JP6580038B2 - Method and apparatus for soft tissue incision - Google Patents

Description

Priority Application This patent application is a continuation-in-part application, US Provisional Patent Application No. 61 / 687,587 entitled “Instrument for Soft Tissue Discussion” filed on April 28, 2012, US Provisional Patent Application No. 61 / 744,936 entitled “Instrument for Soft Tissue Discussion” filed on October 6, 2012, and “Instruments, “Instrument” filed on April 29, 2013, claiming priority to US Provisional Patent Application No. 61 / 783,834, entitled “Devices, and Related Methods for Soft Tissue Discussion”. claims priority to US patent application Ser. No. 13 / 872,766, entitled “S, Devices, and Related Methods for Soft Tissue Discussion”, which is incorporated herein by reference in its entirety. It is.

  The field of the disclosure relates to methods or devices used to incise tissue during surgery or other medical procedures.

  Surgeons are frequently required to cut or separate tissue during surgery. The following two techniques are commonly used. (1) A “sharp section” where the surgeon uses a cutting instrument to slice and cut tissue with scissors, scalpel, electrosurgical or other slicing instruments, and (2) a blunt section.

  The advantage of sharp dissection is that the cutting instrument easily cuts any tissue. Slicing any and all tissue to which the instrument is applied, regardless of the cut itself. This may also be the case when trying to separate the first tissue without damage, especially if the first tissue is buried and made invisible by the second tissue, more generally many tissues. This is a drawback of the sharp section. Accidental amputation of blood vessels, nerves, or intestines, for example, is not uncommon for even the most experienced surgeon, and can result in serious and even fatal intraoperative complications that have a prognosis for the patient. May be prolonged.

  The separation of the first tissue that is implanted in the other tissue is therefore frequently performed by the blunt dissection. In the blunt dissection, blunt instruments are used to push tissue apart by tearing rather than cutting, or to open two tissues apart or otherwise separate tissue. Almost all surgeries require a blunt dissection of tissue to expose a target structure such as a blood vessel to be ligated or a nerve bundle to be avoided. An example of thoracic surgery involves the separation of blood vessels during hilar incision for lobectomy and lymph node exposure.

  A blunt dissection can be achieved by inserting a blunt probe or instrument, reversing the forceps (ie, spreading), and tissue by rubbing with forceps or with a “wiping dissecting instrument” (eg, a surgical gauze held on a forceps). Includes a range of procedures including various methods for tearing soft tissue such as pulling. When necessary, the sharp dissection is carefully used to cut tissue that resists tearing in the blunt dissection.

  A common goal is to tear tissue or other methods such as the membrane or mesentery away from the target structure without tearing or destroying any target structures or critical structures such as nearby blood vessels or nerves It is to destroy with. Surgeons take advantage of different mechanical behaviors of tissue, such as the presence of different stiffness of adjacent tissue or the presence of a softer tissue surface between stronger tissues. Frequently, the goal is to loose mechanically soft tissue composed of more tightly packed fiber components and mechanically soft tissue composed of looser packed fiber components (eg, loose collagen, reticuline and elastin). Network) to separate target organizations embedded in the network. Tighter packed fibrous tissue is composed of tightly packed collagen and other fibrous connective tissue that usually has a highly organized anisotropic distribution of fiber components, often in a hierarchical composition. Including an organization consisting of Examples include blood vessels, nerve sheaths, muscles, fascia, sacs and tendons. Loosely packed fiber tissue is composed of materials that have a much lower number of fibers per unit volume or are less well organized such as fat and mesentery. The fiber component includes fibers, fibrils, filaments and other filamentous components. When a tissue is referred to as a “fiber,” it usually refers to an extracellular filamentous component such as collagen or elastin that polymerizes into a linear structure of varying complexity that changes to form the extracellular matrix. is there. As mentioned in the previous paragraph, the density, orientation, and texture of the fiber components greatly determine the mechanical behavior of the tissue. In some cases, the tissue is referred to as a “sturdy fibrous tissue” which indicates that the fibrous or filamentous component comprises a significant portion of the densely packed tissue. However, all tissues are, in a sense, substantially fibrous with fibers and other filamentous extracellular components present in the tissue.

  The key to this discussion is that the softer tissue is more easily torn than the stronger tissue, and therefore the blunt dissection proceeds by applying sufficient force to tear the softer tissue rather than the stronger tissue. Is to try to do.

  Blunt sections can be difficult and often time consuming. It is not easy to determine the force to tear soft tissue rather than tightly juxtaposed hard tissue. Therefore, blood vessels can be torn. Nerves can be stretched or torn. In response, the surgeon carefully attempts sharp dissection, but blood vessels and nerves, especially small side branches, may be severed. This all leads to an increased risk of complications such as long and tedious incisions and bleeding, air leakage from the lungs and nerve damage.

  Surgeons frequently use forceps for blunt dissection. 1A and 1B show a typical forceps 10 of the prior art. FIG. 1A shows the forceps 10 in a closed position for clamping tissue 34 between opposing first and second clamping elements 30 and 31. FIG. 1B shows the forceps 10 in an open position to force the tissue 34 apart. The first finger engaging portion 20 and the opposing second finger engaging portion 21 are used for operating the mechanism. The first finger engagement portion 20 drives the first clamp element 30, and the second finger engagement portion 21 drives the second clamp element 31. The pivot shaft 40 attaches the first clamping element 30 and the second clamping element 31 and allows a scissor-like action to force the first clamping element 30 and the second clamping element 31 together or away. Thereby clamping the tissue 34 between the two clamping surfaces 35 and 36 or tearing the tissue 34 by spreading the first clamping element 30 and the second clamping element 31. Frequently, the ratchet clasp 50 is used to lock the first clamp element 30 and the second clamp element 31 together.

  Laparoscopes and thoracoscopes (collectively referred to herein as “endoscopes”) instruments use similar actions. FIG. 2 shows an example of a conventional endoscope forceps 110. The first finger engaging portion 120 and the opposing second finger engaging portion 121 are used to operate the mechanism. The first finger engaging portion 120 is firmly attached to the instrument main body 150. The second finger engaging portion 121 drives the opposing clamp elements 130 and 131. The pivot shaft 140 attaches the two clamping elements 130 and 131 so that the operation of the second finger engaging portion 121 pushes the clamping elements 130 and 131 together, so that the two clamping surfaces 135 and 136 Clamp the tissue between. As in FIG. 1, endoscopic forceps 110 can be used to push open tissue. Clamp elements 130 and 131 are closed and inserted into the tissue and then opened to tear the tissue.

  For either the forceps 10 or endoscopic forceps 110 instrument, the surgeon closes the forceps, pushes the closed forceps into the tissue, and then opens the forceps inside the tissue as necessary to tear and release the tissue. Perform the blunt dissection by using the force applied by opening the forceps jaws. Therefore, the surgeon proceeds to incise the tissue by a combination of pushing into the tissue and opening the forceps jaws.

  The blunt dissection is generally used for wet and smooth tissue, and the smooth inert surface of most surgical instruments is easy to slide along the tissue and use leverage to separate the tissue Impair the ability of the instrument. Furthermore, the surgeon has only limited controls that can only be thrust, moved or separated. An improved instrument for blunt dissection that was able to differentially separate soft tissue without destroying hard tissue would greatly facilitate many operations.

  The disclosed embodiments include a method and apparatus for blunt dissection that differentially destroys a patient's soft tissue without destroying the patient's hard tissue. In one embodiment, a differential dissection instrument for differential dissection of composite tissue is disclosed. The differential dissecting instrument includes a handle, a longitudinal central axis, and an elongated member having a proximal end and a distal end. The differential dissecting instrument also includes a differential dissecting member configured to be rotatably attached to the distal end, the differential dissecting member including at least one tissue engaging surface and a rotational axis of the differential dissecting member. At least one tissue engaging surface in at least one direction relative to the composite tissue by mechanically rotating a differential incision member about a rotational axis and a first torque point disposed on the first side of the And a mechanism configured to move. The mechanism includes at least one force transmitting member having a distal end and a proximal end attached to the first torque point member. The proximal end of the at least one force transmission member is attached to a power source configured to vibrate the differential dissection member. Further, the at least one engagement surface is moved when the differential incision member is pressed by the surgeon against the patient's composite tissue so that the at least one tissue engagement surface moves across the composite tissue. The surface is configured to selectively engage the composite tissue so as to destroy at least one soft tissue in the composite tissue but not to destroy the hard tissue in the composite tissue.

FIG. 1A shows an example of the prior art. FIG. 1A shows a forceps used to grasp tissue. FIG. 1B shows an example of the prior art. FIG. 1B shows an exemplary forceps used in a blunt dissection for dividing tissue. FIG. 2 shows a prior art laparoscopic forceps. FIG. 3A shows an exemplary differential cutting instrument. FIG. 3A shows a differential cutting instrument having a rotational differential cutting member within the shroud. FIG. 3B illustrates an exemplary differential cutting instrument. FIG. 3B shows a differential cutting instrument having a rotational differential cutting member within the shroud. FIG. 3C illustrates an exemplary differential cutting instrument. FIG. 3C shows a differential cutting instrument having a rotational differential cutting member within the shroud. FIG. 3D-1 illustrates an exemplary differential cutting instrument. FIG. 3D-1 shows a side view of the differential incision member. FIG. 3D-1 is a side view of the differential incision member. FIG. 3D-2 illustrates an exemplary differential cutting instrument. FIG. 3D-2 shows a side view of the differential dissection member. FIG. 3D-2 shows the details of the surface of the differential dissection member. FIG. 3D-3 illustrates an exemplary differential cutting instrument. FIG. 3D-3 shows a front view of the differential incision member. FIG. 3D-3 shows a front view of the same differential cutting member. FIG. 3E-1 illustrates an exemplary differential cutting instrument. 3E-1 shows a different type of differential cutting member, differential cutting member type I. FIG. FIG. 3E-2 illustrates an exemplary differential cutting instrument. FIG. 3E-2 shows a different type of differential cutting member, differential cutting member type II. FIG. 3E-3 illustrates an exemplary differential cutting instrument. FIG. 3E-3 shows a different type of differential cutting member, differential cutting member type III. FIG. 3E-4 illustrates an exemplary differential cutting instrument. 3E-4 shows a different type of differential cutting member, differential cutting member type IV. FIG. 3F-1 illustrates an exemplary differential cutting instrument. Figures 3F-1 and 3F show the differential dissection member in a side view including the tissue to be dissected. FIG. 3F-2 illustrates an exemplary differential cutting instrument. FIG. 3F-2 shows the differential dissection member in a front view including the tissue to be dissected. FIG. 4A shows how an exemplary differential dissection instrument exposes hard tissue to break soft tissue rather than hard tissue in a composite tissue. FIG. 4B shows how an exemplary differential dissection instrument exposes hard tissue to break soft tissue rather than hard tissue in a composite tissue. FIG. 4C shows how an exemplary differential dissection instrument exposes hard tissue to break soft tissue rather than hard tissue in a composite tissue. FIG. 4D shows how an exemplary differential dissection instrument exposes hard tissue to break soft tissue rather than hard tissue in a composite tissue. FIG. 4D illustrates how the differential dissection member engages and breaks tissue having a dispersed fiber component but cannot engage the fiber component and consequently break. FIG. 4E shows how an exemplary differential dissection instrument exposes hard tissue to break soft tissue rather than hard tissue in a composite tissue. FIG. 4E illustrates how the differential dissection member engages and breaks tissue having a dispersed fiber component but cannot engage the fiber component and consequently break. FIG. 4F shows how an exemplary differential dissection instrument exposes hard tissue to break soft tissue rather than hard tissue in a composite tissue. FIG. 4F illustrates how the differential dissection member engages and breaks tissue having a dispersed fiber component but cannot engage the fiber component and consequently break. FIG. 5A shows the tissue engaging end of a different exemplary differential cutting instrument with a cutting wheel attached to a shroud. FIG. 5A shows an instrument having one configuration of an incision wheel. FIG. 5B shows the tissue engaging end of a different exemplary differential cutting instrument with a cutting wheel attached to a shroud. FIG. 5B shows an instrument having one configuration of an incision wheel. FIG. 5C shows the tissue engaging end of a different exemplary differential cutting instrument with a cutting wheel attached to the shroud. FIG. 5C-1 shows another instrument having a different configuration of the cutting wheel. FIG. 5C-1 shows the incision wheel in an exploded view away from the instrument. FIG. 5C-2 shows the tissue engaging end of a different exemplary differential cutting instrument with a cutting wheel attached to the shroud. FIG. 5C-2 shows another instrument having a different configuration of the cutting wheel. FIG. 5C-2 shows the incision wheel in place. FIG. 6A shows that the rotational axis of the differential dissection member has many different orientations relative to the differential dissection instrument including a differential dissection instrument having flexible or articulated elongate members. FIG. 6 illustrates a different configuration of an exemplary differential dissection member in a differential dissection instrument that illustrates whether it is possible. FIG. 6B shows that the rotational axis of the differential dissection member has many different orientations relative to the differential dissection instrument including a differential dissection instrument having flexible or articulated elongate members. FIG. 6 illustrates a different configuration of an exemplary differential dissection member in a differential dissection instrument that illustrates whether it is possible. FIG. 6C shows that the axis of rotation of the differential dissection member has many different orientations relative to the differential dissection instrument including a differential dissection instrument having flexible or articulated elongate members. FIG. 6 illustrates a different configuration of an exemplary differential dissection member in a differential dissection instrument that illustrates whether it is possible. FIG. 6D shows that the rotational axis of the differential incision member has many different orientations relative to the differential incision instrument, including differential incision instruments having flexible or articulated elongated members. FIG. 6 illustrates a different configuration of an exemplary differential dissection member in a differential dissection instrument that illustrates whether it is possible. FIG. 7A illustrates an exemplary differential cutting instrument that uses a cutting wire instead of a cutting wheel or other differential cutting member. FIG. 7B illustrates an exemplary differential cutting instrument that uses a cutting wire instead of a cutting wheel or other differential cutting member. FIG. 8A illustrates an exemplary differential cutting instrument that uses a flexible belt as the differential cutting member. FIG. 8B illustrates an exemplary differential cutting instrument that uses a flexible belt as the differential cutting member. FIG. 8C illustrates an exemplary differential cutting instrument that uses a flexible belt as the differential cutting member. FIG. 9A shows how a change in the exposure of the tissue engaging surface of the differential dissection member changes the range of the differential dissecting instrument operation, particularly the angle of exposure of the tissue engaging surface. FIG. 9B shows how a change in the exposure of the tissue engaging surface of the differential dissection member changes the range of the differential dissecting instrument operation, particularly the angle of exposure of the tissue engaging surface. FIG. 9C shows how a change in the exposure of the tissue engaging surface of the differential dissection member alters the operation of the differential dissection instrument, particularly the range of angles of exposure of the tissue engaging surface. FIG. 10A shows how changing the exposure of the tissue engaging surface of the differential dissection member changes the direction of the frictional force on the tissue and hence the angle of strain on that tissue. FIG. 10B shows how changing the exposure of the tissue engaging surface of the differential dissection member changes the direction of the frictional force on the tissue and hence the angle of strain on that tissue. FIG. 10C shows how changing the exposure of the tissue engaging surface of the differential dissection member changes the direction of the frictional force on the tissue and hence the angle of strain on that tissue. FIG. 11A shows an exemplary differential cutting instrument having a water outlet that discharges beside the differential cutting member. FIG. 11B illustrates an exemplary differential cutting instrument having a water outlet that discharges beside the differential cutting member. FIG. 12 shows an exemplary differential cutting instrument having two opposing flexible belts that generate friction forces in opposite directions and thus reduce torque in the differential cutting instrument. FIG. 13 illustrates an exemplary differential cutting instrument that can have multiple parts disposed within a shroud including suction lines, water tubes, and light emitting diodes. FIG. 14-1 illustrates how the elongate member of the exemplary differential dissecting instrument can be articulated by the bendable region to facilitate the placement of the differential dissecting member. FIG. 14-1 shows the elongate member of the differential dissecting instrument in position 1, straight line. FIG. 14-2 illustrates how the elongate member of the exemplary differential dissecting instrument can be articulated by the bendable region to facilitate the placement of the differential dissecting member. FIG. 14-2 shows the elongated member of the differential dissecting instrument curved at 45 degrees. FIG. 14-3 illustrates how the elongate member of the exemplary differential dissecting instrument can be articulated by the bendable region to facilitate the placement of the differential dissecting member. FIG. 14-3 shows the elongated member of the differential dissecting instrument curved at 90 degrees. FIG. 15A shows different exemplary differential cutting members that illustrate some important dimensions and features of the differential cutting member. FIG. 15A shows a top view of an exemplary differential dissection member rotating about a rotating joint. FIG. 15B-1 shows different exemplary differential cutting members that illustrate some important dimensions and features of the differential cutting member. FIG. 15B-1 shows the differential dissection member as in FIG. 15A. FIG. 15B-1 shows the differential dissection member in a side cross-sectional view. FIG. 15B-2 shows different exemplary differential cutting members that illustrate some important dimensions and features of the differential cutting member. FIG. 15B-2 shows a differential dissection member as in FIG. 15A. FIG. 15B-2 shows a detailed view of the tip of the differential dissection member shown in FIG. 15B-1. FIG. 15B-3 shows different exemplary differential cutting members that illustrate some important dimensions and features of the differential cutting member. FIG. 15B-3 shows the differential dissection member as in FIG. 15A. FIG. 15B-3 shows a detailed view of the surface of the differential dissection member shown in FIG. 15B-2. FIG. 15C shows different exemplary differential cutting members that illustrate some important dimensions and features of the differential cutting member. FIG. 15C illustrates another embodiment of a differential dissection member having a scalloped tissue engaging surface. FIG. 15D shows a different exemplary differential cutting member that illustrates some important dimensions and features of the differential cutting member. FIG. 15D shows a perspective view of the differential dissection member shown in FIG. 15C. FIG. 15E-1 shows different exemplary differential cutting members that illustrate some important dimensions and features of the differential cutting member. FIG. 15E-1 shows an end view of the differential dissection member shown in FIG. 15C. FIG. 15E-2 shows different exemplary differential cutting members that illustrate some important dimensions and features of the differential cutting member. FIG. 15E-2 shows a detailed view of the tissue engaging surface of the differential dissection member shown in FIG. 15E-1. FIG. 15E-3 shows different exemplary differential cutting members that illustrate some important dimensions and features of the differential cutting member. FIG. 15E-3 details a very detailed view of the surface features of the differential dissection member shown in FIGS. 15E-1 and 15E-2. FIG. 16-1 illustrates one exemplary means for changing the level of invasiveness of the differential dissection member. FIG. 16-1 illustrates a differential incision member having some pointed but still not sharp features. FIG. 16-2 illustrates one exemplary means for changing the level of invasiveness of the differential dissection member. FIG. 16-2 shows a differential dissection member having more rounding features than shown in FIG. 16-1. FIG. 16-3 illustrates one exemplary means for changing the level of invasiveness of the differential dissection member. FIG. 16-3 shows a differential dissection member having a blunt feature further than that of the differential dissection member shown in FIG. 16-1 or FIG. 16-2. FIG. 17A illustrates how a feature such as a scallop of a tissue engaging surface results in a tissue engaging surface having various angles of attack as it moves over the tissue. FIG. 17A shows a differential dissection member having a leaf morphology. FIG. 17B-1 illustrates how a feature such as a scallop of the tissue engaging surface results in a tissue engaging surface having various angles of attack as it moves over the tissue. FIG. 17B-1 shows that of the same differential incision member impacting the tissue. FIG. 17B-2 illustrates how a feature such as a scallop of the tissue engaging surface results in a tissue engaging surface having various angles of attack as it moves over the tissue. FIG. 17B-2 is a detail view of a leaf-shaped differential dissection member leaf detailing the angle of attack of the tissue engaging surface to the tissue. FIG. 18 shows how the relative placement of the center of rotation and center of gravity of the differential incision member vibration can cause the differential incision instrument to vibrate. FIG. 19A shows how an exemplary differential dissection member or surrounding shroud distorts tissue in a direction perpendicular to the direction of movement of the tissue engaging surface. FIG. 19B shows how an exemplary differential dissection member or surrounding shroud distorts tissue in a direction perpendicular to the direction of movement of the tissue engaging surface. FIG. 19C shows how an exemplary differential dissection member or surrounding shroud distorts tissue in a direction perpendicular to the direction of movement of the tissue engaging surface. FIG. 19D shows how an exemplary differential dissection member or surrounding shroud distorts tissue in a direction perpendicular to the direction of movement of the tissue engaging surface. FIG. 19D illustrates how this strain can align the fiber components within the tissue, thereby facilitating their destruction by the tissue engaging surface. FIG. 20 further includes a method by which the differential dissection member distorts the tissue to destroy fiber components such as interstitial fibers, and illustrates how an exemplary differential dissection member destroys tissue. Yes. FIG. 21A illustrates how the relative movement of the differential cutting instrument shroud and the differential cutting member can change the wedge angle and thus create more or less strain in the tissue. FIG. 21A shows a side view of a differential dissection member having a thin dissection wheel and encased in a shroud. FIG. 21B-1 illustrates how the relative movement of the differential cutting instrument shroud and the differential cutting member can change the wedge angle and therefore create more or less strain in the tissue. FIG. 21B-1 further shows a front view of the shrouded differential dissection member in FIG. 21A. FIG. 21B-2 illustrates how the relative movement of the differential cutting instrument shroud and the differential cutting member can change the wedge angle and thus create more or less strain in the tissue. FIG. 21B-2 further shows a detailed view of the shrouded differential dissection member in FIG. 21A, respectively. FIG. 21C-1 illustrates how the relative movement of the differential cutting instrument shroud and the differential cutting member can change the wedge angle and therefore create more or less strain in the tissue. FIG. 21C-1 shows four different positions of the shroud covering the differential incision member of the differential incision instrument. FIG. 21C-2 illustrates how the relative movement of the differential cutting instrument shroud and the differential cutting member can change the wedge angle and thus create more or less strain in the tissue. FIG. 21C-2 shows four different positions of the shroud covering the differential dissection member of the differential dissection instrument. FIG. 21C-3 illustrates how the relative movement of the differential dissection instrument shroud and the differential dissection member can change the wedge angle and thus create more or less strain in the tissue. FIG. 21C-3 shows four different positions of the shroud covering the differential dissection member of the differential dissection instrument. FIG. 21C-4 shows how the relative movement of the differential dissecting instrument shroud and the differential dissecting member can change the wedge angle and thus create more or less strain in the tissue. FIG. 21C-4 shows four different positions of the shroud covering the differential cutting member of the differential cutting instrument. FIG. 22 shows an example of an exemplary reciprocating mechanism for a differential cutting member that uses a Scotch yoke mechanism to convert shaft rotation to reciprocating vibration of the differential cutting member. FIG. 23A further illustrates the Scotch yoke mechanism shown in FIG. FIG. 23B further illustrates the Scotch yoke mechanism shown in FIG. FIG. 23C further illustrates the Scotch yoke mechanism shown in FIG. FIG. 24A further illustrates the Scotch yoke mechanism shown in FIG. FIG. 24B further illustrates the Scotch yoke mechanism shown in FIG. FIG. 25A further illustrates the scotch yoke mechanism shown in FIG. 22 including how many differential incisions can be covered to reduce trauma to the patient's tissue. FIG. 25B further illustrates the scotch yoke mechanism shown in FIG. 22 including how many differential dissection members can be covered to reduce trauma to the patient's tissue. FIG. 25C further illustrates the scotch yoke mechanism shown in FIG. 22 including how many differential dissection members can be covered to reduce trauma to the patient's tissue. FIG. 25D further illustrates the scotch yoke mechanism shown in FIG. 22 including how many differential dissection members can be covered to reduce trauma to the patient's tissue. FIG. 26A-1 illustrates how an exemplary differential cutting member can be fitted with a retractable blade to allow the differential cutting instrument to also perform a sharp dissection of tissue. FIG. 26A-1 shows a side view. FIG. 26A-1 shows a differential dissection member having a retractable scalpel withdrawn. FIG. 26A-2 illustrates how an exemplary differential dissection member can be fitted with a retractable blade to allow the differential dissection instrument to also perform a sharp dissection of tissue. FIG. 26A-2 shows a plan view. FIG. 26A-2 shows a differential dissection member having a retractable scalpel withdrawn. FIG. 26B-1 illustrates how an exemplary differential cutting member can be fitted with a retractable blade to allow the differential cutting instrument to also perform a sharp dissection of tissue. FIG. 26B-1 shows a side view. FIG. 26B-1 shows the same differential dissection member with the retractable scalpel extended. FIG. 26B-2 illustrates how an exemplary differential cutting member can be fitted with a retractable blade to allow the differential cutting instrument to also perform a sharp dissection of tissue. FIG. 26B-2 shows a plan view. FIG. 26B-2 shows the same differential incision member having an extended retractable knife. FIG. 27A illustrates how an exemplary differential dissection member can be attached with a clasp member to allow the differential dissection instrument to function as a forceps. FIG. 27B illustrates how an exemplary differential incision member can be attached with a clasp member to allow the differential incision instrument to function as a forceps. FIG. 28 illustrates an exemplary differential dissection member having a tissue engaging surface and a lateral surface. FIG. 29A shows an enlarged view of the tissue engaging surface and side of the differential dissection member in FIG. 28 where the tissue engaging surface is composed of alternating rows of valleys and protrusions. FIG. 29B shows an enlarged view of the tissue engaging surface and sides of the differential dissection member in FIG. 28 where the tissue engaging surface is composed of alternating rows of valleys and protrusions. FIG. 29C-1 shows an enlarged view of the tissue engaging surface and sides of the differential dissection member in FIG. 28 where the tissue engaging surface is composed of alternating rows of valleys and protrusions. FIG. 29C-2 shows an enlarged view of the tissue engaging surface and sides of the differential dissection member in FIG. 28 where the tissue engaging surface is composed of alternating rows of valleys and protrusions. FIG. 29C-2 shows details of the corners of the protrusions shown in FIG. 29C-1. FIG. 29D shows an enlarged view of the tissue engaging surface and sides of the differential dissection member in FIG. 28 where the tissue engaging surface is composed of alternating rows of valleys and protrusions. FIG. 29E shows an enlarged view of the tissue engaging surface and sides of the differential dissection member in FIG. 28 where the tissue engaging surface is composed of alternating rows of valleys and protrusions. FIG. 29E-1 shows two alternative versions of the valley and protrusion arrangement that forms the surface of the differential dissection member. FIG. 29E-2 shows an enlarged view of the tissue engaging surface and side of the differential dissection member in FIG. 28 where the tissue engaging surface is composed of alternating rows of valleys and protrusions. FIG. 29E-2 shows two alternative versions of the valley and protrusion arrangement that forms the surface of the differential dissection member. FIG. 30A shows how the outer surface of the differential dissection member in FIGS. 28 and 29A-29C aligns and distorts the tissue containing the interstitial fiber component and how the interstitial fiber component is distorted. Shows how they facilitate alignment, entry into the valley and subsequent tearing by the protrusion. FIG. 30B shows how the outer surface of the differential dissection member in FIGS. 28 and 29A-29C aligns and distorts the tissue containing the interstitial fiber component and how the interstitial fiber component is distorted. Shows how they facilitate alignment, entry into the valley and subsequent tearing by the protrusion. FIG. 30C shows how the outer surface of the differential dissection member in FIGS. 28 and 29A-29C aligns and distorts the tissue containing the interstitial fiber component and how the interstitial fiber component is distorted. Shows how they facilitate alignment, entry into the valley and subsequent tearing by the protrusion. FIG. 30D shows how the outer surface of the differential dissection member in FIGS. 28 and 29A-29C aligns and distorts the tissue containing the interstitial fiber component and how the interstitial fiber component is distorted. Shows how they facilitate alignment, entry into the valley and subsequent tearing by the protrusion. FIG. 31 further illustrates with different lines of sight how the tissue fiber component is distorted and torn by protrusions after entering the valleys. FIG. 32 shows an exploded view of a complete exemplary differential cutting instrument. FIG. 33A shows an enlarged view of the differential dissection member of the differential dissection instrument in FIG. 32 highlighting how the Scotch yoke mechanism allows the axis of rotation to drive the reciprocating vibration of the differential dissection member. Yes. FIG. 33B shows an enlarged view of the differential dissection member of the differential dissection instrument in FIG. 32 highlighting how the Scotch yoke mechanism allows the axis of rotation to drive the reciprocating vibration of the differential dissection member. Yes. FIG. 33C shows an enlarged view of the differential dissection member of the differential dissection instrument in FIG. 32 highlighting how the Scotch yoke mechanism allows the axis of rotation to drive the reciprocating vibration of the differential dissection member. Yes. FIG. 34 shows an exploded view of another exemplary differential dissecting instrument having a retractable blade. FIG. 35A shows an enlarged view of the differential dissection member of the differential dissection instrument in FIG. 34, including a method in which this mechanism can also be used to change the amplitude of the vibration of the differential dissection member. FIG. 35A shows an exploded view of an exemplary differential dissection instrument. FIG. 35B shows an enlarged view of the differential dissection member of the differential dissection instrument in FIG. 34, including a method in which this mechanism can also be used to change the amplitude of the vibration of the differential dissection member. FIG. 35B shows details of an exemplary differential dissection member assembly. FIG. 35C shows an enlarged view of the differential dissection member of the differential dissection instrument in FIG. 34, including a method in which this mechanism can also be used to change the amplitude of vibration of the differential dissection member. FIGS. 35C-1 and 35C-2 illustrate how the angular amplitude of the differential cutting member can be controlled by the longitudinal position of the cam receiver body. FIG. 35C shows an enlarged view of the differential dissection member of the differential dissection instrument in FIG. 34, including a method in which this mechanism can also be used to change the amplitude of vibration of the differential dissection member. FIGS. 35C-1 and 35C-2 illustrate how the angular amplitude of the differential cutting member can be controlled by the longitudinal position of the cam receiver body. FIG. 36A-1 is an exemplary retractable blade that is a retractable hook having a sharpened elbow hook that allows selective slicing of tissue for a more invasive tissue engaging surface and sharp dissection. Is shown. FIG. 36A-1 shows the hook extended from the differential incision member. FIG. 36A-2 illustrates an exemplary retractable blade that is a retractable hook with a sharpened elbow hook that allows selective slicing of tissue for a more invasive tissue engaging surface and sharp dissection. Is shown. FIG. 36A-2 shows the hook retracted into the differential incision member. FIG. 36B-1 is an exemplary retractable blade that is a retractable hook having a sharper elbow hook that allows selective slicing of tissue for a more invasive tissue engaging surface and sharp dissection. Is shown. FIG. 36B-1 shows the extended hook. FIG. 36B-1 shows the differential dissection member in the rest position. FIG. 36B-2 is an exemplary retractable blade that is a retractable hook having a sharper elbow hook that allows selective slicing of tissue for a more invasive tissue engaging surface and sharp dissection. Is shown. FIG. 36B-2 shows the extended hook. FIG. 36B-2 shows a differential cutting member that vibrates actively. FIG. 36B-3 is an exemplary retractable blade that is a retractable hook having a sharper elbow hook that allows selective slicing of tissue for a more invasive tissue engaging surface and sharp dissection. Is shown. FIG. 36B-3 shows the stored hook. FIG. 36B-3 shows the differential dissection member in the rest position. FIG. 36B-4 is an exemplary retractable blade that is a retractable hook with a sharpened elbow hook that allows selective slicing of tissue for a more invasive tissue engaging surface and sharp dissection. Is shown. FIG. 36B-4 shows the stored hook. FIG. 36B-4 illustrates a differential incision member that actively vibrates. FIG. 37-1 illustrates how the retractable hook shown in FIGS. 36A and 36B can be used to quickly and safely split membrane structures such as the peritoneum. FIG. 37-1 shows the hook extended from the tip of the differential dissecting member that is stationary when the differential dissecting instrument is suspended by the surgeon over the patient's tissue. FIG. 37-2 illustrates how the retractable hook shown in FIGS. 36A and 36B can be used to quickly and safely split a membranous structure such as the peritoneum. FIG. 37-2 shows a hook that extends from a vibrating differential dissection member and thus vibrates against the surface of the tissue. FIG. 37-3 illustrates how the retractable hook shown in FIGS. 36A and 36B can be used to quickly and safely split a membranous structure such as the peritoneum. FIG. 37-3 shows a stationary differential dissection member having an elongated hook that engages the edge of the tissue capsule. FIG. 37-4 illustrates how the retractable hook shown in FIGS. 36A and 36B can be used to quickly and safely split membrane structures such as the peritoneum. FIG. 37-4 shows a differential dissection member that has an elongated hook and vibrates, thus cutting the tissue capsule layer. FIG. 38 shows a complete exemplary differential dissecting instrument having a pistol grip and the ability to rotate the instrument insertion tube and thus rotate the vibrating surface of the differential dissecting member. FIG. 39 shows how an exemplary differential dissection instrument can be attached to the arm of a surgical robot and, if necessary, a conductive patch for electrocautery can be attached. . FIG. 40-1 shows an exemplary laparoscopic version of a differential dissection instrument having an electromechanical actuator distal to the joint in a linear position. FIG. 40-2 shows an exemplary laparoscopic version of a differential dissection instrument having an electromechanical actuator distal to the joint in a curved position. FIG. 41 shows one exemplary version of a differential dissection instrument driven by a flexible drive shaft. FIG. 42A shows a perspective view and an enlarged view of one embodiment of a differential dissection instrument in the form of a slender pencil grip specifically designed for open surgery. FIG. 42B shows a perspective view and an enlarged view of one embodiment of a differential dissection instrument in the form of a slender pencil grip specifically designed for open surgery. FIG. 42C shows a perspective view and an enlarged view of one embodiment of a differential dissection instrument in the form of a slender pencil grip specifically designed for open surgery. FIG. 42D shows a perspective view and an enlarged view of one embodiment of a differential dissection instrument in the form of a slender pencil grip specifically designed for open surgery. FIG. 42E shows a perspective and enlarged view of one embodiment of a differential dissection instrument in the form of a slender pencil grip specifically designed for open surgery. FIG. 43A shows different embodiments of several mechanisms that can drive the vibration of the differential dissection member. FIG. 43B shows different embodiments of several mechanisms that can drive the vibration of the differential dissection member. FIG. 43C illustrates different embodiments of several mechanisms that can drive the vibration of the differential dissection member. FIG. 44A shows a different embodiment of a mechanism that protects both the differential dissecting instrument and the incised tissue from excessive loading. FIG. 44A shows a different embodiment of a mechanism that protects both the differential dissecting instrument and the incised tissue from excessive loading. FIG. 44B shows a different embodiment of a mechanism that protects both the differential dissecting instrument and the incised tissue from excessive loading. FIG. 44C shows a different embodiment of a mechanism that protects both the differential dissecting instrument and the incised tissue from excessive loading. FIG. 44C shows a different embodiment of a mechanism that protects both the differential dissecting instrument and the incised tissue from excessive loading. FIG. 45A illustrates a method of using a differential dissection instrument to separate tissue surfaces without damaging blood vessels and other anatomical structures at the tissue surface. FIG. 45B illustrates a method of using a differential dissecting instrument to separate tissue surfaces without damaging blood vessels and other anatomical structures at the tissue surface. FIG. 45C illustrates a method of using a differential dissection instrument to separate tissue surfaces without damaging blood vessels and other anatomical structures at the tissue surface. FIG. 45D illustrates a method of using a differential dissection instrument to separate tissue surfaces without damaging blood vessels and other anatomical structures at the tissue surface. FIG. 45E illustrates a method of using a differential dissection instrument to separate tissue surfaces without damaging blood vessels and other anatomical structures at the tissue surface. FIG. 45F illustrates a method for using a differential dissection instrument to separate tissue surfaces without damaging blood vessels and other anatomical structures at the tissue surface. FIG. 45G illustrates a method of using a differential dissecting instrument to separate tissue surfaces without damaging blood vessels and other anatomical structures at the tissue surface. FIG. 46A-1 shows an instrument for tunneling with a differential dissecting instrument coupled to an endoscope. FIG. 46A-2 shows an instrument for tunneling with a differential dissecting instrument coupled to an endoscope. FIG. 46B-1 illustrates an instrument for tunneling with a differential dissecting instrument coupled to an endoscope. FIG. 46B-2 shows an instrument for tunneling with a differential dissecting instrument coupled to an endoscope. FIG. 46C-1 shows an instrument for tunneling with a differential dissecting instrument coupled to an endoscope. FIG. 46C-2 shows an instrument for tunneling with a differential dissecting instrument coupled to an endoscope. FIG. 47A-1 illustrates another instrument for tunneling with a differential dissecting instrument coupled to an endoscope, including an accessory to enhance the incision and improve the field of view of the endoscope. ing. FIG. 47A-2 shows another instrument for tunneling with a differential dissecting instrument coupled to an endoscope, including an accessory for strengthening the incision and improving the field of view of the endoscope. ing. FIG. 47B-1 illustrates another instrument for tunneling with a differential dissecting instrument coupled to an endoscope, including an accessory to enhance the incision and improve the endoscope's field of view. ing. FIG. 47B-2 illustrates another instrument for tunneling with a differential dissecting instrument coupled to an endoscope, including an accessory to enhance the incision and improve the field of view of the endoscope. ing. FIG. 47C illustrates another instrument for tunneling with a differential dissecting instrument coupled to an endoscope, including an accessory for enhancing the incision and improving the field of view of the endoscope. . FIG. 47D illustrates another instrument for tunneling with a differential dissecting instrument coupled to an endoscope, including an accessory for enhancing the incision and improving the field of view of the endoscope. .

