａ）の状態から第２の枢支軸３２を支点としてハンドル３７，３９を左右方向の左横方向に最大（９０°）に回動させた状態を示している。このとき、処置部３は、右横方向に最大（９０°）に回動される。すなわち、第１の駆動棒５を操作部４側に引っ張った状態である。第２の駆動棒６を操作部４側に引っ張り、第３の駆動棒７ａを処置部３側に押出した状態である。また、第２および第３の駆動棒６ａ，７ａは、互いに平行な状態を維持しながら互いに対して屈曲部の分だけ離間した状態である。そして、第１の突き当て面６０と、一方の第２の突き当て面６１とは、互いに当接している。
【００８３】
また、図２７に示すように、第１および第２の処置片１２，１４のそれぞれの把持面１２ｂ，１４ｂには、必要に応じて例えばタングステンカーバイドなどの超硬素材が貼り付けてあり、その表面にはローレット目による滑り止めが施されている。これにより、把持対象物である縫合針、縫合糸、生体組織等を確実に把持することができるようになっている。
【００８４】
（作用）
このような外科用処置具１の動作については、第１の実施の形態とほぼ同様であるので、説明を省略する。
【００８５】
次に、このような作用を有する外科用処置具１を用いて例えばＣＡＢＧ手術を行う場合について説明する。この実施の形態で説明する手技は、第１の実施の形態とは異なり、左前下行枝６４に対して側方からアプローチするものである。なお、この実施の形態では、右手で外科用処置具１を操作する場合について説明する。もちろん、左手で操作する場合には、以下に説明する操作を左右逆にして行えばよい。
【００８６】
図２８（Ａ）は、心臓がある部位の胸部を下側から見た断面図を示している。左前下行枝６４と称されている冠状動脈の側方にトロッカー１１８を介して硬性鏡６７を挿入する。すなわち、術部の側方から観察しながら手術を行う。すなわち、左前下行枝６４に対して側方からトロッカー１１８を介して硬性鏡６７で観察しながらアプローチすることを示している。
【００８７】
また、図２８（Ｂ）は血管吻合を行う前段階が終了した状態を示している。図２８（Ｂ）に示すように、内視鏡的に胸部側方に開けたポートを用いて、図２８（Ａ）に示す胸壁６６から内胸動脈７０が剥離されている。そして、左前下行枝６４内に狭窄を起こした部位の下流側にはさみ鉗子６９を用いて切開口７１を形成している。また、硬性鏡６７が挿入されるトロッカー１１８に隣接した位置に２つの他のトロッカー１１８が挿入される。そして、このトロッカー１１８の一方には、図１１に示すように保持した状態で外科用処置具１の処置部３から体腔内に挿入する。また、トロッカー１１８の他方には、把持鉗子６８などの処置具を挿入する。
【００８８】
図２９ないし図３５は、内視鏡下で行う血管吻合（縫合）手技の流れを順に示している。
【００８９】
まず、第２の湾曲針７４の先端部が処置部３の左横側に配設されるように湾曲針７４の基端側を処置部３で把持しておく。そして、図２９（Ａ）に示すように、把持鉗子６８で胸壁６６から剥離させた内胸動脈７０を把持する。この状態で、湾曲針７４が内胸動脈７０の切断部（端部）近傍の内壁部に向かうように、ハンドル３７，３９を右横方向に回動操作する。処置部３は左横方向に回動して第２の湾曲針７４の先端部は内胸動脈７０に刺し入れられる。すなわち、術者から見て、内壁部から外側に向かって処置部３を下側に回動して湾曲針７４の先端部を内胸動脈７０の内壁部に引っ掛ける。そして、さらに回動させて、湾曲針７４の先端部を内壁部から外側に向かって貫通させる。この状態で一旦、湾曲針７４を放す。
そして、ハンドル３７，３９を左横方向の適当な角度に回動させて処置部３を右横方向に適当な角度に回動させた状態にする。この後、湾曲針７４の先端部が処置部３の左横側を向くように湾曲針７４の先端側を処置部３で再把持する。
さらに、ハンドル３７，３９を右横方向に最大に回動操作して、処置部３を左横方向に最大もしくは最大付近まで回動させる。このようにして、湾曲針７４の基端部を湾曲針７４の湾曲度合にほぼ沿わせながら内胸動脈７０から抜き取る。すなわち、第２の湾曲針７４を把持した状態で内胸動脈７０に縫合糸７５を通す。
【００９０】
そして、第２の湾曲針７４の先端部が処置部３の左横側に配設されるように湾曲針７４の基端側を処置部３で再把持しておく。この状態で、湾曲針７４の先端部が左前下行枝６４の切開口７１近傍の外壁部に向かうように、ハンドル３７，３９を右横方向に回動操作する。処置部３は左横方向に回動して第２の湾曲針７４の先端部は左前下行枝６４の外壁部から内側に向かって刺し入れられる。すなわち、術者から見て、外壁部から内側に向かって処置部３を下側に回動して湾曲針７４の先端部を左前下行枝６４の外壁部に引っ掛ける。そして、さらに回動させて、湾曲針７４の先端部を外壁部から内側に向かって貫通させる。この状態で一旦、湾曲針７４を放す。
そして、ハンドル３７，３９を左横方向の適当な角度に回動させて処置部３を右横方向に適当な角度に回動させた状態にする。この後、図２９（Ｂ）に示すように、湾曲針７４の先端部が処置部３の左横側を向くように湾曲針７４の先端側を処置部３で再把持する。
さらに、ハンドル３７，３９を右横方向に最大に回動操作して、処置部３を左横方向に最大もしくは最大付近まで回動させる。このようにして、湾曲針７４の基端部を湾曲針７４の湾曲度合にほぼ沿わせながら左前下行枝６４から抜き取る。すなわち、第２の湾曲針７４を把持した状態で左前下行枝６４に縫合糸７５を通す。
【００９１】
次いで、内胸動脈７０の内壁部から外側へ、そして、左前下行枝６４の外壁部から内側に湾曲針７４を通して内胸動脈７０と左前下行枝６４とを縫合していく作業を順次実施していく。
【００９２】
この作業においては、まず、第２の湾曲針７４の先端部が処置部３の左横側に配設されるように湾曲針７４の基端側を処置部３で再把持しておく。この状態で、図２９（Ｃ）に示すように、湾曲針７４の先端部が内胸動脈７０の切断部の内壁部に向かうように、ハンドル３７，３９を右横方向に回動操作する。処置部３は左横方向に回動して第２の湾曲針７４の先端部は内胸動脈７０の切断部の内壁部から外側に向かって刺し入れられる。さらに、この操作で、左前下行枝６４の外壁部から内側に向かって刺し入れられる。すなわち、処置部３の回動によって内胸動脈７０の内壁部から外側を通り、さらに、左前下行枝６４の外壁部から内側に向かって湾曲針７４の先端部を引っ掛ける。ここで、図３１はこのような状態になるまでの内胸動脈７０および左前下行枝６４に対する処置部３の一連の動きを図２９（Ｃ）に示す２９Ｃ−２９Ｃ断面に沿って示している。
【００９３】
図３１（Ａ）に示すように、ハンドル３７，３９を左横方向に最大（例えば、−９０°）に回動させて、処置部３の左右方向の回動角度を右横方向に最大（例えば、−９０°）に回動させる。この状態で処置部３を左前下行枝６４の切開口７１と内胸動脈７０の端部との間に挿入し、湾曲針７４の先端を内胸動脈７０の内壁部の任意の位置に刺す。
次に、図３１（Ｂ）に示すように、ハンドル３７，３９を左横方向の最大回動位置から右横方向に向かって回動させる。つまり、ハンドル３７，３９をニュートラル方向に戻す。すると、処置部３の回動角度が小さくなる方向、すなわち、処置部３が左横方向に向かって回動し、湾曲針７４の先端部を内胸動脈７０の内壁部を貫通して、左前下行枝６４の外壁部から内側に刺し入れる。そして、この状態で一旦、湾曲針７４を放す。
そして、図３１（Ｃ）に示すように、ハンドル３７，３９を右横方向の適当な角度に回動させて処置部３を左横方向に適当な角度に回動させた状態にする。この後、湾曲針７４の先端部が処置部３の左横側を向くように湾曲針７４の先端側を処置部３で再把持する。
さらに、ハンドル３７，３９を右横方向に最大に回動操作して、処置部３を図３１（Ａ）に示す方向に対して反対側の左横方向に最大に回動させる。このようにして、湾曲針７４の基端部を湾曲針７４の湾曲度合にほぼ沿わせながら左前下行枝６４から抜き取る。すなわち、図３１（Ｄ）に示すように、第２の湾曲針７４を把持した状態で内胸動脈７０および左前下行枝６４に縫合糸７５を通す。
【００９４】
このような操作を繰り返し行って、図２９（Ｄ）に示すように、術者から見て左前下行枝６４の切開口７１の３時から９時まで反時計回り方向に順次縫合する。
【００９５】
次に、第２の湾曲針７４が一端に取り付けられた縫合糸７５の他端に配設された第１の湾曲針７３を用いて縫合を開始する。すなわち、図３０（Ａ）に示すように、図２９（Ａ）ないし図２９（Ｄ）に示した位置から左前下行枝６４の長手方向に対して対称的な方向に縫合を行う。第１の湾曲針７３の先端部が処置部３の左横側に配設されるように湾曲針７３の基端側を処置部３で把持しておく。また、把持鉗子６８で内胸動脈７０を把持しておく。この状態で、湾曲針７３の先端部が内胸動脈７０の外壁側から左前下行枝６４の内壁側に向かって刺し入れられる。ここで、図３２および図３３はこのような状態になるまでの左前下行枝６４および内胸動脈７０に対する処置部３の一連の動きを図３０（Ａ）に示す３０Ａ−３０Ａ断面に沿って示している。
【００９６】
図３２（Ａ）に示すように、ハンドル３７，３９を左横方向に最大に回動させて、処置部３の左右方向の回動角度を右横方向に最大に回動させる。この状態で湾曲針７３の先端部を内胸動脈７０の外壁部に刺す。
図３２（Ｂ）に示すように、ハンドル３７，３９を左横方向の最大回動位置から右横方向に向かって回動させる。つまり、ハンドル３７，３９をニュートラル方向に戻す。すると、処置部３の回動角度が小さくなる方向、すなわち、処置部３が左横方向に向かって回動し、湾曲針７３の先端部を内胸動脈７０の外壁部に刺し入れる。
さらに、図３２（Ｃ）に示すように、この状態で、湾曲針７３の先端部を左前下行枝６４の内壁部から外側に向かって刺し入れる。すなわち、湾曲針７３の先端は、内胸動脈７０と左前下行枝６４とが接触した状態で、両者７０，６４に貫通する。そして、この状態で一旦、湾曲針７３を放す。
そして、図３３（Ａ）に示すように、ハンドル３７，３９をやや右横方向に回動させて、処置部３をやや左横方向に回動させる。この後、湾曲針７３の先端部が処置部３の左横側を向くように湾曲針７３の先端側を処置部３で再把持する。
さらに、ハンドル３７，３９を右横方向に最大に回動操作して、処置部３を図３２（Ａ）に示す方向に対して反対側の左横方向に最大に回動させる。このようにして、湾曲針７３の基端部を内胸動脈７０および左前下行枝６４から抜き取る。すなわち、図３３（Ｂ）に示すように、第１の湾曲針７３を把持した状態で内胸動脈７０および左前下行枝６４に縫合糸７５を通す。
【００９７】
このような操作を繰り返し行って、図３０（Ａ）に示すように、術者から見て左前下行枝６４の切開口７１の３時から６時まで時計回り方向に順次縫合する。
【００９８】
次に、第２の湾曲針７４を用いて縫合を開始する。すなわち、図３０（Ｂ）に示すように、図２９（Ａ）ないし図２９（Ｄ）に示した位置から左前下行枝６４の長手方向に対して対称的な方向に縫合を行う。第２の湾曲針７４の先端部が処置部３の右横側に配設されるように湾曲針７４の基端側を処置部３で把持しておく。また、把持鉗子６８で内胸動脈７０を把持しておく。この状態で、湾曲針７４の先端部が左前下行枝６４の外壁側から内胸動脈７０の内壁側に向かって刺し入れられる。ここで、図３４および図３５はこのような状態になるまでの左前下行枝６４および内胸動脈７０に対する処置部３の一連の動きを図３０（Ｂ）に示す３０Ｂ−３０Ｂ断面に沿って示している。
【００９９】
図３４（Ａ）に示すように、ハンドル３７，３９を右横方向に最大に回動させて、処置部３の左右方向の回動角度を左横方向に最大に回動させる。この状態で湾曲針７４の先端部を左前下行枝６４の外壁部に刺す。
図３４（Ｂ）に示すように、ハンドル３７，３９を右横方向の最大回動位置から左横方向に向かって回動させる。つまり、ハンドル３７，３９をニュートラル方向に戻す。すると、処置部３の回動角度が小さくなる方向、すなわち、処置部３が右横方向に向かって回動し、湾曲針７４の先端部を左前下行枝６４の外壁部に刺し入れる。
さらに、図３４（Ｃ）に示すように、この状態で、湾曲針７４の先端部を内胸動脈７０の内壁部から外側に向かって刺し入れる。すなわち、湾曲針７４の先端は、左前下行枝６４と内胸動脈７０とが接触した状態で、両者６４，７０に貫通する。そして、この状態で一旦、湾曲針７４を放す。
そして、図３５（Ａ）に示すように、ハンドル３７，３９をやや左横方向に回動させて、処置部３をやや右横方向に回動させる。この後、湾曲針７４の先端部が処置部３の左横側を向くように湾曲針７４の先端側を処置部３で再把持する。
さらに、ハンドル３７，３９を左横方向に最大に回動操作して、処置部３を図３４（Ａ）に示す方向に対して反対側の右横方向に最大に回動させる。このようにして、湾曲針７４の基端部を左前下行枝６４および内胸動脈７０から抜き取る。すなわち、図３５（Ｂ）に示すように、第２の湾曲針７４を把持した状態で左前下行枝６４および内胸動脈７０に縫合糸７５を通す。
【０１００】
このような操作を繰り返し行って、図３０（Ｂ）に示すように、術者から見て左前下行枝６４の切開口７１の９時から６時まで反時計回り方向に順次縫合する。すなわち、左前下行枝６４の切開口７１に対する内胸動脈７０の端部の全周に渡る縫合（吻合）を終了する。
【０１０１】
そして、図３０（Ｃ）に示すように、処置部３を操作して縫合糸７５を任意の位置で結んで、数回結び目を形成して縫合糸７５を留める。その後、縫合糸７５の結び目近くで縫合糸７５を切り、第１および第２の湾曲針７３，７４を体外に取り出す。
【０１０２】
（効果）
以上説明したように、この実施の形態の外科用処置具１は、左右方向に例えば±９０°回動することができる。このため、内胸動脈７０を剥離させるのに使用したポートをそのまま使用して吻合を行うことができる。すなわち、様々な方向から目的部位の処置を行うのにアプローチすることができる。したがって、患者の負担を低減させることができる。
【０１０３】
また、処置片１２，１４に設けた滑り止めが長持ちするので、取り替え頻度を減らすことができる。また、処置片１２，１４自体は取り替えることは少なくて済み、超硬チップを付け替えるだけで済む。このため、外科用処置具１の使用者の負担を減らすことができる。
【０１０４】
［第３の実施の形態］
次に、図３６を用いて第３の実施の形態について説明する。この実施の形態は、第１の実施の形態の変形例であって、同一の部材には同一の符号を付し、詳しい説明を省略する。
【０１０５】
（構成）
図３６は、処置部３の第１および第２の処置片１２，１４の変形例を示している。図３６に示すように、第１および第２の処置片１２，１４の把持面１２ｂ，１４ｂには、必要に応じて例えばダイヤモンド、ルビー、サファイアなどの微小粒が吹き付けられて微細な粗面が形成されて滑り止めが施されている。これにより、把持対象物である縫合針（湾曲針）、縫合糸、生体組織等を確実に把持することができるようになっている。さらに、第１および第２の処置片１２，１４の先端には、血管等の傷つけ防止を図る略球形部１２ｃ，１４ｃが形成されている。
【０１０６】
そして、第１の回転ピン２２と第２の回転ピン２３とが異なる高さに枢支されている。また、第３の回転ピン４７と第４の回転ピン４８とが異なる高さに枢支されている。さらに、第１の回転ピン２２と第３の回動ピン４７とは同一の高さに枢支されている。また、第２の回転ピン２３と第４の回動ピン４８とは同一の高さに枢支されている。すなわち、第２および第３の駆動棒６ｂ，７ｂは第２および第４の回動板２１ａ，４６ａで互いに異なる高さに平行を維持しながら配設されている。
【０１０７】
第２および第３の駆動棒６ｂ，７ｂの高さが異なるので、互いに干渉せず、もしくは干渉し難くなる。このため、例えば、回動の程度によっては、第２の駆動棒６ａの下側に第３の駆動棒７ｂが配設されることも可能である。したがって、処置部３の左右方向の回動角度を大きく取ることができる。
【０１０８】
（作用）
このような外科用処置具１の動作、作用等については、第１の実施の形態とほぼ同様であるので、説明を省略する。
【０１０９】
（効果）
以上説明したように、この実施の形態の外科用処置具１は、左右方向に任意の角度に回動させることができる。
【０１１０】
ところで、第１および第２の処置片１２，１４の把持面１２ｂ，１４ｂの変形例について図３７ないし図４０を用いて説明する。
【０１１１】
図３７に示すように、把持面１２ｂ，１４ｂは、基端部が幅広に、先端部が細く形成されている。また、ゴム材などの高分子材からなるゴムパッド８７が配設されて滑り止めが施されている。
このため、縫合針（湾曲針）、縫合糸、生体組織等を確実に把持することができるようになっている。
【０１１２】
図３８（Ａ）に示すように、ゴムパッド８７が把持面１２ｂ，１４ｂに配設されていないときには、例えば湾曲針７３を把持するときには、図３８（Ａ）中のａ，ｂ，ａ’の３点支持である。このため、充分な把持力が得られない可能性がある。
【０１１３】
しかし、図３８（Ｂ）に示すように、この実施の形態のように、ゴムパッド８７を把持面１２ｂ，１４ｂに配設すると、例えば第１の湾曲針７３を把持するときには、ゴムパッド８７が弾性変形する。このため、充分な把持力を得ることができる。また、湾曲針７３に過大な力が加えられたときのクッションとしても作用する。
【０１１４】
さらに、図３９に示すように、第１の処置片１２は把持面１２ｂ’を有する。また、第２の処置片１４は把持面１４ｂ’を有する。把持面１２ｂ’，１４ｂ’は、例えば湾曲針７３の形状に合わせて形成されている。すなわち、第１の把持面１２ｂが凹面状に形成され、第２の把持面１４ｂが凸面状に形成されている。このため、特に縫合針（湾曲針７３）を把持するときには、縫合針の湾曲具合に合わせて充分な把持力を得ることができる。したがって、湾曲針７３が外力により、容易には回転しない。
【０１１５】
また、図４０に示すように、第１の処置片１２は把持面１２ｂ”を有する。また、第２の処置片１４は把持面１４ｂ”を有する。第１および第２の把持面１２ｂ”，１４ｂ”が共に湾曲針７３の湾曲度合に沿って凸面状に形成されている。このため、特に縫合針（湾曲針）を使用するときには、一方の側の把持面１２ｂに密着し、他方の側の把持面１４ｂの最も凸部、すなわち頂点で押さえられるので、確実に把持することができるようになっている。したがって、湾曲針７３が外力により、容易には回転しない。
【０１１６】
したがって、図４０（Ａ）に示すように、湾曲針７３を第２の処置片１４側に当接するように把持する場合と、図４０（Ｂ）に示すように、湾曲針７３を第１の処置片１２側に当接するように把持する場合とで、それぞれ充分な把持力を得ることができる。
【０１１７】
これまで、いくつかの実施の形態について図面を参照しながら具体的に説明したが、この発明は、上述した実施の形態に限定されるものではなく、その要旨を逸脱しない範囲で行なわれるすべての実施を含む。
【０１１８】
上記説明によれば、下記の事項の発明が得られる。また、各項の組み合わせも可能である。
【０１１９】
［付記］
（付記項１）　体内に挿入される細長い挿入部と、
この挿入部の一端部に設けられ、少なくとも２つの軸を中心として回動可能かつ、開閉可能な処置部と、
前記挿入部の他端部に設けられ、少なくとも２つの軸を中心として回動可能かつ、開閉可能な操作部と、
この操作部と処置部とを連結し、操作部の操作力を処置部に伝達して処置部を動作させる第１のリンク棒とこの第１のリンク棒に平行に配置された第２のリンク棒とからなる駆動手段と
を備え、前記処置部の開閉方向に沿った面内を回動する上下方向とこの上下方向に直交した面内を回動する左右方向との少なくとも２つの平面内で前記操作部および処置部が連動して回動可能な外科用処置具において、
前記挿入部の他端部と前記操作部とには、互いに当接する突き当て部が挿入部の軸方向に対して所定の角度をもって形成され、
前記操作部を左右方向に最大に回動操作したときに、前記挿入部の他端部と前記操作部とが互いの突き当て部で当接されるとともに、前記挿入部の軸方向に対する操作部の回動角度が規定されて、前記処置部の左右方向の回動角度が規定されることを特徴とする外科用処置具。
【０１２０】
（付記項２）　体内に挿入される細長い挿入部と、
この挿入部の一端部に設けられ、少なくとも２つの軸を中心として回動可能かつ、開閉可能な処置部と、
前記挿入部の他端部に設けられ、少なくとも２つの軸を中心として回動可能かつ、開閉可能な操作部と、
それぞれ両端部に枢軸対を有し、前記処置部を動作させる第１のリンク棒とこの第１のリンク棒に平行に配置された第２のリンク棒とからなり、前記操作部と処置部とを連結し、操作部の操作力を処置部に伝達する駆動手段と
を備え、前記処置部の開閉方向に沿った面内を回動する上下方向とこの上下方向に直交した面内を回動する左右方向との少なくとも２つの平面内で前記操作部および処置部が連動して回動可能な外科用処置具において、
前記第１のリンク棒の両端部に設けられた前記枢軸対と、第２のリンク棒の両端部に設けられた前記枢軸対との少なくとも一方は、それぞれ第２のリンク棒と、第１のリンク棒とに近接する側に偏りをもって設けられ、
前記第１および第２のリンク棒を互いに逆方向に進退させたときに、前記処置部の回動角度を増すようにしていることを特徴とする外科用処置具。
【０１２１】
（付記項３）　前記第１および第２のリンク棒は、前記操作部を左右方向にそれぞれ最大に回動操作したときにそれぞれ互いに当接することを特徴とする付記項１もしくは付記項２に記載の外科用処置具。
【０１２２】
（付記項４）　前記挿入部の突き当て部は、挿入部の軸方向に対して対称的に形成されていることを特徴とする付記項１ないし付記項３のいずれか１に記載の外科用処置具。
