JP4383297B2 - Biological tissue cutting instrument - Google Patents

Description

  The present invention relates to a biological tissue cutting instrument for pulling and collecting a subcutaneous blood vessel under observation by an endoscope.

  In recent years, in blood vessel bypass surgery, blood vessels in the lower limbs, such as the patient's own large saphenous vein, may be used as bypass blood vessels. For example, Patent Document 1 proposes a living body collection apparatus for collecting blood vessels of the lower limbs under observation of an endoscope.

  This biological collection apparatus is composed of instruments such as a dissector and a harvester. An endoscope can be inserted into the dissector and the harvester, and the surgeon can collect blood vessels while viewing the endoscope image. The dissector is inserted through the trocar, which is a guide tube set at the incision near the patient's knee, and is inserted over the entire length of the blood vessel to be collected, thereby gradually peeling the blood vessel and its surrounding tissue. It is. The harvester is an instrument having a bipolar cutter for electrically cutting a side branch of a blood vessel peeled from surrounding tissue by a dissector.

In this bipolar cutter, a groove is formed at the tip, and a pair of electrodes are disposed so as to sandwich the groove vertically. When the bipolar cutter is advanced, the side branch that has entered the groove at the tip is cut while hemostasis is caused by discharge between these two electrodes. In addition, the bipolar cutter is formed of a synthetic resin such as polycarbonate or a ceramic whose cutter body is a transparent member.
JP 2004008241 A

  However, as described above, in the bipolar cutter described in Patent Document 1, when the entire cutter body is formed of a synthetic resin, there is a possibility that durability is slightly impaired by heat generated by discharge between two electrodes. There is. On the other hand, when the cutter body is formed of ceramics, there is a problem that the manufacturing cost is high and the workability is inferior to that of synthetic resin.

  In addition, the bipolar cutter cuts the living tissue from one application-side electrode to the other feedback-side electrode by a thermal action by discharging a high-frequency current. Therefore, even if the bipolar cutter is not formed entirely in ceramics, it suppresses the possibility of impairing durability due to heat by forming the part only between a pair of electrodes, especially the part in contact with the electrode on the application side. Can do. That is, it is preferable that the bipolar cutter has a structure in which the main cutter body is made of a synthetic resin that is inexpensive and has good workability, and a ceramic member is provided between a pair of electrodes.

  However, ceramics have higher thermal conductivity than synthetic resins such as polycarbonate. Therefore, in the bipolar cutter, the amount of heat generated in the applied electrode and the cut biological tissue due to the high-frequency current discharged between the pair of electrodes is transmitted over a wide range of members formed of ceramics. As a result, the living tissue to be cut has a problem that the amount of heat consumed at the time of cutting is reduced and the hemostatic property is lowered.

  Then, this invention is made | formed in view of the said situation, It aims at providing the biological tissue cutting instrument which is excellent in thermal durability and the hemostatic property of biological tissues, such as the blood vessel cut | disconnected, improves. .

In order to achieve the above object, a biological tissue cutting instrument of the present invention is a biological tissue cutting instrument for cutting a biological tissue, and is a cutter body formed of an insulating member and having a groove for guiding the biological tissue at the tip. When the application electrode disposed on one surface of the cutter body, a return electrode disposed on the other surface of the cutter body, in between the application electrode and the return electrode, arrangement on the tip portion of the cutter body And a heat-resistant member having a slit groove formed so that the living tissue guided by the groove enters from the distal end side to the proximal end side, and the distal end portion of the application electrode is formed on the base of the slit groove. It is arranged on one surface of the heat-resistant member so as to cover the end, and suppresses the propagation of heat generated at the application electrode by surrounding the tip of the application electrode that contacts and cuts the living tissue that has entered the slit groove. Circumferential The groove, characterized in that formed on one surface of the applying electrodes are arranged in the heat-resistant member.

  ADVANTAGE OF THE INVENTION According to this invention, the biological tissue cutting instrument which is excellent in heat durability and the hemostatic property of biological tissues, such as the blood vessel cut | disconnected, improves.

(First embodiment)
Embodiments of the present invention will be described below with reference to the drawings.
In the first embodiment, a blood vessel sampling operation method using a living body sampling operation system, a configuration of the living body sampling surgery system, and a harvester which is a living tissue cutting instrument of the present invention will be described in this order.

First, regarding a venectomy operation method that is a tissue to be collected using a living body collection device, a blood vessel collection operation method will be described with reference to FIGS. 1 to 6.
FIG. 1 is a flowchart for explaining a surgical method of collecting by pulling a subcutaneous blood vessel. 2 to 6 are diagrams for explaining the operation method. A blood vessel sampling operation method will be described with reference to FIG. 1 and FIGS. 2 to 6.

  In the heart bypass operation, a blood vessel, which is a tissue to be collected from the lower limb, is used for a bypass blood vessel. A case will be described in which a large saphenous vein (hereinafter also simply referred to as a blood vessel) is collected over the entire length from the thigh of the lower limb, which is a blood vessel to be collected, to the ankle. In addition, the detailed structure of the dissector 31, the trocar 21, and the harvester 41 which are the instruments used for the collection is mentioned later. Further, an endoscope can be inserted into the dissector 31 and the harvester 41, and the surgeon can collect blood vessels while viewing the endoscope image. The endoscope is a rigid endoscope 51 shown in FIG. 7, which will be described later, and is connected to the TV monitor 102 via a TV camera head connected to the eyepiece, and the endoscope is displayed on the screen of the TV monitor 102. An image is displayed. Illumination light is emitted from the distal end of the rigid endoscope, and the subcutaneous tissue and blood vessel 11 can be illuminated.

  As shown in FIG. 2, the collection target blood vessel 11 exists between the inguinal portion 13 of the lower limb 12 and the ankle 14. The blood vessel 11 to be collected is assumed to be 60 cm long, for example.

  First, the surgeon specifies the position of the blood vessel 11 (step (hereinafter abbreviated as S) 1). The position of the blood vessel 11 is specified by the operator's tactile sensation or using a device such as sonar. Next, the surgeon has a length of 2. for example with a scalpel, just above the specified blood vessel 11 and slightly below the knee 15, approximately along the direction of the tube of the blood vessel 11. A 5 cm skin 16 is provided (S2). Subsequently, at the skin incision 16, the blood vessel 11 is exposed, and the tissue around the blood vessel 11 is peeled off (S3).