  The illustrated embodiment includes a method and apparatus for blunt dissection that does not destroy the patient's strong tissue but differentially destroys the patient's soft tissue. In one embodiment, a differential cutting instrument for differentially cutting complex tissue is disclosed. The differential dissecting instrument includes a handle, a longitudinal central axis, and an elongated member having a proximal end and a distal end. The differential dissecting instrument also includes a differential dissecting member configured to be rotatably attached to the distal end, the differential dissecting member including at least one tissue engaging surface and a rotational axis of the differential dissecting member. At least one tissue engaging surface in at least one direction relative to the composite tissue by mechanically rotating a differential incision member about a rotational axis and a first torque point disposed on the first side of the And a mechanism configured to move. The mechanism includes at least one force transmitting member having a distal end and a proximal end attached to the first torque point member. The proximal end of the at least one force transmission member is attached to a power source configured to vibrate the differential dissection member. Furthermore, the at least one tissue engaging surface moves when the differential incision member is pressed against the patient's composite tissue by the surgeon, so that the at least one tissue engaging surface moves across the composite tissue. The mating surface is configured to selectively engage the composite tissue so as to destroy at least one soft tissue in the composite tissue, but not to destroy the hard tissue in the composite tissue.

  Specifically, a “differential dissection instrument” is disclosed. The term “discriminatory” is used because a differential dissecting instrument can destroy soft tissue while avoiding firm tissue destruction. The effector end of the differential dissecting instrument can be pressed against tissue composed of both hard and soft tissue, and soft tissue is broken much more easily than hard tissue. Therefore, when the differential cutting instrument is pressed into the composite tissue, the differential cutting instrument destroys the soft tissue and thereby exposes the hard tissue. This discriminatory action is automatic and is a function of the device design. Caution requires less attention to the operator than traditional methods for blunt dissection, and the risk of accidental damage to tissue is greatly reduced.

  For the purposes of this patent application, “soft tissue” is defined as various soft tissues that are separated, torn, removed or otherwise generally broken into blunt dissections. “Target tissue” is defined as tissue that is isolated and preserves its integrity, such as blood vessels, gallbladder, urethra, or nerve bundles, during blunt dissection. “Strong tissue” is defined as tissue that is mechanically strong and usually comprises one or more layers of tightly packed collagen or other extracellular fibrous matrix. Examples of rigid tissue include vessel walls, nerve fiber sheaths, fascia, tendons, ligaments, gallbladder, pericardium and many others. “Composite tissue” is a tissue composed of both soft tissue and strong tissue, and can include a target tissue.

  3A, 3B and 3C show the effector end of a differential dissecting instrument 300 that can differentially destroy soft tissue without destroying hard tissue. In this embodiment, the cutting member comprises a cutting wheel 310 that rotates about a shaft 320 held inside a cavity 331 inside the shroud 330. FIG. 3A shows the separate parts. 3B and 3C show two different views of the assembly. The incision wheel 310 is rotated by any of several mechanisms such as a motor or a manually driven drive with appropriate transmission means. The incision wheel 310 has a tissue engaging surface 340 that can grip and break soft tissue rather than hard tissue. Examples of the tissue engaging surface 340 and the cutting wheel 310 include a diamond grinding wheel or grinding stone or a surface otherwise covered by a small obtrusion or protrusion (defined further below) from the surface. The shroud 330 covers a portion of the cutting wheel 310 so that only a portion of the cutting wheel 310 is exposed. In use, the cutting wheel 310 rotates at a speed ranging from about 60 (60) to about 25,000 (25,000) rpm or from about 60 (60) to about 100,000 (100,000) rpm. Is selectable by the operator. Further, the direction of rotation of the incision wheel 310 can be reversed by the operator. Alternatively, the cutting wheel 310 can vibrate (reciprocate) at a frequency in the range of about 60 to about 20,000 (20,000) cycles per minute in one embodiment. In other embodiments, the cutting wheel 310 can oscillate (reciprocate) at a frequency in the range of about 2,000 to 1,000,000 cycles per minute.

  The incision wheel 310 is an example of a “differential dissection member” (hereinafter “DDM”) capable of differentially destroying soft tissue rather than hard tissue. FIG. 3D shows a side, front and perspective view of one embodiment of the DDM 350 separated from the remainder of the differential dissecting instrument 300 for clarity. The DDM 350 includes a main body 360 having a rotation shaft 365 around which the main body 360 rotates. The rotation can be oscillatory (ie, back and forth) or continuous. The body 360 has an outer surface 361 having a tissue engaging surface 370 distributed over at least a portion of the outer surface 361 of the body 360. The non-tissue engaging surface 371 is a part of the outer surface 361 that is not covered by the tissue engaging surface 370. In this embodiment, the portion of the outer surface 361 that contacts the tissue, particularly the tissue engaging surface 370 should not have sharp enough features to slice the tissue, so a knife edge (such as a scalpel or scissors) , There must be no sharp teeth (such as saws), sharp corners and sharp edges (such as drill bits or arthroscopic shavers) fluting. Here, sharp means that it has a radius of curvature of less than 25 μm. The typical maximum dimension of a DDM is between about 3 (3) to about 20 (20) millimeters (mm). Alternatively, a small version for microsurgery takes between about 2 (2) to about 5 (5) mm.

The tissue engaging surface 370 is further comprised of a plurality of protrusions 375 (shown in the enlarged detailed views of FIGS. 3D-1 to 3D-3) from the outer surface 361 of the body 360, each protrusion 375 being And a protrusion length 380 measured from the valley to the peak in a direction substantially perpendicular to the local region of the outer surface 361 of the body 360. The different protrusions 375 on the tissue engaging surface 370 can all have the same protrusion length 380 or they can have different protrusion lengths 380. The protrusion 375 preferably has a protrusion length 380 of less than about 1 (1) mm. Alternatively, for some embodiments, the protrusion length can be greater than about 1 (1) mm but less than about 5 (5) mm. In summary, all the protrusions 375 on the tissue engaging surface 370 have an average protrusion length (P _avg ). The protrusions 375 are separated by a gap 385 that preferably spans a distance of about 0.1 mm to about 10 (10) mm.

Referring now to FIGS. 3D-1 to 3D-3, FIGS. 3D-1 to 3D-3 show front and side views of the differential dissection member. 3D-1 is a side view of the differential incision member, while FIG. 3D-2 shows details of the surface of the differential incision member, and FIG. 3D-3 is a front view of the same differential incision member Is shown. The body 360 of FIGS. 3D-1 to 3D-3 can be shaped such that the tissue engaging surface 370 is located at various distances from the rotational axis 365, if desired. Therefore, the placement radius R can be measured in a plane perpendicular to the rotational axis 365 from the rotational axis 365 to any point on the tissue engaging surface 370. Therefore, there is a minimum placement radius R _min with the shortest length and a maximum placement radius R _max with the maximum length, as shown in FIGS. 3D-1 to 3D-3 and FIGS. 3E-1 to 3E-4. In addition, R _min is greater than zero whenever the tissue engaging surface 370 does not completely cover the surface 361 of the DDM 350. Therefore, (R _max −R _min ) is greater than zero when the body 360 is shaped such that the tissue engaging surface 370 is disposed at various distances from the rotational axis 365. In some embodiments of DDM, this relationship (R _max −R _min ) is greater than about 1 (1) mm. In other embodiments, this relationship (R _max −R _min ) is greater than P _avg . Alternatively, as shown in the examples in FIGS. 3D-1 to 3D-3 and FIGS. 3E-1 to 3E-4, R _min is generally at least 5% shorter than R _max . Typical sizes for DDM are R _min > about 1 (1) mm and R _max <about 50 (50) mm. However, a small version for micro incision can have smaller dimensions consisting of R _min > about 0.5 mm and R _max <about 5 (5) mm.

  Referring now to FIGS. 3E-1 through 3E-4, four different embodiments of the DDM are shown in side views where the rotation axis 365 is perpendicular to the page plane. As described in subsequent paragraphs, the cross-sectional shape of the DDM in a plane perpendicular to the axis of rotation 365 is important. The following are four scenarios for the cross-sectional shape of the DDM.

DDM type I: The cross-sectional shape can be any shape other than a circular or circular wedge. The rotation axis 365 is located at an arbitrary point in the cross section as shown in FIGS. 3D-1 to 3D-3 that produces the result P _avg <(R _max −R _min ). As shown in FIGS. 3D-1 to 3D-3, DDM Type I has regular and irregular cross sections including various asymmetries, wavy / undulation / scallop boundaries, cutouts, involute boundaries, etc. Shapes can be included. In this example, DDM type I reciprocates between two end positions (broken line contours). Alternatively, the action can be rotation.

DDM type II: The cross-sectional shape is a circular or circular wedge. The rotation axis 365 is located at an arbitrary point in the cross-section so as to produce the result P _avg <(R _max −R _min ) (ie, the rotation axis 365 is not near the center of the circle).

DDM type III: The cross-sectional shape is a circular or circular wedge. The axis of rotation 365 is located at any point in the cross-section sufficiently close to the center of the circle to produce a result from P _avg (R _max −R _min ) (ie, the axis of rotation 365 is approximately the center of the circle Is).

DDM type IV: The cross-sectional shape is an element that repeats regularly on the outer periphery, such as scallop, which produces a result of P _avg <(R _max −R _min ) wherever the rotation axis 365 is located including the center of the cross-sectional shape Have Type I DDM and Type IV DDM are closely related in that the axis of rotation 365 can be anywhere in the cross-sectional shape and can produce the result P _avg <(R _max −R _min ). .

  Any regularly repeating element of scalloping, undulation or DDM does not include perforations or holes in the tissue engaging surface 370 because the walls of the perforations do not significantly contact the tissue. For example, the suction passage disclosed in US Pat. No. 6,423,078 includes a hole in the polishing surface that acts as a tissue engaging surface of the polishing member. These holes do not have the features disclosed for DDM because the holes act only as fluid ports at the tissue engaging surface and the walls of the suction passage do not burden the tissue. Nevertheless, the DDM disclosed herein can include suction passages such as these.

  Type I to IV DDMs can also include any of a variety of shapes other than page surfaces. As described above, “the cross-sectional shape of the DDM in a plane perpendicular to the rotation axis 365 is important”. Therefore, the cutting wheel 310 in FIGS. 3A-3C is an example of DDM type III.

  3F-1 and 3F-2 illustrate a DDM 390 similar to the DDM 350 shown in FIGS. 3D-1 to 3D-3. The DDM 390 has a first end and a second end 392, the first end 391 is directed away from the composite tissue 399, such that the DDM 390 rotates about the axis of rotation 365 by the mechanism. Is rotatably engaged with a mechanism (not shown). The mechanism can include electric and manual drives. The second end 392 is directed to the composite tissue 399 and has a semi-ellipsoidal shape defined by three orthogonal semi-axes, a major semi-axis A, a first minor semi-axis B, and a second minor semi-axis C. The major half axis A is in the direction of the line connecting the first end 391 and the second end 392, and the minor half axis C is parallel to the rotational axis 365 (ie, A is the rotational axis). The short semi-axis B is perpendicular to both the long semi-axis A and the short semi-axis C. A semi-ellipsoid can have a predetermined range of shapes (eg, different relationships between the lengths of the three semi-axes, including A = B = C, A ≠ B ≠ C, A> B and A> C. May be). In one embodiment, A> B> C has been found to be very effective for DDM.

  FIGS. 4A-4C illustrate how the effector end of the differential dissecting instrument 300 can be used to dissect a composite tissue composed of both soft and hard tissue, and the DDM is an incision wheel 310. . In FIG. 4A, the surgeon begins to rotate the incision wheel 310 as indicated by arrow 410 before or when contacting the soft tissue 400. In FIG. 4B, the surgeon then presses the exposed tissue engaging surface 340 of the incision wheel 310 against the mass of soft tissue 400 for blunt dissection to reach into the target tissue 420. Arrows 430 and 440 in FIG. 4B illustrate two possible surgeon performing operations of the differential dissecting instrument 300. Only a portion of the tissue engaging surface 340 of the incision wheel 310 exposed outside the shroud 330 contacts the soft tissue 400, thereby destroying the portion of the soft tissue 400 that contacts the tissue engaging surface 340. The tissue can be destroyed because the exposed moving portion of the tissue engaging surface 340 can break the tissue without further action by the surgeon (eg, without the surgeon's forced scrubbing of the differential dissection instrument 300 relative to the soft tissue 400). It can be easily broken by adding the rotating cutting surface 340 of the cutting wheel 310 to any part of the soft tissue 400, but if the cutting wheel 310 contacts the hard tissue of the target tissue 420, it will Do not destroy. It should be noted here that pressing the incision wheel 310 against the soft tissue 400 as indicated by the arrowheads at arrow 430 is “plunge” —because it does not destroy the hard tissue and therefore does not destroy the target tissue 420. The incision wheel 310 can be pressed against the soft tissue 400 by groping. Other motions of the differential dissecting instrument 300 include motions orthogonal to arrows 430 and 440, curvilinear motions and other 3D motions that can be used to dissect soft tissue 400. Once the target tissue 420 is exposed, the differential dissection instrument 300 can expose and remove the target tissue 420, as shown in FIG. 4C.