【０１２３】
（付記項５）　前記処置部の最大回動角度は、略±７０°であることを特徴とする付記項１ないし付記項４のいずれか１に記載の外科用処置具。
【０１２４】
（付記項６）　前記操作部を左方向と右方向とのそれぞれの最大回動位置の中間部に位置させたときに、前記第１および第２のリンク棒の端部は、互いのリンク棒の近接する端部の方向に屈曲されて形成されていることを特徴とする付記項１もしくは付記項２に記載の外科用処置具。
【０１２５】
（付記項７）　前記第１のリンク棒の駆動軸対と前記第１のリンク棒との間の距離と、前記操作部の突き当て部と、前記第１および第２のリンク棒の近接する端部に設けられた枢軸との間の距離とは、前者の距離が後者の距離以上に形成されていることを特徴とする付記項１、付記項２および付記項６のいずれか１に記載の外科用処置具。
【０１２６】
（付記項８）　前記処置部の最大回動角度は、略±９０°であることを特徴とする付記項１、付記項２、付記項６および付記項７のいずれか１に記載の外科用処置具。
【０１２７】
（付記項９）　付記項１もしくは付記項２に記載の外科用処置具の操作部を操作して、縫合糸をそれぞれの基端部に備えて互いに接続した任意の湾曲度合を有する湾曲針を処置部で把持して被移植血管（左前下行枝）の吻合口に移植血管（内胸動脈）の吻合口を吻合する外科用処置具を術部の上方で操作して行う血管吻合手術方法であって、
前記湾曲針の先端部が前記被移植血管および／もしくは移植血管の吻合口近傍の内壁部に向かうように、操作部を左右方向に回動操作して処置部を操作部に対して反対側方向に回動させて湾曲針の先端部を前記被移植血管および／もしくは移植血管の吻合口近傍の内壁部に刺し入れて、２つの湾曲針の先端部を被移植血管および移植血管のそれぞれの吻合口の内壁部から延出し、
前記湾曲針同士を接続する縫合糸に沿って前記被移植血管および移植血管の吻合口同士を一致させて前記被移植血管および移植血管の吻合位置を規定し、
操作部を左右方向の最大回動位置に回動させて、処置部の操作部に対して反対側方向の回動角度を最大回動位置に回動させて湾曲針の先端部を前記被移植血管もしくは移植血管の吻合口近傍の外壁部から内側に向かうように位置させ、
操作部を左右方向の最大回動位置から反対側方向に向かって回動させて、操作部を左方向の最大回動位置と右方向の最大回動位置との間の中間位置に戻して処置部を左右方向の回動位置から反対側方向に向かって回動させて湾曲針の先端部を前記被移植血管もしくは移植血管の吻合口近傍の外壁部に刺し入れるとともに、湾曲針の先端部を前記被移植血管および移植血管のいずれか一方に湾曲針が刺された以外の血管の内壁部から外側に向かって刺し入れ、
前記操作部を開閉操作して処置部を開き、湾曲針を処置部から解放し、
操作部を最大回動位置と中間位置との間の任意の位置に回動させて処置部を最大回動位置と中間位置との間に位置させ、
湾曲針の先端部が処置部で把持していた方向と同一の方向を向くように操作部を開閉操作して湾曲針の先端側を処置部で再把持し、
操作部を反対側方向の最大回動位置に回動させて、処置部を操作部に対して反対側方向の最大回動位置に回動させて、湾曲針の基端部を前記被移植血管および移植血管の吻合口近傍から抜き取って糸を通し、
前記被移植血管および移植血管の吻合口同士を前記湾曲針を延出した位置から時計回り方向もしくは反時計回り方向に順次縫合する。
【０１２８】
（付記項１０）　付記項１もしくは付記項２に記載の外科用処置具の操作部を操作して、処置部に糸を有する任意の湾曲度合を有する湾曲針を把持させて被移植血管（左前下行枝）の吻合口に移植血管（内胸動脈）の吻合口を吻合する外科用処置具を術部の側方で操作して行う血管吻合手術方法であって、
前記湾曲針の先端部が前記被移植血管および／もしくは移植血管の吻合口近傍の内壁部に向かうように、操作部を左右方向に回動操作して処置部を操作部に対して反対側方向に回動させて湾曲針の先端部を前記被移植血管および／もしくは移植血管の吻合口近傍の内壁部に刺し入れて、２つの湾曲針の先端部を被移植血管および移植血管のそれぞれの吻合口の内壁部から延出し、
前記湾曲針同士を接続する縫合糸に沿って前記被移植血管および移植血管の吻合口同士を一致させて前記被移植血管および移植血管の吻合位置を規定し、
操作部を左右方向の最大回動位置に回動させて、処置部の操作部に対して反対側方向の回動角度を最大回動位置に回動させて湾曲針の先端部を前記被移植血管もしくは移植血管の吻合口近傍の内壁部から外側に向かうように位置させ、
操作部を左右方向の最大回動位置から反対側方向に向かって回動させて、操作部を左方向の最大回動位置と右方向の最大回動位置との間の中間位置に戻して処置部を左右方向の回動位置から反対側方向に向かって回動させて湾曲針の先端部を前記被移植血管もしくは移植血管の吻合口近傍の内壁部に刺し入れるとともに、湾曲針の先端部を前記被移植血管および移植血管のいずれか一方に湾曲針が刺された以外の血管の外壁部から内側に向かって刺し入れ、
前記操作部を開閉操作して処置部を開き、湾曲針を処置部から解放し、
操作部を最大回動位置と中間位置との間の任意の位置に回動させて処置部を最大回動位置と中間位置との間に位置させ、
湾曲針の先端部が処置部で把持していた方向と同一の方向を向くように操作部を開閉操作して湾曲針の先端側を処置部で再把持し、
操作部を反対側方向の最大回動位置に回動させて、処置部を操作部に対して反対側方向の最大回動位置に回動させて、湾曲針の基端部を前記被移植血管および移植血管の吻合口近傍から抜き取って糸を通し、
前記被移植血管および移植血管の吻合口同士を前記湾曲針を延出した位置から時計回り方向もしくは反時計回り方向に順次縫合して、前記被移植血管および移植血管の略半周を縫合し、
操作部を左右方向の最大回動位置に回動させて、処置部の操作部に対して反対側方向の回動角度を最大回動位置に回動させて湾曲針の先端部を前記被移植血管もしくは移植血管の吻合口近傍の外壁部から内側に向かうように位置させ、
操作部を左右方向の最大回動位置から反対側方向に向かって回動させて、操作部を中間位置に戻して処置部を左右方向の回動位置から反対側方向に向かって回動させて湾曲針の先端部を前記被移植血管もしくは移植血管の吻合口近傍の外壁部に刺し入れるとともに、湾曲針の先端部を前記被移植血管および移植血管のいずれか一方に湾曲針が刺された以外の血管の内壁部から外側に向かって刺し入れ、
前記操作部を開閉操作して処置部を開き、湾曲針を処置部から解放し、
操作部を最大回動位置と中間位置との間の任意の位置に回動させて処置部を最大回動位置と中間位置との間に位置させ、
湾曲針の先端部が処置部で把持していた方向と同一の方向を向くように操作部を開閉操作して湾曲針の先端側を処置部で再把持し、
操作部を反対側方向の最大回動位置に回動させて、処置部を操作部に対して反対側方向の最大回動位置に回動させて、湾曲針の基端部を前記被移植血管および移植血管の吻合口近傍から抜き取って糸を通し、
前記被移植血管および移植血管の吻合口同士を前記湾曲針を延出した位置から時計回り方向もしくは反時計回り方向に順次縫合して、前記被移植血管および移植血管の残りの略半周を縫合する。
【０１２９】
（付記項１１）　前記処置部の開閉操作により目的対象を把持可能な互いに対向した把持面対を備え、この把持面対の一方の把持面は凸面円筒状であり、他方の把持面は凹面円筒状に形成されていることを特徴とする付記項１ないし付記項６のいずれか１に記載の外科用処置具。
【０１３０】
（付記項１２）　前記処置部の開閉操作により目的対象を把持可能な互いに対向した把持面対を備え、この把持面対の両方の把持面はそれぞれ凸面円筒状に形成されていることを特徴とする付記項１ないし付記項６のいずれか１に記載の外科用処置具。
【０１３１】
（付記項１３）　前記把持面には、放電加工またはエッチングにより表面が微細に荒らされていることを特徴とする付記項１１もしくは付記項１２に記載の外科用処置具。
【０１３２】
（付記項１４）　前記把持面は、超硬素材からなり、ローレット目が形成されていることを特徴とする付記項１１もしくは付記項１２に記載の外科用処置具。
【０１３３】
（付記項１５）　前記把持面には、ダイヤモンド、ルビー、サファイアなどの微小粒が吹き付けられて微細な粗面が形成されていることを特徴とする付記項１１もしくは付記項１２に記載の外科用処置具。
【０１３４】
（付記項１６）　前記把持面の先端部には、略球形部が形成されていることを特徴とする付記項１１ないし付記項１５のいずれか１に記載の外科用処置具。
【０１３５】
【発明の効果】
以上説明したように、この発明によれば、操作性を向上させて手技時間を短縮することができる外科用処置具を提供することができる。
【図面の簡単な説明】
【図１】処置部を上方に上げた状態の第１の実施の形態にかかる外科用処置具の側面図。
【図２】図１に示す外科用処置具の処置部を上方から見た斜視図。
【図３】図１に示す外科用処置具の処置部を下方から見た斜視図。
【図４】外科用処置具の処置部の処置片が開いた状態を上方から見た斜視図。
【図５】図１に示す外科用処置具の操作部を下方から見た斜視図。
【図６】ハンドルのカバーを外した状態で図１に示す外科用処置具の操作部を下方から見た斜視図。
【図７】ハンドルのカバーを外した状態で図１に示す外科用処置具の操作部を上方から見た斜視図。
【図８】（Ａ）はハンドルを下方に回動させて処置部を上方に回動させたことを示す側面図、（Ｂ）は（Ａ）の状態からハンドルを上方に回動させて処置部を挿入部の軸方向に対して水平にしたことを示す側面図。
【図９】（Ａ）は第１の実施の形態にかかる外科用処置具のハンドルおよび処置部を上下方向に回動させたときの概略的な上面図、（Ｂ）は（Ａ）に示す外科用処置具のハンドルを左側に最大に回動して処置部を右側に最大に回動させた状態を示す概略的な上面図。
【図１０】第２の回動板と第２および第３の駆動棒との接続状態を示す概略的な上面図。
【図１１】第１の実施の形態にかかるトロッカーを介して術部の上方向からアプローチさせた外科用処置具を示す概略図。
【図１２】心臓がある部位の胸部を下側から見た断面図。
【図１３】心臓と剥離後の内胸動脈との位置関係を示すとともに、左前下行枝を切開して手術を行うことを説明する概略図。
【図１４】（Ａ）ないし（Ｃ）は、内視鏡下で行う血管吻合手技の流れを示す概略図。
【図１５】（Ａ）ないし（Ｃ）は、内視鏡下で行う血管吻合手技の流れを示す概略図。
【図１６】（Ａ）ないし（Ｄ）は、内視鏡下で行う血管吻合手技の流れを示す概略図。
【図１７】（Ａ）ないし（Ｃ）は、内視鏡下で行う血管吻合手技の流れを示す概略図。
【図１８】図１４（Ａ）に示す手技を説明する図であって、（Ａ）および（Ｂ）は湾曲針を内胸動脈の内壁部から外側に向かって刺し入れることを説明する概略図、（Ｃ）および（Ｄ）は刺し入れた湾曲針を内胸動脈から抜く操作を説明する概略図。
【図１９】図１４（Ｂ）に示す手技を説明する図であって、（Ａ）および（Ｂ）は湾曲針を左前下行枝の外壁部から内側に向かって刺し入れることを説明する概略図、（Ｃ）および（Ｄ）は刺し入れた湾曲針を左前下行枝から抜く操作を説明する概略図。
【図２０】図１４（Ｃ）に示す手技を説明する図であって、（Ａ）および（Ｂ）は湾曲針を内胸動脈の内壁部から外側に向かって刺し入れることを説明する概略図、（Ｃ）および（Ｄ）は刺し入れた湾曲針を内胸動脈から抜く操作を説明する概略図。
【図２１】図１５（Ａ）に示す手技を説明する図であって、（Ａ）および（Ｂ）は湾曲針を左前下行枝の外壁部から内側に向かって刺し入れることを説明する概略図、（Ｃ）および（Ｄ）は刺し入れた湾曲針を左前下行枝から抜く操作を説明する概略図。
【図２２】図１６（Ａ）に示す手技を説明する図であって、（Ａ）ないし（Ｃ）は湾曲針を内胸動脈の外壁部から内側に向かって刺し入れるとともに左前下行枝の内壁部から外側に向かって刺し入れることを説明する概略図。
【図２３】図１６（Ａ）に示す手技を説明する図であって、（Ａ）および（Ｂ）は、図２２（Ｃ）で刺し入れた湾曲針を内胸動脈および左前下行枝から抜く操作を説明する概略図。
【図２４】図１６（Ｃ）に示す手技を説明する図であって、（Ａ）ないし（Ｃ）は湾曲針を内胸動脈の外壁部から内側に向かって刺し入れるとともに左前下行枝の内壁部から外側に向かって刺し入れることを説明する概略図。
【図２５】図１６（Ｃ）に示す手技を説明する図であって、（Ａ）および（Ｂ）は、図２４（Ｃ）で刺し入れた湾曲針を内胸動脈および左前下行枝から抜く操作を説明する概略図。
【図２６】第２の実施の形態にかかる外科用処置具であって、（Ａ）は外科用処置具のハンドルおよび処置部を上下方向に回動したときの概略的な上面図、（Ｂ）は（Ａ）に示す外科用処置具のハンドルを左側に最大に回動して処置部を右側に最大に回動させた状態を示す概略的な上面図。
【図２７】外科用処置具の処置部の先端部を上方から見たときの概略的な斜視図。
【図２８】（Ａ）は心臓がある部位の胸部を下側から見た断面図を示し、トロッカーを介して術部の側方から内視鏡をアプローチさせた状態を示す概略図、（Ｂ）は心臓と剥離後の内胸動脈と、内視鏡などの処置装置との位置関係を示すとともに、左前下行枝を切開して手術を行うことを説明する概略図。
【図２９】（Ａ）ないし（Ｄ）は、内視鏡下で行う血管吻合手技の流れを示す概略図。
【図３０】（Ａ）ないし（Ｃ）は、内視鏡下で行う血管吻合手技の流れを示す概略図。
【図３１】図２９（Ｃ）に示す手技を説明する図であって、（Ａ）および（Ｂ）は湾曲針を内胸動脈の内壁部から外側に向かって刺し入れるとともに左前下行枝の外壁部から内側に向かって刺し入れることを説明する概略図、（Ｃ）および（Ｄ）は刺し入れた湾曲針を内胸動脈および左前下行枝から抜く操作を説明する概略図。
【図３２】図３０（Ａ）に示す手技を説明する図であって、（Ａ）ないし（Ｃ）は湾曲針を内胸動脈の外壁部から内側に向かって刺し入れるとともに左前下行枝の内壁部から外側に向かって刺し入れることを説明する概略図。
【図３３】図３０（Ａ）に示す手技を説明する図であって、（Ａ）および（Ｂ）は図３２（Ｃ）で刺し入れた湾曲針を内胸動脈および左前下行枝から抜く操作を説明する概略図。
【図３４】図３０（Ｂ）に示す手技を説明する図であって、（Ａ）ないし（Ｃ）は湾曲針を左前下行枝の外壁部から内側に向かって刺し入れるとともに内胸動脈の内壁部から外側に向かって刺し入れることを説明する概略図。
【図３５】図３０（Ｂ）に示す手技を説明する図であって、（Ａ）および（Ｂ）は図３４（Ｃ）で刺し入れた湾曲針を左前下行枝および内胸動脈から抜く操作を説明する概略図。
【図３６】第３の実施の形態にかかる外科用処置具の処置部の処置片が開いた状態を上方から見た斜視図。
【図３７】外科用処置具の処置部の処置片が開いた状態を上方から見た斜視図。
【図３８】（Ａ）は従来の技術にかかる外科用処置具の処置部の処置片で湾曲針を把持した状態を示す概略的な側面図、（Ｂ）は図３７に示す外科用処置具の処置部の処置片で湾曲針を把持した状態を示す概略的な側面図。
【図３９】外科用処置具の処置部の処置片の変形例であって、これらの処置片で湾曲針を把持した状態を示す概略的な側面図。
【図４０】（Ａ）および（Ｂ）は外科用処置具の処置部の処置片の変形例であって、これらの処置片で湾曲針を把持した状態を示す概略的な側面図。
【図４１】（Ａ）は従来の技術にかかる外科用処置具のハンドルおよび処置部を上下方向に回動したときの概略的な上面図、（Ｂ）は（Ａ）に示す外科用処置具のハンドルを左側に最大に回動して処置部を右側に最大に回動させた状態を示す概略的な上面図。
【図４２】（Ａ）ないし（Ｃ）は従来の技術にかかる内視鏡下で行う血管吻合手技の流れを示す概略図。
【符号の説明】
１…外科用処置具、２…挿入部、３…処置部、４…操作部、６…第２の駆動棒、７…第３の駆動棒、２１…第２の回動板、２２…第１の回転ピン、２３…第２の回転ピン、３７…第１のハンドル、３８…第２の開閉枢支ピン、３９…第２のハンドル、４６…第４の回動板、４７…第３の回動ピン、４８…第４の回動ピン、６０…第１の突き当て面、６１…第２の突き当て面、６４…左前下行枝（冠状動脈）、６７…硬性鏡（内視鏡）、７０…内胸動脈、７１…切開口（吻合口）、７３…第１の湾曲針、７４…第２の湾曲針、７５…縫合糸[0001]
TECHNICAL FIELD OF THE INVENTION
The present invention relates to a surgical treatment tool.
[0002]
[Prior art]
For example, Japanese Patent Application No. 2001-119904 discloses a surgical treatment tool 201 having a treatment section 203 rotatable in two directions. As shown in FIG. 41, an insertion portion 202 of the surgical treatment tool 201 has an elongated support portion 208 and two drive rods 206 and 207 arranged along the support portion 208. These drive rods 206 and 207 are disposed without contacting each other even when the operation unit 204 is rotated to rotate the treatment unit, in order to prevent damage. The distance a between the drive rods 206, 207 is always greater than zero.
[0003]
The treatment section 203 of the surgical treatment instrument 201 has a maximum rotation angle in the vertical direction, that is, in the vertical direction in which the first and second treatment pieces 212 and 214 open and close with respect to each other. About 90 °. The maximum rotation angle in the left-right direction orthogonal to this plane is about ± 50 ° to ± 60 ° with respect to the horizontal state.
[0004]
For example, to perform coronary revascularization (hereinafter, referred to as CABG) under an endoscope, the grasping forceps 268 is used. As shown in FIG. 42, a case where a blood vessel 270 having a diameter of about 2 to 3 mm is sewn using forceps 268 will be described. In this forceps 268, in order to penetrate the distal end of the curved needle 273 from the inner wall side of the blood vessel 270 cut obliquely, insert the forceps 268 into the blood vessel 270 and penetrate the distal end of the curved needle 273 outward. Let it. Then, once the bending needle 273 is released, the distal end of the bending needle 273 is re-gripped and pulled upward, and the thread connected to the base end of the bending needle 273 is passed outward from the inner wall of the blood vessel 270. .
[0005]
[Problems to be solved by the invention]
In suturing a blood vessel using such forceps 268, the distal end of the forceps 268 does not rotate, so that it is necessary to perform the suture by tilting the forceps 268 greatly or moving the forceps 268 up and down as a whole. Therefore, it is not suitable for performing a fine treatment such as suturing a blood vessel 270 having a small diameter of about 2 mm to 3 mm. Further, since the distal end of the forceps 268 does not rotate as described above, it is necessary to finely move the forceps 268 in accordance with the degree of curvature of the bending needle 273, and this places a heavy burden on the operator. For this reason, the operation is time-consuming and places a burden on the patient.
