DE19711288B4 - Applicator to hold and close a surgical clip - Google Patents

Abstract

applicator for picking up and closing a surgical clip, characterized in that the applicator two plungers (38, 39), which over actuators (34.37) actuated and act on one arm of a clip, the clip over a rear extension (13) in the middle of the bracket and a recess (14) in the middle of the Brace distally has which each when closing in a recess (41) and a retaining pin (40) engage around the asymmetrical closing force with which the respective clamp arms are operated independently of each other.

Description

To clamp vessels and hold wounds together, many different types of clips and clips are used in medicine today, which are designed according to their application. So z. B. closes wounds, in particular on the skin with clips that simultaneously gather the tissue when closing and compress the wound edges, for example DE 32 04 532 , Special clips have also been developed for clamping vessels, which have a V-shaped basic shape and are then pressed together using an applicator and kept closed, for example EP 0510826 B1 ,

There are special clips for anastomosis on the intestine, which are arranged in rows in an applicator and, after appropriate preparation of the intestinal ends, are closed with a tool in the applicator so that the edges of the vessels are held together. The clip and applicator must be coordinated to achieve an optimal result. With these clamps and clips, the closure is accomplished mechanically by a corresponding device, the two arms being bent symmetrically or deformed by a tool in the applicator and thus effecting the desired clamp or holding effect. In DE 44 18 766 C2 describes a surgical thread for applying a surgical suture, in which there are two parts connected to a thread, one part being placed on a needle in one jaw of the applicator and the second part being fastened to the opposite jaw. This jaw of the applicator is moved proximally during the threading of the tissue edges so that it does not hinder the threading. Then the two tissue edges to be sewn are threaded over the needle, the upper jaw is pushed distally and the jaws are closed by advancing a sleeve, so that the two parts snap into each other with the tissue in between. After opening the two jaws, the parts connected to the tissue and the thread are free and the tissue is clamped between them. This device is not suitable for use in corona surgery because the tissue edges cannot be anchored in the epicardial tissue.

In DE 42 30 102 A1 describes a rectangular clip with an applicator, in which the front part of the clip is designed as a tip. The fabric edges are loaded into the clip via the tip and then the clip is closed via the bendable upper part, the tip passing through a recess in the upper part, which is then bent over to secure the clip when it is closed. To close, the clip is pulled into the applicator: This arrangement, too, cannot be used for corona surgery because of the clip geometry.

In coronary surgery anastomoses d. H. Seam connections between a vein or internal mammary artery and a coronary artery. The conventional connection between two blood vessels, i.e. H. the anastomosis, is characterized by a continuous, overworkable Seam achieved.

As soon as endoscopic coronary surgery, d. H. without opening the Sternum, and just over small access holes on the side and front of the chest should be made, is a manual one direct connection of the coronary vessel with the vein or artery mammaria internally technically difficult. Reasons for the high Technical difficulty of joining seams with limited access are the depth of the surgical target area and the limited possibility a needle through both the vein wall and the artery wall with the typical needle holder movement.

Here it makes sense to unite both vessels by means of a staple. Crucial for a successful stapling technique is quick feasibility, the secure fit of each clip and the tightness of the anastomosis.

But Even in open surgery, a stapler has advantages because the setting of Staples take less time than the seam.

The Applicator described in the following invention serves the Anastomosis of coronary blood vessels which e.g. is used in a bypass operation. For this too Appliqué brackets are known which can be used with tweezers pushed together vessel edges and then squeezed which keeps the edges of the vessels together become. However, these brackets have the disadvantage that they are relative easily come off again and thus serious complications z. B. the bleeding may occur.

The The object of the invention is an applicator and a matching one To develop bracket that eliminates the disadvantages described above and coronary blood vessels and safely connects.

The task is performed by the generic ß applicator and the matching bracket solved by the features specified in the characterizing part of claim 1. Advantageous refinements are specified in the subclaims.

in the Contrary to the conventional clamp, which is flattened when open U corresponds, it is for the vascular anastomosis crucial that the Bracket is constructed asymmetrically. Accordingly, an arm should of the U longer than be the other. The shorter one Arm is closed first. First one hooks with the shorter one Arm the bypass vessel, d. H. the bypass vein or the internal mammary artery and guides them to the rim of the vessel to anastomosing coronary artery and punctures it as well. The two vessel walls will adapted to each other and the shorter one Arm is closed. The longer one still open arm is now under the individual necessary tension inserted into the epicardial adipose tissue, then closed and struck there with the tip of the already closed shorter arm. The clip is then released from the applicator.