  4D-4F illustrate one embodiment of DDM, how to destroy soft tissue without destroying strong tissue. FIG. 4D shows a cross-sectional view of a DDM as an incision wheel 310 having a tissue engaging surface 340 having protrusions 375. The incision wheel 310 moves in and out of the page surface by an axis 320 (not shown) substantially parallel to the page surface. Therefore, the protrusion 375 moves across the page surface. FIG. 4D further illustrates the mass of soft tissue 400 that remains substantially in place as the cutting wheel 310, tissue engaging surface 340, and protrusion 375 move across the page surface. Considering the movement of the protrusion 375 relative to the soft tissue 400 that is substantially stationary, the incision wheel 310 destroys the soft tissue 400. Specifically, the soft tissue 400 is composed of both the fiber component 401 and the gel substance 402. (Soft tissue is frequently composed of extracellular material having fiber components 401 such as collagen fibers and small bundles of fibers and thin sheet components such as thinner membranes dispersed in water-swollen gel-like material. ) The protrusions 375 can sweep the gel-like material 402 so that they encounter and grab the individual fiber components 401 (eg, at points 450 and 451), and the fiber components 401 It is torn by the relative movement of the protrusion 375 on the cutting wheel 310 across the soft tissue 400. As the cutting wheel 310 is pressed deeply against the tissue 400, the protrusions 375 grab the fiber components deeper and tear them as well. Therefore, soft tissue 400 with dispersed components can be incised by DDM.

  FIG. 4E shows how tightly packed fibrous tissue can withstand incision by the incision wheel 310, in contrast to FIG. 4D. The rigid tissue 403 is frequently composed of fiber components 401 tightly packed in parallel, crossed or in other organized arrangements (eg, fascia and vessel walls) or tightly packed 2D and 3D meshes. The gel substance 402 covers the array of fiber components 401. In FIG. 4E, the hard tissue 403 is depicted with a tightly packed fiber component 401, with their long axis perpendicular to the page plane, and therefore the filament layer in which the cross section of the fiber component 401 is depicted as a circle. It is comprised from the gel-like substance 402 (stipple area | region) which covers thinly. In this image, the incision wheel 310 reciprocates to the left and right of the page as indicated by the arrow 405 and sweeps the protrusion 375 across the surface of the strong tissue 403. Due to the tight clogging of the fiber component 401 in the rigid tissue 403, the protrusion 375 cannot be engaged and gripped separately from the fiber component 401, and therefore applies sufficient stress to tear the fiber component 401. I can't. Furthermore, the gel-like substance 402 functions as a lubricant, and causes the protrusion 375 to slip on the fiber component 401 tightly packed in the strong tissue 403. Finally, any conformity of the surface of the hard tissue 403 exposed to the cutting wheel 310 prevents tensioning in the hard tissue 403 or the fiber component 401 and deflects the hard tissue 403 from any pressure exerted by the cutting wheel 310. Bring. Therefore, the hard tissue 403 resists failure by DDM by a combination of tightly packed fiber and sheet components 401, lubrication of these components by the gel material 402 and the compatibility of the hard tissue 403.

  As mentioned above, the operation of DDM can be either rotation or vibration. The speed of a point on the DDM past a particular area of tissue strongly affects the ability of the DDM to destroy that tissue. FIG. 4F shows an incision wheel 310 that sweeps across the soft tissue 400 by contact 470 (as indicated by double arrow 460) left and right within the page plane. The translation speed of the contact 470 is determined by the rotational speed of the DDM and the distance 480 that separates the contact 470 from the center of rotation (not shown). For rotational motion, the translational speed is equal to 2πDω, where D is the distance 480 and ω is the rotational frequency in rotations per second. For oscillating motion, the translational speed is equal to Dψ2X, where D is the distance 480, ψ is the oscillating frequency in cycles per second, and X is the sweep angle in radians. For a differential incisor, the distance 480 ranges from about 1 (1) mm to about 40 (40) mm and the rotational speed ranges from about 2 (2) revolutions per second to about 350 (350) revolutions per second. The vibration frequency ranges from about 2 (2) Hertz (Hz) to about 350 (350) Hz, and the sweep angle ranges from 2 ° to 270 °. Therefore, the translation speed of contact 470 on the differential incisor can range from about 1 (1) mm per second to about 60,000 (60,000) mm per second. In one embodiment, an oscillating motion having a distance 480 of about 15 (15) mm and a frequency of about 100 (100) Hz sweeping over about 45 degrees (45 °), producing about 2400 (2400) mm per second Is very effective for many soft tissues. Note that this is because the speed of the action performed by the operator (as shown in FIG. 4) is such that the instruments move only slowly because the surgeon is paying attention during the incision. Without (usually much less than 100 (100) mm per second), meaning that it is always less than the speed of the contacts on the DDM during the incision. Furthermore, the operation of the DDM is described throughout this document as arising from rotational motion (continuous rotation or reciprocation, ie back and forth, vibration). However, as described above, any operation of the DDM can be used, including linear movement with respect to the tissue such that the tissue engaging surface of the DDM properly engages the tissue.

  DDM can be pressed against vascular walls, pleura, pericardium, esophagus, gallbladder and almost any other organ or tissue composed of or covered by tightly packed fibrous tissue, It does not significantly destroy such strong structures under light pressure. Conversely, DDM can be pressed against the mesentery or other soft tissue, which soft tissue is rapidly destroyed under light pressure. A differential dissection instrument that fits any one of the various DDMs disclosed herein is for dissecting the inner thoracic artery away from the inner wall of the chest to quickly dissect between the planes of the lobes. To separate the blood vessels and bronchioles in the hilar lobe, to incise the esophagus from the surrounding tissue, rather than through the fiber bundles, rather than from the muscle fibers to penetrate between To dissect fascia and tendon, to clean the dissected fascia, to expose branching vessels and lymphatic structures, to open a pocket in tissue, and many It has been found by the present inventor to separate tissue planes in different tissues. The utility of differential cutting instruments is wide and therefore has many potential uses. Importantly, due to the composition of the skin and surgical gloves, the skin and surgical gloves are not cut or destroyed by DDM, even when subjected to high pressure. The inventors have shown that a vibration DDM of the type disclosed herein can be held against the facial cheek without any harm. Therefore, differential dissection instruments are inherently safe to use and simplify use during surgery, especially when the surgeon's finger must be near the incision point.

  The DDM is preferably formed from a rigid material (eg, 70 or more Shore A), such as a metal or rigid polymer, rather than a soft polymer and elastomer (eg, less than 70 Shore A). The use of a rigid material keeps the protrusions from the tissue engaging surface deflecting away from the tissue as may occur if a soft material is used. The DDM or components thereof are from bulk material constructed by stereolithography, molded by any means known in the art (eg, injection molding) or by any such method known in the art. Can be processed.

  The protrusion of the tissue engaging surface of the DDM can be manufactured by any of several means. The protrusions can be formed by coating the tissue engaging surface with a grit similar to sandpaper using a grit that is coarser than 1000 but finer than 10 in the Coated Abrasives Manufacturers standard. it can. The grit can include particles made of diamond, carborundum, metal, glass, sand, or other materials known in the art. The protrusions can be formed on the surface of the material comprising the DDM by sanding, sandblasting, machining, chemical treatment, electrical discharge machining, or other methods known in the art. The protrusions can be molded directly on the surface of the DDM. The protrusions can be formed on the surface by stereolithography. The protrusions can be irregularly shaped, similar to the grit particles, or they can be regularly shaped with defined, faceted, curved or inclined surfaces. Can. The protrusions may be elongated and the major axis of these protrusions may be angled with respect to the tissue engaging surface. The protrusion has a cross-sectional shape when the tissue engaging surface is viewed from above, and this shape may be a circle, a facet, or a composite. The cross-sectional shape of the protrusion may be oriented with respect to the moving direction of the DDM.

  Maintaining tissue wetting helps with a differential incision. Fully wet solid structures are lubricated and greatly reduce DDM failure. Conversely, well-wet soft tissue swells with water and remains soft, separating the spacing of individual fibers and promoting them to be engaged and torn by protrusions from the tissue-engaging surface of the DDM To do. Tissue wetting can be achieved by any of several means including simply moistening the tissue with saline during the incision. Wetting can be performed using procedures already used in surgery, such as a wetting line, or by one of the devices disclosed below. In addition, wetting the tissue, and hence the tissue engaging surface of the DDM, reduces clogging of the tissue engaging surface by the destroyed tissue.

  FIGS. 5A and 5B show another embodiment of the effector end of a differential dissecting instrument 500 according to DDM type III configured as a cylinder 510. FIG. 5A shows a cylinder 510 having another axis 520 that is separate from the shroud 530. The tissue engaging surface 540 covers the side surface of the cylinder 510. A double-headed arrow indicates rotation about the rotation axis 575. FIG. 5B shows both portions configured to use only a limited portion of the exposed tissue engaging surface 540.

  FIGS. 5C-1 and 5C-2 show other embodiments of the effector end of the differential dissection instrument having different configurations for the shroud and DDM, here other DDM type III. FIGS. 5C-1 and 5C-2 illustrate a differential cutting instrument 550 having a cutting wheel 560 having a shaft 570 that is separate from the shroud 580. The tissue engaging surface 590 covers the periphery of the incision wheel 560. A double-headed arrow indicates the rotation shaft 575. FIG. 5C-2 shows both portions configured for use with only a limited portion of the exposed tissue engagement surface 590. FIG. This configuration is problematic because it makes it difficult for the shroud 580 to position the tissue engaging surface 590 relative to the tissue, and the shroud 580 blocks the operator's view.

  FIG. 6A illustrates one embodiment of a differential dissecting instrument 600 that includes a surgeon's handle 610. The handle 610 connects an elongate member 620 comprising a first end 621 connected to the handle 610 and a second end 622 connected to the DDM 630. The elongate member 620 can be shortened to allow better manual control of the DDM 630 in the surgical instrument under direct vision or it can be lengthened and the differential dissecting instrument 600 is a laparoscopic instrument Is possible. A drive mechanism that rotates the DDM 630, such as a scotch yoke or a crank / slider rotary drive shaft, is easily adapted to any elongated member 620, long or short, or any device capable of driving the DDM 630. The DDM 630 has a second end 622 such that the DDM 630 reciprocates about its rotational axis 640 as indicated by the double arrow (the rotational axis 640 is orthogonal to the page plane in FIG. 6A). 3 is a type III DDM rotatably attached to the elongated member 620. First end 621 and second end 622 define a centerline 650 of elongate member 620. The tangent line 651 of the center line 650 as the center line 650 approaches the second point 622, and therefore the axis of rotation 640 defines a presentation angle 670 (not shown—perpendicular to the page). In this example, presentation angle 670 is 90 ° (ie, axis of rotation 640 is aligned perpendicular to tangent 651). Rather than the handle 610, the first end 621 of the elongate member 620 can be attached to a robotic arm for robotic surgery. The DDM can be easily adapted to any other device capable of moving or rotating the DDM.

  FIG. 6B shows another embodiment of a similar differential dissecting instrument 601 having a rotation axis parallel to the centerline. The handle 610 is connected to an elongated member 620 that includes a first end 621 connected to the handle 610 and a second end 622 connected to a Type III DDM 631. The DDM 631 is rotatably attached to the elongated member 620 at the second end 622 so that the DDM 631 reciprocates around the rotation shaft 640. The rotation axis 640 is parallel to the page surface in FIG. 6B. The first end 621 and the second end 622 define the centerline 650 of the elongate member 620 by a tangent 651 so that the centerline 650 approaches the second point 622. Therefore, the rotation axis 640 is aligned parallel to the tangent line 651 (ie, the presentation angle 670 is 0 °). (Also in this case, the presentation angle 670 is not presented in FIG. 6B because the presentation angle is 0 °). Therefore, the differential dissecting instrument 601 is similar to the differential dissecting instrument 550 in FIG. 5C, and thus positioning the tissue engaging surface of the DDM 631 relative to the tissue without interrupting the operator's view. Has similar limitations including difficulty.

  FIG. 6C illustrates another embodiment of a differential dissecting instrument 603 having a curved elongated member 620 having a center line 650 curved so that the center line 650 approaches the second point 622 and a tangent 651 to the center line 650. Is shown. The axis of rotation 640 is perpendicular to a tangent 651 that forms a presentation angle 670 that is 90 ° in this example. The elongate member 620 may be similarly curved, joined, articulated, or formed from a plurality of parts. In all cases, the presentation angle 670 is formed by the DDM axis of rotation and the tangent to the centerline so that it approaches the second point 622.

  FIG. 6D shows another embodiment of a differential dissection instrument 604 similar to the differential dissection instrument 602 in FIG. 6B. The handle 610 is connected to an elongated member 620 that includes a first end 621 connected to the handle 610 and a second end 622 connected to a Type III DDM 631. The DDM 631 is rotatably attached to the elongated member 620 at the second end 622 so that the DDM 631 reciprocates around the rotation shaft 640. The rotation axis 640 is parallel to the page surface in FIG. 6D. The first end 621 and the second end 622 define the center line 650 of the elongate member 620 by a tangent 651 so that the center line 650 approaches the second end 622. Therefore, the rotation axis 640 is aligned at a non-zero angle with respect to the tangent 651 (ie, the presentation angle 670 is between 0 ° and 90 °). In a preferred embodiment, the presentation angle 670 is not equal to 0 ° for the reasons described for the differential dissecting instrument 603 in FIGS. 5C and 6B.

  7A and 7B show another embodiment of the effector end of a differential dissecting instrument 700 that uses a dissecting wire 710 as a DDM. FIG. 7A shows the assembled device. The cutting wire 710 protrudes from the backing surface 726 of the shroud 730 by a distance 725, and the cutting wire 710 exits the first post 720 and extends to the gap 722 and to the second post 721 at the end of the shroud 730. enter. The cutting wire 710 is a continuous loop of wire that is driven so that the exposed portion of the cutting wire 710 moves across the gap 722 in FIG. 7A in the direction indicated by arrow 723.

  FIG. 7B shows a schematic side view of this embodiment of the differential dissecting instrument 700 depicting the dissecting wire 710 and the loop of the drive mechanism. The cutting wire 710 is a continuous loop that exits the first post 720 after passing through the first idler bearing 750 housed in the first post 720. The cutting wire 710 moves across the gap 722, moves in the direction of arrow 723, and enters the second post 721 as it passes through the second idler bearing 751. The loop of the cutting wire 710 further returns to the shroud 730 when passing through a drive wheel 760 that is rotated by a motor in the direction of the curved arrow 724, for example. Therefore, rotation of the drive wheel 760 drives the cutting wire 710. Note that the cutting wire 710 can be a flexible linear element having any cross-sectional shape, so that instead of a wire with a circular cross-sectional shape, the cutting wire 710 has an outer surface with a tissue engaging surface. That is, it can be a flexible flat belt having side faces. Similarly, the cutting wire 710 can be a flexible cord having a larger diameter than allowing the wire to pivot through idler bearings 750 and 751, wherein the flexible cord is tissue engaging. Has a surface. Further, the distance 725 between the cutting wire 710 and the backing surface 726 can be arbitrarily increased or decreased, for example, the distance 725 can include the cutting wire 710, the backing surface 726 and the first post 720 and the first post 720. It can be large enough to form a solid region surrounded by two posts 721 and therefore surround the target tissue to be removed. In contrast, the distance 725 can be zero if the cutting wire 710 moves along the surface of the shroud 730 or from behind the narrow receiving groove that supports the cutting wire 710. Such a receiving groove may have a semi-circular cross-sectional shape, thus exposing only a portion of the cross-sectional shape of the cutting wire 710 to the tissue to be cut. Further, the shape of the backing surface 726 can be flat, or it can be slightly or significantly curved, and the curved surface can have a convex region, a concave region, or a combination thereof.

  8A-8C illustrate the effector end of a differential dissecting instrument 800 that uses a flexible belt as the DDM. FIG. 8A shows the separate parts. The flexible belt 840 has an outer tissue engaging surface 850. The flexible belt 840 moves across an idler wheel 810 that rotates about an axis 820 that is all contained within the shroud 830.

  FIG. 8B shows the assembled effector end of the differential dissecting instrument 800 having a limited portion of the tissue engaging surface 850 of the exposed flexible belt 840.

  FIG. 8C shows a schematic plan view of an example of how a flexible belt, such as flexible belt 840, can be driven. The idler wheel 810 and the drive wheel 860 are attached to the inside of the shroud 830. The flexible belt 840 is wound around the idler wheel 810 and the drive wheel 860. The drive wheel 860 is powered so as to rotate so that the flexible belt 840 is driven in the direction indicated by the curved arrow 870. The tissue engaging surface 850 exposed to the outside of the shroud 830 is used to break the tissue. The drive wheel 860 can be driven by any of several mechanisms such as a motor, hand crank, and the like. The drive wheel 860 and idler wheel 810 need not be right circular cylinders, and their rotational axes need not be parallel.

  The degree of exposure of the tissue engaging surface outside the shroud can be greater or less than that shown in the previous example. In practice, changing the exposure changes several aspects of the operation of the differential dissection instrument.

  First, large exposure increases the exposed area of the tissue engaging surface, increases the amount of tissue destroyed per unit time, and increases the surface area of the removed tissue. Therefore, reducing exposure allows more accurate removal of tissue, but it reduces the total amount of material removed. Second, increasing the exposure changes the angle of the exposed tissue engaging surface. Consider FIGS. 9A-9C, which show schematic plan views of the effector end of a differential dissecting instrument 800 with sequentially limited exposure of the tissue engaging surface 850 as controlled by the opening 900 in the shroud. The opening 900 is largest in FIG. 9A and smallest in FIG. 9C. As exposure is limited, the range of angles of the arrows perpendicular to the tissue engaging surface 850 decreases. In FIG. 9A, the tissue engaging surface 850 breaks both the front and both sides. In FIG. 9C, the tissue engaging surface 850 breaks only forward. Therefore, when the tissue engaging surface 850 is applied to tissue, different directions of contact are applied depending on the angle of the exposed tissue engaging surface.

  Second, increasing the angle of exposure of the tissue engaging surface 850 also changes both the angle at which the tissue contact surface is distorted and the torque at the instrument. Consider FIGS. 10A-10C showing friction on tissue 400 formed by application of tissue engaging surface 1010.

  In FIG. 10A, tissue engaging surface 1010 has moved in the direction of arrow 1020. This creates a frictional force in the direction of arrow 1030. The larger the contact area, the greater the frictional force. The friction forces both pull tissue 400 laterally (in the direction of arrow 1030) to shear tissue 400 and push tissue engaging surface 1010 in the direction of the opposite arrow 1020. When the tissue engaging surface 1010 is attached to the instrument 1060 at a predetermined distance from the point 1040 held by the operator, the friction force sets a torque 1050 about the point 1040. This torque can cause the end 1070 of the instrument 1060 opposite the point 1040 to be pulled away from the desired application point, making incision control more difficult. Therefore, limiting the degree of exposure of the tissue engaging surface reduces friction and improves control by reducing torque at the handle.

  FIG. 10B shows how the friction force in different directions depends on how the circular tissue engaging surface 850 is perpendicular to the tissue engaging surface 850 and therefore depends on the contact area of the tissue 400 on the circular tissue engaging surface 850. It shows how to produce. The multi-directional shear force obtained on the tissue 400 creates a more complex strain pattern in the tissue 400. As in FIG. 10A, the frictional force further creates a net upward force 1080 at the tip of the shroud 830. However, it does not create a net left / right (inside or outside of tissue 400) force at the tip of the shroud 830. FIG. 10C shows that reducing the exposure of the tissue engaging surface 850 by narrowing the opening 900 makes the frictional force on the tissue more one-dimensional and simplifies the strain pattern in the tissue.

  Despite this discussion of friction against tissue, as described above with respect to wet tissue, the DDM described herein has a unique quality that is effective when it has low friction against composite tissue. Non-tissue engaging surfaces and tissue engaging surfaces are effective even when the entire DDM is sufficiently soaked with a lubricant such as a surgical lubricant or a hydrogel lubricant.

  In surgery, it is preferable to minimize unintentional movement of tissue relative to other parts of the body. The tissue debris may adhere to the tissue engaging surface of the differential dissecting instrument disclosed herein. Unintentional movement can be minimized in two ways. First, narrowing and controlling the shape of the opening 900 as shown in FIGS. 10B and 10C may cause a broken tissue fragment attached to the tissue engaging surface 850 to be deposited on the shroud or It means that it is only carried a short distance before entering the shroud. Similarly, if they are delivered tangentially away from the tissue engagement surface 850 after they have been deposited, narrowing the opening 900 may indicate the surface area available for attachment, the time available for attachment. And reducing the distance that the material can accelerate. Second, the tissue engaging surface 850 can resist tissue attachment. Surface treatment of the tissue engaging surface 850 can be accomplished by any of several techniques known in the art such as chemical treatment, vapor deposition, sputtering and others. For example, fluorinating tissue engaging surface 850 by any of several known methods (eg, dip coating, chemical vapor deposition, chemical cross-linking with silane, etc.) A tissue engaging surface 850 that resists tissue attachment can be formed by both tissue components. In one embodiment, diamond / carbide coated tissue engaging surfaces may be used and we have found that it is much less likely to have tissue attachment to these surfaces.

  Material movement can also be reduced by the use of vibration (reciprocating) motion of the DDM rather than continuous unidirectional or continuous rotational motion. The vibration prevents movement over a distance that exceeds the distance of the vibration over only a few degrees of rotation (eg, 5 ° to 90 °). Any of a number of mechanisms can be used to drive the reciprocating oscillating motion by a rotary motor such as a scotch yoke or crank / slider.

  Tissue attachment is also a problem to reduce the effectiveness of the tissue engaging surface 850. Clogging of the tissue engaging surface 850 forms a thick coat of material on the tissue engaging surface 850 and has little effect in cutting soft tissue. As described above, forming surface resistance to adhesion by tissue reduces this problem. Fluorinated tissue engagement surfaces and diamond / carbide tissue engagement surfaces do not easily clog, especially when adipose tissue is destroyed.

  As mentioned above, clogging is also reduced when the tissue is wet and further when the tissue engaging surface 850 is washed away with water. FIGS. 11A and 11B show a differential dissection instrument 1100 in which a first array of three water outlets 1111 discharges from the shroud 830 to the side of the tissue engaging surface 850. A second array of three water outlets 1112 discharges to the opposite side of the tissue engaging surface 850. Other arrangements of the water outlet are possible. FIG. 11A shows an entity model in a perspective view. FIG. 11B shows that the water tube 1121 carries other fluids such as water or saline to one side of the shroud 830 to the interior and water outlet 1111, and the second water tube 1122 to the other side of the shroud 830 to the interior and water outlet 1112. FIG. 2 shows a schematic side view of a differential dissecting instrument 1100 for delivering fluid. Water outlets 1111, 1112 discharge from both sides of the opening 900 and provide fluid to both sides of the tissue engaging surface 850. The liquid discharge from the water outlet can carry a physiologically active substance, if desired, and is dissolved or suspended in the liquid. Physiologically active substances can include various pharmaceutical compounds (antibiotics, anti-inflammatory agents, etc.) and active biomolecules (eg, cytokines, collagenases, etc.).

  Proper placement of the tissue engaging surface 850 creates a frictional force on the tissue that can be advantageously used during blunt dissection. FIG. 12 shows a differential dissecting instrument 1200 having two opposing flexible belts 1201 and 1202 exposed in the opening 1230. Each belt is configured as shown in FIG. 10B by a flexible belt 1201 moving on the idler portion 1211 and a flexible belt 1202 moving on the idler portion 1212. The flexible belts 1201 and 1202 are configured as shown in FIG. Circulates opposite each other. Thus, the flexible belt 1201 and the flexible belt 1202 are aligned in the same direction as indicated by arrows 1203 and 1204 but are exposed to the tissue 1205 as indicated by arrows 1271 and 1272. Is the opposite direction. Therefore, the flexible belt 1201 creates a downward net force 1251 on the shroud 1220, and the flexible belt 1202 creates an upward net force 1252, whereby these forces 1251 and 1252 cancel. Thus, little or no net force is left on the shroud 1220. This eliminates any torque application of the differential dissecting instrument 1200 (as described in FIG. 10A) and makes it easier for the operator to control. Further, the opposite movement directions 1271 and 1272 of the flexible belts 1201 and 1202 create an opposite frictional force on the tissue 1205 during the incision, thereby pulling the tissue 1205 in the region identified by the double arrow 1260. Release. This pulling operation can facilitate blunt dissection due to tissue tearing in the region of the double arrow 1260. Note that the gap 1280 between the flexible belts 1201 and 1202 inside the shroud 1220 can be varied and reduced to zero so that the flexible belts 1201 and 1202 are in contact. it can. Contact between the flexible belts 1201 and 1202 can help the drive mechanism to match the running speed of the flexible belts 1201 and 1202. Indeed, the friction between the flexible belts 1201 and 1202 allows one belt, for example 1201, to drive the other belt, in this example 1202. Thus, for example, a motor can actively drive the flexible belt 1201 and the flexible belt 1202 is driven by the flexible belt 1201. This can simplify the drive mechanism for the two belts.

  FIG. 13 shows how the shroud 1330 of the differential dissection instrument 1300 can accommodate other elements that allow more functionality. The incision wheel 810 is exposed to the opening 900. Suction lines 1301 and 1302 can be connected to the front face of the shroud 1330 near the tissue engaging surface 850 and any debris from breakage or fluid from the water pipes 1121 and 1122 discharging through the water outlets 1111 and 1112. It also helps to remove excess fluid such as. A light emitting diode (LED) can be placed on the shroud 1330 to better illuminate the area for the blunt dissection. For example, LEDs 1311 and 1312 are powered by cables 1313 and 1314, respectively, and the light from LEDs 1311 and 1312 directly illuminates the tissue in the destruction area.