[0006]
Also, in the surgical treatment tool 201 described in Japanese Patent Application No. 2001-119904 shown in FIG. 41, the treatment portion can be rotated, and thus such a treatment can be performed more smoothly than the forceps 268 shown in FIG. Can be performed, but the maximum pivot angle is less than the desired angle. For this reason, many operations such as changing and holding the curved needle 273 are necessary, and it takes time to suture the blood vessel.
[0007]
Further, in this surgical treatment tool 201, there is a possibility that the gripping force of the curved needle 273 changes depending on the rotational position of the treatment section 203. For example, when a delicate curved needle 273 for cardiovascular surgery or the like is gripped and the treatment is performed, the curved needle may rotate in an unexpected direction, which is inconvenient.
[0008]
The present invention has been made to solve such a problem, and an object of the present invention is to provide a surgical treatment tool capable of improving operability and reducing operation time.
[0009]
[Means for Solving the Problems]
In order to solve the above-mentioned problem, an elongated insertion portion to be inserted into a body of the present invention, and a treatment portion provided at one end of the insertion portion and rotatable around at least two axes and capable of opening and closing are provided. An operating portion provided at the other end of the insertion portion and rotatable around at least two axes and openable and closable, connecting the operating portion and the treatment portion, and operating the operating portion with an operating force. And a driving means including a first link rod for operating the treatment section by transmitting the first link rod and a second link rod arranged in parallel to the first link rod, the driving means being arranged along the opening and closing direction of the treatment section. In a surgical treatment tool, the operation unit and the treatment unit can rotate in cooperation with each other in at least two planes of a vertical direction rotating in a plane and a horizontal direction rotating in a plane perpendicular to the vertical direction. The other end of the insertion section and the operation section, The contacting contact portion is formed at a predetermined angle with respect to the axial direction of the insertion portion, and when the operation portion is rotated to the maximum in the left-right direction, the other end of the insertion portion and the operation portion are mutually moved. Abutting portion of the insertion portion, the rotation angle of the operation portion with respect to the axial direction of the insertion portion is defined, and the rotation angle of the treatment portion in the left-right direction is defined. is there.
[0010]
An elongated insertion portion to be inserted into the body, a treatment portion provided at one end of the insertion portion, rotatable around at least two axes and openable and closable, and provided at the other end of the insertion portion. An operating portion rotatable around at least two axes and openable and closable, a first link rod having a pair of pivot shafts at both ends thereof for operating the treatment section, and a first link rod. A drive unit configured to connect the operation unit and the treatment unit, and to transmit an operation force of the operation unit to the treatment unit, the driving unit including a second link rod disposed in parallel with the treatment unit, A surgical treatment tool in which the operation unit and the treatment unit can rotate in at least two planes: a vertical direction that rotates in a plane that is rotated and a horizontal direction that rotates in a plane perpendicular to the vertical direction. In the above, the front provided at both ends of the first link rod At least one of the pair of pivots and the pair of pivots provided at both ends of the second link rod is provided with a bias toward a side close to the second link rod and the first link rod, respectively. When the first and second link rods are moved forward and backward in opposite directions, the turning angle of the treatment section is increased.
[0011]
By adopting such a configuration, the operability of a procedure that requires an increase in the turning angle of the treatment section in the left-right direction and a large turning angle can be improved, and the operation time can be reduced.
[0012]
BEST MODE FOR CARRYING OUT THE INVENTION
Hereinafter, embodiments of the present invention will be described with reference to the drawings.
[0013]
[First Embodiment]
First, a first embodiment will be described with reference to FIGS.
[0014]
(Constitution)
As shown in FIG. 1, a surgical treatment tool 1 according to this embodiment has an elongated insertion section 2, a treatment section 3 disposed at a distal end of the insertion section 2, and a proximal end of the insertion section 2. And an operation unit 4 for operating the treatment unit 3.
[0015]
An elongated and rigid support portion 8 is provided in the insertion portion 2. The central portion of the support portion 8 is formed in an elongated substantially flat plate shape. Further, along the axial direction of the support portion 8, a first driving rod 5 constituting an opening / closing link mechanism and second and third driving rods 6, 7 (first and third driving rods) constituting a rotating link mechanism. 2 link rods) are provided in parallel or substantially in parallel. The first driving rod 5 is provided on the lower side in FIG. The second and third drive rods 6 and 7 are provided on the upper side in FIG. The second and third drive rods 6, 7 are arranged symmetrically with respect to the central axis in the longitudinal direction of the insertion portion 2, and can be independently advanced and retracted in the axial direction.
[0016]
As shown in FIGS. 2 to 4, a slit 8 a is provided at the tip of the support 8. A first turning plate 10 that can turn in the left-right direction by a pivot 9 that is orthogonal to the axial direction of the insertion portion 2 is connected to the slit portion 8a. A first pivot pin 11 is fixed to the first rotating plate 10 in a direction orthogonal to the pivot 9. The base end of the first treatment piece 12 is rotatably supported by the first pivot pin 11. Further, a portion of the first treatment piece 12 located near the first pivot pin 11 is formed as a bent portion 12a. The second and third drive rods 6, 7 are connected to the bent portion 12a by means described later.
[0017]
A second treatment piece 14 is rotatably connected to an intermediate portion of the first treatment piece 12 by a first opening / closing pivot pin 13. As a result, the first and second treatment pieces 12 and 14 are rotatable about the first opening / closing pivot pin 13 as a fulcrum. One end of the first connecting member 16 is pivoted at the base end of the second treatment piece 14 via the first connecting pin 15 extending in the left-right direction (the direction orthogonal to the axial direction of the insertion section 2). They are freely connected. The other end of the first connecting member 16 is connected to a second connecting member 18 via a second connecting pin 17 orthogonal to the axial direction of the insertion section 2. The other end of the second connecting member 18 is rotatably connected to the distal end of the first driving rod 5 via a third connecting pin 19 extending in the left-right direction.
[0018]
Further, a T-shaped second rotating plate 21 is connected to the bent portion 12a of the first treatment piece 12 via a second pivot pin 20 extending in the left-right direction. The proximal end side of the second rotating plate 21 is wide in the left-right direction, and the proximal end side of the second rotating plate 21 has a first rotating pin ( A pivot 22 and a second pivot pin (axis) 23 are provided apart from each other in the left-right direction. Further, the second rotating plate 21 has an orthogonal portion extending in a predetermined axial direction orthogonal to the wide portion. The above-described second pivot pin 20 is disposed at the tip of the orthogonal portion. The first rotation pin 22 is connected to the second drive rod 6, and the second rotation pin 23 is connected to the third drive rod 7.
[0019]
Further, as shown in FIG. 4, the first treatment piece 12 has a grip surface 12b. The second treatment piece 14 has a grip surface 14b. In this case, when the first and second treatment pieces 12 and 14 are closed with each other, the gripping surfaces 12b and 14b are positioned substantially parallel to each other, and cooperate to grip the gripping target. It is possible. The gripping surfaces 12b and 14b are subjected to unevenness processing to form a fine rough surface by, for example, electric discharge machining or etching, if necessary. Thereby, the suture needle, the suture, the living tissue, and the like, which are the objects to be grasped, can be securely grasped.