  Next, the surrounding tissue is exfoliated over the entire length of the blood vessel 11 using the disector 31 (S4). Specifically, the surgeon sets the trocar 21 at the skin incision 16, passes the dissector 31 through the guide tube 22 of the trocar 21, and views the endoscopic image from the skin incision 16 to the groin. It is gradually inserted in the direction of 13 (indicated by arrow A1), and the blood vessel 11 is bluntly detached from the surrounding tissue. The endoscopic image is necessary for the surgeon in order for the surgeon to peel off the surrounding tissue along the blood vessel 11.

  When the peripheral tissue of the blood vessel 11 is peeled, for example, if the skin surface direction is raised with respect to the blood vessel 11, the operator peels the blood vessel 11 in the vertical direction and further peels the left and right direction, whereby the blood vessel 11 The surrounding tissue can be completely exfoliated over the entire circumference. By peeling off the entire circumference of the blood vessel 11, the side branch of the blood vessel 11 can be seen well in the endoscopic image.

  When separation from the surrounding tissue of the blood vessel 11 in the direction of the inguinal portion 13 is finished, the disector 31 is pulled out from the trocar 21. Next, the direction of the trocar of the skin incision 16 is changed, and the dissector is gradually inserted from the skin incision 16 in the direction of the ankle 14 (indicated by the arrow A2), and the blood vessel 11 is viewed while viewing the endoscopic image. Remove from the surrounding tissue.

  FIG. 3 is a cross-sectional view showing a state where the dissector is inserted into the lower limb 12 through the trocar 21 from the skin incision 16 toward the groin 13. The trocar 21 includes a cylindrical guide tube portion 22 for inserting the insertion portion 32 of the disector 31, a seal portion 23, and a fixing portion 24 for fixing to the skin. When the trocar 21 is set in the skin cut portion 16, the guide tube portion 22 is inserted from the skin cut portion 16 toward the groin portion and fixed to the skin by the fixing portion 24. The insertion part 32 of the dissector 31 is inserted subcutaneously into the lower limb 12 through the guide tube part 22 of the trocar 21 fixed to the skin cutting part 16 by the fixing part 24. As will be described later, an endoscope insertion portion is inserted into the insertion portion 32. Since the insertion direction of the dissector 31 is along the direction of the blood vessel 11, the operator gradually inserts the tissue around the blood vessel 11 so as to peel from the blood vessel 11 while viewing the endoscopic image. In other words, the insertion is not performed along the blood vessel 11 from the skin incision 16 and below the groin 13. While the dissector 31 is advanced and retracted along the insertion direction, the blood vessel 11 up to the inguinal portion 13 and the blood vessel 11 up to the ankle 14 are gradually separated.

  At this time, a predetermined gas, for example, carbon dioxide gas is sent from the air supply tube 34 connected to the gripping portion 33 of the disector 31 by the air supply connector provided in the disector 31, and is supplied to the distal end portion of the insertion portion 32. It ejects from the provided opening 35a. Accordingly, the blood vessel 11 is exfoliated from the surrounding tissue, and a predetermined gas, for example, carbon dioxide gas, is interposed between the exfoliated tissue and the blood vessel, so that the surgical field of the endoscope is widened and visually recognized. This makes it easier for the surgeon to perform the peeling operation.

  Next, the dissector 31 is extracted from the trocar 21, and the harvester 41 (see FIG. 5) is inserted while the trocar 21 is left as it is, and the side branch of the blood vessel 11 between the skin incision 16 and the ankle 14 is cut. (S5).

  In order to cut the side branch 11A, the harvester 41 is first inserted from the skin incision 16 to below the ankle 14, and the side branch 11A of the blood vessel 11 is cut one by one from the ankle 14 toward the skin incision 16. .

  The cutting of the side branch 11 </ b> A is performed by a bipolar cutter 43 that is an electric knife provided at the distal end portion of the insertion portion 42 of the harvester 41. The side branch 11A cut by the bipolar cutter 43 is in a state where the cut portion is substantially hemostatic. Using the harvester 41, all of the side branches 11A of the blood vessel 11 up to the ankle 14 are cut.

  Although the configuration of the harvester 41 will be described later, the configuration will be briefly described here. The blood vessel 11 is hooked on a vein keeper 45 that is a blood vessel holding portion provided at the tip of the harvester 41. When the blood vessel 11 is hooked on the vane keeper 45, a mechanism that opens the part of the vane keeper 45, hooks the blood vessel 11 at the open place, closes the opened part after the hook is applied, is applied to the vein keeper of the harvester 41. 45 has. Further, the vane keeper 45 is movable in the axial direction of the harvester 41 and can be moved in a direction to move the vane keeper 45 away from the distal end portion of the endoscope, so that the hooked blood vessel 11 can be easily seen in the endoscopic image. be able to.

  Further, a groove having a width of 0.5 mm is formed at the tip of the bipolar cutter 43, and when the side branch 11A is cut, the side branch 11A is compressed by inserting the side branch 11A into the groove so as to be pushed. Disconnected in state. Furthermore, a wiper is provided at the distal end of the harvester 41 for wiping off deposits adhering to the window portion at the distal end portion of the rigid endoscope inside the wiper guard portion. A part of the cylindrical wiper guard part is provided with a discharge hole for sweeping out the deposits wiped off by the wiper. Examples of such deposits include blood, fat, and smoke from an electric knife.

  The harvester 41 is also provided with an air feeding connector, and carbon dioxide gas is fed from the air feeding tube 44 connected to the grip portion 400 of the harvester 41 and an opening provided at the distal end portion of the insertion portion 42 ( (Not shown). Therefore, the side branch 11A of the blood vessel 11 can be easily cut.

  Since there are a plurality of side branches 11 </ b> A in the blood vessel 11, the surgeon operates the vane keeper 45 at the distal end portion of the harvester 41 while viewing the endoscopic image at the distal end of the insertion portion 42 of the harvester 41. The side branch 11A is cut by the bipolar cutter 43 while holding and checking the side branches 11A one by one. The structure of the vane keeper 45 will also be described in detail later.