  14-1 to 14-3 illustrate the bendable region 1430 so that the elongate member 1410 of the differential dissecting instrument 1400 can achieve a variable curvature of the elongate member 1410 to facilitate placement of the DDM 1420. Shows how you can articulate. 14-1 shows the elongate member of the differential dissecting instrument in a straight line at position 1, and FIG. 14-2 shows the elongate member of the differential dissecting instrument curved at 45 degrees, and FIG. 3 shows the elongated member of the differential dissecting instrument curved at 90 degrees. In position 1 (FIG. 14-1), the elongated member 1410 is a straight line. In position 2 (FIG. 14-2) and position 3 (FIG. 14-3), the elongate member 1410 is continuously in the bendable region 1430 such that the DDM 1420 moves from the forward position in position 1 to the lateral position in position 3. It is curved. The bendable region 1430 can be a rotating joint or any other mechanism to allow bending.

15A-15E illustrate different DDMs that illustrate some important dimensions and features of the DDM. FIG. 15A shows a top view of an exemplary differential dissection member rotating about a rotating joint. FIG. 15A shows a plan view of a DDM 1500 that rotates about a rotary joint 1510. The operation of the DDM 1500 causes the tissue engaging surface 1520 (coarse portion) to oscillate up and down in a reciprocating manner as indicated by a double arrow 1506 so that the tissue engaging surface 1520 (coarse portion) is swung by an arc having a radius _RA . The vibration of the DDM 1500 can oscillate over a range of ± 90 °. The tissue engaging surface has a minimum radius R _S at the plane of rotation (plane perpendicular to the plane of rotation-here the page plane).

FIG. 15B shows a side view in cross-section with two consecutive enlarged views. (Thus, DDM 1500 vibrates in and out of the page in this figure). 15B-1 to 15B-3 show the differential incision member as in FIG. 15A, FIG. 15B-1 shows the differential incision member in a side cross-sectional view, and FIG. FIG. 15B shows a detailed view of the tip of the differential dissection member shown in FIG. 15B-1 and FIG. 15B-3 shows a detailed view of the surface of the differential dissection member shown in FIG. 15B-2. The first side 1530 and the tissue engaging surface 1520 merge at a first margin 1540 having a radius of curvature R _E , and the second side 1531 and tissue engaging surface 1520 have a second radius of curvature R _E. Merge at the margin 1541. Here, the curvature radii of the first margin 1540 and the second margin 1541 can be different, but must be sufficiently large so that the first margin 1540 and the second margin 1541 are not sharp. The tissue engaging surface 1520 is then formed by a protrusion 1550 having a maximum length L _max defined as the maximum length of the element from the innermost valley to the outermost peak.

FIG. 15C illustrates a different DDM 1501 having a scalloped tissue engaging surface formed by surface element 1560. Here, surface element 1560 is a convex protrusion, but may be any regular or repeating element on tissue engaging surface 1520 having a minimum radius of curvature R _S. Furthermore, the surface element can have a shape that is not in the plane of rotation, as shown in FIGS. 15D and 15E. FIG. 15D shows a perspective view and FIG. 15E shows a side view. 15E-1 shows an end view of the differential dissection member shown in FIG. 15C, and FIG. 15E-2 is a detailed view of the tissue engagement surface of the differential dissection member shown in FIG. 15E-1. FIG. 15E-3 details a very detailed view of the surface features of the differential dissection member shown in FIGS. 15E-1 and 15E-2. The insets in FIGS. 15E-1 through 15E-3 show successive enlargements of the DDM 1502 taken along a 45 ° angle. The DDM 1502 has a surface element 1570 having a shape in a plane of 45 ° with respect to the plane of rotation. Similar to the DDM 1501 in FIG. 15C, the tissue engaging surface 1520 of the DDM 1502 has a protrusion 1550 having a maximum length L _max . In one embodiment, R _A can be between about 1 (1) mm and about 100 (100) mm. In one embodiment, R _S can be between about 0.1 mm and about 10 (10) mm. In one embodiment, R _E can be between about 0.05 mm and about 10 (10) mm so that slice edges are not presented to the tissue. Alternatively, for some embodiments of DDM, Rs and Re can be as low as about 0.025 mm.

The DDM has a scalloped, notched, or wavy shape so that the angle of attack of the tissue engaging surface relative to the surface of the tissue changes as the tissue engaging surface passes through a predetermined point in the tissue. It can have a tissue engaging surface. Indeed, the angle of attack varies for any DDM where P _avg <(R _max −R _min ), such as, for example, a Type I, Type II or Type IV DDM. Various angles of attack make the incision motion more invasive, more invasive DDM can better destroy hard tissue, and less invasive DDM cannot better destroy the same tissue.

  FIGS. 16-1 to 16-3 show alternative means by which DDM can be made at different levels of invasiveness, ie, the invasiveness of DDM can be designed. The DDM 1600 has a tissue engaging surface 1620 that rotates about a rotational axis 1610 and has a protrusion 1622. These protrusions (Figure 16-1) have sharper tips (not yet sharp enough to slice). The DDM 1640 has a tissue engaging surface 1650 having a protrusion with a more rounded tip 1652 (FIG. 16-2). The DDM 1680 has a tissue engaging surface 1690 having a protrusion with an even more rounded tip 1692 (FIG. 16-3). DDM 1600 is more invasive than DDM 1640, which is more invasive than DDM 1680.

  FIG. 17A illustrates one embodiment of a DDM 1700 having a scalloped tissue engaging surface 1710 and a center of rotation 1720. Therefore, DDM 1700 is an example of a Type IV DDM. The longitudinal vibration of DDM 1700, as indicated by double-headed arrow 1730, causes tissue engagement surface 1710 to impose on the tissue engagement surface 1710 so that the edge of the scallop strikes tissue engagement surface 1710 at different angles of attack as each scallop passes over tissue. Move.

FIGS. 17B-1 and 17B-2 illustrate the operation of the DDM 1700 with respect to the tissue 1750. FIG. FIG. 17B-1 shows that of the same differential dissection member impinging on tissue, and FIG. 17B-2 shows a leaf-shaped differential dissection member leaf detailing the angle of attack of the tissue engaging surface against the tissue. FIG. The angle of attack (the angle θ between the operating direction at the contact and the tangent to the tissue engaging surface 1710) is indicated by _two points P ₁ and P ₂ on the tissue engaging surface 1710. θ ₁ is smaller than θ ₂ . Similar operation is achieved by using a circular tissue engaging element 1805 having a tissue engaging surface 1810 and a center of rotation 1820 that is not the center of the circular tissue engaging element 1805, as shown in FIG. Type II DDM), DDM1800. As indicated by the double arrow 1830, the longitudinal vibration of the tissue engaging element 1805 causes the tissue engaging surface 1810 to change at various points on the tissue engaging surface 1810 around the circular tissue engaging element 1805. The tissue engaging surface 1810 is moved over the tissue to move.

  FIG. 18 illustrates another important point for accelerating the operation of the DDM, particularly for tissue 1850, so that the acceleration decelerates after the unidirectional sweep and sweeps in the opposite direction. Occurs whenever the DDM is loaded or unloaded every time it accelerates. DDM 1800 is attached to its center of gravity 1870 which is offset from center of rotation 1820. A solid double arrow 1830 indicates rotation about the rotation center 1820, and a broken double arrow 1840 indicates the operation of the center of gravity 1870. The force that accelerates the mass of the DDM 1800 and the distance between the center of gravity 1870 and the center of rotation 1820 form a moment about the center of rotation 1820 that causes the differential cutting instrument to vibrate. This moment rocks the differential dissecting instrument handle to which the DDM 1800 is attached. A DDM constructed from a denser material makes the swing more extreme. Therefore, it may be advantageous to make a DDM from a lower density material such as a hard polymer than a metal so as to reduce handle wobble. Conversely, the opposite moment may be placed by an appropriate distribution of mass in the DDM to place the center of gravity on the axis of rotation.

  The entire surface of the DDM can be tissue engaged. Alternatively, selected portions of the surface can be tissue engaged. This can be advantageous in limiting the incision effect to a region of the DDM surface, eg, a forward facing surface. FIGS. 19A-19D illustrate a differential cutting instrument 1900 having a DDM that is a cutting wheel 1910 similar to that shown in FIGS. 3A-3C. However, the tissue engaging surface is limited to a thin tissue engaging strip 1920 around the outer periphery of the cutting wheel 1910 that rotates about the rotation axis 365. The rest comprises a non-tissue engaging surface 1930 disposed transversely to either side of the tissue engaging strip 1920 of the exposed surface of the dissecting wheel 1910, and is optionally glass smooth? It has a very smooth surface that has no protrusions or cannot engage fibers in the tissue. FIG. 19B illustrates how the incision wheel 1910 fits into the shroud 1940 and is pressed by the operator in direction 367. As FIG. 19C illustrates, the non-tissue engaging surface 1930, which is smoother than the tissue engaging strip 1920, reduces the destruction of the tissue 1950 after being separated by the tissue engaging strip 1920. The shroud 1940 further protects the tissue 1950 from destruction by the cutting wheel 1910 as the cutting instrument further penetrates into the tissue 1950 in the pushing direction 367.

  FIG. 19D illustrates additional important operations of the non-tissue engaging surface 1930 and the shroud 1940. If there is an element 1901 of operation in the direction of push 367 (not shown here) of the differential dissecting instrument 1900 against the tissue 1950, the wide portions of these differential dissecting instrument 1900 (non-tissue engaging surface 1930 and shroud 1940) Push or push in a portion of the recently separated tissue 1950 to align and distort the fiber component 1980 of the tissue 1950, strain them and align them at right angles to the motion of the tissue engaging strip 1920 Let This strain in the fiber component 1980 facilitates the ability of the tissue engaging material projections in the tissue engaging strip 1920 to grab and tear individual fibers.

  As the tissue engaging strip 1920 moves past and through the tissue 1950 in a direction perpendicular to the page plane, the protrusions on the tissue engaging strip 1920 therein become individual fiber components of the tissue 1950. Tear 1980 (eg, collagen or elastin fibers) and destroy tissue 1950. Such fiber components 1980 frequently have irregular alignment (ie, irregular orientation) in soft tissue. However, as the tissue 1950 is destroyed, the differential dissecting instrument 1900 enters the tissue 1950 in the direction of the working element 1901, and thus the remaining tissue engaging surface 1930 and shroud 1940 enter the separated tissue 1950. As such, at the point of contact of the tissue engaging strip 1920, pressing the tissue 1950 containing the fiber component 1990 cut off from the direction of the arrows 1960 and 1961, aligning the previously randomly oriented fibers. Distort material. This local region of strain aligns and distorts the uncut fiber component 1980 in the direction perpendicular to the direction of motion of the tissue engaging strip 1920, as indicated by the double arrow 1970 (so that the prestress is reduced). ), Making them easier to capture and increasing the likelihood that they will be cut by protrusions from the tissue engaging strip 1920. The non-tissue engaging surface 1930 and the shroud 1940 are when they are tilted relative to each other or when they have a wider width than the tissue engaging surface 1910, as shown in FIGS. 19C and 19D. Even if it exists, it acts as a wedge. In one embodiment, as described in FIG. 3F, the second minor axis C is a significant proportion of the first minor axis B (eg, in one embodiment, 0.2B <C <0.8B) The semi-ellipsoidal shape is an effective shape for the wedge.

  As described in the previous paragraph, fiber alignment can significantly change the way that DDM performs. Alignment can be achieved by a surgeon distorting the tissue in the proper direction by hand or a separate instrument. As described in the previous paragraph, alignment is achieved by a smooth portion on a tissue engaging wheel, such as non-tissue engaging surface 1930 in FIGS. 19C-19D, and a smooth shroud, such as shroud 1940 in FIGS. 19A-19D. Or by a separate mechanism in DDM.

  FIG. 20 shows the details of one version of tissue segment destruction in a human patient. The region 2000 of the patient is shown in a circular window showing a cross-sectional view through two juxtaposed volumes, ie, tissue segment A juxtaposed to tissue segment B, where the juxtaposition is interstitial fibers 2012 and tension. Occurs in a region 2010 that is bridged by both of the interstitial fibers 2015 and bonded to the broken interstitial fibers 2020. Also depicted on the circular window is a DDM 2030 having a tissue engaging surface 2034 further having a protrusion 2032 and a smooth non-tissue engaging surface 2033. In this view, the DDM 2030 repeats about the axis 2036 so that the movement of the fiber-engagement protrusion 2032 is inside and outside the page surface (ie, repeated back and forth from the viewer).

  In addition, each of tissue segment A and tissue segment B forms a film over tissue segment A and tissue segment B (eg, tissue segments A and B include strong tissue) and tissue segment surface 2005 and tissue segment surface A tissue segment surface 2005 and a tissue segment surface 2006, each composed of relatively tightly packed fibers aligned parallel to 2006. The tissue segment A surface 2005 and the tissue segment B surface 2006 are also three-dimensionally curved. While these tissue segment planes 2005 and 2006 may not touch each other at each point, the tissue surface 2005 and the tissue segment plane 2006 are substantially juxtaposed with the tissue segment plane 2005 and the tissue segment plane 2006 being juxtaposed locally. And intersect each other in a region 2010 that is frequently in substantial contact with each other.

  In that region 2010, tissue segment surface 2005 and tissue segment surface 2006 are secured together by a population of relatively loose interstitial fibers 2012 that are generally perpendicular to the two juxtaposed tissue segment surfaces 2005 and 2006. . This sparse population of interstitial fibers 2012 may or may not be obtained from a population of fibers that include a tighter packed fabric surface forming tissue segment surfaces 2005 and 2006 (or members thereof). May be) For example, a given fiber that includes a portion of the tissue segment surface 2005 may be along the surface a slight distance before turning and continuing across the region 2010, thereby allowing the interstitial fibers 2012 to If it becomes a member of a group and can be rotated and interwoven in it, it may continue across the region 2010 up to the tissue segment surface 2006, whereby the fibers comprising the tissue segment surface 2006 Become a member of the group. Therefore, the definition of the interstitial fibers 2012 defines that the region 2010 intersects, bridges, traverses or connects (or closely couples) when the tissue segment surface 2005 and the tissue segment surface 2006 are juxtaposed. Contains any fiber. The interstitial fibers 2012 may be the same type of fibers as in one embodiment, including the tissue segment surface 2005 and tissue segment surface 2006 of tissue segment A and tissue segment B. In other embodiments, the interstitial fibers 2012 may be of different types, and the interstitial fibers 2012 are directly or indirectly strongly or weakly bonded to the tissue segment surface 2005 and the tissue segment surface 2006. Also good.

  In each case, all the fibers involved can transmit forces (via tension) between the two tissue segments, either along the surface of each individual tissue segment, or between the stroma. Mechanically possible. For example, the tension of a fiber comprising interstitial fibers 2010 and tissue segment surfaces 2005 and tissue segment surfaces 2006 can be forced, for example, in directions 2040 and 2041 by a smooth non-tissue engaging surface 2033 pushing these tissue segments. Dependent on the forces acting on tissue segment A and tissue segment B when released. For example, the fibers 2010 resist tensile strain resulting from the motion of the tissue segment surface 2005 in the direction 2040 and the motion of the tissue segment surface 2006 in the direction 2041, and this resistance varies depending on the mechanical properties of the fiber. . For example, if unstrained interstitial fibers 2012 are aligned perpendicular to two juxtaposed tissue segment faces 2005 and 2006, the distance between tissue segment A and tissue segment B is Even if the fiber 2010 is first straightened like a tensed interstitial fiber 2015 and finally increased as indicated by the broken stromal fiber 2020 (as indicated by arrow 2030) Good. The most common fiber type in humans is collagen, which has a break strain of about 5% over its normal unstressed length. When tissue segment A and tissue segment B move away as indicated by arrow 2030, the collagen fibers (here, unstrained interstitial fibers 2012) are first (like strained fibers 2015). I get nervous. When the two tissue segments A and B are moved further apart, the collagen fibers stretch about 5%. Critically, at this point, if the tissue segment A moves from the tissue segment B beyond the strain to more than 5%, the strained interstitial fibers 2015 will break or the strained fibers 2012 will break. If not, the tissue segment itself will either rupture, with detrimental consequences for the patient.

  Because surgeons frequently separate, detach, or move tissue segments from each other and access various areas within the patient's body, the surgeon always distorts the fiber population equivalent to the interstitial fibers 2010 throughout the patient's body. Not. Current practice is to slice the interstitial fibers so that one tissue segment is free from the other, or blunt with forceps (by opening the jaws, forcing the tissue segment apart and thus tearing the interstitial fibers). It is necessary to tear interstitial fibers on a large scale by applying force. Common complications are slicing into tissue segments when trying to cut only interstitial fibers through a sharp dissection, or small tissue segments when trying to blunt dissection of interstitial fibers Or to peel off a large part. Either approach first strains the interstitial fibers 2010 to tension, then stretches them and tears them. The result of the intimate connection of the interstitial fibers 2010 with the tissue segment surfaces 2005 and 2006 described above (eg, air leaks or lung segment bleeding) will now be apparent. The integrated tissue segments themselves must separate the forces required to keep the interstitial fibers from functioning without exposing them to the same forces.

  The differential dissecting instrument embodiment disclosed herein separates forces on the fiber population by generating an initial separation action of tissue segments A and B juxtaposed by the impact of a smooth surface 2033. Specially designed and therefore provided by these currently tensioned interstitial fibers 2015 that expose and pull (pre-stress) individual interstitial fibers 2010, making them more likely to break. To allow the interstitial fibers 2020 that are broken by the local impact of the protrusions 2032 of the tissue engaging surface 2034 of the differential dissection instrument 2030 to be carefully triggered, engaged and transformed. . Thus, a DDM having a smooth, non-tissue engaging surface and / or a shroud connects its adjacent regions of strong tissue and its incision effect on just those fibers in soft tissue that further protects the strong tissue Both the speed and effectiveness of the tissue incision can be greatly increased while limiting the extent of.

  21A to 21C-4 illustrate another differential cutting instrument 2100 that uses a very thin cutting wheel 2110 as the DDM. The incision wheel 2110 can be used to achieve a very thin tissue engagement surface 2009 by operation of the shroud 2120 to protect, separate and prestress the tissue to be incised, as shown in FIG. 19D. 2120 is almost completely wrapped.

  FIG. 21A shows a side view and FIG. 21B shows a front view. FIG. 21A shows a side view of a differential dissection member having a thin dissection wheel and encased in a shroud, and FIGS. 21B-1 and 21B-2 respectively show the shrouded differential in FIG. 21A. Further, a front view and a detailed view of the cutting member are shown. The incision wheel 2110 is attached to two posts, a first post 2130 and a second post 2131, via a rotation shaft 2135 (seen in the side view of FIG. 21B-1). The rotating shaft 2135 rotates freely within the first post 2130 and the second post 2131, but is firmly fixed to the cutting wheel 2110. Sprocket 2140 is also secured to shaft 2135. Sprocket 2140 is rotated by drive belt 2150. Therefore, the drive mechanism 2160 is driven by the first post 2130 and the second post 2131, the shaft 2135, the sprocket 2140 and the drive belt 2150 so as to rotate the incision wheel 2110 within the shroud 2120 in the direction of the arrow 2161. Is formed. Other drive mechanisms can be used and operation can be either rotation or vibration. As shown in the enlarged portion of FIG. 21B-2, the first margin 2111 and the second margin 2112 of the cutting wheel 2110 are preferably not sharp. (The first and second margins 2111 and 2112 are the same as the first and second margins 1540 and 1541 in FIGS. 15B-1 to 15B-3). Sharp margins can be destroyed more invasively than rounded margins. Nevertheless, sharper margins can be used when more invasive or further destruction is desired. Furthermore, one margin can be sharper than the other if differential destruction or destruction is desired. For example, the first margin 2111 can be square or even sharper, while the second margin 2112 can be rounded to achieve more invasive destruction or destruction on the first margin 2111 side. Can do.

  The shroud 2120 leaves only the thin portion of the incision wheel 2110 exposed as the tissue engagement surface 2111 and forms a wedge angle ω that determines the strain on the tissue at the breaking point of the incision wheel 2110 to substantially surround the incision wheel 2110. . A larger wedge angle ω causes the tissue to become more distorted as the DDM 2100 is pushed into the tissue. 21C-1 to 21C-4 show a DDM 2100 having a shroud 2120 in four different locations. The shroud 2120 can be moved independently of the drive mechanism 2160 and the cutting wheel 2110, and the shroud 2120 can be moved in the direction of the double arrow 2190. Therefore, at position 1 (FIG. 21C-1), only a thin portion of the incision wheel 2110 is exposed. In position 2 (FIG. 21C-2), the shroud 2120 is moved in the direction of arrow 2191 leaving a thinner portion of the exposed cutting wheel 2110 and forming a larger wedge angle ω. In position 3 (FIG. 21C-3), the shroud 2120 is moved in the direction of arrow 2192 such that the shroud 2120 completely surrounds the cutting wheel 2110. Therefore, incision wheel 2110 can no longer destroy tissue. In this position, the cutting wheel 2110 effectively acts as a smooth and flat blunt probe. In position 4 (FIG. 21C-4), shroud 2120 is moved in the direction of arrow 2193, increasing the exposure seen at position 1 or position 2 of incision wheel 2110 and decreasing wedge angle ω.

  FIG. 22 shows the distal end of a differential dissecting instrument 2210 that includes one embodiment of a reciprocating mechanism, here a Scotch yoke. The distal end of the differential dissecting instrument 2210 includes a housing 2212 that further includes a pivot bearing 2214, a motor shaft bearing 2216 and a shaft drum bearing 2218. FIG. 22 also shows a motor shaft 2220, a shaft drum 2222 that is coaxial with and fixed to the motor shaft 2220, and that is parallel to the motor shaft 2220 but may not be coaxial and is itself fixed to the shaft drum 2222. A driver pin 2224 is shown. Further, there is a DDM 2230 that is a differential cutting member coupled to the differential cutting housing 2212, an outer surface 2231 that defines the body of the DDM 2230, a tissue engaging surface 2232 that forms at least a portion of the outer surface 2231, and a pivot bearing. And a DDM pivot shaft 2234 that fits into 2214 and further includes a hollow DDM pin follower 2236 that effectively captures the driver pin 2224. The three-dimensional shape inside the hollow DDM pin follower 2236 is similar to that shown in FIG. 22 so that the cross-sectional shape is similar to an hourglass, but the cross-sectional shape is linear at right angles to the figure. It is shown as a prism.

  23A, 23B and 23C show a cross-sectional view of a portion of the DDM 2230 of FIG. 22 through the narrowest part of the waist of the hourglass-shaped hollow DDM pin follower 2236 and perpendicular to the axis of rotation of the axial drum 2222. Yes. The shape of the DDM pin follower 2236 is rectangular in this view, and in this view showing the dimension passing through the waist of 2236, the height of the rectangle is described by the outer diameter of the driver pin 2224 along its circular path 2237. Or larger The rectangular width in this figure corresponds to the outer diameter of the driver pin 2224. The DDM 2230 including the hollow DDM pin follower 2236 rotates about the axis 2233 of the shaft 2234. Therefore, the position of the hollow DDM pin follower 2236, and thus the rotational position of the DDM 2230, is determined by the rotational position of the driver pin 2224.

  In operation, referring to FIG. 22 in conjunction with FIGS. 23A-23C, a motor (not shown) rotates a motor shaft 2220 that rotates a drum 2222 around its rotational axis, causing a driver pin 2224 to move around a circular path 2237. The surface is here perpendicular to the axis of rotation of the drum 2222. As in the Scotch yoke, the rectangular hollow DDM pin follower 2236 converts the circular path 2237 of the driver pin 2224 into a linear movement 2238 of the hollow DDM pin follower 2236. Given that the pin follower 2236 is located some distance away from the shaft 2233, the DDM 2230 is subject to this action about the shaft 2233 and is therefore held in the rotational path 2237 by the linear movement 2238 and hence the pivot bearing 2214. This is converted into a reciprocating motion of the DDM 2230 that rotates about the DDM pivot shaft 2234. The reciprocating pattern of the DDM 2230 can be achieved by changing the shape of the hollow DDM pin follower 2236, the driver pin 2224, the 3D angle of the shaft 2233 around which the shaft 2234 rotates, the distance from the driver pin 2224 to the shaft 2233, and the motor Can be controlled by changing the rotation speed of the motor.

  The DDM 2230 of FIG. 22 may have reciprocal movements 2250 and 2251 as shown in the side views of FIGS. 24A and 24B. The illustrated vibration sequence shows the extreme position of the DDM 2230 as the driver pin 2224 moves around the circular path 2237 when a rotational motion 2299 from a motor (not shown) is provided. The operation of the tissue engaging surface 2232 of the DDM 2230 on the surface of the tissue to be incised is best shown in the side view in FIG.