[0020]
Next, the operation unit 4 will be described with reference to FIGS.
As shown in FIGS. 5 to 7, also at the base end of the insertion portion 2, the base end of the first drive rod 5 is arranged so as to be deviated below the longitudinal center axis of the insertion portion 2. I have. The base ends of the second and third drive rods 6 and 7 are arranged symmetrically above and below the longitudinal center axis of the insertion section 2. Then, the first drive rod 5 is connected to the third connecting member 41 via a configuration described later (see FIG. 6). The second and third drive rods 6 and 7 are connected to a fourth rotating plate 46 via a configuration described later (see FIG. 6).
[0021]
As shown in FIGS. 5 to 7, the support portion 8 protrudes rearward (proximal side) at the proximal end of the insertion portion 2. As shown in FIGS. 6 and 7, the support portion 8 is provided with a first pivot portion 33 having a second pivot shaft 32 orthogonal to the axial direction of the insertion portion 2. The first pivot portion 33 is provided with a third pivot plate 34 that can pivot left and right about the second pivot shaft 32.
[0022]
The third pivot plate 34 is provided with a second pivot portion 36 having a third pivot pin 35 extending in the left-right direction. The second handle 36 is connected to a first handle 37 serving as a first operation unit that can rotate up and down around a third pivot pin 35.
[0023]
As shown in FIGS. 1 and 8, a second handle 39 as a second operating portion is connected to the first handle 37 by a second opening / closing pivot pin 38 so as to be vertically rotatable. I have.
[0024]
As shown in FIG. 6, a fourth connecting pin 42 (extending in the vertical direction) orthogonal to the axial direction of the insertion section 2 is provided at the base end of the first driving rod 5. A third connecting member 41 is connected to the fourth connecting pin 42 so as to be rotatable in the left-right direction. The third connecting member 41 is connected to the fourth connecting member 43 via a fifth connecting pin 40 provided at one end of the fourth connecting member 43 and extending in the left-right direction. It can rotate up and down around the pin 40. A second handle 39 is connected to the other end of the fourth connecting member 43 via a sixth connecting pin 44 extending in the left-right direction so as to be rotatable up and down.
[0025]
In the vicinity of the third pivot pin 35 of the first handle 37, a fourth pivot pin 45 extending in the left-right direction is located. The fourth pivot pin 45 is provided at one end of a fourth pivot plate 46, and the fourth pivot pin 45 pivots up and down about the third pivot pin 35. A first handle 37 is rotatably connected. At the other end of the fourth rotating plate 46, third and fourth rotating pins (pivot shafts) 47, 48 orthogonal to the axial direction of the insertion section 2 (extending in the vertical direction) are separated to the left and right. Is provided. The proximal end of the second drive rod 6 and the proximal end of the third drive rod 7, which are located on the left and right sides, are rotatably connected to the third and fourth pivot pins 47 and 48, respectively. (See FIG. 7).
[0026]
Further, as shown in FIG. 1, the first handle 37 is provided with a first grip 37 a that is gripped by an operator using fingers other than the thumb during operation. The first grip 37a is formed with a round portion 37b held by, for example, a middle finger. Further, on the distal side of the first opening / closing pivot pin 38 of the first grip 37a, there is formed a column 100 to be applied to the abdomen of the hand. A portion corresponding to the abdomen of the hand of the strut 100 is preferably formed with a spherical ball portion 100a.
[0027]
The proximal side of the second opening / closing pivot pin 38 of the second handle 39 is formed in a flat shape so as to abut the abdomen on the tip side of the thumb. On the distal side, a thumb rest portion (bulging portion) 39a is formed in an arc shape along the abdomen of the thumb. Further, a ratchet 82 is formed in the thumb rest portion 39a of the second handle 39 so as to mesh with a tooth portion (not shown) inside the first handle 37. For this reason, the rotation angle of the second handle 39 with respect to the first handle 37 can be kept at a predetermined position.
[0028]
The engagement of the ratchet 82 can be released by a lever 83 provided near the round portion 37b of the first handle 37.
[0029]
FIGS. 8A and 9A show a state in which the first and second handles 37 and 39 are both rotated to the maximum in the vertical direction. That is, the first drive rod 5 is pushed out to the treatment section 3 side. Further, the second and third drive rods 6, 7 are in a neutral state in which they are parallel to each other and do not advance or retreat. In this state, the distance between the second and third drive rods 6, 7 is, for example, a. The first handle 37 has a first abutment surface 60. The longitudinal direction of the support portion 8 is substantially orthogonal to the first abutting surface 60.
[0030]
Further, two second abutting surfaces 61 are formed on the rear end of the support portion 8, that is, on the side of the connection portion with the operation portion 4. The angle θ between these second abutting surfaces 61 is formed, for example, at 40 ° along the longitudinal axis of the support 8. That is, the handles 37 and 39 are rotatable by 70 ° in the left and right directions, respectively.
[0031]
FIG. 9B shows a state in which the handles 37 and 39 are rotated to the maximum (70 °) in one lateral direction from the state of FIG. 9A with the second pivot shaft 32 as a fulcrum. I have. That is, the first drive rod 5 is pushed out to the treatment section 3 side. Further, the second drive rod 6 is pulled toward the operation section 4 and the third drive rod 7 is pushed toward the treatment section 3. The second and third drive rods 6, 7 are in contact with each other while maintaining a state of being parallel to each other. That is, the distance a described above is zero. The first butting surface 60 and one of the second butting surfaces 61 are in contact with each other. At this time, the rotation angle of the treatment section 3 with respect to the axial direction of the support section 8 is 70 °. That is, the angle between the longitudinal direction of the wide portion of the second rotating plate 21 and the axial direction of the support portion 8 is 20 °, and the angle between the wide portion and the treatment pieces 12 and 14 is 90 °. Therefore, the angle formed between the axial direction of the support section 8 and the treatment section 3 is 70 °. At this time, the end of the second rotating plate 21 on the distal side with respect to the tip of the orthogonal portion where the second pivot pin 20 is disposed, and the first abutting surface 60 are mutually moved. It is parallel. Therefore, in the surgical treatment tool 1 according to this embodiment, the treatment section 3 also rotates in proportion to the amount of rotation of the handles 37 and 39.
[0032]
FIG. 10 shows a positional relationship between the second rotating plate 21 and the second and third drive rods 6 and 7. As shown in FIG. 10, for example, the second rotation pin 23 of the third drive rod 7 is close to the second drive rod 6 in a direction orthogonal to the longitudinal direction of the third drive rod 7. It is arranged on the side to be. That is, the width of the third drive rod 7 in FIG. 10 is L, the distance L1 from the outside of the third drive rod 7 to the second rotation pin 23 is L, and the width of the drive rod from the second rotation pin 23 is L1. Assuming a distance L2 to the inside of 7
L = L1 + L2
so,
L1-L2> 0
Is formed. That is, when the distance L2 of the third drive rod 7 is reduced, the distance between the second rotation pin 23 and the side of the third drive rod 7 is reduced. For this reason, it is possible to increase the rotation angle. The strength of the third drive rod 7 is maintained by increasing the distance L1 on the opposite side so that the strength of the portion provided with the second rotation pin 23 is weakened.
Although the description is omitted, it is preferable that the second drive rod 6 is formed similarly to the third drive rod 7.
[0033]
Therefore, when the second and third drive rods 6 and 7 are moved forward and backward, the first and second rotation pins 22 and 23 and the third and second drive rods 7 and 6 are moved more than when L1 = L2. Since the distance therebetween is small, the rotation angle of the second rotation plate 21 increases. For this reason, the treatment section 3 can be rotated at a larger angle.
[0034]
(Action)
Next, the operation of the surgical treatment instrument 1 configured as described above will be described.
[0035]
When the second and third drive rods 6 and 7 are simultaneously advanced from the state shown in FIGS. 2 and 3, the bent portion 12 a of the first treatment piece 12 is moved forward via the second rotation plate 21. Extruded. For this reason, the second treatment piece 14 connected to the first treatment piece 12 via the first opening / closing pivot pin 13 also rotates in the same direction as the first treatment piece 12. As a result, the first and second treatment pieces 12 and 14 rotate substantially horizontally around the first pivot pin 11 orthogonal to the longitudinal center axis of the insertion section 2.
[0036]
Next, when the second drive rod 6 is retracted and the third drive rod 7 is moved forward, the first rotating plate 10 moves rightward (from the operation unit 4 side) with the first pivot 9 as a fulcrum. (See). Therefore, the first and second treatment pieces 12 and 14 (the entire treatment section 3) rotate rightward about the first pivot shaft 9 as a fulcrum.
[0037]
Conversely, when the second drive rod 6 is advanced and the third drive rod 7 is retracted, the first rotating plate 10 is moved leftward (from the operation unit 4 side) with the first pivot 9 as a fulcrum. (See). Therefore, the first and second treatment pieces 12 and 14 (the entire treatment section 3) rotate leftward about the first pivot shaft 9 as a fulcrum.
[0038]
In any rotation state, when the first drive rod 5 is advanced, the base end of the second treatment piece 14 moves forward via the first connection member 16 and the second connection member 18. Pressed. For this reason, the second treatment piece 14 is rotated with respect to the first treatment piece 12 about the first opening / closing pivot pin 13 as a fulcrum. Thereby, the treatment section 3 is opened. Conversely, when the first drive rod 5 is retracted from this open state, the base end of the second treatment piece 14 is pulled back via the first connection member 16 and the second connection member 18. . For this reason, the second treatment piece 14 is rotated with respect to the first treatment piece 12 about the first opening / closing pivot pin 13 as a fulcrum. Thereby, the treatment section 3 is closed.
[0039]
As described above, according to this embodiment, the entire treatment section 3 including the first and second treatment pieces 12 and 14 that can be opened and closed can be rotated vertically and horizontally. Therefore, the first and second treatment pieces 12 and 14 can easily approach the target site, and the degree of freedom of treatment can be improved.
[0040]
In an actual operation, first, the round part 37b of the first grip 37a of the first handle 37 of the operation unit 4 shown in FIG. At the same time, the thumb is attached to the second grip (thumb rest part) 39a of the second handle 39. Then, from the horizontal state shown in FIG. 8B, the first and second handles 37 and 39 of the operation unit 4 are simultaneously rotated downward by 90 ° about the third pivot pin 35 as a fulcrum. Then, the second and third drive rods 6 and 7 are simultaneously retracted along the insertion portion 2 via the fourth rotation plate 46. At the same time, the first drive rod 5 advances toward the treatment section 3 via the fourth connection member 43 and the third connection member 41 so as to interlock with this. Therefore, the first connection pin 15 is protruded to the distal end side via the first connection member 16 on the treatment section 3 side connected to the first drive rod 5, and the second rotation plate 21. Thus, the bent portion 12a of the first treatment piece 12 is pulled backward. For this reason, the first and second treatment pieces 12 and 14 do not relatively rotate, and maintain their closed state, and rotate around the first pivot pin 11 as a fulcrum until they become 90 ° upward. Move. This state is shown in FIG. 1 and FIG.
[0041]
Conversely, from the state shown in FIG. 1 and FIG. 8A, the first handle 37 and the second handle 39 are pivoted upward about the third pivot pin 35 as a fulcrum, and the first and third handles are rotated. Level the handles 37, 39 of the second. Then, the first drive rod 5 retreats to the operation unit 4 side via the fourth connecting member 43 and the third connecting member 41, and the second and third driving rods 5 pass through the fourth rotating plate 46. Are simultaneously advanced along the insertion portion 2. Therefore, the first connection pin 15 is pulled toward the operation unit 4 via the first connection member 16 on the treatment section 3 side connected to the first drive rod 5, and the second rotation plate 21 is moved. The bent part 12a of the first treatment piece 12 is pushed forward through the first treatment piece 12. For this reason, the first and second treatment pieces 12 and 14 rotate substantially horizontally with the first pivot pin 11 as a fulcrum while maintaining the closed state without rotating relatively ( Straighten) (see FIG. 8B).
[0042]
As described above, in the surgical treatment tool 1 of this embodiment, the first and second handles 37 and 39 on the operation section 4 side are vertically rotated about the third pivot pin 35 as a fulcrum. In addition, the treatment section 3 can be positioned straight along the axial direction of the insertion section 2, or can have an angle with respect to the axial direction of the insertion section 2.
[0043]
Further, if the first operation handle 37 and the second operation handle 39 are relatively rotated, the first and second treatment pieces 12 and 14 are relatively rotated, and the treatment section 3 is moved. Can be opened. That is, when the second handle 39 is rotated with respect to the first handle 37 with the second opening / closing pivot pin 38 as a fulcrum (when the first handle 37 and the second handle 39 are opened), the second handle 39 is opened. The first drive rod 5 moves forward and backward via the fourth connection member 43 and the third connection member 41. Therefore, the first connection pin 15 moves back and forth via the first connection member 16 on the treatment section 3 side connected to the first drive rod 5. For this reason, the second treatment piece 14 rotates with respect to the first treatment piece 12 about the first opening / closing pivot pin 13 as a fulcrum, and the treatment section 3 opens and closes.
[0044]
FIG. 9B shows a state in which both the first and second handles 37 and 39 are rotated, for example, 70 ° in the left lateral direction (as viewed from the operation unit 4 side). In this state, with the rotation of the first and second handles 37, 39, the first and second treatment pieces 12, 14 are also rotated rightward by 70 ° in a closed state. That is, when the first handle 37 and the second handle 39 are simultaneously rotated leftward about the second pivot shaft 32 as a fulcrum, the second drive rod 6 is moved through the fourth rotation plate 46. Retreat, the third drive rod 7 moves forward. Therefore, the first rotation pin 22 in the treatment section 3 retreats, and the second rotation pin 23 advances. For this reason, the first treatment piece 12 rotates rightward about the first pivot 9 via the second rotation plate 21, and as a result, the entire treatment section 3 rotates rightward. I do.
[0045]
Conversely, when the first and second handles 37 and 39 are simultaneously rotated rightward with the second pivot 32 as a fulcrum, the second drive rod 6 advances through the fourth rotation plate 46. Then, the third drive rod 7 moves backward. Therefore, the first rotation pin 22 in the treatment section 3 moves forward, and the second rotation pin 23 moves backward. Therefore, the first treatment piece 12 rotates leftward about the pivot shaft 9 via the second rotation plate 21. As a result, the entire treatment section 3 rotates to the left.
[0046]
As described above, in the surgical treatment tool 1 according to the present embodiment, the first and second treatment pieces 12 and 14 are moved by the right and left rotations of the first and second handles 37 and 39. , 39 while rotating substantially to the left. Further, in conjunction with the left rotation of the first and second handles 37, 39, the first and second treatment pieces 12, 14 rotate rightward while maintaining a substantially parallel state with the handles 37, 39. Move. That is, the treatment section 3 can be directed in any direction by turning the first and second handles 37, 39 up, down, left, and right.
[0047]
Next, a procedure for performing, for example, a CABG operation using the surgical treatment tool 1 having such an operation will be described. In this embodiment, a case where the surgical treatment tool 1 is operated with the right hand will be described. Of course, when operating with the left hand, the operation described below may be performed by reversing left and right. This operation may be performed under cardiac arrest using, for example, an extracorporeal circulation device. Alternatively, a stabilizer (for example, see Japanese Patent Application Laid-Open No. 2000-116663) may be inserted from another port to partially stop the heartbeat at the site where the vascular anastomosis is to be performed, and the heartbeat may be performed.
[0048]
FIG. 11 shows how to hold the surgical treatment tool 1 according to this embodiment, and shows how the surgical treatment tool 1 is inserted into a body cavity and used. Further, as shown in FIG. 11, in CABG surgery under an endoscope, the CABG is often used in a state where the vertical rotation angle is held substantially at right angles to the insertion section 2. In the CABG operation described below, it is used while being held at a substantially right angle.
[0049]
As shown in FIG. 11, the thumb 113 is placed on the thumb rest 39 a of the second handle 39. The index finger 114 holds the vicinity of the connection between the insertion section 2 and the operation section 4. The middle finger 115 holds the round portion 37b of the first handle 37. The ring finger 116 and the little finger 117 support the second opening / closing pivot pin 38 of the first handle 37 on the distal side or the column 100.