  Next, the ankle 14 is cut with a small cut having a cut length of 1 cm or less, for example, and the distal end of the blood vessel 11 is pulled out from the cut 17 and threaded or forceps are placed. A treatment is performed (S6). In this case, the harvester 41 in the vicinity of the skin incision 16 is inserted again under the ankle 14, and the surgeon looks at the blood vessel 11 and the forceps under the skin 17 using an endoscope, and the blood vessels with the forceps. The blood vessel 11 is pulled out from the skin incision 17 by pinching 11.

  FIG. 4 is a view for explaining the treatment of the distal end portion of the blood vessel 11. In the treatment of the end portion of the blood vessel 11, a part of the blood vessel 11 is tied with a thread, and the blood vessel 11 is cut at a position 11b closer to the knee 15 than the knot 11a. In addition, the skin cutting in the skin cutting part 17 is performed by an operator etc. closing the skin cutting part 17 with a tape etc. after that.

  In the treatment of the distal end portion of the blood vessel 11, the operator pulls out the blood vessel 11 from the skin incision 17 while viewing the subcutaneous blood vessel in the skin incision 17 with an endoscope.

  Subsequently, the harvester 41 is extracted from the trocar 21, the direction of the guide tube portion 22 of the trocar 21 of the skin cutting portion 16 is changed to the direction of the groin portion 13, the harvester 41 is inserted, and the groin portion 13 from the skin cutting portion 16 is inserted. Until then, the side branch of the blood vessel 11 is cut (S7). As performed in S <b> 6, the operator cuts the side branch 11 </ b> A of the blood vessel 11 from the skin incision 16 to the groin 13 while viewing the endoscopic image.

  In this case as well, the side branch 11A is cut by inserting the harvester 41 from the skin incision 16 to the bottom of the inguinal part 13 and moving the side branch 11A of the blood vessel 11 from the inguinal part 13 toward the incision 16. Cut one by one.

  FIG. 5 is a cross-sectional view showing a state where the harvester is inserted into the lower limb 12 through the skin incision 16 through the trocar 21. The insertion portion 42 of the harvester 41 is inserted subcutaneously into the lower limb 12 through the guide tube portion 22 of the trocar 21 fixed to the skin incision portion 16 by the fixing portion 24. As will be described later, an endoscope insertion portion is inserted into the insertion portion 42. Since the insertion direction of the harvester 41 is along the direction of the blood vessel 11, the operator cuts the side branch 11A of the blood vessel 11 while viewing the endoscopic image.

  When the cutting of the side branch 11A of the blood vessel 11 is completed, as shown in FIG. 4, the inguinal portion 13 is cut with a small skin having a cut length of 1 cm or less, for example, and the distal end portion of the blood vessel 11 is cut from the skin cutting portion 18. Pull out and apply a thread or place a forceps to treat the end (S8). Also in this case, the harvester 41 in the vicinity of the skin incision 16 is inserted again under the inguinal part 13, and the surgeon looks at the subcutaneous blood vessel 11 and the forceps of the skin incision 18 with an endoscope. The blood vessel 11 is pinched and the blood vessel 11 is pulled out from the skin incision 18. As treated at the skin incision 17 of the ankle 14, the treatment of the distal end of the blood vessel 11 ties a part of the blood vessel 11 with a thread and cuts the blood vessel 11 at a position 11d on the side of the knee 15 from the knot 11c. The skin cut at the skin cut portion 18 is also performed by the operator by closing the skin cut portion 18 with a tape or the like thereafter.

  Then, the surgeon removes, for example, a 60 cm blood vessel 11 from the skin incision 16 as shown in FIG. 6 (S9). FIG. 6 is a view for explaining a state in which the blood vessel 11 is removed from the skin incision 16. When extraction of the blood vessel 11 is completed, if the extracted blood vessel 11 has a hole, it cannot be used as a bypass blood vessel, so the surgeon performs a leak test on the blood vessel 11 (S10).

  While performing the leak test, the operator applies a thread knot to all the side branches 11A of the blood vessel 11 so that blood does not leak from the tip of the side branch 11A with the tip cut off. In this way, in a state where all the side branches 11A are tied with a thread knot, taking into consideration the direction of the valve in the blood vessel 11, a syringe is attached to one end of the blood vessel 11, and physiological saline is placed in the blood vessel 11. The surgeon performs a leak test on the blood vessel 11 depending on whether there is a hole through which physiological saline leaks.

  If there is a portion where the physiological saline leaks, the hole at that portion is sutured (S11). Finally, the skin incision 16 is sutured (S12).

  As described above, the above-described endoscope is used in comparison with the conventional operation of incising the tissue at a predetermined site of the lower limb 12 so that the blood vessel 11 can be seen from the groin portion 13 to the ankle 14 of the lower limb 12. The method for removing blood vessels is, for example, having only three skin incisions and is minimally invasive to the patient. For example, there is a possibility that the period until the patient can walk after the operation can be shortened.

Next, the living body sampling operation system will be described with reference to FIG.
FIG. 7 is a configuration diagram showing a configuration of a living body sampling operation system including devices, instruments and the like used in the above-described operation. A living body collection surgery system (hereinafter simply referred to as a surgery system) 101 includes a trocar 21, a dissector 31 that is a biological peeling device, a harvester 41 that is a biological tissue cutting device, and a rigid endoscope that is an endoscope. A mirror 51 is included. The surgical system 101 further includes a television monitor 102 as a display device, a camera control unit (hereinafter referred to as CCU) 103, a television camera device 104, a light source device 105, a light guide cable 106, and an electric knife device 107. And an air supply device 108.

  One end of a light guide cable 106 is connected to the light guide connector portion 52 of the rigid endoscope 51. The other end of the ride guide cable 106 is connected to the light source device 105. Light from the light source device 105 is supplied to the rigid endoscope 51 through a light guide cable 106 through which a light guide of an optical fiber is inserted, and the subject is illuminated from the distal end portion of the rigid endoscope 51. Done. A television camera head portion of the television camera device 104 is connected to the eyepiece 53 on the proximal end side of the rigid endoscope 51. The television camera device 104 is connected to the CCU 103, and an image of the subject obtained by the rigid endoscope 51 is displayed on the screen of the connected television monitor 102.