  Surgeons operating on the patient's body want to minimize the trauma that can occur to the tissue in the manner of the target tissue that is not the focus of the procedure. For this purpose, FIGS. 25A-25C depict an outline view of an embodiment of a substantially wrapped DDM assembly 2500, and further, a wrapped projecting perpendicular to the page (ie, at the viewer). Pivoting shaft 2510, internal motor shaft 2550, internal driver drum 2522, driver pin 2524, DDI housing 2512, and DDM 2520 reciprocating around wrapped pivot shaft 2510 (and thus in the page plane) A tissue engaging DDM surface 2534, a smooth DDM surface 2518, a substantially circular DDM region 2516, a shroud margin 2517, and a shroud-DDM gap 2514. Taken as a whole, with all the outer surfaces of the DDM assembly 2500 included as one, the enveloped DDM assembly 2500 provides a substantially continuous smooth surface for the patient's tissue. In this regard, with the exception of the limited extent of the tissue engaging DDM surface 2534, the entire differential dissecting instrument with the DDM assembly 2500 attached acts only like a polished probe.

  Once activated, the DDM 2520 reciprocates within and relative to the housing 2512. The edge of the housing 2512 closest to the DDM 2520 is a shroud margin 2517. A shroud-DDM gap 2514 can be seen between the shroud margin 2517 and the DDM 2520. In one embodiment, a differential cutting instrument with a DDM assembly 2500 attached is provided to maintain smooth characteristics outside the differential cutting instrument. Therefore, the shroud-DDM gap 2514 presents a challenge in that any relative movement of the DDM 2520 with respect to the housing 2512 presenting a sharp edge in tissue could expand the shroud-DDM gap 2514. Alternatively, a portion of the DDM 2520 can affect the housing 2512. Also, in one embodiment, the shroud-DDM gap 2514 is always kept as small as possible. To facilitate this, the DDM 2520 has a circular DDM region 2516 defined in this regard as part of a DDM 2520 mass having a circular cross section with its center coincident with the axis of the shroud pivot axis 2510. This circular DDM region 2516 occupies the outer surface portion of the DDM 2520 that passes through the shroud margin 2517 during the reciprocating motion of the DDM 2520, defined by a distance that defines the shroud-DDM gap 2514. This maintains the shroud-DDM gap 2514 at a constant value (ie, the shroud-DDM gap 2514 changes regardless of the operation of the DDM 2520) because the circular DDM region 2516 maintains the same radius of the DDM 2520 over the rotation angle. do not do). Therefore, a differential dissecting instrument fitted with this DDM assembly presents a continuously smooth surface to the tissue anywhere over time.

  FIG. 25D illustrates a housing 2512, a DDM 2520 (see FIGS. 25A-25C) reciprocating about a wrapped pivot axis 2510, a tissue engaging DDM surface 2534, a smooth DDM surface 2518, and a generally circular shape. Shown is a perspective view of a substantially wrapped DDM assembly 2500 showing a DDM region 2516, a shroud margin 2517, and a shroud-DDM gap 2514.

  The sharp section is frequently alternated with the blunt section when exposing the target tissue. This occurs whenever a membrane or large fiber component that resists blunt dissection is encountered and the surgeon must be cut to further penetrate into the tissue. Current practice requires that the surgeon use a suboptimal instrument for blunt dissection (eg, a non-active electrosurgical scalpel) or replace the instrument while exposing the target tissue. The use of suboptimal instruments reduces the ease of blunt dissection and increases the potential risk to the target tissue. The exchange is time consuming and particularly troublesome for many minimally invasive procedures where instruments such as laparoscopic and thoracoscopy can be gently guided to the affected area after passing through a narrow opening in the body wall. The differential cutting instrument can comprise a sharp cutting element that can be selectively actuated by the surgeon, further eliminating the need for instrument replacement while providing the surgeon with the optimal instrument.

  FIGS. 26A-1 and 26A-2 are each similar to the differential dissection instrument 2000 shown in FIG. 20, but also include a retractable scalpel blade covered in the blunt dissection here. FIG. 6 shows a top view and a side view of one embodiment of 2600. 26A-1 and 26B-1 show side views, FIGS. 26A-2 and 26B-2 show plan views, and FIGS. 26A-1 and 26A-2 are pulled out. 1 shows a differential incision member having a retractable knife. The retractable surgical scalpel blade can be protruded outward by the surgeon for the sharp dissection and further retracted before the blunt dissection is advanced. The differential dissecting instrument 2600 has an elongated member consisting of a shroud 2620 to which a DDM 2610 is rotatably mounted via a rotating shaft 2635. One side of the DDM 2610 is a slot 2612 with the retractable surgical knife blade 2622 below so that the retractable surgical knife blade 2622 is completely covered by the shroud 2620. The retractable surgical scalpel blade 2622 is actuated by a retracting mechanism (not shown) controlled by the surgeon. The operation of the retractable surgical scalpel blade 2622 can be controlled manually via a slider, by electrical actuation (such as a solenoid), or by any suitable mechanism that can be controlled by the operator.

  FIGS. 26B-1 and 26B-2 illustrate a differential dissection instrument 2600 having an extended retractable surgical scalpel blade 2622 for a sharp dissection. FIGS. 26B-1 and 26B-2 show the same differential dissection member with an extended retractable knife. The retractable surgical scalpel blade 2622 is an example of a sharp dissection tool. In other embodiments, the differential dissection instrument 2600 could include other sharp dissection tools such as an electrosurgical blade, ultrasonic cutter, or break hook. In other embodiments, the differential dissecting instrument 2600 could include an energy disruption tool, such as an electrocautery blade or an electrosurgical head. Further, instead of retracting, the retractable surgical scalpel blade 2622 or other suitable tool may be used by one of several mechanisms, such as by pop-out, by deployment, or other mechanisms known in the art. Therefore, it could be selectively exposed.

  27A and 27B are similar to the differential dissection instrument 2600 shown in FIGS. 26A and 26B, respectively, but here to allow the differential dissection instrument 2700 to also function as a forceps. FIG. 22 shows a top view and a side view of another embodiment of a differential dissection instrument 2700 having a gripping member. The differential dissecting instrument 2700 has a DDM 2710 rotatably attached to the instrument shaft 2720 and is rotated by an electric mechanism (not shown). The push rod 2730 is inside the instrument shaft 2720 and is actuated by a mechanism in a handle (not shown) and is manually activated by the operator. When DDM 2710 is active, it oscillates back and forth as indicated by arrow 2740. When the operator turns off the operation of the DDM 2710, the operator can press the push rod 2730 on the forceps jaw 2750 having a control horn 2760 that causes the forceps jaw 2750 to rotate about the pivot point 2770 to open. . The opposing jaw for the forceps is a DDM2710. The surgeon can then grasp and release the object between the forceps jaw 2750 and the DDM 2710 by pressing or pulling the push rod 2730.

  28 and 29A to 29D show another embodiment of the DDM. In fact, this embodiment provides great differential motion and rapid incision through complex tissue. For this embodiment of the DDM, the tissue engaging surface protrusions are formed by valleys cut into the surface of the DDM. Referring to FIG. 28, the DDM 2800 has a first end 2810 and a second end 2820 having a central axis 2825 connecting the first end 2810 and the second end 2820. The first end 2810 is directed away from the incised composite tissue (not shown), and a drive mechanism (not shown) that moves the DDM 2800 so that the second end 2820 sweeps along the direction of motion. Is engaged. Here, the mechanism vibrates DDM 2800 about rotational axis 2830 perpendicular to central axis 2825 such that operational direction 2840 is an operational arc in a plane perpendicular to rotational axis 2830. Second end 2820 has a tissue facing surface 2850 directed to the composite tissue including at least one tissue engaging surface 2860 and at least one side surface 2870.

  In this example, the operation of DDM 2800 is a reciprocating (back and forth) vibration, but other DDMs can have continuous rotation or linear motion. The rotation is preferably between 2,000 and 25,000 cycles per minute, all of which can range from 60 cycles per minute to 900,000 cycles per minute, much lower than ultrasound. . In certain embodiments, a rate of 300 to 25,000 cycles per minute has been found to be very effective.

  29A through 29E-2 show an enlarged view of the surface 2850 facing the tissue of DDM2800 from FIG. FIG. 29A shows a perspective view of a tissue facing surface 2850 having elements that can be identified. FIGS. 29B-D show different views of the tissue-facing surface 2850 having a geometric shape that is better described in particular with respect to the elements of the tissue-facing surface 2850. FIG. FIG. 29C-2 shows details of the corners of the protrusion shown in FIG. 29C-1, and FIGS. 29E-1 and 29E-2 show the arrangement of valleys and protrusions that form the surface of the differential dissection member. Two alternative versions are shown. Finally, FIGS. 29E-1 and 29E-2 illustrate several different embodiments of these elements. The tissue facing surface 2850 is disposed on the tissue engaging surface 2860, the first side 2871 disposed on the side and one side of the tissue engaging surface 2860, and on the side and opposite the tissue engaging surface. It has two sides with a second side 2872 provided. Referring to FIGS. 29A, 29C-1 and 29C-2, the tissue engaging surface 2860 has elements in a direction where the intersection of at least one valley 2910 and at least one protrusion 2920 is perpendicular to the direction of motion 2840. Alternating at least one valley 2910 and one protrusion 2920 arranged along a direction of motion 2840 that is a circular motion on the tissue-facing surface 2850 so as to define at least one valley edge 2930 oriented It consists of columns.

The valley edge 2930 should not be sharp and should not be sliced into, for example, a composite tissue, particularly a strong tissue. For example, a point on the trough edge 2930 should not have a radius of curvature R _c less than about 0.025 mm (see FIG. 29C-1, enlarged view). This radius of curvature R _c is the same as the radius of curvature of the surface R _s and the edge R _e as shown in FIG. We have shown through testing that edges with a radius of curvature R _c not less than about 0.050 mm are also effective. Further, the radius of curvature R _c can vary along the length of the valley edge 2930. In the embodiment shown in FIGS. 29A-29D, the radius of curvature R _c is minimal when the valley edge 2930 is furthest away from the axis of rotation 2830 and closer to the first side 2871 and the second side 2872. . Furthermore, the minimum radius of curvature R _c for the valley edge 2930 can be different for different valley edges in the same DDM and for valley edges on the opposite side of the same valley.

  The protrusion 2920 in the DDM 2800 can be formed by subtractive manufacturing in one embodiment. Indeed, as shown in FIG. 29B, FIG. 29C-1 and FIG. 29C-2, the valley 2910 is aligned with the major axis A (see FIG. 28) aligned perpendicular to the rotational speed 2830 and parallel to the central axis 2825. (See) (ie facing the composite tissue) and cut from the surface of a semi-ellipsoid having a first short semi-axis B and a second short semi-axis C parallel to the rotational speed 2830. Thus, the protrusion 2920 has a protrusion tip 2940 that is the remaining semi-ellipsoidal surface and is continuous with the side surfaces 2971 and 2972. Therefore, the tissue engaging surface 2860 is formed in this embodiment by lateral limitations of the valley 2910 and is bridged to the tissue facing surface between the valleys 2910 forming the protrusions 2920. In other embodiments, the protrusions can be formed by other means and therefore have a more differently shaped protrusion tip including a protrusion tip that is not formed as the rest of the surface. For example, in one embodiment, the protrusion can be effectively constructed from the surface, allowing for more complex protrusion tips.

  Referring to FIGS. 29A, 29C, and 29C-2, each trough 2910 can have a first trough side 2911, a second trough side 2912, and a trough bottom 2913, whereby the first trough side 2911 and The second valley side 2912 is on both sides of the valley 2910. The valley bottom 2913 is a straight line or a curve, and can be two-dimensional or three-dimensional. For example, the valley bottom in DDM 2800 is a straight line aligned parallel to rotational speed 2830. The first valley side 2911 and the second valley side 2912 rise from the valley bottom 2913 to the valley edge 2930. Transitions from the valley bottom can be gradual and indeterminate, as in valley 2910 in DDM 2800, or the transition can be a step. The valley 2910 may be curved in a two-dimensional shape that is a straight line in a direction parallel to the valley bottom 2913 (thus, parallel to the rotation axis 2830). However, the valley side can have any shape including a three-dimensionally curved surface.

  The valley edge is formed by the intersection of the valley wall with the protrusion tip. Therefore, the valley edge can have different shapes depending on the shape of the protrusion tip and the valley edge. The valley edge 2930 in the DDM 2800 traces a three-dimensional curve and therefore has both curvature and twist (as defined geometrically and mathematically) that are non-zero and vary along the valley edge. The valley edge can have a smoothly changing curvature and twist (as in the valley edge 2930) or the valley edge can be curved.

FIG. 29C-1 shows an enlarged view of the valley edge in a plane perpendicular to the valley edge. Projecting tip 2920 and the valley (here 2911 or 2912) forms a surface angle Γ having a radius of curvature R _c described above in this plane rounded at the intersection (i.e., it mechanic express it Like "rounding"). The face angle Γ can form an angle of less than 90 ° that appears sharp in the first inspection, but the sharpness is determined by the edge radius of curvature R _c . The face angle Γ can vary along the length of the valley edge as is done for the DDM 2800 when the face angle Γ is minimal at a point on the valley edge furthest from the axis of rotation 2830. In one embodiment, a face angle of about 30 degrees (30 °) to about 150 degrees (150 °) may be effective.

  A valley has a length, width and depth, the valley length is the length of the valley bottom, and the valley width separates the valley edges of one valley measured at the longest distance of their separation. The depth of the trough is the maximum perpendicular distance from the trough edge to the bottom of the trough (eg, peak to trough height). Typical dimensions for the valley include a valley length of 0.25 mm to 10 mm, a valley width of 0.1 mm to 10 mm, and a valley depth of 0.1 mm to 10 mm. In one embodiment, a valley length of about 3 (3) mm, a valley depth of about 3 (3) mm and a valley width of about 2 (2) mm are found to be very effective. Has been.

  If the DDM has multiple valleys, such as DDM 2800, the valleys can be parallel to all parallel valley bottoms 2913, such as valleys 2910 of DDM 2800, or they can be at non-zero angles relative to each other or It can be non-parallel to the valleys located at variable angles relative to each other.

  The valley 2910 of the DDM 2800 has a single channel (a space surrounded by a valley side and a valley bottom). However, a valley can have multiple intersecting channels so that the valley bottom can branch or increase branches or can form a network on the tissue engaging surface. FIGS. 29E-1 and 29E-2 show plan views of two DDMs, the left DDM 2980 having a parallel valley 2981 with a valley bottom that is not parallel to the rotational speed, while the right DDM 2990 is rotating It has a network of multiple valleys 2991 that intersects the velocity and all at different angles to each other.

  As described above, the tissue facing surface 2850 of the DDM 2800 has a major half axis A, a first minor half axis B, a rotational speed 2830 aligned perpendicular to the rotational axis 2830 and parallel to the central axis 2825. And a semi-ellipsoidal surface having a second minor semi-axis C parallel to the surface. The tissue facing surface 2850 may have an elliptical shape of A> B> C in one embodiment. However, any relationship between the lengths of the half axes is possible. For example, in other embodiments, the DDM may be manufactured for A = B = C (eg, the tissue facing surface is hemispherical).

  The first side surface 2871 and the second side surface 2872 of the DDM 2800 are a continuous semi-ellipsoidal shape. As such, they are positioned at an angle relative to each other and shown in FIGS. 19D and 20 ahead to align and distort the fiber components of the composite tissue that allow the protrusions to hook and break the fiber components. Form rust as if it were.

  FIG. 30A presents the situation of the first tissue region 3011 wrapped in the first membrane 3016 and the second tissue region 3012 wrapped in the second membrane 3017. The first film 3016 and the second film 3017 are in contact with the tissue surface 3020. The first membrane 3016 and the second membrane 3017 are formed from tightly packed fiber components and therefore contain a strong tissue. The interstitial material spanning the tissue surface from the first membrane 3016 to the second membrane 3017 includes a fiber component 3030. These fiber components 3030 are not so packed, so the interstitial material contains soft tissue. The tissue-facing surface 2850 is pressed into the tissue surface 3020 in the direction of arrow 3050 to separate the two tissue regions 3011 and 3012, so that the first side 2871 and the second side 2872 are protuberances. A first diffusing force 3041 and a second diffusing force 3042 that align and distort the fiber component 3030 at the tip 2940 are applied on the tissue regions 3011 and 3012, respectively (see FIGS. 29C-1 and 29C-2). This allows the fiber component 3030 to enter the valley 2910, and thus a protrusion when the tissue facing surface 2850 rotates about the axis of rotation 2830 and moves away from the page plane (towards the viewer). It can be hooked and torn by 2920. In addition, since the protrusion tip 2940 is continuous with the side surface, more lateral regions of the protrusion tip 2940 also add additional diffusive forces 3043 and 3044 that push into the tissue regions 3011 and 3012 as well, and fiber Increase distortion to component 3030.

  FIGS. 30B-30D illustrate how the curvature of the first side 2871 and the second side 2872 can be altered to make the DDM more or less invasive. Consider the first DDM 3060 in FIG. 30B. As illustrated in FIG. 30A, more side regions of the protrusion tip 2940 exert diffusing forces 3043 and 3044 that push away adjacent tissue regions. Furthermore, the first side surface 2871 and the second side surface 2872 exert the first diffusing force 3041 and the second diffusing force 3042. As the first angle 3065 formed by the diffusing forces 3043 and 3044 reaches 180 ° (as shown for DDM 3061 in FIG. 30C), the wedge effect on the side region of the protrusion tip 2940 decreases. (Note that the angle 3065 is similar to the wedge angle ω described in FIGS. 21A-21C.) If the protrusion 2920 is also thinned laterally (left and right in this view), the protrusion Although it breaks soft tissue more quickly, it also has a greater tendency to ablate or destroy hard tissue. As in FIG. 30A, the first and second side surfaces 2871 and 2872 form diffusing forces 3041 and 3042, respectively, that form a second angle 3066 (effectively a second wedge angle ω). If the second angle 3066 is similar to the first angle 3065 (as shown for DDM 3060 in FIG. 30B), these surfaces join to form a single wedge surface. As in FIG. 30C, if the second angle 3066 ′ is greater than the first angle 3065 (ie, the sides 2871 and 2872 are more generally parallel), the second angle 3066 ′ has little or no wedge effect. Does not demonstrate. Conversely, if, as in FIG. 30D, the second angle 3066 ″ is less than the first angle 3065 (ie, the side surfaces 2871 and 2872 are more substantially vertical), the second angle 3066 ″ is Greater wedge effect. A DDM such as 3061 has proven to be more effective in incising a tissue surface having collagen fibers that cross from one side to the other and span the tissue surface.

  Referring back to FIG. 30A, FIG. 30A also illustrates important aspects of DDM. DDM automatically follows organizational aspects. Because the tissue surface tends to be bounded by hard tissue (eg, membranes, tubes, etc.) and straddles soft tissue, DDM does not move into hard tissue but into soft tissue due to its differential behavior. Moving and hence subsequent separation to the tissue surface has little or no guidance from the operator. This does not require the surgeon to have a detailed understanding of the anatomy as required by current practice, or conversely, when the tissue surface is destroyed by the tumor or the tissue becomes swollen or inflamed. It means that the DDM allows a skilled surgeon to open an uncertain anatomy more confidently when waking.

  FIG. 31 shows a side view of the tissue-facing surface 2850 when hooked and stretched to break the fiber component 3030 shown in FIG. 30A. The three fiber components (the first fiber component 3031, the second fiber component 3032, and the third fiber component 3033) have three protrusions (the first protrusion 2921, the second protrusion 2922, and the third protrusion, respectively). 2923). The tissue-facing surface 2850 rotates to produce a motion direction 2840 that is a circular motion as indicated by arrow 3100. The first fiber component 3031 simply enters the first valley 2911 and has not yet been caught by the first protrusion 2921. The second fiber component 3032 enters the second valley 2912 at a point in time earlier and is hooked and distorted by the second protrusion 2922. The third fiber component 3033 enters the third valley 2913 at an earlier point in time and is hooked by the third protrusion 2923 and further distorted. Finally, all three fiber components 3031, 3032 and 3033 are distorted to break.

  FIG. 31 illustrates an important aspect of the design of the DDM2800. Since the valleys are bridged from one side 2871 to the opposite side 2872, each valley forms an open space that extends across the end of the DDM2800 where distorted fiber components can enter, and hence , Making them easy to be caught by the protrusions.

  It is important to note that DDM2800 does not have an array of microprojections that give any portion of its surface texture, as described above. Rather, all surfaces of DDM2800 are smooth and preferably have a low friction surface. The shape and configuration of the surface elements of DDM2800 are responsible for the ability to differentially dissect complex tissue. In fact, the DDM 2800 works best when all of its surfaces that are in contact with the tissue are well lubricated, eg, with surgical lubricant.

  FIG. 32 shows an exploded view of one embodiment of a complete differential dissection instrument. The differential dissecting instrument 3200 generally includes an instrument handle 3212 that protrudes from an instrument insertion tube 3290 having a first end 3291 attached to the instrument handle 3212 and a second end 3293 rotatably attached to the DDM 3292. It is configured. The instrument handle 3212 is assembled from an upper housing 3220 that includes an upper battery cover 3222 and a lower housing 3230 that is held together by instrument housing bolts 3236. The upper housing 3220 and the lower housing 3230 include a motor 3260 and a battery pack 3270. Within upper housing 3220 is a switch port 3224 that can access switch 3282 (which can be a momentary switch or an on-off switch) to provide power from battery pack 3270 to motor 3260. A flexible printed circuit board 3280 further including a power level adjuster 3281 (which can be any convenient element, but shown here as a linear potentiometer) is provided and mounted on the surface of the upper housing 3220. Can be accessed via the sex switch cover 3284. Also included are a front spring battery connector 3272 and a rear spring battery connector 3274 that relay power from the battery pack 3270. Upper housing 3220 further includes an instrument insertion tube support 3226 for securing and orienting instrument insertion tube 3290 proximate and coaxial with motor 3260.

  The lower housing 3230 further provides access to the battery pack 3270 to secure the integral lower battery cover 3232 with the motor housing portion 3234 and further retain it in the upper housing 3220 using three instrument housing bolts 3236. Is done. The motor housing 3234 holds and fixes the motor 3260 coaxially with the instrument insertion tube 3290 that passes through the instrument insertion tube support 3226. The motor 3260 is pressed forward by the motor housing portion 3234 against the motor collar 3264 whose inner diameter leaves room for the motor shaft coupler 3262. Motor shaft coupler 3262 is securely mounted on the shaft end of motor 3260 with the aid of motor shaft coupler bolt 3266 and further grips first end 3295 of drive shaft 3294. The drive shaft 3294 is rotated by the motor 3260 inside and concentrically with the instrument insertion tube 3290. The drive shaft 3294 also has a second end 3297 of the drive shaft 3294 that is concentrically supported by a bearing 3296 mounted on the second end 3293 of the instrument insertion tube 3290. The DDM 3292 is rotatably mounted on the bearing 3296 such that the drive shaft 3294 rotates the DDM 3292. The DDM 3292, the bearing 3296, the drive shaft 3294, and the instrument insertion tube 3290 jointly form the DDM assembly 3299 described next.

  33A, 33B and 33C show details of the DDM assembly 3299 including how the DDM 3292 is assembled with other elements so that the motor 3260 drives the vibration of the DDM 3292. FIG.

  Referring now to FIG. 33A, the DDM 3292 in this embodiment includes a tissue facing surface 3322 on the first end 3321 and a bearing grip 3324 on the second end 3323. The bearing grip 3324 is further fitted to the two pivot pins 3325. The DDM 3292 may be partially hollow with a bearing cavity 3326 that allows the bearing 3296 to fit inside. The bearing cavity 3326 further includes a cam driven cavity 3328. The shape of the cam driven cavity 3328 may be elliptical at a very narrow point in one direction, forming a slot. The bearing 3296 has a hole 3336, a bearing tip 3332, a screw receiving end 3338, and two pivot pinholes 3334. The screw bearing end 3338 screws the screw bearing mount 3342 at the second end 3293 of the instrument insertion tube 3290. The hole 3336 can have a diameter that is greater than the diameter 3385 of the drive shaft 3294 anywhere along its length, except for the bearing tip 3332, thereby reducing the contact surface between the bearing 3296 and the drive shaft 3294. Let The second end portion 3297 of the drive shaft 3294 is changed to include a main shaft portion 3352 and a cam shaft portion 3354. The various sub-elements of these elements allow their assembly and operation, as can be seen in FIGS. 33B and 33C.

  Referring to FIG. 33B, the drive shaft 3294 is shown coaxially within the instrument insertion tube 3290 of the bearing 3296 and DDM assembly 3299. This aligns the threaded end 3338 of the bearing 3296 to screw the threaded bearing mount 3342 located at the second end 3293 of the instrument insertion tube 3290. The bearing tip 3332 houses the drive shaft 3294 and prevents misalignment with the DDM 3292. The second end 3293 of the drive shaft 3294 exits the bearing tip 3332 so that the cam shaft 3354 is fully exposed. Once the instrument insertion tube 3290, bearing 3296, and drive shaft 3294 are assembled, the DDM 3292 may include (a) a pivot point pin 3325 inserted into the pivot pin hole 3334 and (b) a cam as shown in FIG. 33C. The shaft 3354 is mounted on the bearing 3296 so as to be inserted into the cam driven cavity 3328.

  FIG. 33C shows the assembled DDM assembly 3299. The DDM 3292 fits on a bearing 3296 that is screwed to the screw bearing mount 3342 of the instrument insertion tube 3290, all of which surround the drive shaft 3294 coaxially. It should be noted that the pivot pin 3325 on the bearing grip 3324 fits into the pivot pin hole 3334 of the bearing 3296. This structure in combination with the bearing cavity 3326 allows the hollow DDM 3292 to rotate freely on the pivot pin 3325. The rotation of the drive shaft 3294 rotates the cam shaft portion 3354 inside the cam driven cavity 3328, drives the DDM 3292 to vibrate around the pivot pinhole 3334, and is structured left and right as indicated by a double arrow 3377. The surface 3322 facing the surface is swept.