[0050]
FIG. 12 is a cross-sectional view of the chest at the site where the heart is located as viewed from below. When the trocar 118 is inserted, the pressure in the thoracic cavity becomes positive, and the lung 65 collapses. A rigid endoscope 67 is inserted via a trocar 118 directly above the coronary artery, referred to as the left anterior descending branch 64. That is, the operation is performed while observing from directly above the operation site. Further, two other trocars 118 are inserted at positions adjacent to the trocar 118 into which the rigid endoscope 67 is inserted. Then, one of the trocars 118 is inserted into the body cavity from the treatment section 3 of the surgical treatment instrument 1 while being held as shown in FIG. In addition, a treatment tool such as grasping forceps 68 is inserted into the other side of the trocar 118.
The blood vessel diameter of the left anterior descending branch 64 and the internal thoracic artery 70 described in this embodiment is, for example, about 2 mm to 3 mm.
[0051]
FIG. 13 shows a state where the pre-stage for performing the vascular anastomosis has been completed. As shown in FIG. 13, the internal thoracic artery 70 is detached from the chest wall 66 shown in FIG. 12 using a port opened to the side of the chest (not shown) endoscopically. An incision 71 is formed using scissors forceps 69 on the downstream side of the stenosis in the left front descending branch 64.
[0052]
14 to 25 sequentially show the flow of the vascular anastomosis (suturing) procedure performed under the endoscope. The tips of the very fine first and second bending needles 73 and 74 capable of suturing a blood vessel having a diameter of about 2 mm to 3 mm are sharply formed and bent with an appropriate bending degree. A suture 75 connecting the two is provided at the base end.
[0053]
First, the treatment section 3 holds the proximal end of the curved needle 74 so that the distal end of the second curved needle 74 is disposed on the right side of the treatment section 3. Then, as shown in FIG. 14A, the internal thoracic artery 70 separated from the chest wall 66 is gripped by the gripping forceps 68. In this state, the handles 37 and 39 are rotated leftward and rightward so that the curved needle 74 moves toward the inner wall near the cut portion (end) of the internal thoracic artery 70. The treatment section 3 rotates rightward and the distal end of the second curved needle 74 is inserted into the internal thoracic artery 70. That is, the distal end of the curved needle 74 is pushed outward from the inner wall. Here, FIG. 18 shows a series of movements of the treatment section 3 with respect to the internal thoracic artery 70 until such a state is obtained, along the section 14A-14A of FIG.
[0054]
As shown in FIG. 18 (A), the handle 37, 39 is turned to the maximum rightward (for example, + 70 °), and the rotation angle of the treatment unit 3 in the left-right direction is made maximum (for example, leftward). , + 70 °). In this state, the tip of the curved needle 74 is inserted into the internal thoracic artery 70.
Next, as shown in FIG. 18B, the handles 37, 39 are turned from the maximum turning position in the right lateral direction to a substantially central position in the left lateral direction. That is, the handles 37 and 39 are returned to a substantially neutral state. Then, the direction in which the rotation angle of the treatment section 3 is reduced, that is, the treatment section 3 is rotated rightward to the substantially neutral position at the center, and the distal end of the curved needle 74 is moved to the inner wall of the internal thoracic artery 70 Stab at any position. Then, in this state, the bending needle 74 is once released.
Then, as shown in FIG. 18C, the handles 37, 39 are rotated to an appropriate angle in the left lateral direction, and the treatment section 3 is rotated to an appropriate angle in the right lateral direction. After that, the distal end side of the curved needle 74 is gripped again by the treatment section 3 so that the distal end portion of the curved needle 74 faces the right side of the treatment section 3.
Further, the handles 37 and 39 are rotated leftward in the maximum direction (e.g., -70 degrees) to move the treatment section 3 in the rightward direction opposite to the direction shown in FIG. (For example, -70 °). In this manner, the proximal end of the curved needle 74 is pulled out from the internal thoracic artery 70 while substantially conforming to the degree of curvature of the curved needle 74. That is, as shown in FIG. 18 (D), the suture thread 75 is passed through the internal thoracic artery 70 with the second curved needle 74 held.
[0055]
Then, the proximal end side of the curved needle 74 is gripped again by the treatment section 3 so that the distal end of the second curved needle 74 is disposed on the left side of the treatment section 3. In this state, as shown in FIG. 14 (B), the handles 37 and 39 are turned rightward and leftward so that the distal end of the curved needle 74 faces the outer wall near the incision 71 of the left front descending branch 64. I do. The treatment section 3 rotates leftward and the tip of the second curved needle 74 is inserted from the outer wall of the left front descending branch 64 inward. That is, the tip of the curved needle 74 is hooked inward from the outer wall of the left front descending branch 64 by the rotation of the treatment section 3. Here, FIG. 19 shows a series of movements of the treatment section 3 with respect to the left front descending branch 64 until such a state is obtained, along the section 14B-14B shown in FIG. 14B.
[0056]
As shown in FIG. 19 (A), the handle 37, 39 is rotated to the left to the maximum, and the rotation angle in the left and right direction of the treatment section 3 is rotated to the right to the maximum. In this state, the tip of the curved needle 74 is stuck at an arbitrary position on the outer wall of the left front descending branch 64.
Next, as shown in FIG. 19 (B), the handles 37, 39 are turned from the maximum turning position in the left lateral direction toward the right lateral direction. That is, the handles 37 and 39 are returned to the neutral direction. Then, the treatment section 3 is rotated in the direction in which the rotation angle of the treatment section 3 is reduced, that is, the treatment section 3 is rotated leftward and leftward, and the distal end of the curved needle 74 is inserted into the outer wall of the left front descending branch 64. Then, in this state, the bending needle 74 is once released.
Then, as shown in FIG. 19 (C), the handle 37, 39 is rotated to an appropriate angle in the right lateral direction, and the treatment section 3 is rotated to an appropriate angle in the left lateral direction. After that, the distal end of the curved needle 74 is re-gripped by the treatment section 3 so that the distal end of the curved needle 74 faces the left side of the treatment section 3.
Furthermore, the handles 37 and 39 are rotated to the right in the maximum direction, so that the treatment section 3 is rotated to the maximum in the left lateral direction opposite to the direction shown in FIG. In this way, the proximal end of the curved needle 74 is pulled out from the left front descending branch 64 while substantially conforming to the degree of curvature of the curved needle 74. That is, as shown in FIG. 19D, the suture thread 75 is passed through the left front descending branch 64 in a state where the second curved needle 74 is gripped.
[0057]
In this state, the distal end of the curved needle 74 penetrates the internal thoracic artery 70 and the left anterior descending branch 64. That is, the suture 75 passes through the internal thoracic artery 70 and the left anterior descending branch 64.
[0058]
Next, the treatment section 3 regrips the proximal end of the curved needle 74 so that the distal end of the second curved needle 74 is disposed on the right side of the treatment section 3. In this state, as shown in FIG. 14C, the handles 37 and 39 are rotated leftward and rightward so that the distal end of the curved needle 74 faces the inner wall of the end of the internal thoracic artery 70. The treatment section 3 rotates rightward and the distal end of the second curved needle 74 is inserted outward from the inner wall of the internal thoracic artery 70. That is, the distal end of the curved needle 74 is pushed outward from the inner wall. Here, FIG. 20 shows a series of movements of the treatment section 3 with respect to the internal thoracic artery 70 until such a state is reached, taken along the section 14C-14C shown in FIG.
[0059]
As shown in FIG. 20 (A), the handle 37, 39 is rotated to the right to the maximum, and the left and right rotation angle of the treatment section 3 is rotated to the left to the maximum. In this state, the distal end of the curved needle 74 is inserted into the inner wall of the internal thoracic artery 70.
As shown in FIG. 20 (B), the handles 37, 39 are turned from the maximum turning position in the right lateral direction toward the left lateral direction. That is, the handles 37 and 39 are returned to the neutral direction. Then, the treatment section 3 rotates in the direction in which the rotation angle of the treatment section 3 becomes smaller, that is, the treatment section 3 rotates rightward and left, and the distal end of the curved needle 74 pierces the inner wall of the internal thoracic artery 70. Then, in this state, the bending needle 74 is once released.
Then, as shown in FIG. 20C, the handle 37, 39 is rotated to an appropriate angle in the left lateral direction, and the treatment section 3 is rotated to an appropriate angle in the right lateral direction. After that, the distal end side of the curved needle 74 is gripped again by the treatment section 3 so that the distal end portion of the curved needle 74 faces the right side of the treatment section 3.
Further, the handle 37, 39 is rotated to the left in the maximum direction to rotate the treatment section 3 to the maximum in the right and left direction opposite to the direction shown in FIG. In this manner, the proximal end of the curved needle 74 is pulled out from the internal thoracic artery 70 while substantially conforming to the degree of curvature of the curved needle 74. That is, as shown in FIG. 20D, the suture 75 is passed through the internal thoracic artery 70 with the second curved needle 74 held.
[0060]
Next, the treatment section 3 regrips the proximal end of the curved needle 74 so that the distal end of the second curved needle 74 is disposed on the right side of the treatment section 3. In this state, as shown in FIG. 15A, the handles 37, 39 are turned rightward and leftward so that the distal end of the curved needle 74 faces the outer wall near the incision 71 of the left front descending branch 64. I do. The treatment section 3 rotates leftward and the tip of the second curved needle 74 is inserted from the outer wall of the left front descending branch 64 inward. That is, the tip of the curved needle 74 is hooked inward from the outer wall. Here, FIG. 21 shows a series of movements of the treatment section 3 with respect to the left front descending branch 64 until such a state is obtained, along the 15A-15A section shown in FIG.
[0061]
As shown in FIG. 21 (A), the handle 37, 39 is rotated to the right to the maximum, and the left and right rotation angle of the treatment section 3 is rotated to the left to the maximum. In this state, the tip of the curved needle 74 is stuck into the outer wall of the left front descending branch 64.
As shown in FIG. 21 (B), the handles 37, 39 are turned from the maximum turning position in the right lateral direction toward the left lateral direction. That is, the handles 37 and 39 are returned to the neutral direction. Then, the treatment section 3 rotates in a direction in which the rotation angle of the treatment section 3 becomes small, that is, the treatment section 3 rotates rightward and leftward, and the tip of the curved needle 74 is inserted into the outer wall of the left front descending branch 64. Then, in this state, the bending needle 74 is once released.
Then, as shown in FIG. 21 (C), the handle 37, 39 is rotated to an appropriate angle in the left lateral direction, and the treatment section 3 is rotated to an appropriate angle in the right lateral direction. After that, the distal end side of the curved needle 74 is gripped again by the treatment section 3 so that the distal end portion of the curved needle 74 faces the right side of the treatment section 3.
Further, the handle 37, 39 is rotated to the left in the maximum direction, and the treatment section 3 is rotated to the maximum in the right lateral direction on the opposite side to the direction shown in FIG. In this manner, the base end of the curved needle 74 is pulled out of the incision 71 of the left front descending branch 64. That is, as shown in FIG. 21 (D), the suture 75 is passed through the left front descending branch 64 with the second curved needle 74 held.
[0062]
Then, as shown in FIG. 15 (B), when the operator looks at the left anterior descending branch 64, in a counterclockwise direction from 12:00 to around 9 o'clock, in a clockwise direction with respect to the internal thoracic artery 70. In the same manner, sewing is sequentially performed. Thereafter, at the time when about 1/4 of both vessels of the left anterior descending branch 64 and the internal thoracic artery 70 are sutured, as shown in FIG. Is defined.
[0063]
Next, suturing is started using the first curved needle 73 provided at the other end of the suture thread 75 to which the second curved needle 74 is attached at one end. That is, as shown in FIG. 16 (A), from the position shown in FIGS. 14 (A) to 14 (C) and FIGS. 15 (A) and 15 (B) with respect to the longitudinal direction of the left front descending branch 64. Sutures in symmetrical directions. The proximal end of the curved needle 73 is gripped by the treatment section 3 so that the distal end of the first curved needle 73 is disposed on the right side of the treatment section 3. Further, the internal thoracic artery 70 is gripped by the gripping forceps 68. In this state, the distal end of the curved needle 73 is inserted from the outer wall side of the internal thoracic artery 70 toward the inner wall side of the left anterior descending branch 64. Here, FIGS. 22 and 23 show a series of movements of the treatment section 3 with respect to the left anterior descending branch 64 and the internal thoracic artery 70 until such a state is shown along the section 16A-16A of FIG. I have.
[0064]
As shown in FIG. 22 (A), the handles 37, 39 are turned to the right and left to the maximum, and the turning angle of the treatment section 3 in the left and right directions is turned to the left to the maximum. In this state, the distal end of the curved needle 73 is inserted into the outer wall of the internal thoracic artery 70.
As shown in FIG. 22 (B), the handles 37, 39 are turned from the maximum turning position in the right lateral direction toward the left lateral direction. That is, the handles 37 and 39 are returned to the neutral direction. Then, the treatment section 3 rotates in the direction in which the rotation angle of the treatment section 3 becomes small, that is, the treatment section 3 rotates rightward and left, and the distal end of the curved needle 73 is inserted into the outer wall of the internal thoracic artery 70.
Further, as shown in FIG. 22C, in this state, the distal end of the curved needle 73 is pierced outward from the inner wall of the left front descending branch 64. That is, the distal end of the curved needle 73 penetrates both the internal thoracic artery 70 and the left anterior descending branch 64 in a state of contact with the two. Then, in this state, the bending needle 73 is once released.
As shown in FIGS. 22 (B) and 22 (C), in order to suture the internal thoracic artery 70 and the left anterior descending branch 64, two rotation operations are performed. In some cases, only a moving operation is required. That is, the curved needle 73 may penetrate the two blood vessels 70 and 64 by one rotation operation.
[0065]
Then, as shown in FIG. 23A, the handles 37 and 39 are rotated to the substantially neutral position, and the treatment section 3 is set to the substantially neutral position. Thereafter, the distal end of the curved needle 73 is re-gripped by the treatment section 3 so that the distal end of the curved needle 73 faces the right side of the treatment section 3.
Furthermore, the handles 37 and 39 are rotated to the left in the maximum direction to rotate the treatment section 3 to the maximum in the right and left direction opposite to the direction shown in FIG. In this manner, the proximal end of the curved needle 73 is extracted from the internal thoracic artery 70 and the left anterior descending branch 64. That is, as shown in FIG. 23 (B), the suture thread 75 is passed through the internal thoracic artery 70 and the left anterior descending branch 64 with the first curved needle 73 held.
[0066]
Then, as shown in FIG. 16B, when the operator looks at the left anterior descending branch 64, the internal thoracic artery 70 and the left anterior descending branch 64 are sequentially sewn clockwise from about 12:00 to about 3:00. .
[0067]
Next, the treatment section 3 re-grips the proximal end of the curved needle 73 so that the distal end of the first curved needle 73 is disposed on the left side of the treatment section 3. In this state, as shown in FIG. 16C, the distal end of the curved needle 73 is pierced from the outer wall side of the internal thoracic artery 70 toward the inner wall side of the left anterior descending branch 64. Here, FIGS. 24 and 25 show a series of movements of the treatment section 3 with respect to the left anterior descending branch 64 and the internal thoracic artery 70 up to such a state from the opposite side to FIGS. Is shown along the 16C-16C section.
[0068]
As shown in FIG. 24 (A), the handles 37, 39 are turned to the left in the left-hand direction to the maximum, and the turning angle of the treatment unit 3 in the left-right direction is turned to the right in the right-hand direction. In this state, the distal end of the curved needle 73 is inserted into the outer wall of the internal thoracic artery 70.
As shown in FIG. 24 (B), the handles 37, 39 are turned from the maximum turning position in the left lateral direction toward the right lateral direction. That is, the handles 37 and 39 are returned to the neutral direction. Then, the treatment section 3 rotates in the direction in which the rotation angle of the treatment section 3 becomes small, that is, the treatment section 3 turns leftward, and the tip of the curved needle 74 is inserted into the outer wall of the internal thoracic artery 70.
Further, as shown in FIG. 24C, in this state, the distal end of the curved needle 73 is pierced outward from the inner wall of the left front descending branch 64. That is, the distal end of the curved needle 73 penetrates both the internal thoracic artery 70 and the left anterior descending branch 64 in a state of contact with the two. Then, in this state, the bending needle 74 is once released.
Then, as shown in FIG. 25A, the handles 37 and 39 are rotated to the substantially neutral position, and the treatment section 3 is set to the substantially neutral position. Thereafter, the distal end of the curved needle 74 is gripped again by the treatment section 3 such that the distal end of the curved needle 73 faces the left side of the treatment section 3.
Further, the handle 37, 39 is rotated to the right in the maximum direction to rotate the treatment section 3 to the maximum in the left lateral direction opposite to the direction shown in FIG. In this manner, the proximal end of the curved needle 73 is extracted from the internal thoracic artery 70 and the left anterior descending branch 64. That is, as shown in FIG. 25 (B), the suture 75 is passed through the internal thoracic artery 70 and the left anterior descending branch 64 with the first curved needle 73 held.