  The distal end insertion portion 54 of the rigid endoscope 51 can be inserted into the rigid endoscope insertion channel 36 of the disector 31 from the proximal end side of the disector 31. Similarly, the distal end insertion portion 54 of the rigid endoscope 51 can be inserted from the proximal end side of the harvester 41 into a rigid endoscope insertion channel 46 that passes through an insertion portion 42 described later of the harvester 41.

  The air supply tube 34 of the dissector 31 is connected to the air supply device 108, receives supply of a predetermined gas, for example, carbon dioxide gas, from the air supply device 108, and discharges it from the opening 35a which is an air supply outlet.

  The air supply tube 44 of the harvester 41 is also connected to the air supply device 108, and is supplied with a predetermined gas, for example, carbon dioxide gas from the air supply device 108, and is an opening that is an air supply outlet (not shown in FIG. 7). )).

  The harvester 41 has an electrical cable 47 for the bipolar cutter 43, and is connected to the electrical knife device 107 by a connector provided at the proximal end of the electrical cable 47.

  Using the operation system 101 having such a configuration, an operator can perform the above-described operation.

  Next, the harvester which is the biological tissue cutting instrument of the present invention will be described with reference to FIGS.

  FIG. 8 is a side view of the harvester 41. A bipolar cutter 43 is provided at the top of the metal insert portion 42 of the harvester 41, and a vane keeper 45 as a retainer is provided inside the bottom portion, and is connected to the base end of the insert portion 42. When the bipolar cutter lever 401 and the vane keeper lever 402 provided in the grip portion 400 are advanced and retracted along the longitudinal axis, the bipolar cutter 43 and the vane keeper 45 may be advanced and retracted forward of the insertion portion 42 in conjunction with the advance and retreat. It can be done.

  FIG. 9 is a partial perspective view illustrating the configuration of the proximal end side of the harvester 41. As shown in FIG. 9, the configuration of the proximal end side of the harvester 41 is such that the rigid endoscope 51 is easily and reliably fixed to the proximal end portion of the harvester 41, so that the inner peripheral surface of the proximal end portion 400 a of the harvester 41. The guide groove 400 b is provided along the axial direction of the harvester 41. Further, a fixing member 400c is fixed to the guide groove 400b with a screw. The fixing member 400c is formed by bending a metal plate-like member into a U shape, and both ends of the U shape are bent so as to have convex portions toward the inside of the U shape. On the other hand, a convex portion (not shown) is provided on the distal end side of the eyepiece 53 of the rigid endoscope 51.

  Further, the base end portion 400a is provided with a notch portion 400d so that the light guide connector portion 52 can move along the notch portion 400d.

  When the rigid endoscope 51 is inserted from the proximal end portion of the harvester 41, the convex portion of the rigid endoscope 51 extends along the guide groove 400b provided on the inner peripheral surface of the proximal end portion 400a shown in FIG. In addition, the rigid endoscope 51 is inserted into the proximal end portion of the harvester 41 so that the light guide connector portion 52 enters along the notch portion 400d. When the rigid endoscope 51 is inserted from the proximal end portion of the harvester 41, the convex portion of the rigid endoscope 51 moves along the inside of the guide groove 400b and resists the elastic force of the fixing member 400c. The convex portion of the metal fixing member 400c is exceeded. At this time, the light guide connector part 52 also moves along the notch part 400d provided in the base end part 400a.

  Therefore, when the rigid endoscope 51 is inserted from the proximal end portion of the harvester 41, the light guide connector portion 52 enters the notch portion 400d, and the convex portion of the rigid endoscope 51 enters the guide groove 400b. Thus, after setting the positional relationship between the harvester 41 and the rigid endoscope 51, the rigid endoscope 51 is inserted into the harvester 41. As the rigid endoscope 51 is inserted into the harvester 41, the convex portion of the rigid endoscope 51 is engaged and fixed so as to be sandwiched by the fixing member 400c, and the elastic force of the fixing member 400c. It will not come off easily.

  In addition, since a “click” sound is generated between the engaged rigid endoscope 51 and the harvester 41 when being engaged and fixed, the user confirms that the set has been made by sound. can do.

  10 is a partial perspective view showing the configuration of the tip of the harvester 41, FIG. 11 is a diagram for explaining the operation of the lock shaft 414 in FIG. 10, and FIG. 12 is a view as seen from the arrow A in FIG.

  As shown in FIG. 10, the vein keeper 45 of the harvester 41 includes a vein keeper shaft 412 that holds a substantially U-shaped blood vessel holding table 411 so as to be movable back and forth in the longitudinal axis direction, and a substantially U shape that is parallel to the vein keeper shaft 412. 10 is configured with a lock shaft 414 that can be advanced and retracted in the longitudinal axis direction with respect to the blood vessel holding table 411 that forms a closed space 413 that stores a blood vessel in the blood vessel holding table 411. In the state of FIG. The space 413 is formed in a state of being locked to the blood vessel holding table 411 similarly to the vane keeper shaft 412. However, by releasing the lock state of the lock shaft 414, the closed space 413 is released as shown in FIG. The blood vessel 11 can be advanced and retracted so as to be accommodated therein.

  A notch 415 is provided at the tip side surface of the insertion portion 42 where the bipolar cutter 43 is provided, and a cutter shaft (described later) for moving the bipolar cutter 43 forward and backward is inserted through the notch 415. A guard portion 416 having a circular arc cross section is provided on the inner wall surface of the notch 415, and a wiper for wiping off deposits adhering to the window portion of the distal end portion of the rigid endoscope 51 on the distal end inner surface of the insertion portion 42. 417 is provided. And the wiper guard part is formed because the other end of the wiper 417 sweeps the inside of the guard part 416 around one end of the wiper 417 as an axis. A part of the cylindrical wiper guard part is provided with a discharge hole 419a for sweeping out the deposit 418 (see FIG. 12) wiped by the wiper 417 to the outside. Examples of the deposit 418 include blood, fat, and smoke generated by an electric knife.

  The wiper 417 is swept by a wiper lever 419 (see FIG. 8) via a wiper shaft (not shown: see FIG. 16).