critical and what is new is a gradual, successive closing of the first one, then the other arm of the asymmetrically shaped bracket. In the first step, only the vein or mammary is attached to the coronary artery approximated and hooked, in the second the staple is made by inserting it of the longer one Armes closed in the epicardial fat and the brace in this firmly anchored. This presupposes that the mechanism that the closing movement of the two branches consecutively, can be finely dosed. The second tip meets the first tip in this adipose tissue, so after the closing quasi a closed ring is created by putting the tips together glide past, through the offset, one-sided bevel of the tip.

By the asymmetrical structure of the bracket as well as the gradual release of the clamp closing mechanism the conventional seam sequence with needle and Imitation thread, in which the direction of the stitch first Vein from the outside is pierced inside and led to the artery wall, the from the inside to the outside is punctured.

Just the possibility of separate closing allows adjust the tension of the vein towards the coronary vessel accordingly and by hooking the second arm into the surrounding epicardial fat tissue to anchor. This creates a tight fit of the bracket and thus the firm pressing together of the vessel edges for the required tightness the anastomosis reached. Make the path of the arms of the clip As already mentioned, essentially a closed circulation and then this has about the same path as this with the conventional seam technique, which has proven itself in thousands of operations, the case is. This requires that the applicator have these locking functions Fulfills.

To the To absorb the asymmetrical closing force, the clamp must be in one holder be firmly anchored in the applicator, which is due to the rear extension and the distal recess on the clip corresponding to a recess and a holding pin in the applicator. A cross-sectional taper on The bending point specifies the beginning of each clamp arm when closing.

The Applicator for closing the clip has two independently of one another working locking tools, so first the Vessel side hooked on and can be closed and then the anchorage in which the Surrounding coronary vessels epicardial tissue performed becomes. The applicator is advantageously designed so that it both with the previously usual open surgery, as well as a minimally invasive procedure can be used. This may require the applicator with an additional one Equip joint to adapt the tip to the anatomical To better allow the condition of the vessels to be connected.

Farther the applicator is designed so that it is a removable magazine with different sizes up to the maximum required number, can hold approx. 20 brackets. After closing completely and Ejecting a clip will make another clip from the magazine manually pushed into the bracket-receiving position, the rest Brackets in the magazine are all advanced by one position. This Pushing can also be designed so that after ejecting one closed bracket is done automatically which makes the operation of the device simplified.

The The shape of the bracket itself is preferably asymmetrical, the in arm engaging the vessel the smaller one and the larger one anchored in the tissue. For fixation during of closing the clip has an extension in the applicator at its proximal end and in the middle distally a small recess around it in the one-sided closing fix in the applicator and absorb the one-sided closing force. The closing the arms are made by a pushing plunger, which has a groove-shaped recess at its distal end, in which the clamp arm rests and slides and the side slipping prevented. By pushing forward of the pestle Arm on which has reached through cross.

The invention is described in more detail below and by 1 - 10 added.

It demonstrate:

1 a skin clip applicator with clip for tissue gathering according to the prior art

2 Anchoring the clip in the tissue after application with the applicator according to the invention

3 special asymmetrical clip for use in the applicator according to the invention

4 an applicator in principle for receiving and closing the clip according to the invention

5 a further embodiment of the applicator with a magazine

6 a combined version of an applicator for closing the clip with two tapers on one side and one on the other.

7 Applicator with stacking magazine and moving hold-down device.

8th Applicator with stacking magazine and moving holding pin.

9 Hold-down at the stretched magazine.

10 Transport plate for the stretched magazine.

1 shows a clip according to the prior art, which is intended for closing skin wounds. The two arms 1 the skin clip are moved by the closer in the direction of the arrow 2 pushed forward and around the abutment 3 bent so that the clip closes.

When closing, the pre-shaped arms describe 1 a path inwards and gather the tissue hooked in with the tips when they are in their end position 4 are located.

2 shows the clip applied with the applicator in situ with the vein 20 with the artery open 21 to be connected by the shorter arm 11 the bracket 10 through the rim of the vein 20 and the coronary artery 21 goes and she with her longer arm 12 in the epicardial tissue 19 is anchored.

Several clamps are used to connect the vessels tightly 10 attached around the vessel opening.