[0069]
Then, as shown in FIG. 16 (D), when the operator views the incision 71 of the left front descending branch 64, it is sequentially sewn clockwise from 3 o'clock to 6 o'clock.
[0070]
Next, the treatment section 3 re-grips the proximal end of the curved needle 73 so that the distal end of the first curved needle 73 is disposed on the left side of the treatment section 3. In this state, as shown in FIG. 17A, the distal end of the curved needle 73 is inserted from the outer wall of the internal thoracic artery 70 toward the inner wall of the left anterior descending branch 64. In this manner, when the operator views the incision 71 of the left front descending branch 64, the incision 71 is sequentially sewn clockwise from 6 o'clock to 9 o'clock. That is, suturing (anastomosis) over the entire circumference of the end of the internal thoracic artery 70 with respect to the incision 71 of the left anterior descending branch 64 is completed.
[0071]
Then, as shown in FIG. 17B, the treatment section 3 is operated to tie the suture 75 at an arbitrary position, a knot is formed several times, and the suture 75 is fastened.
Thereafter, as shown in FIG. 17C, the suture 75 is cut near the knot of the suture 75, and the curved needles 73 and 74 are taken out of the body.
[0072]
(effect)
As described above, in the surgical treatment tool 1 according to this embodiment, the rotation angle of the treatment section 3 is set to be larger than the rotation angle of the treatment section of the conventional surgical treatment instrument, such as about ± 70 °. be able to. Therefore, during the CABG operation, the treatment section 3 can be rotated according to the degree of bending of the bending needles 73 and 74. For this reason, it is possible to suture the blood vessels such as the left anterior descending branch 64 and the internal thoracic artery 70 having a diameter of about 2 mm to 3 mm without applying excessive force. Further, the tip of the curved needle can be pierced by a single rotation operation between a transplanted blood vessel such as the internal thoracic artery 70 and a transplanted blood vessel such as a coronary artery such as the left anterior descending branch 64. Therefore, it is possible to reduce the number of times the operating unit 4 of the surgical treatment tool 1 is changed and the number of times the operating unit 4 is rotated. Further, the number of times the surgical treatment instrument 1 is moved up and down can be reduced. For this reason, the operation time can be significantly reduced.
[0073]
That is, since the rotation angle of the treatment section 3 can be made larger than the rotation angle of the treatment section of the surgical treatment instrument according to the conventional technique, such as ± 70 °, complicated needle movement operations (pushing, hooking) in CABG can be performed. , Counterclockwise rotation and clockwise rotation operation) can be handled without switching. For this reason, the operation time can be shortened, and various contributions can be made, such as a reduction in invasion to the patient and a reduction in operating room running costs.
[0074]
In this embodiment, the left and right rotation angles of the surgical treatment tool 1 are ± 70 ° for the handles 37 and 39 and ± 70 ° for the treatment section 3, but such angles are only examples. Of course, other angles are acceptable.
[0075]
Further, the left anterior descending branch 64 as a coronary artery and the internal thoracic artery 70 peeled from the chest wall are only examples, and may be applied when other blood vessels are sutured (anastomosis).
[0076]
[Second embodiment]
Next, a second embodiment will be described with reference to FIGS. This embodiment is a modification of the first embodiment, and the same members are denoted by the same reference numerals and detailed description thereof will be omitted.
[0077]
(Constitution)
As shown in FIG. 26, the second and third drive rods 6a and 7a provided along the support portion 8 are supported near the second rotation plate 21 and the fourth rotation plate 46, respectively. A bent portion bent in an L-shape toward the inside of 8 is formed. That is, both ends of the second and third drive rods 6a and 7a are bent in the L-shape at the respective ends in the same direction.
[0078]
Further, the rear end side of the support portion 8, that is, the vicinity of the second pivot shaft 32 on the operation portion 4 side of the support portion 8 is thinner than the central portion of the support portion 8 and is parallel to each other. A second butting surface 61a is formed.
[0079]
Further, an end portion on the distal side with respect to the distal end portion of the orthogonal portion where the second pivot pin 20 of the second rotation plate 21 is disposed, and first and second rotation pins from this end portion. Let L3 be the distance between the centers 22 and 23. Also, the distance between the end of the fourth rotating plate 46 on the first abutting surface 60 side and the center of the third and fourth rotating pins (pivots) 47 and 48 from this end is L3. Is formed.
[0080]
The distance between the side of the center of the second drive rod 6a and the line connecting the first rotation pin 22 and the third rotation pin 47 is L4. Similarly, the distance between the side of the central portion of the third drive rod 7a and the line connecting the second rotation pin 23 and the fourth rotation pin 48 is also formed as L4. At this time,
L4-L3 ≧ 0
Is formed. The second and third drive rods 6a, 7a are less likely to interfere with the second and fourth rotating plates 21, 46. That is, in a state where the first butting surface 60 and the second butting surface 61 are in contact with each other, the second and third driving rods 6a and 7a, the second and fourth rotating plates 21 and 46, Are in contact with or separated from each other. Therefore, the handles 37 and 39 and the treatment section 3 are rotatable until they become a right angle.
[0081]
FIG. 26 (A) shows a state where it is rotated to the maximum in the vertical direction. That is, the first drive rod 5 is pushed into the treatment section 3 side. Further, the second and third drive rods 6a, 7a are in a neutral state in which they are parallel to each other and do not move forward or backward. The longitudinal direction of the support portion 8 is substantially perpendicular to the first abutting surface 60.
[0082]
FIG. 26B shows a state in which the handles 37 and 39 are rotated leftward and rightward in the left-right direction (90 °) from the state shown in FIG. ing. At this time, the treatment section 3 is turned to the maximum (90 °) in the right lateral direction. That is, the first drive rod 5 is pulled toward the operation unit 4. This is a state where the second drive rod 6 is pulled toward the operation section 4 and the third drive rod 7a is pushed toward the treatment section 3. The second and third drive rods 6a, 7a are separated from each other by a bent portion while maintaining a parallel state. The first butting surface 60 and one of the second butting surfaces 61 are in contact with each other.
[0083]
As shown in FIG. 27, a super hard material such as tungsten carbide is attached to each of the gripping surfaces 12 b and 14 b of the first and second treatment pieces 12 and 14 as necessary. The surface is knurled to prevent slippage. Thereby, the suture needle, the suture, the living tissue, and the like, which are the objects to be grasped, can be securely grasped.
[0084]
(Action)
The operation of such a surgical treatment instrument 1 is substantially the same as that of the first embodiment, and thus the description thereof will be omitted.
[0085]
Next, a case in which, for example, a CABG operation is performed using the surgical treatment tool 1 having such an operation will be described. The procedure described in this embodiment differs from the first embodiment in that the left front descending branch 64 is approached from the side. In this embodiment, a case where the surgical treatment tool 1 is operated with the right hand will be described. Of course, when operating with the left hand, the operation described below may be performed by reversing left and right.
[0086]
FIG. 28A is a cross-sectional view of the chest at a site where the heart is located as viewed from below. The rigid endoscope 67 is inserted via the trocar 118 to the side of the coronary artery called the left anterior descending branch 64. That is, the operation is performed while observing from the side of the operation part. In other words, it indicates that the left front descending branch 64 is approached from the side while observing with the rigid endoscope 67 via the trocar 118.
[0087]
FIG. 28B shows a state in which the pre-stage of performing the vascular anastomosis has been completed. As shown in FIG. 28 (B), the internal thoracic artery 70 is detached from the chest wall 66 shown in FIG. 28 (A) using a port opened to the side of the chest endoscopically. An incision 71 is formed using scissors forceps 69 on the downstream side of the stenosis in the left front descending branch 64. Further, two other trocars 118 are inserted at positions adjacent to the trocar 118 into which the rigid endoscope 67 is inserted. Then, one of the trocars 118 is inserted into the body cavity from the treatment section 3 of the surgical treatment instrument 1 while being held as shown in FIG. In addition, a treatment tool such as grasping forceps 68 is inserted into the other side of the trocar 118.
[0088]
29 to 35 sequentially show the flow of the vascular anastomosis (suturing) procedure performed under the endoscope.
[0089]
First, the treatment section 3 holds the proximal end side of the curved needle 74 so that the distal end of the second curved needle 74 is disposed on the left lateral side of the treatment section 3. Then, as shown in FIG. 29A, the internal thoracic artery 70 separated from the chest wall 66 is gripped by the gripping forceps 68. In this state, the handles 37 and 39 are rotated rightward and leftward so that the curved needle 74 is directed to the inner wall near the cut portion (end) of the internal thoracic artery 70. The treatment section 3 rotates leftward and the distal end of the second curved needle 74 is inserted into the internal thoracic artery 70. That is, as seen from the surgeon, the treatment section 3 is rotated downward from the inner wall to the outer side, and the distal end of the curved needle 74 is hooked on the inner wall of the internal thoracic artery 70. Then, by further rotating, the distal end portion of the curved needle 74 penetrates from the inner wall portion to the outside. In this state, the bending needle 74 is once released.
Then, the handle 37, 39 is rotated to an appropriate angle in the left lateral direction, so that the treatment section 3 is rotated to an appropriate angle in the right lateral direction. After that, the distal end of the curved needle 74 is re-gripped by the treatment section 3 so that the distal end of the curved needle 74 faces the left side of the treatment section 3.
Further, the handle 37, 39 is rotated to the right in the maximum direction to rotate the treatment section 3 to the maximum in the left direction or to the vicinity of the maximum. In this manner, the proximal end of the curved needle 74 is pulled out from the internal thoracic artery 70 while substantially conforming to the degree of curvature of the curved needle 74. That is, the suture 75 is passed through the internal thoracic artery 70 with the second curved needle 74 held.
[0090]
Then, the proximal end side of the curved needle 74 is gripped again by the treatment section 3 so that the distal end of the second curved needle 74 is disposed on the left side of the treatment section 3. In this state, the handles 37 and 39 are turned to the right and left so that the distal end of the curved needle 74 faces the outer wall near the incision 71 of the left front descending branch 64. The treatment section 3 rotates leftward and the tip of the second curved needle 74 is inserted from the outer wall of the left front descending branch 64 inward. That is, when viewed from the surgeon, the treatment section 3 is rotated downward from the outer wall to the inner side, and the distal end of the curved needle 74 is hooked on the outer wall of the left front descending branch 64. Then, the distal end of the curved needle 74 is further penetrated inward from the outer wall portion by further rotating. In this state, the bending needle 74 is once released.
Then, the handle 37, 39 is rotated to an appropriate angle in the left lateral direction, so that the treatment section 3 is rotated to an appropriate angle in the right lateral direction. Thereafter, as shown in FIG. 29 (B), the distal end of the curved needle 74 is re-gripped by the treatment section 3 such that the distal end of the curved needle 74 faces the left side of the treatment section 3.
Further, the handle 37, 39 is rotated to the right in the maximum direction to rotate the treatment section 3 to the maximum in the left direction or to the vicinity of the maximum. In this way, the proximal end of the curved needle 74 is pulled out from the left front descending branch 64 while substantially conforming to the degree of curvature of the curved needle 74. That is, the suture thread 75 is passed through the left front descending branch 64 in a state where the second curved needle 74 is gripped.
[0091]
Next, the operation of suturing the internal thoracic artery 70 and the left anterior descending branch 64 sequentially from the inner wall of the internal thoracic artery 70 to the outside and from the outer wall of the left anterior descending branch 64 through the curved needle 74 is sequentially performed. Go.
[0092]
In this operation, first, the proximal end side of the curved needle 74 is gripped again by the treatment section 3 so that the distal end of the second curved needle 74 is disposed on the left side of the treatment section 3. In this state, as shown in FIG. 29 (C), the handles 37, 39 are rotated rightward and leftward so that the distal end of the curved needle 74 faces the inner wall of the cut portion of the internal thoracic artery 70. The treatment section 3 is rotated leftward and the distal end of the second curved needle 74 is inserted outward from the inner wall of the cut section of the internal thoracic artery 70. Further, by this operation, the left front descending branch 64 is stabbed inward from the outer wall. That is, the distal end of the curved needle 74 is hooked from the inner wall of the internal thoracic artery 70 to the outside, and further from the outer wall of the left anterior descending branch 64 to the inside by the rotation of the treatment section 3. Here, FIG. 31 shows a series of movements of the treatment section 3 with respect to the internal thoracic artery 70 and the left anterior descending branch 64 until such a state is obtained, along a section 29C-29C shown in FIG.
[0093]
As shown in FIG. 31 (A), the handle 37, 39 is rotated to the maximum left (for example, −90 °), and the rotation angle of the treatment section 3 in the horizontal direction is maximized to the right (right). (For example, -90 °). In this state, the treatment section 3 is inserted between the incision 71 of the left anterior descending branch 64 and the end of the internal thoracic artery 70, and the tip of the curved needle 74 is inserted into an arbitrary position on the inner wall of the internal thoracic artery 70.
Next, as shown in FIG. 31 (B), the handles 37 and 39 are turned from the maximum turning position in the left lateral direction toward the right lateral direction. That is, the handles 37 and 39 are returned to the neutral direction. Then, the direction in which the rotation angle of the treatment section 3 becomes smaller, that is, the treatment section 3 rotates leftward, and the distal end of the curved needle 74 penetrates the inner wall of the internal thoracic artery 70, and the left front The lower branch 64 is stabbed inward from the outer wall. Then, in this state, the bending needle 74 is once released.
Then, as shown in FIG. 31 (C), the handle 37, 39 is rotated to an appropriate angle in the right lateral direction, and the treatment section 3 is rotated to an appropriate angle in the left lateral direction. After that, the distal end of the curved needle 74 is re-gripped by the treatment section 3 so that the distal end of the curved needle 74 faces the left side of the treatment section 3.
Further, the handle 37, 39 is rotated to the right in the maximum direction to rotate the treatment section 3 to the maximum in the left lateral direction opposite to the direction shown in FIG. In this way, the proximal end of the curved needle 74 is pulled out from the left front descending branch 64 while substantially conforming to the degree of curvature of the curved needle 74. That is, as shown in FIG. 31 (D), the suture 75 is passed through the internal thoracic artery 70 and the left anterior descending branch 64 with the second curved needle 74 held.
[0094]
By repeating such an operation, as shown in FIG. 29 (D), sewing is sequentially performed in a counterclockwise direction from 3 o'clock to 9 o'clock in the incision 71 of the left front descending branch 64 as seen from the operator.
[0095]
Next, suturing is started using the first curved needle 73 provided at the other end of the suture thread 75 to which the second curved needle 74 is attached at one end. That is, as shown in FIG. 30 (A), the sewing is performed in a direction symmetrical with respect to the longitudinal direction of the left front descending branch 64 from the position shown in FIGS. 29 (A) to 29 (D). The proximal end side of the curved needle 73 is gripped by the treatment section 3 so that the distal end of the first curved needle 73 is disposed on the left side of the treatment section 3. Further, the internal thoracic artery 70 is gripped by the gripping forceps 68. In this state, the distal end of the curved needle 73 is inserted from the outer wall side of the internal thoracic artery 70 toward the inner wall side of the left anterior descending branch 64. Here, FIG. 32 and FIG. 33 show a series of movements of the treatment section 3 with respect to the left anterior descending branch 64 and the internal thoracic artery 70 until such a state is shown along a section 30A-30A shown in FIG. ing.
[0096]
As shown in FIG. 32 (A), the handle 37, 39 is rotated to the left in the maximum direction, and the rotation angle of the treatment section 3 in the left and right direction is rotated to the maximum in the right side. In this state, the distal end of the curved needle 73 is inserted into the outer wall of the internal thoracic artery 70.
As shown in FIG. 32 (B), the handles 37, 39 are turned from the maximum turning position in the left lateral direction toward the right lateral direction. That is, the handles 37 and 39 are returned to the neutral direction. Then, the treatment section 3 rotates in the direction in which the rotation angle of the treatment section 3 becomes smaller, that is, the treatment section 3 turns leftward, and the tip of the curved needle 73 is inserted into the outer wall of the internal thoracic artery 70.
Further, as shown in FIG. 32 (C), in this state, the distal end of the curved needle 73 is inserted outward from the inner wall of the left front descending branch 64. That is, the distal end of the curved needle 73 penetrates both the internal thoracic artery 70 and the left anterior descending branch 64 in a state of contact with the two. Then, in this state, the bending needle 73 is once released.
Then, as shown in FIG. 33 (A), the handles 37, 39 are slightly rotated rightward and leftward, and the treatment section 3 is slightly rotated leftward. After that, the distal end of the curved needle 73 is re-gripped by the treatment section 3 so that the distal end of the curved needle 73 faces the left side of the treatment section 3.