  As shown in FIG. 12, which is an arrow view seen from the arrow A in FIG. 10, the opening of the rigid endoscope insertion channel 420 through which the rigid endoscope 51 is inserted into a predetermined inner side than the distal end surface of the insertion portion 42 and the air supply An opening of an air supply channel 421 for performing the above is provided adjacently.

  FIG. 13 is a cross-sectional view in the major axis direction showing the operational configuration of the harvester 41, and FIG.

  As shown in FIG. 13, along the axial direction of the harvester 41, the metal tube member 420 a that forms the rigid endoscope insertion channel 420 is disposed inside the harvester 41 from the proximal end side of the grip portion 400 to the distal end portion of the insertion portion 42. Is inserted. The bipolar cutter 43 is connected to a bipolar cutter lever 401 provided in the grip portion 400 by a bipolar shaft 450 that passes through the insertion portion 42. When the bipolar cutter lever 401 is advanced and retracted along the longitudinal axis, the advancing / retracting force is provided. Is transmitted to the bipolar cutter 43 via the bipolar shaft 450 so that the bipolar cutter 43 can be advanced and retracted forward of the insertion portion 42.

  Similarly, the vane keeper 45 is connected to a vane keeper lever 402 provided in the grip portion 400 by a vane keeper shaft 412 that passes through the insertion portion 42, and when the vane keeper lever 402 is advanced and retracted along the longitudinal axis, The advancing / retreating force is transmitted to the vane keeper 45 via the vane keeper shaft 412 so that the vane keeper 45 can be moved forward and backward with respect to the insertion portion 42.

  The vane keeper lever 402 and the vane keeper shaft 412 can be integrally moved on the inner surface of the gripper 400 by a click mechanism 451 that pin-presses the inner surface of the gripper 400, and the click mechanism 451 is provided on the inner surface of the gripper 400. For example, if it is located in any one of the three click grooves 452, the vein keeper lever 402 and the vein keeper shaft 412 can be stably held at that position, and a force can be applied to the longitudinal axis to easily click. The mechanism 451 can be made to escape from the click groove 452.

  The vane keeper lever 402 is detachably connected to the lock lever 453, and the vane keeper lever 402 can be separated from the lock lever 453 by pressing a lock button 454. The lock lever 453 is connected to the lock shaft 414. By moving the lock lever 453 forward and backward while being separated from the vane keeper lever 402, the blood vessel 11 can be advanced and retracted in the closed space 413 so as to be retractable. (See FIG. 10 and FIG. 11).

  As shown in FIG. 14, the vane keeper lever 402 is firmly fixed to the vane keeper shaft 412 by screws 460 and adhesion.

  FIG. 15 is a cross-sectional view in the major axis direction showing the air supply configuration of the harvester 41, and FIG.

  As shown in FIG. 15, along the axial direction of the harvester 41, a metal air supply pipe 461 that forms an air supply channel 421 is disposed inside the harvester 41 from the proximal end side of the grip portion 400 to the distal end portion of the insertion portion 42. Is inserted. An air supply tube 44 is fitted into one end of the air supply pipe 461 on the proximal end side of the grip portion 400 in the grip portion 400, and an air supply connector 44a is provided at the base end of the air supply tube 44. The air connector 44 a is connected to a connector of a tube connected to the air supply device 108.

  As described above, in the present embodiment, as shown in FIG. 17, by moving the vane keeper lever 402 forward and backward, the vane keeper 45 can be advanced and retracted at the distal end, so that, for example, an endoscope at the time of cutting the side branch 11A If the image is an image as shown in FIG. 18 and it is difficult to confirm the state of the side branch 11A, the vane keeper 45 is advanced in the longitudinal direction as shown in FIG. As shown in FIG. 19, an endoscopic image suitable for confirming the state of the side branch 11A can be visually recognized.

Next, the bipolar cutter 43 inserted into the harvester 41 will be described with reference to FIGS.
20 is an exploded perspective view of the tip portion of the bipolar cutter 43, FIG. 21 is a top view of the bipolar cutter 43 as viewed from above, FIG. 22 is a bottom view of the bipolar cutter 43 as viewed from below, and FIG. FIG. 24 is a cross-sectional view of the bipolar cutter 43 showing a cross section taken along the line BB of FIG. 21, FIG. 25 is a view of the tissue sandwiching portion 423 viewed from the bottom, and FIG. FIG. 27 is a cross-sectional view of the tissue sandwiching portion 423 showing a cross section taken along the line CC of FIG. 25, and FIG. 27 is a cross-sectional view of the tissue sandwiching portion 423 showing a cross section taken along the line DD of FIG.

  As shown in FIGS. 20 to 25, the bipolar cutter 43 is made of a cutter body 422 made of a synthetic resin, which is a transparent insulating member such as polycarbonate, and ceramics, which is a heat-resistant member disposed in the approximate center of the tip portion. A tissue sandwiching portion 423, an application electrode 425 that is a first electrode that is one of bipolars, a feedback electrode 424 that is a second electrode that is the other of bipolars, and two lead wires 428 (application-side lead wires) 428a, a return side lead wire 428b) and a lead wire cover 426.

  When viewed from the longitudinal axis, the cutter body 422 has a shape in which the cross section is curved in an arc shape along the arc-shaped inner peripheral surface of the notch 415 (see FIG. 10) of the harvester 41 (see FIG. 24). ) The cutter body 422 is insulated from a V-shaped groove 436 formed at the tip, a fitting portion 435 that is a groove into which a tissue clamping portion 423 described later is fitted, and an application-side lead wire 428a and a feedback-side lead wire 428b. It has a groove 422j in which the lead wire cover 431 is fitted and a recess 422l in which the return electrode 424 is placed. In addition, two long grooves are formed on the bottom surface of the groove portion 422j over the entire length in order to maintain insulation between the application side lead wire 428a and the feedback side lead wire 428b.

  The insertion portion 435 includes a first groove portion 435a formed in a slit shape from the V-shaped groove 436 at the distal end of the cutter body 422, and a second portion formed in a substantially circular shape when the base end side is viewed from above. It has a groove portion 435b.