3 shows the asymmetrical bracket 10 according to the task with a shorter arm 11 and the longer arm 12 as well as the rear extension 13 and the recess 14 , which serve as a counter bearing when closing. The cross-sectional tapering is also at the beginning of the leg 15 visible, which represent the joints of the arms.

A second taper 27 can be attached to the shorter arm, which means there are two bends on the arm. This has the advantage that the clip closes more tightly, which, for. B. in the shorter arm 11 can be advantageous for the asymmetrical clamp, whereas the longer arm has only one bending point at the beginning of the arm.

4 represents a basic embodiment of an applicator for receiving and closing the clip 10 according to the invention. Since the clip must be closed functionally in two steps, one-sided forces arise on the clip, which is due to the rear extension 13 and the recess 14 from the applicator 43 be included. The clip 10 must be fixed in the applicator by the holding pin 40 in the recess 14 the bracket and the extension 13 in the recording 41 comes to rest. Advantageously, the extension 13 through a fixation 32 , which after inserting the clip over the holder 41 advances held in place. As a result, the clip is firmly seated in the applicator even when hooking the edges of the vessel. The fixation 32 is via the button 35 controlled.

Now with the shorter arm the vessel edges are grasped accordingly, which is then by the actuating element 34 is closed by the extension of the leaf spring acting as an actuating element of the plunger 38 is pushed distally and closes the arm of the clip. The pestles 38 and 39 have a groove at the distal end 42 in which the arm of the clip comes to rest so that it cannot move up or down. The operations 34 and 37 , in the 4 Shown as leaf springs can also be used as knee joints 33 as in 5 shown, be formed, which then also the plunger 38 and 39 push distally.

The same procedure is followed after setting the second arm by the actuating element 37 is pressed which pushes forward via the leaf spring or the corresponding knee joint of the pestle 39 causes and the longer arm of the clip is closed. After resetting the controls 34 . 37 and trigger the fixation 32 via operating button 35 the clip can be removed from the applicator and a new clip can be inserted into the receptacle by manually pushing a clip out of the magazine attached to the applicator, not shown here, in the receptacle 41 through fixation 32 is fixed, then applied by the surgeon with the actuators 34 and 37 closed and by pressing the fixation again 32 is released again by the applicator.

5 shows the overall view of such an applicator, the actuator 46 reloading, ie inserting a new clip from the magazine 45 causes in the recording and at the same time pushing the fixation 32 takes over. Furthermore, the controls 34 and 37 recognizable for closing the arms. The controls are advantageous 34 and 37 staggered so that it can be closed with the thumb and index finger against the applicator housing 43 can be done and not both controls are accidentally operated at the same time. Another embodiment of the applicator is that the operating elements are locked against one another by means of a corresponding mechanism, so that the operating element 37 can only be operated when the control element 34 was already pressed and was reset. Technically, this problem can be solved in such a way that a slide with a corresponding hole after operating the control element 34 is in a position in which a pin of control element 37 can retract when actuated. Was the control 34 not yet moved, the pen hits the slide directly and locks the control element 37 , By manual reloading 39 this slide is reset to its starting position by friction.

Another embodiment is an automatically operating applicator, which essentially only contains the operating elements 34 and 37 to close the bracket. In addition, a magazine 45 be placed, which contains the corresponding number of brackets that are required z. B. 10, 15 or 20 pieces, so that the necessary number of brackets is available according to the application. Furthermore, the control element 37 for the second closing as listed above, locked until the control element 34 was pressed. The clamp is closed via the toggle joints 33 ,

After the actuator 34 was actuated and reset, the actuating element can now 37 operated, which closes the long arm of the clip. Will the control 37 pressed further, so the fixation is first 32 reset and unlocked the clip so that it is released from the applicator. When pressing the control element further 37 an internal lock is released, which releases a spring that reloads a new clip into the holder 41 causes and this at the same time via the fixation 32 locked. The control element 37 jumps out and is manually pushed in again as far as it will go, thereby releasing the spring for reloading from the magazine and releasing the lock for reloading. Then the normal function of the control element 37 fully available again.

To close the brackets with several tapering, that is, several bending points per arm, it is necessary that the closer presses laterally on the arm of the bracket after the tapering in order to accomplish the first bend as 6 shows. After that, the next bending point is automatically moved as you press it further and one arm of the clamp is then in its end position. This locking function is also divided into two, ie a closer that can be operated separately for each side. Lateral closing is accomplished by using the closer 57 a sleeve from behind 56 is pushed forward, which its abutment in two grooves 55 in the middle of the applicator housing 43 Has. Such a sleeve is also provided for the other side and is slidably anchored in the applicator if the clip has several tapering on both sides.