Further, the handles 37 and 39 are rotated to the right in the maximum direction to rotate the treatment section 3 to the maximum in the left lateral direction opposite to the direction shown in FIG. In this manner, the proximal end of the curved needle 73 is extracted from the internal thoracic artery 70 and the left anterior descending branch 64. That is, as shown in FIG. 33B, the suture thread 75 is passed through the internal thoracic artery 70 and the left anterior descending branch 64 with the first curved needle 73 held.
[0097]
By repeating such an operation, as shown in FIG. 30 (A), the sutures are sequentially sewn clockwise from 3 o'clock to 6 o'clock in the incision 71 of the left front descending branch 64 as seen from the operator.
[0098]
Next, suturing is started using the second curved needle 74. That is, as shown in FIG. 30 (B), the sewing is performed in a direction symmetrical with respect to the longitudinal direction of the left front descending branch 64 from the position shown in FIGS. 29 (A) to 29 (D). The proximal end side of the curved needle 74 is gripped by the treatment section 3 so that the distal end of the second curved needle 74 is disposed on the right side of the treatment section 3. Further, the internal thoracic artery 70 is gripped by the gripping forceps 68. In this state, the distal end of the curved needle 74 is pierced from the outer wall of the left anterior descending branch 64 toward the inner wall of the internal thoracic artery 70. Here, FIG. 34 and FIG. 35 show a series of movements of the treatment section 3 with respect to the left anterior descending branch 64 and the internal thoracic artery 70 until such a state is taken along a 30B-30B section shown in FIG. ing.
[0099]
As shown in FIG. 34 (A), the handle 37, 39 is turned to the right and left to the maximum, and the left and right turning angle of the treatment section 3 is turned to the left and left to the maximum. In this state, the tip of the curved needle 74 is stuck into the outer wall of the left front descending branch 64.
As shown in FIG. 34 (B), the handles 37, 39 are turned from the maximum turning position in the right lateral direction toward the left lateral direction. That is, the handles 37 and 39 are returned to the neutral direction. Then, the treatment section 3 rotates in a direction in which the rotation angle of the treatment section 3 becomes small, that is, the treatment section 3 rotates rightward and leftward, and the tip of the curved needle 74 is inserted into the outer wall of the left front descending branch 64.
Further, as shown in FIG. 34C, in this state, the distal end of the curved needle 74 is pierced outward from the inner wall of the internal thoracic artery 70. That is, the distal end of the curved needle 74 penetrates through the left anterior descending branch 64 and the internal thoracic artery 70 in a state where they are in contact with each other. Then, in this state, the bending needle 74 is once released.
Then, as shown in FIG. 35 (A), the handles 37, 39 are rotated slightly leftward and the treatment section 3 is slightly rotated rightward. After that, the distal end of the curved needle 74 is re-gripped by the treatment section 3 so that the distal end of the curved needle 74 faces the left side of the treatment section 3.
Further, the handles 37 and 39 are rotated to the left in the maximum direction to rotate the treatment section 3 to the maximum in the right and left direction opposite to the direction shown in FIG. In this manner, the proximal end of the curved needle 74 is extracted from the left anterior descending branch 64 and the internal thoracic artery 70. That is, as shown in FIG. 35 (B), the suture 75 is passed through the left anterior descending branch 64 and the internal thoracic artery 70 with the second curved needle 74 held.
[0100]
By repeating such an operation, as shown in FIG. 30 (B), sewing is sequentially performed in a counterclockwise direction from 9 o'clock to 6 o'clock in the incision 71 of the left front descending branch 64 as seen from the operator. That is, suturing (anastomosis) over the entire circumference of the end of the internal thoracic artery 70 with respect to the incision 71 of the left anterior descending branch 64 is completed.
[0101]
Then, as shown in FIG. 30 (C), the treatment section 3 is operated to tie the suture 75 at an arbitrary position, a knot is formed several times, and the suture 75 is fastened. Thereafter, the suture 75 is cut near the knot of the suture 75, and the first and second curved needles 73 and 74 are taken out of the body.
[0102]
(effect)
As described above, the surgical treatment tool 1 according to this embodiment can be rotated in the left-right direction, for example, ± 90 °. Therefore, an anastomosis can be performed using the port used to exfoliate the internal thoracic artery 70 as it is. That is, it is possible to approach the treatment of the target site from various directions. Therefore, the burden on the patient can be reduced.
[0103]
In addition, since the non-slip provided on the treatment pieces 12 and 14 lasts longer, the frequency of replacement can be reduced. In addition, the treatment pieces 12 and 14 themselves need not be replaced frequently, and only need to be replaced with a carbide tip. Therefore, the burden on the user of the surgical treatment tool 1 can be reduced.
[0104]
[Third Embodiment]
Next, a third embodiment will be described with reference to FIG. This embodiment is a modification of the first embodiment, and the same members are denoted by the same reference numerals and detailed description thereof will be omitted.
[0105]
(Constitution)
FIG. 36 shows a modification of the first and second treatment pieces 12 and 14 of the treatment section 3. As shown in FIG. 36, fine surfaces such as diamond, ruby, and sapphire are sprayed on the gripping surfaces 12 b and 14 b of the first and second treatment pieces 12 and 14 as necessary, so that a fine rough surface is formed. Formed and non-slip. This makes it possible to securely hold the suture needle (curved needle), the suture, the living tissue, and the like, which are the objects to be grasped. Further, substantially spherical portions 12c and 14c are formed at the distal ends of the first and second treatment pieces 12 and 14 to prevent damage to blood vessels and the like.
[0106]
The first rotation pin 22 and the second rotation pin 23 are pivotally supported at different heights. Further, the third rotation pin 47 and the fourth rotation pin 48 are pivotally supported at different heights. Further, the first rotation pin 22 and the third rotation pin 47 are pivotally supported at the same height. The second rotation pin 23 and the fourth rotation pin 48 are pivotally supported at the same height. That is, the second and third drive rods 6b, 7b are arranged by the second and fourth rotating plates 21a, 46a while maintaining their parallel positions at different heights.
[0107]
Since the heights of the second and third drive rods 6b and 7b are different, they do not interfere with each other or hardly interfere with each other. For this reason, for example, depending on the degree of rotation, the third drive rod 7b can be provided below the second drive rod 6a. Therefore, the turning angle of the treatment section 3 in the left-right direction can be increased.
[0108]
(Action)
The operation, operation, and the like of such a surgical treatment tool 1 are substantially the same as those in the first embodiment, and thus description thereof is omitted.
[0109]
(effect)
As described above, the surgical treatment tool 1 according to the present embodiment can be rotated at an arbitrary angle in the left-right direction.
[0110]
By the way, a modified example of the gripping surfaces 12b, 14b of the first and second treatment pieces 12, 14 will be described with reference to FIGS.
[0111]
As shown in FIG. 37, the grip surfaces 12b and 14b are formed such that the base ends are wide and the ends are narrow. Also, a rubber pad 87 made of a polymer material such as a rubber material is provided to prevent slippage.
For this reason, a suture needle (curved needle), a suture, a living tissue, and the like can be securely grasped.
[0112]
As shown in FIG. 38A, when the rubber pad 87 is not disposed on the gripping surfaces 12b and 14b, for example, when gripping the curved needle 73, three points a, b, and a 'in FIG. Point support. For this reason, there is a possibility that a sufficient gripping force cannot be obtained.
[0113]
However, as shown in FIG. 38 (B), when the rubber pad 87 is provided on the grip surfaces 12b and 14b as in this embodiment, when the first curved needle 73 is gripped, for example, the rubber pad 87 is elastically deformed. I do. Therefore, a sufficient gripping force can be obtained. In addition, it acts as a cushion when an excessive force is applied to the curved needle 73.
[0114]
Further, as shown in FIG. 39, the first treatment piece 12 has a grip surface 12b ′. Further, the second treatment piece 14 has a grip surface 14b '. The grip surfaces 12b 'and 14b' are formed, for example, according to the shape of the curved needle 73. That is, the first gripping surface 12b is formed in a concave shape, and the second gripping surface 14b is formed in a convex shape. Therefore, particularly when gripping the suture needle (curved needle 73), a sufficient gripping force can be obtained in accordance with the degree of curvature of the suture needle. Therefore, the curved needle 73 is not easily rotated by the external force.
[0115]
Also, as shown in FIG. 40, the first treatment piece 12 has a grip surface 12b ″. The second treatment piece 14 has a grip surface 14b ″. Both the first and second gripping surfaces 12b ", 14b" are formed in a convex shape along the degree of curvature of the bending needle 73. For this reason, especially when using a suturing needle (curved needle), it is held in close contact with the gripping surface 12b on one side and is pressed down by the most convex portion, that is, the vertex of the gripping surface 14b on the other side, so that the gripping is performed securely. Can be done. Therefore, the curved needle 73 is not easily rotated by the external force.
[0116]
Therefore, as shown in FIG. 40A, the curved needle 73 is gripped so as to contact the second treatment piece 14 side, and as shown in FIG. Sufficient gripping force can be obtained in the case where the treatment piece 12 is gripped so as to be in contact with the treatment piece 12 side.
[0117]
So far, some embodiments have been specifically described with reference to the drawings. However, the present invention is not limited to the above-described embodiments, and all of the embodiments may be performed without departing from the gist thereof. Including implementation.
[0118]
According to the above description, the following inventions can be obtained. Further, a combination of each item is also possible.
[0119]
[Appendix]
(Appendix 1) An elongated insertion portion to be inserted into the body,
A treatment portion provided at one end of the insertion portion and rotatable around at least two axes and capable of opening and closing;
An operation unit that is provided at the other end of the insertion unit, is rotatable around at least two axes, and is openable and closable;
A first link rod for connecting the operation unit and the treatment unit, transmitting an operation force of the operation unit to the treatment unit, and operating the treatment unit, and a second link arranged in parallel to the first link rod. Drive means consisting of a rod and
The operation unit and the treatment unit are provided in at least two planes, a vertical direction that rotates in a plane along the opening and closing direction of the treatment unit and a horizontal direction that rotates in a plane perpendicular to the vertical direction. In a surgical treatment tool that can rotate in conjunction with
The other end of the insertion portion and the operating portion, abutting portions that abut each other are formed at a predetermined angle with respect to the axial direction of the insertion portion,
When the operation unit is rotated to the maximum in the left-right direction, the other end of the insertion unit and the operation unit are brought into contact with each other by abutting parts, and the operation unit in the axial direction of the insertion unit Wherein the rotation angle of the treatment section is defined, and the rotation angle of the treatment section in the left-right direction is defined.
[0120]
(Appendix 2) An elongated insertion portion to be inserted into the body,
A treatment portion provided at one end of the insertion portion and rotatable around at least two axes and capable of opening and closing;
An operation unit that is provided at the other end of the insertion unit, is rotatable around at least two axes, and is openable and closable;
It has a pair of pivots at both ends, and comprises a first link rod for operating the treatment section and a second link rod arranged in parallel to the first link rod, and the operation section and the treatment section And a driving unit for transmitting the operating force of the operating unit to the treatment unit.
The operation unit and the treatment unit are provided in at least two planes, a vertical direction that rotates in a plane along the opening and closing direction of the treatment unit and a horizontal direction that rotates in a plane perpendicular to the vertical direction. In a surgical treatment tool that can rotate in conjunction with
At least one of the pair of pivots provided at both ends of the first link rod and the pair of pivots provided at both ends of the second link rod are respectively a second link rod and a first link rod. It is provided with a bias on the side close to the link rod,
A surgical treatment instrument, wherein when the first and second link rods are moved in opposite directions, the rotation angle of the treatment section is increased.
[0121]
(Additional Item 3) The first or second link bar is characterized in that the first and second link rods come into contact with each other when the operating portion is rotated to the maximum in the left-right direction, respectively. Surgical treatment tools.
[0122]
(Supplementary item 4) The surgical device according to any one of supplementary items 1 to 3, wherein the abutting portion of the insertion portion is formed symmetrically with respect to the axial direction of the insertion portion. Treatment tools.
[0123]
(Supplementary item 5) The surgical treatment tool according to any one of supplementary items 1 to 4, wherein a maximum rotation angle of the treatment section is approximately ± 70 °.
[0124]
(Additional Item 6) When the operation unit is located at an intermediate portion between the maximum rotation positions of the left direction and the right direction, the ends of the first and second link rods are linked to each other. 3. The surgical treatment tool according to additional item 1 or item 2, wherein the surgical treatment tool is formed by being bent in a direction of an adjacent end portion.
[0125]
(Additional Item 7) The distance between the drive shaft pair of the first link rod and the first link rod, the abutting portion of the operation unit, and the proximity of the first and second link rods. The distance from the pivot provided at the end portion is defined as any one of the additional items 1, 2, and 6 wherein the former distance is greater than the latter distance. Surgical treatment tools.
[0126]
(Supplementary item 8) The surgical apparatus according to any one of supplementary items 1, 2, 6, and 7 wherein a maximum rotation angle of the treatment section is approximately ± 90 °. Treatment tools.
[0127]
(Additional Item 9) By operating the operating section of the surgical treatment tool according to Additional Item 1 or Additional Item 2, a curved needle having an arbitrary degree of curvature connected to each other with a suture thread provided at each base end is provided. A vascular anastomosis surgical method performed by operating a surgical treatment tool for grasping the anastomotic opening of a transplanted blood vessel (internal thoracic artery) to the anastomotic opening of a transplanted blood vessel (left anterior descending branch) by grasping the surgical treatment instrument above the surgical operation part. So,
The operating unit is rotated left and right so that the distal end of the curved needle is directed to the inner wall near the anastomotic port of the transplanted blood vessel and / or the transplanted blood vessel, and the treatment unit is moved in a direction opposite to the operating unit. The distal end of the curved needle is inserted into the inner wall portion near the anastomotic opening of the transplanted blood vessel and / or the transplanted blood vessel, and the distal ends of the two curved needles are anastomosed with the transplanted blood vessel and the transplanted blood vessel, respectively. Extending from the inner wall of the mouth,
The anastomotic position of the transplanted blood vessel and the transplanted blood vessel is defined by matching the anastomotic openings of the transplanted blood vessel and the transplanted blood vessel along the suture connecting the curved needles,
The operating unit is turned to the maximum turning position in the left-right direction, the turning angle in the opposite direction to the operating unit of the treatment unit is turned to the maximum turning position, and the distal end of the curved needle is implanted. Positioned inward from the outer wall near the anastomotic port of the blood vessel or transplanted vessel,
The operation unit is rotated from the left-right maximum rotation position toward the opposite direction, and the operation unit is returned to an intermediate position between the left maximum rotation position and the right maximum rotation position to perform the treatment. The tip of the curved needle is inserted into the outer wall near the anastomotic port of the transplanted blood vessel or transplanted blood vessel by rotating the portion from the left-right rotation position toward the opposite direction, and the distal end of the curved needle is The implanted blood vessel and the transplanted blood vessel are pierced outward from the inner wall portion of the blood vessel other than the punctured curved needle,
Opening the treatment section by opening and closing the operation section, releasing the curved needle from the treatment section,
Rotating the operation unit to an arbitrary position between the maximum rotation position and the intermediate position to position the treatment unit between the maximum rotation position and the intermediate position,
Opening and closing the operation unit so that the distal end of the curved needle faces the same direction as the direction gripped by the treatment unit, and re-grip the distal end side of the curved needle with the treatment unit,
The operating section is rotated to the maximum rotation position in the opposite direction, the treatment section is rotated to the maximum rotation position in the opposite direction to the operation section, and the proximal end of the curved needle is placed in the transplanted blood vessel. And pulled out from near the anastomotic opening of the transplanted blood vessel and threaded,
The anastomotic ports of the transplanted blood vessel and the transplanted blood vessel are sequentially sewn clockwise or counterclockwise from the position where the curved needle extends.