  In operation, referring to FIGS. 32 and 33A-33C, the surgeon holds the differential dissecting instrument 3210 by the instrument handle 3212 and orients the distal end that attaches the DDM 3292 toward the incised composite tissue. After selecting the power level by sliding the power level adjuster 3281 to the desired position, the surgeon places his thumb on the switch 3282 and presses it to close the switch. When the switch 3282 is closed, the motor 3260 is turned on, and the motor shaft coupler 3262 and the drive shaft 3294 are sequentially rotated. Drive shaft 3294 is coaxially and very accurately held in place by bearing 3296, particularly bearing tip 3332, such that cam shaft portion 3354 of drive shaft 3294 oscillates within cam driven cavity 3328 of bearing cavity 3326 of DDM3292 Is done. The cam follower cavity 3328 is elliptical and, in the embodiment shown in FIGS. 33A-33C, occurs in a direction perpendicular to the rotational joint axis formed by the pivot pin 3325 and the pivot pin hole 3334. It has its narrowest dimension. In this embodiment, the narrowest dimension of the cam driven cavity 3328 barely allows the passage of the camshaft portion 3354 of the rotary drive shaft 3294. Accordingly, the rotational vibration of the cam shaft portion 3354 affects the long wall of the cam driven cavity 3328, and the vibration arc 3377 is in a plane perpendicular to the rotational joint axis formed by the pivot pin 3325 and the pivot pin hole 3334. The entire DDM 3292 is forcibly rotated via the. In this embodiment, the amplitude of the oscillating arc 3377 on which the tissue-facing surface 3322 of the differential incision member 3292 swings depends on the diameter 3385 of the drive shaft 3294 from which the camshaft portion 3354 is partially shaved and the tissue-facing surface. 3322 and the distance 3379 separating pivot pinhole 3334. The frequency of vibration matches the frequency of rotational vibration of the motor 3260. The surgeon can control the vibration frequency of the surface 3322 facing the tissue by changing the position of the power level adjuster 3281. Note that the mechanism for converting the rotation of the motor 3260 and hence the rotation of the drive shaft 3294 into the vibration of the DDM 3292 is similar to the Scotch yoke shown in FIGS. 22-25C. .

  The differential dissection instrument 3200 is an example of a DDM implementation and many variations are possible. For example, the vibration of the DDM can be driven by a crank and slider mechanism that uses a slider that moves back and forth in the longitudinal direction inside the instrument insertion tube. Alternatively, the motor can be placed adjacent to the DDM, with the motor shaft directly driving the DDM and only the electrical wiring for powering the motor goes through the instrument insertion tube. Further, since the DDM fits well at the end of the tube, making the instrument insertion tube much longer allows a differential dissection instrument such as, for example, the differential dissection instrument 3200 to be a laparoscopic instrument. To do. Although longer or shorter tubes are easily accommodated in the design, a differential dissection instrument having an instrument insertion tube as long as 36 (36) cm may be used. A DDM as disclosed herein can be easily adapted to an arm of a surgical robot such as the Da Vinci surgical robot from Intuitive Surgical (Sunnyvale, Calif.). DDM can be very small. For example, an effective differential cutting instrument in which the DDM and instrument insertion tube fit into a 5 (5) mm hole such as a surgical port can be constructed, allowing minimally invasive surgery. These small devices are easily constructed.

  Furthermore, the differential cutting instrument can be used with the drive shaft replaced by a flexible drive shaft, and the instrument insertion tube is curved. This forms a differential dissection instrument with a curved instrument insertion tube, similar to that shown in FIG. 6C. Instrument insertion tube joints are also possible, for example, using a drive shaft with a universal joint or other bendable coupler at the joint.

As previously disclosed, additional features can be added to the end of the differential cutting instrument. For example,
FIGS. 11B and 13 show how the DDM design allows fluid to be delivered to the DDM for irrigation or how aspiration is applied to clarify the surgical field Or how a light source can be placed on or near the DDM to illuminate the surgical field.

  FIGS. 26A to 26D show differential cutting instruments with retractable cutting blades that can be sharply shaped for cutting or energized by an electrosurgical electrosurgical generator (unipolar or bipolar) Is disclosed.

  FIGS. 27A and 27B show how the DDM design allows the DDM to be adapted to function as a forceps.

  Additional features can be easily added to the differential cutting instrument. For example, the DDM or any size patch on the side of the shroud that holds the DDM can be energized so that the patch can be used for electrocautery. To simplify manufacturing, the drive shaft can be used to conduct electricity from the handle to the DDM. The DDM design allows the forceps shown in FIGS. 27A and 27B to be used instead as scissors. Additional features can include video cameras for imaging or ultrasound surgery for sharp dissection. The improved design of DDM allows many of these additional functions to be combined together in one differential cutting instrument. The benefits realized from the combination of DDM functions at the working end of the differential cutting instrument include: Reducing the number of instruments a surgeon needs for treatment; simplifying hospital and logistics inventory for support staff; and, most importantly, slowing surgery and major surgical complications Reduce changes in the source instrument during surgery. This is especially true in laparoscopic and robotic surgery, which often requires positioning the instrument in the body through a small incision with an airtight port.

  FIG. 34 shows a perspective view of one embodiment of an assembled differential dissection instrument. The differential dissecting instrument 3400 extends from an instrument handle 3412 that projects an instrument insertion tube 3490 having a first end 3491 attached to the instrument handle 3412 and a second end 3493 rotatably attached to the DDM 3492. It is composed entirely. The instrument handle 3412 is assembled from an upper housing 3420 that includes an upper battery cover 3422 and a lower housing 3430 that includes a lower battery cover 3432. Encapsulated within the upper housing 3420 and the lower housing 3430 are a motor 3460 and a battery 3470 that can be assembled into a battery pack if desired. Within the upper housing 3420 is a switch 3482 (which can be a momentary switch or an on-off switch) to provide power from the battery pack 3470 to the motor 3460. A flexible switch cover 3484 mounted on the surface of the upper housing 3420 allows access to the interior of the power level adjuster 3581 (FIG. 35A). Upper housing 3420 further includes an instrument insertion tube support for orienting instrument insertion tube 3490 near and coaxial with motor 3460, with retractable blade hook control button 3499 (secured by control button bolt 3498). 3426.

  FIG. 35A shows an exploded view of the differential dissecting instrument 3400. The differential dissecting instrument 3400 extends from an instrument handle 3412 that projects an instrument insertion tube 3490 having a first end 3491 attached to the instrument handle 3412 and a second end 3493 rotatably attached to the DDM 3492. It is composed entirely. The instrument handle 3412 is assembled from an upper housing 3420 that includes an upper battery cover 3422 and a lower housing 3430 that includes a lower battery cover 3432 that are held together by an instrument housing bolt 3536. Included within upper housing 3420 and lower housing 3430 are motor 3460 and battery 3470, shown as battery type CR123A (3V each, 18V for all six batteries 3470), but other battery types And voltage are available. We use batteries as low as 3V in total in some embodiments. Within the upper housing 3420 is a switch port 3524 to which a switch 3482 (which can be a momentary switch or an on-off switch) can be accessed to provide power from the battery pack 3470 to the motor 3460. A flexible printed circuit board 3580 further including a power level adjuster 3581 (which can be any convenient element, but shown here as a linear potentiometer) is provided and mounted on the surface of the upper housing 3420. Access via the sex switch cover 3484. Also included are a front spring battery connector 3572 and a rear spring battery connector 3574 that relay power from the battery 3470. Upper housing 3420 further includes an instrument insertion tube support 3426 for securing and orienting instrument insertion tube 3490 in the vicinity of and coaxially with motor 3460. The instrument insertion tube holding bolt 3527 securely holds the instrument insertion tube 3490 at the instrument insertion tube support 3426.

  The lower housing 3430 further provides access to the battery 3470 and secures the integral lower battery cover 3432 with the motor housing portion 3534 and is further retained in the upper housing 3420 using three instrument housing bolts 3536. The The motor housing part 3534 holds and fixes the motor 3460 coaxially with the instrument insertion tube 3490 that passes through the instrument insertion tube support part 3426. The motor 3460 is pressed forward by the motor housing portion 3534 against the motor spring 3562 whose inner diameter leaves room for the motor shaft coupler 3562. The motor shaft coupler 3562 is securely mounted on the shaft end of the motor 3460 with the help of the motor shaft coupler bolt 3566 and further grips the first end 3595 of the drive shaft 3494. The motor 3460 can slide back and forth in the longitudinal direction within the motor housing portion 3534 under the control of the retractable blade hook control button 3499. The motor 3460 further includes a power contact plate 3569 that slidably operates relative to a spring motor power contact 3563 mounted on the circuit board 3580. Also mounted on the circuit board 3580 is an adjustable power contact pressure control bolt 3561. Usually, the spring 3567 holds the motor 3460 rearward. In that position, the spring motor power contacts 3563 mounted on the printed circuit board 3580 are aligned with and pressed against the power contact plate 3569 in the motor 3460 so that the power from the battery pack 3470 causes the motor to rotate. Can be driven. When the retractable blade hook control button 3499 is pressed forward, the motor 3460 is slid forward. The power contact plate 3569 receives power from the battery pack 3470 when the motor 3460 is slid far enough forward toward the insertion tube second end 3493 to interrupt contact with the spring motor power contact 3563. It is shorter than the full range of movement of the motor 3460 under the influence of the retractable blade hook control button 3499 so that it is automatically shut off.

  The drive shaft 3494 also has a second end 3597 that is concentrically supported by a bearing 3496 that passes through and is mounted on the second end 3493 of the instrument insertion tube 3490. Referring also to FIG. 35B, the second end 3597 of the drive shaft 3494 further includes a cam receiver retainer 3555 (operating from and inward from the tip of the second end of 3597), a cam receiver driver 3554, Bearing gap portion 3552. The DDM 3492 is rotatably mounted on the bearing 3496 so that the drive shaft 3494 rotates the DDM 3492 by reciprocating vibration. The DDM 3492, bearing 3496, cam receiver 3596, cam receiver retainer 3555, drive shaft 3494 and instrument insertion tube 3490 together form the DDM assembly 3598 described next.

  FIG. 35B shows details of DDM assembly 3598 including how DDM 3492 is assembled with other elements such that motor 3460 drives the reciprocating vibration of DDM 3492. The DDM 3492 in this embodiment includes a tissue facing surface 3522 on the first end 3521 and a bearing grip 3524 on the second end 3543. The bearing grip 3524 is further fitted into two pivot pinholes 3525. The DDM 3492 may be partially hollow with a bearing cavity 3526 that allows the bearing 3496 to fit therein. The bearing cavity 3526 further mounts a cam receiver cavity 3548 that is shaped to allow the cam receiver 3596 to slide easily therein. In this embodiment, the tissue facing surface 3522 of DDM3492 further comprises a retractable blade slot 3506. The bearing 3496 has a hole 3536, a bearing tip 3532, a screw receiving end 3538, and two insertion pivot pins 3535 that fit into the screw hole 3534. The screw bearing end 3538 is screwed to the screw bearing mount 3542 of the second end 3493 of the instrument insertion tube 3490. The hole 3536 can have a diameter that is greater than the diameter 3585 of the drive shaft 3494 anywhere along its length, except for the bearing tip 3532, thereby reducing the contact surface between the bearing 3496 and the drive shaft 3494. Let The second end portion 3497 of the drive shaft 3494 is changed to include a main shaft portion 3552, a cam shaft portion 3554, and a cam receiving retainer 3555. The cam receiver 3596 further includes a cam receiver main body 3502, a cam receiver chamber 3505, and a retractable blade 3501. The retractable blade 3501 can further include a hook 3504 and a tissue engaging surface 3503. The tissue engaging surface 3503 of the retractable blade 3501 can be more or less invasive than the tissue engaging surface of the DDM3492. The various sub-elements of these elements allow their assembly and operation as disclosed elsewhere in this document.

  The DDM 3492 fits on a bearing 3496 that is screwed to a screw bearing mount 3542 of the instrument insertion tube 3490, all of which surrounds the drive shaft 3494 coaxially. It should be noted that the pivot pin hole 3525 on the bearing grip 3524 fits on the pivot pin 3535 of the bearing 3496. This structure in combination with the bearing cavity 3526 allows the DDM 3492 to rotate freely on the pivot pin 3535. The rotation of the drive shaft 3494 rotates the cam shaft portion 3554 inside the cam receiver 3596, drives the DDM 3492 to reciprocate around the pivot pinhole 3525, and sweeps the surface 3522 facing the tissue to the left and right. . The tissue facing surface 3522 can have a tissue engaging surface (not shown here) to perform as a DDM.

  In operation, the surgeon holds the differential dissecting instrument 3400 by the instrument handle 3412 and orients the distal end that mounts the DDM 3492 toward the incised composite tissue. After selecting the power level by sliding the power level adjuster 3581 to the desired setting, the surgeon places his thumb on the switch 3482 and presses it to close the switch. When the switch 3482 is closed, the motor 3460 is turned on to sequentially rotate the motor shaft coupler 3562 and the drive shaft 3494. The drive shaft 3494 is coaxial and in place by a bearing 3496, particularly a bearing tip 3532 such that the cam shaft portion 3554 of the drive shaft 3494 rotates and vibrates within the cam receiver chamber 3505 of the cam receiver 3502 captured within the DDM 3492. Is held very accurately. The rotational vibration of the cam shaft portion 3554 acts on the wall of the cam receiving chamber 3505 of the cam receiver 3502 configured as a Scotch yoke as described above, and the entire DDM3492 is formed by the pivot pin 3535 and the pivot pin hole 3525. Forcibly rotate through a vibrating arc in a plane perpendicular to the rotating joint axis. The surgeon can extend the retractable blade 3501 by pressing the retractable blade hook control button 3499 forward. Advancement of retractable blade hook control button 3499 advances motor 3460 and power contact plate 3569, separates power contact plate 3569 from spring motor power contact 3563, disconnects power to the motor as described above, and Prevent vibration. At the same time, the forward movement of the motor 3460 pushes the drive shaft 3494 forward toward the second end 3493 of the instrument insertion tube 3490. The forward movement of the drive shaft 3494 sequentially presses the cam receiver retainer 3555 against the upper part of the cam receiver chamber 3505 inside the cam receiver main body 3502, thereby further pressing the cam receiver main body 3502 to the cam receiver cavity 3548, Retractable blade 3501 is extended from retractable blade slot 3506. Therefore, forward movement of retractable blade hook control button 3499 stops motor 3460 and causes retractable blade 3501 to extend from DDM3492. When the retractable blade hook control button 3499 is released, the motor spring 3562 pushes the motor 3460 backward, retracts the retractable blade 3501, and restores electrical contact to the motor.

  In this embodiment, the amplitude of the oscillation of the tissue-facing surface 3522 of the differential dissection member 3492 is such that the diameter 3585 of the drive shaft 3494 from which the camshaft 3554 is partially shaved, the surface 3522 facing the tissue, and It is a function of the distance 3579 separating the pivot pinholes 3525. The frequency of reciprocating vibration (cycles per minute) of the DDM 3492 relative to the composite tissue matches the frequency of rotation of the motor 3460 (rotations per minute). The surgeon can control the vibration frequency of the surface 3342 facing the tissue by changing the position of the power level adjuster 3581. It should be noted that the mechanism for converting the rotation of the motor 3460 and hence the rotation of the drive shaft 3494 into the vibration of the DDM 3492 is similar to the Scotch yoke shown in FIGS. 22 to 25C. .

  FIGS. 35C-1 and 35C-2 illustrate the front / rear operation of the drive shaft 3494, and hence the cam receiver body 3502, and the amplitude of the reciprocating vibration of the DDM 3492 is varied. The drive shaft 3494 is depicted at a rear position (moved in the direction of arrow 3595) in FIG. 35C-1 and a forward position (moved in the direction of arrow 3597) in FIG. 35C-2. Therefore, when the cam receiver body 3502 moves forward inside the cam receiver cavity 3548, the distance D from the cam receiver body 3548 and the pivot pinhole 3525 increases to D ′ while (as described above, The lateral displacement of the receiver 3599 remains constant (as determined by the diameter 3585 of the drive shaft 3494). As D 'increases, the large angular amplitude of DDM3596 in the left frame decreases to the small angular amplitude of DDM3492 in the right frame. This effect can be used to reduce the amplitude of vibration when the retractable blade is extended. Also, for example, if a surgeon wants narrow vibrations for a more precise incision, it can be used to change the amplitude of vibrations in the DDM blunt dissection.

  36A-1, 36A-2, 36B-1, 36B-2, 36B-3, and 36B-4 illustrate a DDM 3610 that is rotatably attached to an instrument insertion tube 3620 via a rotational joint 3630. FIG. The end of a differential dissecting instrument 3600 is shown. The differential dissection instrument 3600 also has a retractable hook 3640 that can be extended or retracted by movement in the direction indicated by double arrow 3650. Retractable hook 3640 can be retracted or extended using, for example, the mechanisms described in FIGS. 34, 35A and 35B. FIG. 36A shows how the retractable hook 3640 can be arranged in two configurations. Configuration 1 (FIG. 36A-1) shows the retractable hook 3640 in the extended position, and Configuration 21 (FIG. 36A-2) shows the retractable hook 3640 in the retracted position. The retractable hook 3640 has a tip 3670 that can be sharpened or rounded, and a tissue engaging surface that can be more invasive or less invasive than the tissue engaging surface 3690 of the DDM 3610. 3660. Retractable hook 3640 has an elbow 3680 that can be sharpened or blunted for slicing, as shown here. Furthermore, it can be serrated and the sharpened area can be located anywhere in the elbow. In configuration 2, the retractable hook is hidden inside the DDM 3610, which alone interacts with the tissue. In configuration 1, retractable hook 3640 is exposed such that tissue engaging surface 3690 interacts with tissue (eg, to break soft tissue) or tip 3670 interacts with tissue (eg, The elbow 3680 can be used to interact with the tissue, or the elbow 3680 can be used to position the retractable hook 3640 relative to the tissue. Interact with (eg, slice tissue). Further, the retractable hook 3640 can be held in any intermediate position between configurations 1 and 2, including being able to be variably extended by the operator.

  36B-1 to 36B-4 show the end of the differential dissection instrument 3600, where the DDM 3610 is in the extended configuration (Configuration 1) 1 (FIG. 36B-1) or the storage configuration (Configuration 2) 1 (FIG. 36B). -2) illustrates that it can be vibrated by the retractable hook, and that the retractable hook 3640 can be retracted or extended before activation of the vibration of the DDM 3610 or during the vibration of the DDM 3610. An arrow 3601 indicates a retractable hook that moves between a retracted configuration (lower left frame) and an extended configuration (upper left frame in FIG. 36B-3) when the DDM 3610 is not vibrating. Arrow 3602 indicates that DDM 3610 can be switched from stationary (upper left frame) to vibration (upper right frame in FIG. 36B-4) when retractable hook 3640 is in the extended configuration. Arrow 3603 indicates that retractable hook 3640 can be moved from the extended configuration (upper right frame) to the retracted configuration (lower right frame) when DDM 3610 is vibrating. Arrow 3604 indicates that DDM 3610 can change from stationary (lower left frame) to vibrating (lower right frame) when retractable hook 3640 is in the retracted configuration. Retractable hook 3640 is formed from a conductive material such as stainless steel and external surgical electrosurgical generator to allow retractable hook 3640 to act as an electrosurgical hook, if desired. Can be electrically connected.

  Many tissues to be incised are wrapped in a film or capsule that the surgeon needs to divide to gain access to the tissue. Once the membrane or capsule is split, the surgeon advances an incision through the tissue. FIGS. 37-1 to 37-4 illustrate the use of a differential dissection instrument 3600 in four views to safely and quickly divide a membrane 3710 covering a tissue 3700 such as the peritoneum covering the gallbladder and the surrounding capsule of the liver. It illustrates the method that is possible. In the upper left figure (Figure 37-1), the differential dissecting instrument can be seen approaching the membrane 3710 by the retractable hook 3640 in the extended configuration. In the upper right view (FIG. 37-2), the tissue engaging surface 3660 of the retractable hook 3640 is pressed by the surgeon against the membrane 3710 and the DDM 3610 is vibrated so that the tissue engaging surface 3660 erodes the membrane 3710. . (Alternatively, retractable hook 3640 can be held in a retracted configuration, and tissue engaging surface 3690 of DDM 3610 can be used to erode membrane 3710. Two tissue engaging surfaces 3660 and 3690 are provided. With different levels of aggressiveness, the surgeon has the flexibility to choose between a more invasive or less invasive tissue engaging surface to erode the membrane 3710). The tissue is eroded until a small opening 3720 is formed in the membrane 3710. Next, as shown in the lower left view (FIG. 37-3), the surgeon pushes the tip 3670 of the retractable hook 3640 through the opening 3720 and below the membrane 3710 and away from the tissue 3700. Lift or “tent” the flap 3730. The surgeon then moves the DDM 3600 in the direction of arrow 3740, thereby pushing the flap 3730 into the elbow 3680 of the retractable hook 3640, which is sharpened to slice the tissue. Finally, as shown in the lower right view (FIG. 37-4), the surgeon oscillates the DDM 3610 and oscillates the retractable hook 3640, thus allowing the surgeon to continue moving the DDM 3600 in the direction of arrow 3740 Along with this, the sharp edge of the elbow 3680 of the retractable hook 3640 is quickly moved to the membrane 3710. New tissue to be a simple, quick and safe way to split membranes such as the peritoneum that covers the gallbladder and bile ducts without damaging the underlying structures (eg gallbladder, bile duct or liver) Has been demonstrated by The tip 3680 of the retractable hook 3640 can be dull enough to not easily penetrate the membrane 3710 or the underlying structure. Furthermore, the placement of sharp edges only in the elbow 3680 prevents the critical structures from being exposed to the sharp edges 3680, thus reducing the likelihood that such critical structures will be cut. Examples of membranes or capsules overlying critical structures include the peritoneum, gallbladder, gallbladder duct and gallbladder artery overlying the liver, and the pleura, pulmonary artery, pulmonary vein, and bronchus overlying the lung.

  Retractable hooks are used in a manner similar to that shown in FIGS. 37-1 to 37-4 to dissect severe fibrous structures, such as adhesions around renal arteries or veins and scar tissue, fibrous tissue Is possible. For example, the surgeon can use the tip of the retractable hook to grab all or part of the fibrous structure and press the tissue against the sharp elbow of the hook. The surgeon can then vibrate the DDM and hook to use the sharp edge inside the hook to cut tissue. The advantage of this approach is that it applies stress at that location of the tissue to be segmented. In current practice, the surgeon splits such tissue by various techniques including simply grabbing the sides or ends of such tissue and pulling them until they break. This can sometimes stress the tissue being pulled, such as the bowel wall, leading to accidental tearing of important tissues such as the bowel wall (thus piercing the bowel). Apply stress more locally and directly to the tissue to be split (especially at the sharp elbow of the hook) and not over a large spread of tissue (eg, between two pairs of forceps) This allows the surgeon to have greater certainty that more distant tissue such as the bowel wall is intact.

  It is important to note that the method of dividing these tissues by using vibrated hooks does not heat the tissue, in stark contrast to the extreme heating resulting from current practice using electrosurgery. is there. Heating from electrosurgery is widely recognized as a major risk leading to inadvertent thermal damage of surrounding tissue. Competing techniques for sharp dissection, such as ultrasound ablation (eg, Ethicon Endosurgery's “Harmonic Scissors”) have been developed to reduce heat and thereby reduce the risk of thermal damage to tissue. Nevertheless, local heating is still significant and there is still a risk of thermal damage. In contrast, splitting the membrane with an oscillating hook or incising the fiber structure as described herein does not cause tissue heating and eliminates this major source of iatrogenic trauma.

  FIG. 38 illustrates one embodiment of a differential dissection instrument 3800 for laparoscopic surgery. It uses the mechanism for vibration of the DDM3810 shown in FIGS. 34, 35A and 35B, including a retractable blade (which is not visible in this view because it is in a retracted configuration). The differential dissection instrument 3800 uses a pistol style handle 3820 having a trigger 3830 for starting / stopping vibration of the DDM 3810 and a speed control 3840 for controlling the speed of vibration. Thumb activation push button 3850 is used to extend a retractable blade that is normally held in a retracted configuration by a spring mechanism within handle 3820. The rotating wheel 3860 can be reached and rotated by the index finger, and the rotation of the rotating wheel 3860 can be adjusted so that the vibrating surface 3880 of the DDM 3810 can be easily rotated over 360 ° and the instrument insertion tube 3870 and attached. Rotate the resulting DDM 3810, thereby allowing the surgeon to orient the tissue surface in the body to the vibrating surface 3880 while maintaining good ergonomics about the handle 3820. Indicator 3862 on rotating wheel 3860 provides the surgeon with a visual cue outside the body regarding the orientation of vibrating surface 3880, and similarly, a visual cue such as an embossed stripe is placed on instrument insertion tube 3870 or DDM 3810. Thereby providing a visual cue at the camera during laparoscopic viewing. The electrical plug 3890 allows for optional attachment via a cable to an external electrosurgical generator for electrosurgical and electrocautery (external attached to the electrosurgical generator for electrosurgical generator control). Controlled by a foot pedal or a push button (not shown) can be placed on the handle 3820 and used for control of the electrosurgical generator). Thus, the differential dissection instrument 3800 allows the surgeon to perform blunt dissection (with differential dissection), sharp dissection (with retractable hook or electrosurgery), coagulation (with electrocautery) with a single instrument. Thereby reducing instrument modifications complicated for laparoscopic surgery.