6 basically shows the function. The closer 57 presses sideways on the clip and is through the sleeve 56 actuated, which in turn over the bar 58 is pushed forward and with its bends in the grooves 55 running. It is also possible for the applicator to contain both types of function, the shorter arm of the clip being closed laterally up to the first bending point and the closer 57 then moves back and the further closure of the shorter arm as in 5 is executed with its tip as a pestle, which moves distally. The larger arm of the clip is placed over the plunger in a conventional manner as described 39 closed. However, this somewhat more complex configuration has the advantage that after the partial arm is closed after the additional tapering 27 the closer 57 no longer has a disruptive effect since the further closing process takes place from the rear of the clip. The mechanics required for this can be accommodated in the applicator.

7 shows an embodiment with a magazine in which the brackets 10 one above the other are arranged and are guided on the outside in the magazine. The brackets are in the magazine 63 by a spring 64 held and pushed and the holder 65 holds the remaining brackets back when the feed pusher 60 a bracket 10 takes and this under the baffle 68 in the recording 41 pushes. The springy hold-down 61 holds this bracket in the recording 41 , so that the clamp fits tightly together with the retaining pin 40 receives as necessary to close the same. About an increase 62 becomes the springy hold-down 61 when advancing the feed pusher 60 lowered to hold the clamp. When pulling back the feed slide 60 the hold-down device is used to get another clamp 61 raised and the clip can then be removed from its receptacle when it is closed.

Another embodiment of the holding down and release of the clip is in 8th shown. Here is the hold-down 66 shown as a resilient element and the retaining pin 40 , which serves as a stop for the clip, is via a leaf spring 67 lowered to which it is attached. Through a wedge, which is between the housing 43 and leaf spring 67 is pushed when the feed slide is pulled back 69 the leaf spring 67 lowered, which thus the holding pin 40 takes it down so that the clip becomes free and can be pulled distally out of the clip applicator. Instead of the wedge, the leaf spring can have a cutout 70 get in which a ball slides, which over the rod 72 is pulled proximally with the transport slider and the leaf spring 67 pushes down through the tapering gap and the retaining pin 40 the bracket releases.

9 shows another way of attaching a magazine 74 with brackets in a row. Here too is a resilient hold-down 75 available, which can be part of the magazine or is attached to the applicator itself, which holds the clip in its holder 41 holds. The magazine 74 is designed so that the brackets are guided in series in the magazine. The clips are transported in stages in the magazine by a transport strip 78 , in which the brackets are pushed forward and then pushed back again by a little more than one bracket position. This transport strip 78 has like in 10 shown two tabs per bracket position 79 , which protrude slightly springy from the strip and a counterholder 80 on which the rear extension 13 the bracket is on. The resilient tabs press when pushed forward 79 on the back of the clip this to the front. The counter tongue 80 prevents the resilient tabs from slipping 79 , The bracket will be with these tabs 79 and the shortened counterhold 81 in the recording 41 pushed and by the resilient hold-down device 75 held there. When pulling back the transport strip 78 slide the resilient tabs 79 in each case under the next clamp and bring it forward by one position when pushing forward and thus into the position for reloading. So that the clips are not moved backwards by the resilient tabs when the feed slide is pulled back, the magazine has teeth on its top 82 with a locking effect, which prevents the clip from sliding back in the magazine, because when the clip is pushed back, its rearward extension engages in the toothing and is held there. Since the transport routes of the clips are fixed in the magazine, it is sufficient to attach as many locking teeth as there are clips. The movement of the transport strip 78 or the transport pusher 60 takes place either manually or automatically as already described above.

In this case, the clip is released using a resilient hold-down device by lowering the retaining pin 40 accomplished.

The shown possibilities to close the bracket through the applicator can be made by combinations of the given solutions even more variety achieve which is also within the meaning of this invention.