Further, the cutter body 422 is formed with a step 422a (see FIGS. 21 and 24) serving as an inward flange on the inner peripheral side where the fitting portion 435 is formed, and corresponds to the proximal end portion of the tissue sandwiching portion 423. A fitting recess 422b (see FIGS. 20 and 23) is formed at the position.

  A through portion 422e (see FIGS. 21 and 22) through which the lead wire connecting portion 425a of the application electrode 425 is inserted is formed in the groove where the application side lead wire of the groove portion 422j is disposed. Accordingly, in the application electrode 425 disposed on the lower surface side of the cutter body 422, the lead wire connection portion 425a is inserted through the through portion 422e, and the application electrode 425a disposed on the end portion of the lead wire connection portion 425a and the upper surface of the groove portion 422j. The side lead wire 428a can be electrically connected.

  In addition, the cutter body 422 has a total of three retaining portions 422c on the upper surface and the lower surface, and two retaining portions 422c of the cutter body 422 project upward on the tip side of the recess 422l, and the remaining one retaining portion. 422c protrudes downward. These retaining portions 422c are inserted into holes 425b and 424a formed in the application electrode 425 and the return electrode 424, melted by heat caulking, and then solidified into an outward flange shape (see FIGS. 23 and 24). Thus, the feedback electrode 424 and the application electrode 425 are fixed on the upper and lower surfaces of the cutter body 422, respectively.

  The return electrode 424 is a metal plate having a curved cross section when viewed from the longitudinal axis direction along the upper surface of the recess 422 l of the cutter body 422. The return electrode 424 has a boundary between the upper surfaces of the cutter body 422 and the tissue sandwiching portion 423, that is, a notch portion formed by notching a front rear circle shape when viewed from above so as to substantially follow the respective boundary lines. The above-mentioned two holes 424a are provided on the tip side. The return electrode 424 is provided in parallel with the lead wire connecting portion 424b and the lead wire connecting portion 424b which are electrically connected to the return side lead wire by welding at the proximal end portion, and is fitted into the groove portion 422j of the cutter body 422. And a protrusion 424c to be held.

  Each of the lead wire connecting portion 424b and the protruding portion 424c is bent at a substantially right angle downward, and further bent at a substantially right angle so as to extend toward the base end side. The lead wire connecting portion 424b has a length that extends to the base end side is longer than that of the protruding portion 424c, and has a length that allows sufficient welding connection with the return side lead wire.

  The protrusion 424c has a length that extends to the base end side that is shorter than the length from the base end of the concave portion 422l of the cutter body 422 to the through portion 422e of the groove 422j. Thereby, since insulation is maintained without the protrusion 424c and the lead wire connection part 425a of the application electrode 425 and the application-side lead wire 428a contacting each other, the insulation between the feedback electrode 424 and the application electrode 425 is also maintained.

The application electrode 425 is a substantially rectangular metal plate that is disposed on the lower surface side of the cutter body 422 and the tissue sandwiching portion 423 and has the above-described hole portion 425b. As described above, a lead wire connecting portion 425a electrically connected to the application side lead wire 428a by welding extends from the application electrode 425 to the proximal end side.
The lead wire connecting portion 425a has an end portion in the extending direction bent upward at a substantially right angle, and further, the end portion is bent substantially at a right angle in the extending direction side.

  The application-side lead wire 428a and the return-side lead wire 428b are arranged in parallel in two long grooves formed on the bottom surface of the groove portion 422j of the cutter body 422 so as to be insulative, and an external electric knife device 107 is provided. (See FIG. 7).

  As shown in FIGS. 25 to 27, the tissue sandwiching portion 423 has a columnar portion 423A having a substantially cylindrical base end portion, and a substantially quadrangular prism shape extending from the side peripheral surface of the columnar portion 423A. Thus, it has a so-called front rear circular cone shape having a quadrangular prism-shaped portion 423B in which slit grooves 427 are formed. Note that the tissue sandwiching portion 423 in FIG. 24 shows a surface that becomes the lower surface side when the tissue sandwiching portion 423 is fitted into the cutter body 422.

  As shown in FIG. 24, this tissue sandwiching portion 423 extends long along the longitudinal axis direction, and has two arm portions 423a projecting outward from both side surfaces of the quadrangular columnar portion 423B, and a base of the cylindrical portion 423A. It has a convex part 423b protruding from the side peripheral surface of the end part toward the base end side.

The tissue sandwiching portion 423 is fitted into the fitting portion 435 of the cutter main body 422, the two arm portions 423a are held by the step portion 422a of the first groove portion 435a, and the convex portion 423b is the fitting concave portion 422b of the cutter main body 422. By being fitted and held in the cutter body, the cutter body 422 is fitted.

  Further, the tissue sandwiching portion 423 has a substantially circumferential groove portion 440 formed in the cylindrical portion 423A. As shown in FIG. 22, the groove portion 440 is separated from a substantially distal end portion of the application electrode 425 covering the proximal end portion of the slit groove 427 by a predetermined distance, and surrounds the distal end portion of the application electrode 425 so as to draw a circle. For example, it is a bottomed groove formed with a width of about 0.5 mm and a depth of about 1 to 2 mm. The groove portion 440 is not limited to a substantially circumferential shape, and may have any shape, for example, many shapes such as a quadrangle and a triangle, as long as the groove portion 440 is separated from the distal end portion of the application electrode 425 covering the proximal end portion of the slit groove 427. A groove that draws a square may be used. Furthermore, the width dimension and the depth dimension of the groove part 440 are set so that the tissue clamping part 423 can maintain a predetermined strength.

In addition, the slit groove 427 is grooved to a width of, for example, 0.5 mm in the longitudinal axis direction of the tissue sandwiching portion 423 from the central portion on the distal end side of the quadrangular columnar portion 423B to the substantially central portion of the cylindrical portion 423A.
In addition, this structure clamping part 423 is formed with materials, such as a zirconia and an alumina which are high heat resistant ceramic structural materials.
In addition, a stepped portion 430 that is notched toward the proximal end side is formed on the lower surface of the tissue sandwiching portion 423 in order to position the distal end portion of the application electrode 425.