  FIG. 39 shows a differential dissection instrument 3900 configured as a tool that attaches to the arm of a surgical robot such as da Vinci Robot from Intuitive Surgical. The DDM 3610 is rotatably attached to the instrument insertion tube 3910 via a rotary joint 3630. Retractable hook 3640 can move between retracted and extended configurations as indicated by double arrow 3650. The retractable hook 3640 has a tissue engaging surface 3660, a tip 3670, and an elbow 3680 with a sharp edge for sharp dissection. Retractable hook 3640 is electrically conductive and can be electrically connected to an external electrosurgical generator if desired. Similarly, DDM 3610 or a small conductive patch 3625 on DDM 3610 can be used for an electric scalpel. (Note that the conductive patch can be placed anywhere in the DDM 3610 including the tissue engaging surface 3690). The instrument insertion tube 3910 is attached to a housing 3920 that includes a motor that drives the vibration of the DDM 3610 and retractable hook 3640 as described above. The housing 3920 is configured with a socket 3930 having electrical and mechanical connections for connection to the arm of the surgical robot. The instrument insertion tube 3910 can be elongated so that the housing 3920 is positioned outside the patient's body. Conversely, instrument insertion tube 3910 is positioned within the patient's body by housing 3920 with a robot arm and a joint disposed within the patient's body to allow articulation of differential cutting instrument 3900 within the patient's body. It can be formed short.

All connections from the housing to the handle or housing, and thus via the joint, can be electrical, which can be much simpler than a design that requires transmission of mechanical drive via the joint. from the arrangement of the small motor in the housing close to the body of DDM and patients, to facilitate articulation of the instrument insertion tube discriminatory cutting instrument. The same is true for differential cutting instruments designed for both surgical robots and laparoscopy.

  FIGS. 40-1 and 40-2 show one embodiment of such a device as the end of a laparoscopic differential dissection instrument 4000. FIG. FIGS. 40-1 and 40-2 illustrate exemplary laparoscopic versions of a differential dissection instrument having an electromechanical actuator distal to the joint in a straight and curved position, respectively. DDM 3610 is attached to retractable hook 3640 and conductive patch 3625. The DDM 3610 is rotatably attached to a distal instrument insertion tube 4010 that is articulated at a rotational joint 4030 to a proximal instrument insertion tube 4020. Mounted inside the distal instrument insertion tube 4010 are a motor 4040 having a motor shaft 4050 and a solenoid 4060 having a solenoid plunger 4070. The rotation of the motor shaft 4050 by the motor 4040 drives the vibration of the DDM 4010 and hence the retractable hook 3640 as described above. The solenoid 4060 is rigidly attached to the distal instrument insertion tube 4010 and the solenoid plunger 4070 is attached to a motor 4040 that slides freely inside the distal insertion tube 4010. Therefore, when solenoid 4060 is activated, the solenoid plunger moves up / down (in the direction indicated by arrow 4080), thereby moving motor 4040, motor shaft 4050 and retractable hook 3640 (by arrow 4080). Drive up / down (as shown). The flexible conductor ribbon 4090 provides the power and signals necessary to drive the motor 4040 and solenoid 4060. The articulation of the laparoscopic differential dissecting instrument 4000 at the rotational joint 4030 allows the distal instrument insertion tube 4010 to bend relative to the proximal instrument insertion tube 4020 as shown in the right figure. The movement of the distal instrument insertion tube 4010 relative to the proximal instrument insertion tube 4020 is the operation of some mechanisms such as a control horn driven by a push-pull rod actuated by a manual mechanism in the handle of the laparoscopic differential dissection instrument 4000. It can be driven by either. This actuator (ie, motor 4040 and solenoid 4060) and flexible conductor ribbon 4090 configuration requires the transmission of complex motion beyond articulation in the rotary joint 4030, and expensive complex mechanical components, requiring a large volume. Add and facilitate communication that will tend to fail.

  FIG. 41 has a thin flexible instrument insertion tube 4110 for use in surgical procedures such as single incision laparoscopic surgery (SILS) or natural opening transluminal endoscopic surgery (NOTES). A differential dissecting instrument 4100 is shown. The actuation mechanism is similar to DDM3492, and the retractable hook 3596 in FIGS. 35A and 35B is the same as that shown in FIGS. 35A and 35B. However, rigid instrument insertion tube 3490 and rigid drive shaft 3494 are replaced by flexible instrument insertion tube 4110 and flexible drive shaft 4120 and retractable hook 3596 is replaced by electrosurgical hook 4130. The flexible drive shaft 4120 can be rotated to drive the vibration of the DDM3492 (as indicated by the double arrow 4160), or can retract and extend the electrosurgical hook 4130 (double arrow). Can be push-pull (as indicated by 4162). The multi-tube flexible instrument insertion tube 4110 can be used to reduce wobbling of the flexible drive shaft 4120 inside the flexible instrument insertion tube, thereby extending and retracting the electrosurgical hook 4130. Provides greater authority over the push-pull mechanism of the flexible drive shaft 4120 for storage. The flexible wire 4140 can also be moved within the flexible insertion tube 4110 to allow energization of the electrosurgical hook 4130, and the flexible wire 4140 and the electrosurgical hook 4130 can be soldered. It is connected to the cam receiver body 3502 via a weld 4150 or other suitable mechanism. Therefore, the differential dissecting instrument 4100 can perform electrocautery or electrocautery via a foot pedal or electrocautery by a control in a blunt dissection, electrosurgical sharp dissection, and extracorporeal handset. It is.

  42A-42E have a thin pencil grip handle that can be easily rotated by hand, and allows discrimination 360 ° rotation of the rotational surface of the DDM 4250 about the longitudinal central axis 4299 of the differential dissecting instrument 4200. A perspective view and an enlarged view of one embodiment of a mechanical cutting instrument 4200 are shown.

  42A and 42B show the differential dissecting instrument 4200 in a perspective view assembled in FIG. 42A and in an exploded view in FIG. 42B. The differential dissecting instrument 4200 has a generally cylindrical handle 4210 having a central longitudinal axis 4299. In use, the distal end 4201 of the handle 4210 is directed to the tissue to be incised and the proximal end 4202 points away from the composite tissue toward the user. Attached to the distal end 4201 is an elongate parallel to the longitudinal axis 4299 having a proximal end 4222 attached to the distal end 4201 of the handle 4210 and a distal end 4221 pointing towards the tissue to be incised. Member 4220. DDM 4250 is attached to distal end 4221 of elongate member 4220. In this embodiment, the cylindrical handle 4210 is hollow with a clamshell structure to accommodate a mechanism 4260 configured to mechanically rotate the DDM 4250, as described in the next paragraph.

  Referring to FIGS. 42B, 42D, and 42E, FIG. 42B shows an enlarged view of the differential dissecting instrument 4200, FIG. 42D shows an enlarged view of the drive mechanism of the DDM 4250, and FIG. 42E shows the DDM 4250. A simplified diagram of the drive mechanism is shown with emphasis on the method by which the is driven. The DDM 4250 is rotatably attached to the distal end 4221 of the elongate member 4220 so that the DDM 4250 rotates about the rotation axis 4252. The first torque point located on the first tissue engaging surface 4251 at the distal end 4221 of the DDM 4250 and the first side 4255 of the rotational axis 4252 of the DDM 4250 so that the DDM 4250 faces the tissue to be incised. 4253 (see FIG. 42E). Applying the first force 4270 to the first torque point 4253 creates a moment on the DDM 4250 about the rotation axis 4252 and therefore drives the clockwise rotation of the DDM 4250 about the rotation axis 4252. In the embodiment presented here, there is a second torque point 4254 located on the second side 4256 of the rotating shaft 4252 so that applying the second force 4271 is counterclockwise of the DDM 4250. Drive rotation. Therefore, the moment formed by applying the first force 4270 at the first torque point 4253 forms the opposite torque for the second force 4271 at the second torque point 4254. The alternating application of the first force 4270 and the subsequent second force 4271 thereby drives the vibration of the DDM 4250 about the rotation axis 4252 (clockwise and then counterclockwise). The first force transmission member 4261 and the second force transmission member 4262 are a flexible tensile member such as a cable, a wire, a string, a rope, a tape, a belt, or a chain, or a rigid member such as a push rod or a connecting rod. Note that you can. In the embodiment presented here, the first force transmission member 4261 and the second force transmission member 4264 are flexible tension members such as cables.

  The vibration is driven by a power source 4290 supplied by a motor 4291. Therefore, the power source 4290 drives at least one force transmission member 4261 axially relative to the longitudinal axis 4299 proximally and distally, thereby causing the first torque of the DDM 4250 about the rotational axis 4252. Driving point 4253 so that at least one tissue engaging surface 4251 is configured to selectively engage the tissue to be incised and at least one tissue engaging surface 4251 is incised. Its axis of rotation so that at least one tissue engaging surface 4251 destroys at least one soft tissue in the tissue to be incised by moving across the tissue to be incised, but does not destroy the hard tissue in the tissue to be incised. DDM4250 is vibrated around 4252.

  Referring to FIGS. 42B, 42D and 42E, mechanism 4260 drives the rotation of DDM 4250. The mechanism 4260 (see particularly FIG. 42D) includes at least one force transmission member 4261 that drives the vibration of the DDM 4250 as described in the previous paragraph. 42B, 42D, and 42E, the first force transmission member 4261 and the second force transmission member 4262 extend substantially parallel to the longitudinal axis 4299 inside the elongated member 4220, and The distal end 4264 of the first force transmission member 4261 is attached to the first torque point 4253 of the DDM 4250 and the distal end 4266 of the second force transmission member 4262 is attached to the second torque point 4254 of the DDM 4250. 42B and 42D, the proximal end 4263 of the first force transmission member 4261 is attached to the first follower 4231 of the cam shaft 4230, and the proximal end 4265 of the second force transmission member 4262 is , And adheres to the second follower 4232 of the cam shaft 4230. The first follower 4231 rides on the first eccentric cam 4233 at the cam shaft 4230 (see the inset), and the second follower 4232 rides on the second eccentric cam 4234 at the cam shaft 4230 (inset). See). The cam shaft 4230 rotates around a rotation axis 4235 perpendicular to the longitudinal axis 4299, and the first eccentric cam 4233 and the second eccentric cam 4234 have the first follower 4231 relative to the second follower 4232. It is arranged on the opposite side of the rotating shaft 4235 so as to move 180 degrees out of phase with respect to the phase (see FIGS. 42D and 42E for details). Therefore, the rotation of the camshaft 4230 is alternately pulled by the first force transmission member 4261 and the second force transmission member 4262, and, as described above, the alternating first and second driving the vibration of the DDM 4250, respectively. Force 4270 and 4271.

  The rotation of the cam shaft 4230 is driven by a motor 4291 through a gear train. In the embodiment presented here, the motor 4291 is a direct current motor that forms part of an electrical circuit 4292 powered by at least one battery 4294 (see FIG. 42B), and accordingly the device further comprises , Including at least one switch 4296 operably associated with motor 4291 and at least one battery 4294 to start and stop at least motor 4291. Further control can be added to allow proportional speed control of motor 4291 or speed control through incremental steps. The motor 4291 can be any of several types of motors including brushless DC motors, coreless DC motors, stepping motors, and the like.

  The spring mechanism 4280, compression spring 4281, compression nut 4282, lock nut 4283, inner sleeve 4284, outer sleeve 4286 and spring stop 4285 are more fully described below after FIGS. 44A-44C.

  In the embodiment shown in FIGS. 42A-42C, the switch 4296 allows the motor 4291 on-off switch to be accessed from substantially any direction about the longitudinal axis 4299 of the handle 4210 of the differential dissecting instrument 4200. Part of the omnidirectional control switch 4298. In this embodiment, the omni-directional control switch 4298 is easily activated with any finger regardless of the direction of rotation of the differential dissecting instrument 4200 (about the longitudinal axis 4299) when in the user's hand. In the radial array distributed around the handle 4210 from the proximal end to the distal end 4201 of the handle 4210 is comprised of five switches 4296. In this embodiment, a radial array of 5 (5) switches 4296 prevents fluid intrusion into switch 4296, but from a soft elastomer (eg, silicone rubber) that further facilitates easy operation of switch 4296. Covered by a configured flexible boot 4297. The switch can be either momentary or latched. There may be any number of switches forming a radial array, they may be in a single plane oriented transverse to the longitudinal axis 4299, or they may be discriminating from an array of switches. If it may be further distributed about and along the longitudinal axis 4299 of the cutting instrument 4200, this may not be the case. The array of switches may or may not be the same, and each of the switches 4296 may be of size, shape, type, function (instantaneous, latch on-off, normal on, normal off, single pole single throw, single pole double throw). Throw, double pole double throw, double pole single throw, or digital or analog proportional control), or distance from the longitudinal axis 4299, or any combination. Further, instead of an array of switches, the omni-directional control switch 4298 may be substantially monolithic or toroidal, such as from a first annular conductor held in contact with a second annular conductor. In response, the surgeon can apply pressure to this version of the omni-directional control switch 4298 from any direction, making the first annular conductor in electrical contact with the second annular conductor Let Either or both of the first annular conductor and the second annular conductor may be rigid or flexible. For example, if the second annular conductor forms a small diameter rigid ring about the longitudinal axis 4299 of the differential dissecting instrument 4200, the second annular conductor is elastically suspended out of contact and the first annular conductor and It can be a large-diameter ring that is substantially coaxial. As an example, the surgeon's finger can displace the rigid second annular conductor off-center until it contacts the first annular conductor, or the second annular conductor is in contact with the first annular conductor. It can be flexibly deformed until contact is established. The omni-directional control switch 4298 can take the form of a power switch that directly controls the current to the motor 4291 or to drive a logic circuit that controls the motor 4291 to provide resistance, capacitance or other The surgeon's finger input can be communicated to the parameter change.

  43A-43C illustrate different embodiments for applying torque and counter torque to the DDM 4300. FIG. In FIG. 43A, the first tension element 4261 and the second tension element 4262 are two halves of a single cable 4302 wound around a drive cylinder 4310 attached to the DDM 4300. A single cable 4302 drives the rotation of the drive cylinder 4310 by friction or by being physically attached to the drive cylinder 4310. The single cable 4302 has a first end 4311 and a second end 4312, the first end 4311 operates as the proximal end of the first force transmission member, and the second end 4312 operates as the proximal end of the second force transmission member. The first and second forces 4270 and 4271 are each driven by a linkage 4340 that is non-centrally or eccentrically attached to a driving pulley 4343 that rotates due to a motor 4342 (as indicated by arrow 4344). Formed by the movement of a rocker arm 4320 that locks around the rocker pin 4323 when done.

  Another embodiment is shown in FIG. 43B, where applying the first force 4270 extends the linear spring 4350 by rotating the DDM 4300, and the return force of the linear spring 4350 when the first force 4270 decreases. Linear spring 4350 is attached to second torque point 4254 and fixed anchor point 4351 so that 4271 generates the opposite torque. Similarly, the opposite torque can be generated by a torsion spring 4360, as shown in FIG. 43C.

Figures 44A-1 to 44C-1 illustrate different embodiments of mechanisms that protect both the differential cutting instrument and the tissue to be cut from excessive loads. 44A-1 and 44A-2 illustrate two difficulties in the construction and use of a differential dissection instrument 4400 that uses a tension member as a force transmission member. The DDM 4410 has a tissue engaging surface 4412 at its distal end and a rotational joint 4414 for rotationally connecting to the distal end of the elongate member 4430 at its proximal end. The first tension member 4421 is connected to the first torque point 4423 so that the first tension member 4421 and the second tension member 4422 form an opposite torque around the rotary joint 4414 that drives the vibration of the DDM 4410. The second tension member 4422 is connected to the second torque point 4424. Difficult # 1: For the first tension member 4421 and the second tension member 4422, they must remain taut in order to effectively provide counter torque about the rotating joint 4414. However, poor engagement of parts in the differential cutting instrument 4400, stretching, wear, or other “play” of the first tension member 4421 or the second tension member 4422 is insufficient for the differential cutting instrument 4400. Run or not run. Difficult # 2: During the incision of the tissue 4405, applying an external force F _A against the DDM 4410 pushes the differential dissecting instrument 4400 into the extreme position and causes the first tension member 4421 at the point 4441 inside the elongated member 4430 and Excessive bending or wear of the second tension member 4422 at a point 4442 inside the elongate member 4430 (or at other points of contact between the first or second tension member 4421 or 4422 and other parts). Form. If wider and excessive force is applied to the DDM of the differential cutting instrument, it may damage the differential cutting instrument or the tissue under the cut. Therefore, a means to prevent damage to either the instrument or tissue is beneficial.

FIG. 44B illustrates an embodiment of a differential dissection instrument 4401 that addresses these issues, including means for preventing damage due to overload conditions. Discriminatory dissector 4401, the first overload mechanism 4477 in response to a first threshold force _{F T1} applied to the DDM4410, second over in response to the second threshold force _{F T2} applied to DDM4410 There are two overload mechanisms, a load mechanism 4470. During the incision of tissue 4405, if a force F _A that exceeds a first threshold force F _T1 is applied to DDM 4410, first overload mechanism 4477 may be applied to differential incision instrument 4401 or tissue 4405 to be incised. Stop the rotation of the DDM 4410 to reduce the risk of damage. For example, the first overload mechanism 4477 may include a force sensor 4461 for measuring the force _{F A} applied to the DDM4410. Examples of force sensor 4461 include a load cell, strain gauge and spring loaded electrical contacts. In this example, the overload mechanism 4450 is present in the handle 4411 and the elongated member 4413 is attached to the handle 4411, but can be disposed elsewhere such as within the elongated member 4413. The force sensor 4461 communicates via the electrical circuit 4292 and the wire _4462, when _{the F T1} exceeds _{F A,} the signal is transmitted to the electric circuit 4292 through the wire 4462, responds by cutting power to the motor 4290 By doing so, the vibration of the DDM 4410 is stopped. An alternative exists to stop the rotation of the DDM 4410. For example, the clutch in the motor 4290 can limit the torque applied by the motor 4290 such that when the external force F _A is too great, the torque will be too great and the clutch will slip. May simply be small enough to stop.

If the force _{F A} that exceeds the second threshold force _{F T2} is applied to the DDM4410, the second overload mechanism 4470 (in the direction of arrow 4471) and proximally away from the tissue 4405 draws DDM4410, it To reduce the external force F _A. Note that the first overload mechanism 4477 and the second overload mechanism 4470 can be activated in response to any force, not just an axial force, as shown in FIG. 44B. Furthermore, the first threshold force F _T1 can be equal to, greater than, or less than the second threshold force F _T2 depending on the desired response. It should also be noted that the differential cutting instrument can only be fitted with either one of the two overload mechanisms 4470 and 4477.

44C-1 and 44C-2 illustrate an embodiment of a differential dissection instrument 4402 having a single overload mechanism as described above for FIG. 44B. The differential dissection instrument 4402 is similar to the differential dissection instrument 4401 except that the elongate member 4430 is the same method as the second overload mechanism 4470 described above by withdrawing the DDM 4410 proximally away from the tissue 4405. Has been replaced by another exemplary overload mechanism 4450 operating at The overload mechanism 4450 includes an outer sleeve 4451 having a first spring stop 4454, an inner sleeve 4452 having a second spring stop 4455, and a compression spring 4453. The outer sleeve 4451 and the inner sleeve 4452 are aligned parallel to the longitudinal axis 4299 of the handle. The DDM 4410 is attached to the inner sleeve 4452 at the rotary joint 4414. The inner sleeve 4452 is slidable proximally within the outer sleeve 4451. As shown on the left side (no external force is applied), the compression spring 4453 has an outer sleeve 4451 on the inner sleeve 4452 due to the compression force 4460 applied to the first spring stop 4454 and the second spring stop 4455. Slide distally inside. Sliding is limited by the forces 4462 and 4463 exerted by the first and second tension members 4421 and 4422, respectively, such that the resultant force 4462 and force 4463 is equal to the compression force 4460. Therefore, overload mechanism 4450 causes the compression spring to adjust the position of inner sleeve 4451 relative to outer sleeve 4451 each time any play, such as stretching of first and second tension members 4421 and 4422, accumulates. Then, the above-mentioned difficulty # 1 is corrected. The right side of FIG. 44B shows how the overload mechanism 4450 also mitigates the difficulty # 2 problem. When an external force F _A is applied to the DDM 4410, a moment is formed around the rotary joint 4414 that pushes the DDM 4410 into an extreme position, and a moment is also applied at the torque point 4424 extending the second tension member 4422, and the second tension A large force 4463 is formed in the member 4422. Thereby, the increase in force 4463 increases the compression force 4460 in the compression spring 4453. Accordingly, the compression spring 4453 compresses to allow the inner sleeve 4452 to slide proximally (arrow 4456) within the outer sleeve 4451, thus shortening the overload mechanism 4450. This retracts the DDM 4410 proximally away from the tissue to be incised, thereby reducing the magnitude of the force 4463 at the second tension member 4422 and the differential incision instrument 4402, particularly the second tension member 4422. Reduce the risk of damage to your body. It should be noted that other embodiments that draw DDM in response to overload are possible. Different configurations are all possible, such as springs, flexible or bendable elongate members, friction pads that slide on overload.

  42D, the spring mechanism 4280 includes a compression spring 4281, a compression nut 4282, a lock nut 4283, an inner sleeve 4284, and a spring stop 4285. A compression spring 4281 surrounds the inner sleeve 4284 and a compression nut 4282 (which serves as a first spring stop 482) and a (second spring stop) to pull on the first tension element 4261 and the second tension element 4262. Compressed between the spring stop 4285). The strength with which the compression spring 4282 pulls is set by a compression nut 4282 that is screwed onto the inner sleeve 4284, and the compression nut 4282 that advances downward (relative to the page) compresses the compression spring 4281 and compresses the compression spring 4281. Increases the tensile strength at the first tension element 4261 and the second tension element 4262. After proper tension is established, the compression nut 4283 can be locked by the lock nut 4283. This means for changing the strength with which the compression spring pulls the first tension element 4261 and the second tension element 4262 effectively reduces the threshold force at which the compression spring 4281 is relieved by an external force, as described in FIG. 44B. Set to. Furthermore, the distance of advancement of the compression nut 4283 along the inner sleeve 4284 is the distance that the compression spring can remove sagging from a mechanism resulting from, for example, the strength of the first tension element 4261 and the second tension element 4262. Define Movement of inner sleeve.

  FIGS. 45A-45G illustrate a method for using a differential dissection instrument to separate tissue surfaces without damaging blood vessels and other anatomical structures at the tissue surfaces. 45A-46G illustrate a method for using a differential dissecting instrument 4530 to dissect and separate two adjacent tissues in a tissue plane. In FIG. 45A, the first tissue 4501 and the second tissue 4502 function as an adhesive substance between the first capsule 4506 of the first tissue 4501 and the second capsule 4507 of the second tissue 4502. Adheres to soft tissue 4505 at a common boundary 4504. In this example, one blood vessel 4520 (shown in cross section) is located in the plane of the common boundary 4504 between the first capsule 4506 and the second capsule 4507, and the second blood vessel is A “perforator” 4510 that traverses the common boundary 4504 from tissue 4501 to tissue 4502, and one collagen bundle 4515 also traverses the common boundary 4504 from the first tissue 4501 to the second tissue 4502. Therefore, if the first tissue 4501 is to be separated from the second tissue 4502 by a blunt dissection, the soft tissue 4505 preferably breaks without destroying the perforator 4510, collagen bundle 4515 or blood vessel 4520. It must be. (Vessel destruction can result in unwanted bleeding.) Similarly, 4505 is a soft tissue that typically consists of gelatinous material, mesentery, reticular fibers, and loosely organized collagen fibers. The rigid tissue includes first and second capsules 4506 and 4507, vessel walls 4510 and 4520, and a collagen bundle 4515, respectively.

  Blunt dissection is performed by first grasping the first tissue 4501 with forceps 4540 and pulling in the direction of arrow 4550 to apply tension to the edge of the common boundary 4504 as indicated by double arrow 4536. Applying tension across the common boundary 4504 is important throughout this incision since, as described above, such tension assists the differential operation of the differential incision instrument 4530. The differential dissecting instrument 4530 includes a DDM 4532 having a tissue engaging surface 4533, which is rotatable to the instrument insertion tube 4531 to vibrate in and out of the plane of the page (as indicated by the rotation axis 4535). Mounted and swipes against the edge of the common boundary 4504 on the tissue engaging surface 4533. A force 4551 is applied by the operator to press the tissue engaging surface 4533 against the edge of the common boundary 4504, thereby causing the soft tissue 4505 to be resected, as shown in FIG. 45B, first and second Ensures separation of the first and second capsules 4506 and 4507 of the respective tissues 4501 and 4502 respectively. If the tissue engaging surface 4533 staggers up or down due to inaccuracy or misdirection of the force 4551 placement by the surgeon, the tissue engaging surface 4533 will not be destroyed and will therefore intersect either the capsule 4506 or 4507. do not do. Therefore, the differential dissection instrument automatically follows the plane between the tissues defined by the common boundary 4504.