Claims (15)

Applicator for receiving and closing a surgical clip, characterized in that the applicator has two plungers ( 38 . 39 ) which has actuators ( 34 . 37 ) are actuated and each act on one arm of a clip, the clip via a rear extension ( 13 ) in the middle of the bracket and a recess ( 14 ) in the middle of the clip distally to the side when it is closed into a recess ( 41 ) and a holding pin ( 40 ) intervene to absorb the asymmetrical closing force with which the respective clamp arms are actuated independently of each other. Applicator for receiving and closing a surgical clip according to claim 1, characterized in that the plunger ( 38 . 39 ) a groove-shaped recess at its distal end ( 42 ) have in which an arm of the clip is guided and can slide and the shape of the sliding surface is designed so that the arm of the clip closes with as little friction as possible when the plunger is pushed distally. A surgical clip receiving and closing applicator according to claim 1, since characterized in that instead of the tappet moved distally ( 38 ) a normally open ( 57 ) the arm of the clamp distally after a last taper ( 27 ) detected and this towards the center in a radial direction to close the arm of the clip ( 10 ) is moved by moving a sleeve lying above it in the applicator ( 56 ). Applicator for receiving and closing a surgical clip according to claim 3, characterized in that two independently working closers ( 57 ) available. Applicator for receiving and closing a surgical clip according to one of claims 3 or 4, characterized in that one side of the applicator has a radial closer ( 57 ) and the other side has a pestle ( 39 ) which is operated accordingly to close the arm of the clip. Applicator for receiving and closing a surgical clip according to one of claims 3 or 4, characterized in that on one side of the applicator both a radially operating closer ( 57 ) as well as a pestle working distally upwards ( 38 ) is attached and the other side a distal tappet ( 39 ), whereby after the pre-bending of the arm by actuating the radial closer ( 57 ) this is withdrawn and advanced distally in a corresponding guide and then like the ram working distally ( 38 ) is used to completely close the arm of the clip. Applicator for receiving and closing a surgical clip according to claim 1, characterized in that the applicator is a magazine ( 45 . 63 . 74 ) with up to 20 staples, and this magazine is removable and that the staples lined up in it are automatically re-inserted when the previous staple is ejected after completely closing and leaves the applicator. Applicator for receiving and closing a surgical clip according to claim 7, characterized in that the advancement of the clips in the magazine ( 45 . 74 ) is done manually after a clip has been removed from the magazine and applied. Applicator for receiving and closing a surgical clip according to claim 7, characterized in that the clips in the magazine are arranged one above the other as a stack and individually by the corresponding guide plate ( 65 ) are released. Applicator for receiving and closing a surgical clip according to claim 7, characterized in that the clips in the magazine ( 74 ) are arranged one behind the other and that a transport plate ( 78 ), which has springy, raised tabs ( 79 ) has been used to advance the staples by placing the tabs symmetrically on the back of the staple ( 10 ) and that when the transport plate is pushed back, the tabs slide under the next clamp and then the back of this clamp is grasped and that the transport plate ( 78 ) a pair of tabs for each clip in the magazine ( 79 ) and counterhold ( 80 ) and that the magazine has locking teeth ( 82 ) on the inside into which the rear extension ( 13 ) the bracket ( 10 ) intervenes to slide the bracket back ( 10 ) when pushing back the transport plate ( 78 ) to prevent. Applicator for receiving and closing a surgical clip according to claim 1, characterized in that the clip ( 10 ) can only be closed in a certain order and the second actuating element ( 37 ) remains locked until the first ( 34 ) is returned to its rest position after actuation. Applicator for receiving and closing a surgical clip according to claim 1, characterized in that for holding down the clip ( 10 ) in their recording ( 41 ) a hold-down is attached, which holds the magazine ( 63 ) encloses and resiliently presses down when the clip is in the receptacle ( 41 ) is pushed and that when the transport slider is withdrawn ( 60 ) the hold-down device ( 66 ) is raised, thus releasing the clip for ejection. Applicator for receiving and closing a surgical clip according to claim 1, characterized in that the hold-down device ( 66 ) consists of a resilient element, which the bracket ( 10 ) in their reception ( 41 ) and that to eject the clip the retaining pin ( 40 ) when pulling back the feed slide ( 60 ) is lowered so that the clip can slide distally out of the applicator. Applicator for receiving and closing a surgical clip according to claim 1, characterized in that the actuating elements ( 34 ) and ( 37 ) are laterally offset for ergonomic and trouble-free operation of the applicator with thumb and forefinger. Applicator for receiving and closing a surgical clip according to claim 1, characterized in that a clip is used which has an asymmetrical shape and receiving elements ( 13 . 14 ) through which it in the Appli kator is held when closing and in which the arms have at least one bending point.