The cutting of the side branch 11A by the bipolar cutter 43 of the harvester 41 configured as described above will be described with reference to FIGS. 1 and 28 to 30. FIG.
28 and 29 are views for explaining the cutting of the side branch 11A by the bipolar cutter 43, and FIG. 30 is a view of the tissue sandwiching portion 423 when the side branch 11A is cut as viewed from the lower surface.

  The dissociation (S4) of the surrounding tissue is performed over the entire length of the blood vessel 11 using the dissector 31 described based on the flowchart of FIG. 1, and then the dissector 31 is extracted from the trocar 21 and the trocar 21 is left as it is. Then, the harvester 41 is inserted, and the side branch 11A of the blood vessel 11 between the skin incision 16 and the ankle 14 is cut (S5).

  At this time, the operator slides the bipolar cutter lever 401 of the harvester 41 in the direction in which the bipolar cutter 43 moves forward so that the side branch 11A enters the V-shaped groove 426 of the cutter main body 422 while checking the endoscopic image. . The side branch 11 </ b> A is guided to the slit groove 427 of the tissue clamping unit 423 by the V-shaped groove 426.

  The surgeon confirms that the side branch 11A has entered the slit groove 427 and the side branch 11A is in contact with the application electrode 425, as shown in FIG. 28, and allows a high-frequency current to flow from the electric scalpel device 107. . At this time, the high-frequency current discharged from the application electrode 425 is discharged to the feedback electrode 424 through the side branch 11A.

  The side branch 11 </ b> A in the slit groove 427 of the tissue clamping unit 423 is discharged by the discharge from the application electrode 425. A quantity of heat is generated in a portion in contact with the application electrode 425, and is solidified and cut as shown in FIG.

  Here, based on FIG. 30, a description will be given of the heat flow in which the amount of heat generated in the side branch 11 </ b> A that has received the high-frequency current from the application electrode 425 is propagated to the tissue clamping unit 423.

  In the following description, the side surface of the groove portion 440 on the inner peripheral side of the tissue sandwiching portion 423 is a wall surface 440a, the outer side surface is a wall surface 440b, and a portion where the application electrode 425 and the side branch 11A are in contact is referred to as a heat generation unit 450. Show.

  As described above, the amount of heat generated in the side branch 11 </ b> A is transmitted radially to the tissue sandwiching portion 423 and is propagated to the groove portion 440. The amount of heat transmitted to the groove 440 depends on the thermal conductivity λ of the tissue sandwiching part 423 and the groove 440.

  The heat flux qa of the tissue clamping part 423 from the heat generation part 450 to the wall surface 440a can be calculated by the following equation (1).

qa = λa (th−twh) / δ1 (1)
qa: heat flux
λa: thermal conductivity of the tissue sandwiching part 423
th: temperature of the interface between the tissue sandwiching portion 423 (slit groove 427) and the side branch 11A
twh: temperature of the boundary surface between the wall surface 440a and air
δ1: Distance from slit groove 427 that contacts side branch 11A to wall surface 440a
On the other hand, the heat flux qb of the groove part 440 between the wall surfaces 440a and 440b of the tissue sandwiching part 423 is
It can be calculated by the following equation (2).

qb = λair (twh−tc) / δ2 (2)
λair: thermal conductivity of air
tc: temperature of the boundary surface between the wall surface 440b and air
δ1: Distance from wall surface 440a to wall surface 440b
As can be seen from the above formulas (1) and (2), the value of the heat flux q depends on the value of the thermal conductivity λ as the product value. That is, the thermal conductivity λair of air is extremely small compared to the thermal conductivity λa of the tissue sandwiching portion 423 formed of ceramics. Therefore, the heat flux qb in the groove portion 440 depends on the value of the thermal conductivity λair of air, which is a product value, and is a very small value compared to the heat flux qa of the tissue sandwiching portion 423.

  As a result, the tissue sandwiching portion 423 consumes a large amount of heat in the portion from the heat amount generating portion 450 (a part of the slit groove 427) that sandwiches the side branch 11A that receives the heat amount from the application electrode 425 to the groove portion 440. In other words, in the tissue sandwiching portion 423, rapid heat propagation is suppressed by the groove portion 440, and only the portion from the heat generation unit 450 to the groove portion 440 becomes high temperature. Therefore, since the side branch 11A consumes a large amount of heat, its hemostasis is improved.

  In addition to the above-described effects, the tissue sandwiching portion 423 is provided with the groove portion 440, so that it is difficult for heat to propagate from the groove portion 440 to the outer peripheral portion. As a result, a rapid increase in temperature is suppressed in the portion on the outer peripheral side from the groove portion 440 of the tissue sandwiching portion 423. Thereby, the temperature rise of the cutter main body 422 in which the tissue clamping part 423 is inserted can also be suppressed, and thermal durability can be ensured even if the cutter main body 422 is formed of a synthetic resin having a low use temperature.

  As a result, the cutter body 422 of the bipolar cutter 43 is made of synthetic resin such as polycarbonate, and has good workability and low cost compared to the case where the whole is formed of ceramics.

  Further, the groove portion 440 is formed by grooving from the surface (the lower surface in this embodiment) of the tissue sandwiching portion 423 on which the application electrode 425 is disposed. Therefore, the amount of heat concentrated in the vicinity of the application electrode 425 in contact with the side branch 11 </ b> A suppresses heat propagation to the tissue sandwiching portion 423 in the groove portion 440. Therefore, the vicinity of the application electrode 425 becomes the highest temperature due to the amount of heat consumed by the tissue sandwiching section 423, and as described above, the necessary amount of heat for hemostasis cutting of the side branch 11A is ensured.

  As a result, the bipolar cutter 43 of the harvester 41, which is the cutting means in the present embodiment, is excellent in thermal durability and can cut the side branch 11A of the collection blood vessel 11 that is a living tissue while hemostasis reliably.

  As described above, in order to maintain a creepage distance for withstand voltage, the distal end portion of the application electrode 425 located on the proximal end side of the slit groove 427, that is, the distance from the heat generation unit 450 to the feedback electrode 424 is substantially equal. As shown, the central portion of the feedback electrode 424 is cut out into a substantially circular shape with the base end portion of the slit groove 427 as a substantial center.