  In FIG. 45C, the tissue engaging surface 4533 continues along the common boundary 4504 until it hits the blood vessel 4520. Similarly, the tissue engaging surface 4533 does not destroy the strong tissue including the walls of the blood vessel 4520. Instead, the tissue engaging surface 4533 may determine whether the soft tissue 4505 is more easily destroyed above or below the blood vessel 4520 or whether the operator presses the differential dissecting instrument 4530 above or below the blood vessel 4520. Depending on how it moves, it moves to one side or the other side of the blood vessel 4520 (here, it moves below the blood vessel 4520). The surgeon can detect the differential dissecting instrument 4530 in different directions because the surgeon can detect a tissue engaging surface 4533 that corresponds to the blood vessel 4520 as resistance to the differential dissecting instrument 4530 against the common boundary 4504 increases. The advancement of the differential dissecting instrument 4530 is actually stopped because the tissue engaging surface 4533 does not destroy the hard tissue including the wall of the blood vessel 4520 and therefore intersects the hard tissue. To do.

  The blunt dissection continues along the common boundary 4504 in FIG. 45D as the operator applies tension 4536 across the common boundary 4504 with forceps 4540 and continues to press the differential dissecting instrument 4530 against the common boundary 4504. Capsules 4506 and 4507 have a common boundary by preventing tissue engaging surface 4533 from intersecting either first capsule 4506 or second capsule 4507 until tissue engaging surface 4503 hits collagen bundle 4515. Continue channeling the differential dissecting instrument 4530 along 4504. Similarly, the tissue engaging surface 4533 cannot break the collagen bundle 4515 and similarly, the surgeon detects that the advancement of the differential dissecting instrument 4530 to the common boundary 4504 is blocked. Then, as can be seen from FIG. 45E, the surgeon operates the differential incision instrument to one side or the other side behind the collagen bundle 4515 in this example, and then the tissue engaging surface 4533 is moved to the perforator 4510. The incision continues along the common boundary 4504 until it hits here. Similarly, the surgeon detects an obstacle and moves the differential incision instrument 4530 to one side or the other side, which in this example is behind the perforator 4510, as can be seen from FIG. 45F.

  FIG. 45G shows the resulting incision after the differential dissecting instrument 4530 has been removed. The common boundary 4504 is incised here so that the capsules 4506 and 4507 of tissue 4501 and 4502 are separated, providing an important field of view for the surgeon. Importantly, blood vessel 4520 is intact, collagen bundle 4515 extends into the gap between first capsule 4506 and second capsule 4507, and perforator 4510 is connected to first capsule 4506 and first capsule 4506. Between the two capsules 4507 and stretched across the gap. Collagen bundle 4515 and perforator 4520 are therefore “skeletonized” and they are found here in open space and cauterized and cut without contacting either capsule 4506 or 4507 or tissue 4501 or 4502. Can. This is because when bleeding from the perforator 4510 is to be controlled when the tissues 4501 and 4502 are separated, contact with the electrocautery surface or heat diffusion from the electrocautery surface may cause the tissue 4501 or 4502. This is particularly important when there is a possibility of causing thermal damage to any of 4502.

  An incision technique such as that shown in FIGS. 45A-F separates blood vessels from the sac or from other blood vessels, for example, to separate adjacent muscles, to separate the gallbladder from the liver bed In order to isolate adjacent lobes of the lungs, to isolate pulmonary arteries and gallbladder ducts and gallbladder arteries and many others (ex vivo animal tissue, live animal tissue (pigs) and human cadaver Used by the inventor to make several surgical incisions. Surprisingly, each of these incisions is remarkably bloodless due to the ability of differential incision to dissect even blood vessels as small as 0.5 mm without breaking any blood vessels. Furthermore, the incision is remarkably safe. During these procedures, surgeons deliberately attempted operations that would be catastrophic with other instruments. For example, the surgeon repeatedly pierced the liver with a differential dissection instrument set at high speed, bounced the differential dissection instrument in the pulmonary artery, and punctured the large intestine, bladder and lungs-no organs were damaged. As previously mentioned, the absence of sharp edges in the DDM, unlike any other surgical instrument, allows blunt dissection to be performed safely.

  An incision with a differential incision instrument such as that shown in FIGS. 45A-45F can be used, for example, to incise the fascial surface during an abdominal suturing procedure. In practice, it is possible to cut these tissue surfaces without cauterizing or cutting the perforator. Rather, by using the differential dissection instrument shown herein and operating around the perforator to skeletonize them during the dissection, sufficient separation of the tissue surface will prevent accidental tearing. Enough of the tissue to allow the incision to advance without cutting the perforator normally done to avoid, or to make the incision visible as it advances It can be achieved to allow separation. Preserving the perforators, rather than cutting them, maintains normal blood flow to the upper layers that are otherwise impaired by perforator destruction. This result is truly surprising and very clinically important. Maintaining normal blood flow reduces the possibility of tissue necrosis (due to insufficient blood flow) and increases the possibility of rapid and complete recovery (due to sufficient blood flow). This is very important whenever the skin is lifted from the underlying tissue (eg, for a cosmetic or reconstruction procedure) or whenever the tissue flap is isolated but preserved.

  A differential cutting instrument, such as any of those disclosed herein, can be used to cut through adipose tissue. However, in such an incision through fat, there is no organ capsule or other hard tissue to guide the differential dissecting instrument, and the incision is simply guided rather than guided by a hard tissue boundary. Progress under the guidance of the surgeon. Such incisions have been used to separate the skin from the underlying tissue for cosmetic surgery in human cadaver. Significantly, as described above, sufficient clearance was created to advance the incision to completion without accidental or intentional puncture of the vessel. In living patients, such a procedure will maintain normal blood flow to the tissue through surgery and therefore will recover. This is in stark contrast to the prior art, which involves perforating cauterization of the blood vessels, cutting off this circulation, and including extremely normal blood flow. As mentioned above, rather than cutting them, protecting the perforators maintains normal blood flow to the skin otherwise damaged by perforator destruction. Maintaining normal blood flow reduces the possibility of tissue necrosis (due to insufficient blood flow) and increases the possibility for rapid and complete recovery (due to sufficient blood flow). Both are highly desirable outcomes of all surgical operations, especially cosmetic surgery.

  A differential cutting instrument, such as any of those disclosed herein, can be used to tunnel to and through a body part in a similar manner, a tissue capsule, Vessel walls, nerve bundles, and other rigid tissues can guide the tissue engaging surface along the existing tissue surface. However, for tunneling, the operator does not move the differential cutting instrument from side to side to separate a large portion of the tissue surface. Rather, the surgeon presses the differential dissecting instrument against the tissue surface with only limited lateral movement to form a narrow tunnel. Such tunnels are used in many surgical procedures such as tunneling to place pacing leads for pacemakers and other cardiac rhythm management devices, reducing tissue destruction during surgery and hence trauma to the tissue Are increasingly used in minimally invasive surgical procedures such as robotics, thoracoscopic and laparoscopic surgery. One problem that arises in tunneling is the lack of visibility at the end of the tunnel—surgeons do not like blind motion.

  46A-1, 46A-2, 46B-1, 46B-2, 46C-1 and 46C-2 illustrate an instrument for tunneling with a differential dissecting instrument connected to an endoscope. ing. 46A-46C show a cutting system 4600 with visibility for tunneling with a differential cutting instrument and provided by a television camera or other display device. As shown in FIGS. 46A-1 and 46A-2, the incision system 4600 is comprised of an instrument tube 4610 having two lumens, an endoscope lumen 4620 and an instrument lumen 4630. Additional lumens can be used to introduce multiple instruments simultaneously.

As can be seen from FIGS. 46B-1 and 46B-2, the endoscope lumen 4620 houses an endoscope 4640 with a television camera or other display device mounted at the opposite end (not shown). , Thereby providing a view of the incision for the surgeon. The endoscope 4640 can also include an optical fiber and can be separated from that used in the camera to provide light to the area of the incision. The instrument lumen 4630 is used to insert one of several different instruments within the camera's field of view so that they can incise or manipulate tissue under the field of view of the endoscope 4640. Used for. 46B-1 and 46B-2 show an instrument tube 4610 equipped with an endoscope 4640 inside an endoscope lumen 4620 and a differential dissection instrument 4650 having a DDM 4655 inside the instrument lumen 4630. ing. The endoscope 4640 has a field of view 4645 that allows viewing of the DDM 4655 of the differential dissecting instrument 4650 and its interaction with tissue. The differential dissecting instrument 4650 can be rotated within the instrument lumen 4630 to allow the vibrating surface of the DDM 4655 to rotate to align with different tissue surfaces. (The vibrating surface must be parallel to the tissue surface.)
Multiple instruments can be inserted one at a time into the instrument lumen 4630 as needed. 46C-1 and 46C-2 illustrate an electrosurgical instrument (eg, hook) 4660 that is inserted into the instrument lumen 4630. FIG. The electrosurgical hook 4660 can also be inserted and rotated into the instrument lumen 4630 to allow the hook to point in any direction. In use, the instrument tube 4610 is loaded with an endoscope 4640 within the endoscope lumen 4620 and a differential dissecting instrument 4650 within the instrument lumen 4630. The instrument tube is positioned by the operator at the exact point of the patient, as determined by viewing the display of the endoscope 4640, and activates the differential dissecting instrument 4650 to initiate the blunt dissection. The differential dissecting instrument 4650 can be rotated within the instrument lumen 4630 to align the vibrating surface with the tissue plane, as indicated by the curved double arrow 4657, and also the differential dissecting instrument 4650. Can be advanced into and out of the instrument lumen 4630 so that the DDM 4655 protrudes more or less from the surface 4605 of the instrument tube 4610 as needed for incision, as indicated by the straight double arrow 4656. it can. When the tunnel is opened, the incision system 4600 advances through the tunnel with an endoscope 4640 that provides a field of view for the surgeon as the tunnel opens. If sharp dissection or electrocautery is required, the differential dissection instrument 4650 can be removed and the electrosurgical hook 4660 can be introduced into the instrument lumen 4630 for cutting or cauterization. Can do.

  Conversely, a differential cutting instrument having an extensible electrical surgical hook such as the differential cutting instrument shown in FIG. 41 must switch back and forth between the differential cutting instrument 4650 and the electrical surgical hook 4660. Can be used to avoid having to. Other instruments such as scissors, forceps, bipolar forceps or ultrasonic cutters can also be introduced through the instrument lumen 4630 as needed for incision, or as described above, they are It can be part of a multifunctional differential cutting instrument.

  An incision system, such as incision system 4600, for endoscopic saphenous vein collection, endoscopic tunneling for anterior access to the spinal column, tunneling to the neck, for tunneling to the lung for lobectomy Alternatively, it can be used for many types of endoscopic tunneling, such as for tunneling to the heart for minimally invasive valve replacement. The main advantage of the incision system 4600 over existing endoscopic saphenous vein collection systems is that the addition of a differential incision reduces the possibility of side branch removal and damage to the vessel wall. Such trauma to blood vessels usually requires surgical repair, such as suture removal, which can greatly impair the quality of the graft during coronary artery bypass grafting and reduce the long-term durability of the graft. ing.

  In one demonstration of the effectiveness of a differential dissecting instrument for safely dissecting a main vessel with a side graft, as disclosed herein, a surgeon is in a live pig (about 120 pounds) A differential dissection instrument was inserted into the incision on the blood vessel, and the differential dissection instrument was blindly advanced along the path of minimal resistance, assuming this was the tissue surface covering the blood vessel. At the end of the cut along the 20 cm path, the surgeon makes an incision downward with respect to the axis of the differential dissecting instrument, which is correct and the differential dissecting instrument follows the blood vessel, removing the side branch or damaging the main vessel wall And found that the blood vessels were free from surrounding tissues.

  47A-47D illustrate another instrument for tunneling with a differential dissecting instrument that is coupled to an endoscope and includes an accessory for extending the incision to improve the field of view of the endoscope. 47A-47D illustrate an incision system 4700, such as an incision system 4600 for tunneling tissue such as along a blood vessel. However, incision system 4700 includes:

An inflatable annular balloon 4710 located at the distal end of the instrument tube 4610 that, when inflated, both expand the diameter of the tunnel to the tissue 4701 and form an air tight seal between the instrument tube 4610 and the surrounding tissue 4701 ,as well as,
Allows both the inflation / deflation of the balloon 4710 and the injection of pressurized air into the end of the tunnel and hence the tissue 4701 to expand the end of the tunnel, assisting the blunt dissection, camera A venting system 4720 that provides a cavity 4702 distal to the surface 4605 that allows 4640 to see the motion of the tissue 4701 and the instrument inserted into the second instrument lumen 4630. System to inject air to expand).

  47A-1 and 47A-2 show front and side views, respectively, of the distal end of the dissection system 4700. Similar to the lancing system 4600, an endoscope 4640 inserted in the first instrument lumen 4620 and a differential lancing instrument 4650 (or other instrument) inserted in the second instrument lumen 4630. There is a lumen instrument tube 4610. Balloon 4710 wraps around the end of instrument tube 4610 and can be inflated by airflow 4714 through inflation tube 4712. Balloon 4710 is shown in FIG. 47A and is thereby placed in close juxtaposition with instrument tube 4610 to facilitate insertion of instrument tube 4610 into tissue 4701.

  47B-1 and 47B-2 show front and side views, respectively, of inflation of a balloon 4710 by an air flow 4714 provided by a balloon inflation tube 4712 and driven by an air pump device 4718 (shown in FIG. 47D). Show. The air pump device 4718 can be any number of devices for providing a regulated air flow, including syringes, air pumps, and the like. Note that the airflow 4714 can be in the opposite direction as depicted to allow the balloon 4710 to deflate as needed.

  As shown in FIG. 47C, inflation of balloon 4710 presses tissue 4701 radially away from the distal end of instrument tube 4610, as indicated by arrow 4716. Therefore, the instrument tube 4610 can be inserted into the tissue 4701 using the deflated balloon 4710. After insertion, the balloon 4710 can be inflated to help form the cavity 4702, thereby improving the field of view of the camera 4740 attached to the endoscope 4640.

  A ventilation system 4720 can also be attached to the proximal end of the instrument tube 4610 (see FIG. 47D). The ventilation system 4720 includes a ventilation tube 4726 that connects the second instrument lumen 4630 to an air pump 4728 that provides conditioned airflow. The regulated air flow can be controlled by the operator so that air can be injected or withdrawn from the second instrument lumen 4630 via the vent tube 4726. The air pump 4728 can be any number of devices for providing conditioned air flow including syringes, air pumps, and the like. Pressurized air flows into the vent tube 4726 (as indicated by arrow 4724), into and along the second instrument lumen 4630, distal to the instrument tube 4610 as indicated by arrow 4724 in FIG. 47C. Exit into cavity 4702 at the end. The air is second instrument lumen 4630 by a seal 4722 between the differential dissecting instrument 4650 (or any other instrument inserted into the second instrument lumen 4630) and the second instrument lumen 4630. Is prevented from exiting. Therefore, the air inside the cavity 4702 is pressurized to further expand the cavity 4702 to improve the visibility of the camera 4740 attached to the endoscope 4640 and the operability of the differential dissecting instrument 4650. be able to. Pressurized air inside the cavity 4702 also tensions the tissue along the periphery of the cavity 4702 including the incision region 4704 for DDM4655. (As mentioned above, tissue tension facilitates differential incision; this is also done by placing and operating a differential incision member inside the balloon and incising the tissue through the balloon membrane. Expanding the balloon can apply tension normally supplied by other instruments.) The seal 3022 can be a second instrument, such as a differential dissection instrument 4650 or an electrosurgical hook 4660. It can operate to block airflow when inserted into lumen 4630. A second seal 4723 can be placed between the endoscope 4640 and the first instrument lumen 4620 to stop airflow from any gap, if desired.

  The embodiments described herein are illustrative and are not intended to encompass the entirety of the present invention. Many modifications and embodiments of the invention described herein will be apparent to those skilled in the art to which the invention pertains with the benefit of the teachings presented in the foregoing description and the associated drawings. It will come to mind. Therefore, the invention should not be limited to the specific embodiments disclosed, but it should be understood that modifications and other embodiments are intended to be included within the scope of the appended claims. It is. Although specific terms are used herein, they are not used in a limiting sense, but only in a general and descriptive sense.

Claims (26)

A differential dissection instrument (DDI) for differential dissection of complex tissue,
A handle having a longitudinal central axis;
A distal end of the DDI substantially pointing towards the composite tissue and a proximal end of the DDI substantially pointing towards the user;
An elongate member having a distal end and a proximal end, the proximal end connected to the handle;
A differential dissecting instrument (DDI) comprising a differential dissecting member rotatably attached to a distal end of an elongated member and having an axis of rotation, wherein the differential dissecting member comprises:
At least one tissue engaging surface;
A first torque point disposed on the first side of the rotational axis of the differential incision member;
A second torque point disposed on a second side of the rotational axis of the differential dissection member and configured to provide an opposite torque to the differential dissection member;
A mechanism configured to move at least one tissue engaging surface in at least one direction relative to the composite tissue by mechanically rotating the differential dissecting member about an axis of rotation, the mechanism comprising:
Comprising a first force transmitting member having a distal end and a proximal end, a distal end of the first force transmitting member is attached to the first torque point of discriminatory cutting member, the first force transmitting member Is attached to a power source, and the mechanism further comprises:
A second force transmitting member having a distal end and a proximal end, a distal end of the second force transmitting member is attached to the second torque point of discriminatory incision member, opposing the force transmitting member Forming a pair, the proximal end of the second force transmission member is attached to the power source, the first and second force transmission members are flexible tension members, and the opposite torque is the second force transmission member Provided by and
The at least one tissue engaging surface moves across the composite tissue when the differential incision member is pressed against the composite tissue, and the at least one tissue engaging surface is in the composite tissue. A differential dissecting instrument (DDI) configured to selectively engage a composite tissue so as to destroy at least one soft tissue but not to destroy the hard tissue in the composite tissue.   The DDI of claim 1, wherein the rotation of the differential dissection member imparted by the first force transmission member is balanced by an opposite torque about the axis of rotation. Each of the first force transmitting member and the second force transmitting member, and terminate at each of the cam follower, i.e., the proximal end of the proximal end and the second force transmitting member of the first force transmitting member The DDI of claim 1, terminating in a cam follower.   The DDI according to claim 1, wherein the power source is a camshaft driven by a motor. The DDI of claim 4, wherein the first and second force transmitting members each terminate at a proximal end of a respective cam follower on the camshaft. 6. The DDI of claim 5, wherein the first force transmission member cam follower and the second force transmission member cam follower both engage a single camshaft. A single camshaft provides a first eccentric cam to the cam follower of the first force transmission member and a second eccentric cam to the cam follower of the second force transmission member, the camshaft having a rotation center axis; When the camshaft rotates, the first eccentric cam and the second force transmission member follower are most proximal and at the same time the second force transmission member follower is most distal. The DDI according to claim 6, wherein the eccentric cams are arranged around a rotation center axis of 180 degrees with respect to each other. First force transmission member and the second force transmitting portion is cable, DDI according to claim 1. First force transmission member and the second force transmitting member, respectively, wire, string, rope, tape, and is formed from a flexible tension member such as a belt or chain, DDI according to claim 1.   The DDI of claim 1, wherein the flexible tension member is comprised of a single continuous tension member, such as a loop. A single continuous tension member has a first end and a second end, and the first end of the single continuous tension member is the proximal end of the first force transmission member 11. The DDI of claim 10 , wherein the second end of the single continuous tension member forms the proximal end of the second force transmission member.   The DDI of claim 1, wherein the power source is a linear actuator. The differential dissecting member and the portion of the mechanism configured to mechanically rotate the differential dissecting member about a rotational axis distal to the camshaft form an output shaft and tip assembly; Further, the output shaft and tip assembly may be connected to the distal end of the DDI such that movement of the output shaft and tip assembly toward the distal end of the DDI is resisted and thus limited by the tension in the at least one flexible tension member. The DDI of claim 6 , comprising a compressed compression spring that pushes toward The force applied by the compressed compression spring can be adjusted below a level that damages the tissue so that the proximal force that drives the output shaft and tip assembly proximally further compresses the compressed compression spring. thereby the flexible tension member to reduce the force to the flexible tension member so as to relax, cams shaft stops rotating discriminatory cutting member despite being rotated by the power source, hence the force 14. The DDI of claim 13 , wherein the flexible tension member loses tension so as to constitute an overload safety factor.   Further, the force applied proximally to the differential dissection member such that at least the first overload mechanism stops rotation of the differential dissection member when the force exceeds at least a first threshold force. The DDI of claim 1, comprising at least a first overload mechanism configured to respond.   Further comprising an omni-directional control switch configured to control the power source, the omni-directional control switch being accessible from substantially any direction about the central longitudinal axis of the differential lancing instrument handle The DDI of claim 1, wherein   Further, at least first configured to stop rotation of the differential dissection member when responsive to at least the first threshold force and a force exceeding at least the first threshold force is applied to the differential dissection member. The instrument (DDI) of claim 1, comprising an overload mechanism. 18. The DDI of claim 17, wherein the at least one first overload mechanism stops the power source in response to a force that exceeds at least a first threshold force. When at least the second overload mechanism pulls the differential dissection member proximally away from the tissue to be dissected when the force exceeds at least a second threshold force The DDI of claim 17, wherein the DDI is responsive to a force applied proximally to the differential dissection member. At least the second overload mechanism is
An inner sleeve aligned substantially parallel to the longitudinal central axis of the handle;
An outer sleeve that is aligned substantially parallel to the longitudinal central axis and shaped to allow the inner sleeve to slide inside the outer sleeve in a direction substantially parallel to the longitudinal central axis of the handle;
20. The DDI of claim 19, wherein the inner sleeve is configured to slide proximally relative to the outer sleeve to load a spring that resists sliding of the inner sleeve relative to the outer sleeve. further,
A first spring stop secured to the inner sleeve;
A second spring stop secured to the outer sleeve;
To load the spring between the first spring stop and the second spring stop so that sliding of the inner sleeve relative to the outer sleeve resists sliding between the inner sleeve and the outer sleeve further loading the spring. 21. The DDI of claim 20 , further comprising a spring disposed between the first spring stop and the second spring stop. 23. The DDI of claim 21 , wherein the spring is a compression spring and proximal sliding of the inner sleeve relative to the outer sleeve compresses the spring. The inner sleeve and the outer sleeve are held in a predetermined relative position when no force is applied to the differential incision member such that the compression spring is partially compressed to initial compression by tension in the first force transmission member; 23. The DDI of claim 22, wherein the force associated with the initial compression establishes at least a first threshold force or at least a second threshold force. 24. The DDI of claim 23 , further comprising a mechanism for adjusting the initial compression, and therefore at least the first threshold force or at least the second threshold force. Use a differential dissection instrument for differential dissection of complex tissue,
The handle,
An elongate member having a distal end and a proximal end, the proximal end connected to the handle;
A differential incision device configured to be rotatably attached to the distal end and having an axis of rotation, wherein the differential incision member comprises:
At least one tissue engaging surface;
A first torque point and a second torque point disposed on opposite sides of the differential cutting member, wherein the second torque point is configured to provide an opposite torque to the differential cutting member; The incision member further
A mechanism configured to move at least one tissue engaging surface in at least one direction relative to the composite tissue by mechanically rotating the differential dissecting member about an axis of rotation, the mechanism comprising:
A first force transmission member having a distal end attached to a first torque point of the differential dissection member and a proximal end attached to a linear oscillator configured to drive rotation of the differential dissection member When,
A second force transmission member having a distal end and a proximal end attached to a second torque point of the differential cutting member, wherein the distal end of the second force transmission member is the first of the differential cutting member. Attached to the two torque points, the proximal end of the second force transmission member is attached to the linear oscillator, forming an opposite pair of force transmission members, the first and second force transmission members being flexible An opposing torque provided by the second force transmission member,
The at least one tissue engaging surface moves across the composite tissue when the differential incision member is pressed against the composite tissue, and the at least one tissue engaging surface is in the composite tissue. A differential dissection instrument configured to selectively engage a composite tissue so as to destroy at least one soft tissue, but not to destroy the hard tissue in the composite tissue. In a differential dissection instrument for differential dissection of complex tissue,
The handle,
An elongate member having a distal end and a proximal end, the proximal end connected to the handle, and further having a longitudinal central axis;
A differential incision device configured to be rotatably attached to the distal end and having an axis of rotation, wherein the differential incision member comprises:
At least one tissue engaging surface;
A first torque point and a second torque point disposed on opposite sides of the differential incision member;
A mechanism configured to move at least one tissue engaging surface in at least one direction relative to the composite tissue by mechanically rotating the differential dissecting member about an axis of rotation, the mechanism comprising:
At least one flexible tension member having a distal end attached to the first torque point of the differential dissection member and a proximal end attached to the cam follower;
A torque resistance means operatively connected to the differential cutting member;
A camshaft associated with the proximal end of the at least one flexible tension member and configured to engage the cam follower;
A motor operatively associated with the camshaft such that rotation of the motor rotates the camshaft;
Motor power source,
An omnidirectional control switch operatively associated with the motor and the power source and configured to be accessible from substantially any direction;
A tissue force limiting spring operably associated with the at least one flexible tension member and maintaining a non-zero tension of the at least one flexible tension member;
The at least one tissue engaging surface moves across the composite tissue when the differential incision member is pressed against the composite tissue, and the at least one tissue engaging surface is in the composite tissue. A differential dissection instrument configured to selectively engage a composite tissue so as to destroy at least one soft tissue, but not to destroy the hard tissue in the composite tissue.

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