[0128]
(Additional Item 10) The operating portion of the surgical treatment tool described in Additional Item 1 or Additional Item 2 is operated to grip a curved needle having an arbitrary degree of curvature having a thread in the treatment portion, and the transplanted blood vessel (left front) A vascular anastomosis surgical method performed by operating a surgical treatment tool for anastomosing the anastomotic port of the transplanted blood vessel (internal thoracic artery) to the anastomotic port of the descending branch) on the side of the operative site,
The operating unit is rotated left and right so that the distal end of the curved needle is directed to the inner wall near the anastomotic port of the transplanted blood vessel and / or the transplanted blood vessel, and the treatment unit is moved in a direction opposite to the operating unit. The distal end of the curved needle is inserted into the inner wall portion near the anastomotic opening of the transplanted blood vessel and / or the transplanted blood vessel, and the distal ends of the two curved needles are anastomosed with the transplanted blood vessel and the transplanted blood vessel, respectively. Extending from the inner wall of the mouth,
The anastomotic position of the transplanted blood vessel and the transplanted blood vessel is defined by matching the anastomotic openings of the transplanted blood vessel and the transplanted blood vessel along the suture connecting the curved needles,
The operating unit is turned to the maximum turning position in the left-right direction, the turning angle in the opposite direction to the operating unit of the treatment unit is turned to the maximum turning position, and the distal end of the curved needle is implanted. Positioned from the inner wall near the anastomotic opening of the blood vessel or transplanted vessel to the outside,
The operation unit is rotated from the left-right maximum rotation position toward the opposite direction, and the operation unit is returned to an intermediate position between the left maximum rotation position and the right maximum rotation position to perform the treatment. The tip of the curved needle is inserted into the inner wall portion near the anastomotic opening of the transplanted blood vessel or transplanted blood vessel by rotating the portion from the left-right rotation position to the opposite direction, and the distal end of the curved needle is A curved needle is stabbed inward from the outer wall of the blood vessel other than the stabbed needle in one of the transplanted blood vessel and the transplanted blood vessel,
Opening the treatment section by opening and closing the operation section, releasing the curved needle from the treatment section,
Rotating the operation unit to an arbitrary position between the maximum rotation position and the intermediate position to position the treatment unit between the maximum rotation position and the intermediate position,
Opening and closing the operation unit so that the distal end of the curved needle faces the same direction as the direction gripped by the treatment unit, and re-grip the distal end side of the curved needle with the treatment unit,
The operating section is rotated to the maximum rotation position in the opposite direction, the treatment section is rotated to the maximum rotation position in the opposite direction to the operation section, and the proximal end of the curved needle is placed in the transplanted blood vessel. And pulled out from near the anastomotic opening of the transplanted blood vessel and threaded,
Anastomotic ports of the transplanted blood vessel and the transplanted blood vessel are sequentially sewn in a clockwise direction or a counterclockwise direction from a position where the curved needle is extended, and substantially half a circumference of the transplanted blood vessel and the transplanted blood vessel are sutured,
The operating unit is turned to the maximum turning position in the left-right direction, the turning angle in the opposite direction to the operating unit of the treatment unit is turned to the maximum turning position, and the distal end of the curved needle is implanted. Positioned inward from the outer wall near the anastomotic port of the blood vessel or transplanted vessel,
Rotate the operation unit from the maximum rotation position in the left and right direction to the opposite direction, return the operation unit to the intermediate position, and rotate the treatment unit from the rotation position in the left and right direction to the opposite direction. The distal end of the curved needle is inserted into the outer wall portion near the anastomotic opening of the transplanted blood vessel or the transplanted blood vessel, and the distal end of the curved needle is inserted into one of the transplanted blood vessel and the transplanted blood vessel. Piercing from the inner wall of the blood vessel to the outside,
Opening the treatment section by opening and closing the operation section, releasing the curved needle from the treatment section,
Rotating the operation unit to an arbitrary position between the maximum rotation position and the intermediate position to position the treatment unit between the maximum rotation position and the intermediate position,
Opening and closing the operation unit so that the distal end of the curved needle faces the same direction as the direction gripped by the treatment unit, and re-grip the distal end side of the curved needle with the treatment unit,
The operating section is rotated to the maximum rotation position in the opposite direction, the treatment section is rotated to the maximum rotation position in the opposite direction to the operation section, and the proximal end of the curved needle is placed in the transplanted blood vessel. And pulled out from near the anastomotic opening of the transplanted blood vessel and threaded,
The anastomotic ports of the transplanted blood vessel and the transplanted blood vessel are sequentially sewn clockwise or counterclockwise from the position where the curved needle is extended, and the remaining approximately half circumference of the transplanted blood vessel and the transplanted blood vessel is sutured. .
[0129]
(Supplementary Note 11) A pair of gripping surfaces facing each other that can grip the target object by opening and closing the treatment unit is provided. One gripping surface of the gripping surface pair is a convex cylindrical shape, and the other gripping surface is a concave cylindrical shape. Item 7. The surgical treatment tool according to any one of additional items 1 to 6, wherein the surgical treatment device is formed in a shape.
[0130]
(Supplementary Note 12) A pair of mutually facing gripping surfaces capable of gripping a target object by opening and closing the treatment section is provided, and both gripping surfaces of the pair of gripping surfaces are each formed in a convex cylindrical shape. The surgical treatment tool according to any one of additional items 1 to 6, wherein
[0131]
(Supplementary item 13) The surgical treatment tool according to Supplementary item 11 or 12, wherein the gripping surface is finely roughened by electric discharge machining or etching.
[0132]
(Supplementary item 14) The surgical treatment tool according to additional item 11 or 12, wherein the gripping surface is made of a carbide material and has knurls.
[0133]
(Supplementary item 15) The surgical device according to Supplementary item 11 or 12, wherein fine grains such as diamond, ruby, and sapphire are sprayed on the gripping surface to form a fine rough surface. Treatment tools.
[0134]
(Supplementary item 16) The surgical treatment instrument according to any one of Supplementary items 11 to 15, wherein a substantially spherical portion is formed at a distal end portion of the gripping surface.
[0135]
【The invention's effect】
As described above, according to the present invention, it is possible to provide a surgical treatment tool capable of improving operability and shortening a procedure time.
[Brief description of the drawings]
FIG. 1 is a side view of a surgical treatment tool according to a first embodiment with a treatment section raised.
2 is a perspective view of a treatment section of the surgical treatment tool shown in FIG. 1 as viewed from above.
3 is a perspective view of a treatment section of the surgical treatment tool shown in FIG. 1 as viewed from below.
FIG. 4 is a perspective view of a state in which a treatment piece of a treatment section of the surgical treatment tool is open, as viewed from above.
5 is a perspective view of the operation unit of the surgical treatment tool shown in FIG. 1 as viewed from below.
FIG. 6 is a perspective view of the operation unit of the surgical treatment tool shown in FIG. 1 viewed from below with a cover of a handle removed.
FIG. 7 is a perspective view of the operation unit of the surgical treatment tool shown in FIG. 1 viewed from above with the cover of the handle removed.
FIG. 8A is a side view showing that the handle is turned downward and the treatment section is turned upward, and FIG. 8B is a view showing the treatment by turning the handle upward from the state of FIG. The side view which shows that the part was made horizontal with respect to the axial direction of the insertion part.
FIG. 9A is a schematic top view when the handle and the treatment section of the surgical treatment tool according to the first embodiment are turned up and down, and FIG. 9B is shown in FIG. The schematic top view which shows the state which rotated the handle of the surgical treatment tool to the left most, and rotated the treatment part to the right most.
FIG. 10 is a schematic top view showing a connection state between a second rotation plate and second and third drive rods.
FIG. 11 is a schematic view showing a surgical treatment tool approached from above the operative site via the trocar according to the first embodiment.
FIG. 12 is a cross-sectional view of the chest at the site where the heart is located as viewed from below.
FIG. 13 is a schematic diagram showing the positional relationship between the heart and the internal thoracic artery after exfoliation, and explaining that an operation is performed by incising the left anterior descending branch.
14A to 14C are schematic diagrams showing the flow of a vascular anastomosis procedure performed under an endoscope.
FIGS. 15A to 15C are schematic diagrams showing the flow of a vascular anastomosis procedure performed under an endoscope.
FIGS. 16A to 16D are schematic diagrams showing the flow of a vascular anastomosis procedure performed under an endoscope.
17A to 17C are schematic diagrams showing the flow of a vascular anastomosis procedure performed under an endoscope.
FIGS. 18A and 18B are schematic diagrams illustrating the procedure shown in FIG. 14A, wherein FIGS. 18A and 18B are schematic diagrams illustrating insertion of a curved needle outward from the inner wall of the internal thoracic artery; (C) and (D) are schematic diagrams illustrating an operation of pulling out a pierced curved needle from an internal thoracic artery.
FIGS. 19A and 19B are diagrams illustrating the procedure shown in FIG. 14B, wherein FIGS. 19A and 19B are schematic diagrams illustrating insertion of a curved needle inward from the outer wall of the left anterior descending branch. (C) and (D) are schematic diagrams illustrating an operation of pulling out a stabbed curved needle from a descending left front branch.
FIGS. 20A and 20B are schematic diagrams illustrating the procedure shown in FIG. 14C, wherein FIGS. 20A and 20B are schematic diagrams illustrating insertion of a curved needle outward from the inner wall of the internal thoracic artery; (C) and (D) are schematic diagrams illustrating an operation of pulling out a pierced curved needle from an internal thoracic artery.
FIGS. 21A and 21B are diagrams illustrating the procedure shown in FIG. 15A, wherein FIGS. 21A and 21B are schematic diagrams illustrating insertion of a curved needle inward from the outer wall portion of the left anterior descending branch. (C) and (D) are schematic diagrams illustrating an operation of pulling out a stabbed curved needle from a descending left front branch.
FIG. 22 is a view for explaining the procedure shown in FIG. 16 (A), in which (A) to (C) insert a curved needle inward from the outer wall of the internal thoracic artery and insert the inner wall of the left anterior descending branch; FIG. 4 is a schematic diagram illustrating insertion from a part outward.
23 (A) and 23 (B) are diagrams illustrating the procedure shown in FIG. 16 (A), in which the curved needle inserted in FIG. 22 (C) is pulled out of the internal thoracic artery and the left anterior descending branch. FIG.
24A to 24C are diagrams illustrating the procedure shown in FIG. 16C, in which a curved needle is stabbed inward from the outer wall of the internal thoracic artery and the inner wall of the left anterior descending branch; FIG. 4 is a schematic diagram illustrating insertion from a part outward.
25 (A) and (B) are diagrams illustrating the procedure shown in FIG. 16 (C), in which the curved needle inserted in FIG. 24 (C) is pulled out from the internal thoracic artery and the left anterior descending branch. FIG.
26A is a schematic top view of a surgical treatment tool according to a second embodiment, in which FIG. 26A is a schematic top view when a handle and a treatment portion of the surgical treatment tool are rotated in the vertical direction. () Is a schematic top view showing a state in which the handle of the surgical treatment tool shown in (A) is rotated to the left to the maximum and the treatment section is rotated to the right to the maximum.
FIG. 27 is a schematic perspective view of the distal end portion of the treatment section of the surgical treatment instrument when viewed from above.
FIG. 28A is a cross-sectional view of the chest at the site where the heart is located, as viewed from below, and is a schematic diagram showing a state in which the endoscope is approached from the side of the operation site via a trocar, and FIG. 4) is a schematic diagram showing the positional relationship between the heart and the internal thoracic artery after exfoliation, and a treatment device such as an endoscope, and explaining that an operation is performed by incising the left anterior descending branch.
FIGS. 29A to 29D are schematic diagrams showing the flow of a vascular anastomosis procedure performed under an endoscope.
FIGS. 30A to 30C are schematic diagrams showing the flow of a vascular anastomosis procedure performed under an endoscope.
FIGS. 31 (A) and (B) are views for explaining the procedure shown in FIG. 29 (C), in which a curved needle is inserted outward from the inner wall of the internal thoracic artery and the outer wall of the left anterior descending branch; FIGS. 4C and 4D are schematic diagrams illustrating insertion from a part toward the inside, and FIGS. 3C and 3D are schematic diagrams illustrating an operation of pulling out the inserted needle from the internal thoracic artery and the left anterior descending branch.
FIGS. 32 (A) to (C) are views for explaining the procedure shown in FIG. 30 (A), in which a curved needle is inserted inward from the outer wall of the internal thoracic artery and the inner wall of the left anterior descending branch; FIG. 4 is a schematic diagram illustrating insertion from a part outward.
33 (A) and (B) are views for explaining the procedure shown in FIG. 30 (A), in which the operation of pulling out the curved needle inserted in FIG. 32 (C) from the internal thoracic artery and the left anterior descending branch; FIG.
FIGS. 34 (A) to (C) are views for explaining the procedure shown in FIG. 30 (B), in which a curved needle is inserted from the outer wall of the left anterior descending branch to the inside, and the inner wall of the internal thoracic artery is shown. FIG. 4 is a schematic diagram illustrating insertion from a part outward.
FIGS. 35 (A) and (B) are views for explaining the procedure shown in FIG. 30 (B), in which the curved needle inserted in FIG. 34 (C) is removed from the left anterior descending branch and the internal thoracic artery. FIG.
FIG. 36 is a perspective view of a state in which the treatment piece of the treatment section of the surgical treatment tool according to the third embodiment is open, as viewed from above.
FIG. 37 is a perspective view of a state in which a treatment piece of a treatment section of the surgical treatment tool is open, as viewed from above.
38A is a schematic side view showing a state where a curved needle is gripped by a treatment piece of a treatment section of a surgical treatment tool according to a conventional technique, and FIG. 38B is a surgical treatment tool shown in FIG. 37; The schematic side view which shows the state which clamped the curved needle with the treatment piece of the treatment part of FIG.
FIG. 39 is a schematic side view showing a modified example of the treatment pieces of the treatment section of the surgical treatment tool, showing a state in which a curved needle is gripped by these treatment pieces.
FIGS. 40A and 40B are schematic side views showing modified examples of the treatment piece of the treatment section of the surgical treatment instrument, showing a state in which a curved needle is gripped by these treatment pieces.
41A is a schematic top view when a handle and a treatment section of a surgical treatment tool according to the related art are rotated vertically, and FIG. 41B is a surgical treatment tool shown in FIG. 5 is a schematic top view showing a state in which the handle is rotated to the left to the maximum and the treatment unit is rotated to the right to the maximum.
FIGS. 42A to 42C are schematic diagrams showing a flow of a vascular anastomosis procedure performed under an endoscope according to a conventional technique.
[Explanation of symbols]
DESCRIPTION OF SYMBOLS 1 ... surgical treatment tool, 2 ... insertion part, 3 ... treatment part, 4 ... operation part, 6 ... 2nd drive rod, 7 ... 3rd drive rod, 21 ... 2nd rotating plate, 22 ... 2nd 1 rotating pin, 23 ... second rotating pin, 37 ... first handle, 38 ... second opening / closing pivot pin, 39 ... second handle, 46 ... fourth rotating plate, 47 ... third Rotating pin, 48 ... fourth rotating pin, 60 ... first abutting surface, 61 ... second abutting surface, 64 ... left anterior descending branch (coronary artery), 67 ... rigid endoscope (endoscope) ), 70 ... internal thoracic artery, 71 ... incision (anastomosis), 73 ... first curved needle, 74 ... second curved needle, 75 ... suture

Claims

An elongated insertion portion to be inserted into the body,
A treatment portion provided at one end of the insertion portion and rotatable around at least two axes and capable of opening and closing;
An operation unit that is provided at the other end of the insertion unit, is rotatable around at least two axes, and is openable and closable;
A first link rod for connecting the operation unit and the treatment unit, transmitting an operation force of the operation unit to the treatment unit, and operating the treatment unit, and a second link disposed parallel to the first link rod And a driving means comprising a rod, and in at least two planes of a vertical direction rotating in a plane along the opening and closing direction of the treatment section and a horizontal direction rotating in a plane orthogonal to the vertical direction. In the surgical treatment tool in which the operation unit and the treatment unit can rotate in conjunction with each other,
The other end of the insertion portion and the operating portion, abutting portions that abut each other are formed at a predetermined angle with respect to the axial direction of the insertion portion,
When the operation unit is rotated to the maximum in the left-right direction, the other end of the insertion unit and the operation unit are brought into contact with each other by abutting parts, and the operation unit in the axial direction of the insertion unit Wherein the rotation angle of the treatment section is defined, and the rotation angle of the treatment section in the left-right direction is defined.

An elongated insertion portion to be inserted into the body,
A treatment portion provided at one end of the insertion portion and rotatable around at least two axes and capable of opening and closing;
An operation unit that is provided at the other end of the insertion unit, is rotatable around at least two axes, and is openable and closable;
It has a pair of pivots at both ends and comprises a first link rod for operating the treatment section and a second link rod arranged in parallel to the first link rod, and the operation section and the treatment section And a driving means for transmitting the operating force of the operating unit to the treatment unit, and a vertical direction that rotates in a plane along the opening and closing direction of the treatment unit and a plane that is orthogonal to the vertical direction. A surgical treatment tool in which the operation unit and the treatment unit are rotatable in cooperation with each other in at least two planes with the left and right directions.
At least one of the pair of pivots provided at both ends of the first link rod and the pair of pivots provided at both ends of the second link rod are respectively a second link rod and a first link rod. It is provided with a bias on the side close to the link rod,
A surgical treatment instrument, wherein when the first and second link rods are moved in opposite directions, the rotation angle of the treatment section is increased.