  Therefore, by applying the surface of the tissue sandwiching portion 423 corresponding to the substantially circular shape of the return electrode 424 on the feedback electrode 424 side to the substantially circular shape, that is, the surface shape of the cylindrical portion 423A of the tissue sandwiching portion 423, the application electrode 425 is provided. The heat generated in the above is transmitted to the tissue clamping unit 423 substantially evenly.

  As a result, a locally high temperature portion can be suppressed on the upper surface side of the tissue sandwiching portion 423 serving as a joint surface between the cutter body 422, the return electrode 424, and the application electrode 425. That is, since the heat generated in the heat generation unit 450 spreads uniformly on the upper surface of the tissue sandwiching part 423, it is possible to prevent the cutter body 422 and the tissue sandwiching part 423 from increasing in temperature.

  Further, as described above, in order to hemostatically cut the side branch 11A, which is a living tissue, the amount of heat generated by the high-frequency current discharged from the application electrode 425 to the return electrode 424 is applied by the tissue clamping unit 423 in which the groove 440 is formed. It concentrates on the tissue clamping part 423 near the electrode 425. However, the bipolar cutter 43 of the present embodiment can be configured to have excellent thermal durability by using the tissue sandwiching portion 423 formed of high heat-resistant ceramic between the application electrode 425 and the return electrode 424. it can.

  In the present embodiment, the tissue sandwiching portion 423 made of ceramics having the groove 440 formed at the center of the tip of the cutter body 422 is provided. However, all of the cutter body 422 between the feedback electrode 424 and the application electrode 425 is provided. The tip portion may be made of a ceramic member having a groove 440.

  Furthermore, the value of the thermal conductivity λair of air is affected by the ambient temperature. However, since the amount of heat consumed for the side branch 11A increases, the discharge time of the high-frequency current from the application electrode 425 to the return electrode 424 can be shortened.

  The present invention is not limited to the embodiments described above, and various modifications can be made without departing from the spirit of the invention.

It is a flowchart for demonstrating the operation method which pulls a subcutaneous blood vessel and collects. It is a figure for demonstrating the surgery method which pulls a subcutaneous blood vessel and collects. It is sectional drawing which shows the state by which the dissector was inserted in the subcutaneous part of the lower limbs through the trocar from the skin cut part in the groin part direction. It is a figure for demonstrating the surgery method which pulls a subcutaneous blood vessel and collects. It is sectional drawing which shows the state by which the harvester was inserted into the lower limbs subcutaneously through the trocar from the skin incision. It is a figure for demonstrating the surgery method which pulls a subcutaneous blood vessel and collects. It is a block diagram which shows the structure of the biological collection surgery system which consists of an apparatus, an instrument, etc. which are used for the surgery which pulls a subcutaneous blood vessel and collects. It is a side view of a harvester. It is a fragmentary perspective view explaining the structure of the base end side of a harvester. It is a fragmentary perspective view which shows the structure of the front-end | tip of a harvester. It is a figure explaining the effect | action of the lock shaft of FIG. It is an arrow view seen from the arrow A of FIG. It is sectional drawing of the major axis direction which shows the operation structure of a harvester. It is the attachment conceptual diagram of the vane keeper lever seen from the arrow A of FIG. It is sectional drawing of the major axis direction which shows the air_supply structure of a harvester. It is sectional drawing which shows the AA line cross section of FIG. It is a figure for demonstrating the advance and retreat of a Bain keeper lever and a Bain keeper. It is an endoscopic image at the time of cutting of a side branch. It is an endoscopic image at the time of cutting of a side branch. It is a disassembled perspective view of the front-end | tip part of a bipolar cutter. It is the top view which looked at the bipolar cutter from the upper surface. It is the bottom view which looked at the bipolar cutter from the lower surface. It is sectional drawing of the bipolar cutter which shows the AA line cross section of the bipolar cutter of FIG. It is sectional drawing of the bipolar cutter which shows the BB line cross section of the bipolar cutter of FIG. It is the figure which looked at the tissue clamping part from the lower surface. It is sectional drawing of the structure | tissue clamping part which shows the CC line cross section of FIG. It is sectional drawing of the structure | tissue clamping part which shows the DD sectional view of FIG. It is a figure for demonstrating the cutting | disconnection of the side branch by a bipolar cutter. It is a figure for demonstrating the cutting | disconnection of the side branch by a bipolar cutter. It is the figure which looked at the tissue clamping part at the time of cutting | disconnecting a side branch from the lower surface.

Explanation of symbols

11 ... Blood vessels to be collected
11A ... side branch
41 ... Harvester
43 ... Bipolar cutter
422 ... Cutter body
423 ... Tissue clamping part
424 ... Return electrode
425 ... Applied electrode
427 ... Slit groove
440 ... Groove
Attorney Susumu Ito

Claims (4)

A biological tissue cutting device for cutting a biological tissue,
A cutter body formed of an insulating member and having a groove for guiding the living tissue at the tip ;
And applying electrodes disposed on one surface of said cutter body,
A return electrode disposed on the other surface of the cutter body;
Between the application electrode and the return electrode , a heat-resistant member having a slit groove disposed at the distal end portion of the cutter body and formed so that the living tissue guided by the groove enters the proximal end side from the distal end side. A member,
Comprising
Arranging the tip portion of the application electrode on one surface of the heat-resistant member so as to cover the base end of the slit groove,
The application electrode of the heat-resistant member is arranged with a circumferential groove that surrounds the tip of the application electrode that contacts and cuts the living tissue that has entered the slit groove and suppresses propagation of heat generated by the application electrode. A biological tissue cutting instrument characterized by being formed on one surface . The groove portion is provided with a bottom with a predetermined distance from a tip portion of the application electrode that covers a base end of the slit groove so as to form an air layer that suppresses heat propagation in the heat-resistant member. The biological tissue cutting device according to claim 1, wherein the biological tissue cutting device is a groove . 3. The biological tissue cutting instrument according to claim 1, wherein the heat-resistant member has a base end portion formed in a cylindrical shape with the base end of the slit groove as a center. The said return electrode is arrange | positioned on the other surface of the said heat-resistant member, and has a circular notch part centering on the base end of the said slit groove | channel. The biological tissue cutting instrument according to any one of the above.

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