WO1999017661A1

WO1999017661A1 - Subcutaneous endoscopic dissector

Info

Publication number: WO1999017661A1
Application number: PCT/US1998/020852
Authority: WO
Inventors: Michael J. Miller; John W. Griffin
Original assignee: Board Of Regents, The University Of Texas System
Priority date: 1997-10-02
Filing date: 1998-10-02
Publication date: 1999-04-15

Abstract

This invention is a device (10) for use in minimally invasive surgery. The device includes a hand piece (20), a shaft (30), and opposing retractor blades (40). The hand piece is connected to a proximal end (35) of the shaft, and the opposing retractor blades extend from a distal end (36) of the shaft. The shaft includes a plurality of channels for retraction, suction, irrigation, video, and various operating instruments.

Description

DESCRIPTION

SUBCUTANEOUS ENDOSCOPIC DISSECTOR

FIELD OF THE INVENTION

This application relates to hand-held tools, and more particularly to instruments for use in minimally invasive surgery.

BACKGROUND OF THE INVENTION

Surgery is the art and practice of treating diseases, injuries, or deformities by operations that involve the use of instruments. One way the field of surgery advances is by the development of new instruments that make operations easier to perform, safer for the patient, and less costly. Minimally invasive surgery, or endoscopic surgery, is an example of a major advancement in surgery. It is a new type of surgery in which complex invasive procedures are performed with limited skin incisions and minimal direct surgical exposure.

Reconstructive surgery is a specialized kind of surgery intended to restore normal tissue appearance and function. Many reconstructive procedures require providing additional tissue to an area of deformity. Tissue is usually obtained by harvest from an uninjured location elsewhere on the patient. Techniques have been developed for harvest and transfer of many kinds of tissues: bone, muscle, blood vessels, nerves, fatty tissue, and intraabdominal viscera. Bone may be used for restoring defects in the head and neck or extremities. Muscles may be used for restoring missing tissue bulk to restore body contours, to promote healing in difficult areas, or to provide a functional reconstruction by restoring contractile tissue to an area of loss. Blood vessels may be used for vascular reconstruction, for example, in coronary artery or peripheral vascular disease. Nerves, fatty tissue and viscera each have a variety of important uses. Because many of these useful tissues are located subcutaneously (below the skin), it is ordinarily necessary to incise in the overlying skin in order to harvest them. The skin must then be properly repaired, which prolongs the time of the operation. It also introduces the possibility of wound healing problems like infection and results in scars that may be deforming. It is a major incentive to develop endoscopic methods which can harvest subcutaneous tissues without experiencing these problems. Generally, endoscopic surgery involves use of a video camera for visualization and specialized instruments that displace the effective action of the instrument a longer distance from the hand controls than standard instruments. Complex operations are possible through incisions that are smaller and located at a distant site.

Most endoscopic procedures are currently performed in locations that are topologically closed spaces bounded by specific anatomic structures. For example, the pleura and rib cage enclose the thoracic cavity. The abdominal cavity is contained by the peritoneum. The joint capsule surrounds a joint between bones. These enclosing structures form a potential space that may be filled with optically clear liquid or gas to create a cavity (i.e. an "optical space") into which a camera and surgical instruments may be inserted. Many tissues, however, are not anatomically enclosed and thus are not easily approached using current techniques. Examples are many structures in the neck, subcutaneous muscles, peripheral neurovascular structures including the saphenous vein, and lymph node basins of the extremities. Current methods for working in subcutaneous locations have two principle limitations: (1) difficulty maintaining the optical space in locations not anatomically enclosed and (2) the requirement for simultaneous use of multiple instruments.

Current methods to form an optical cavity do not work well in areas not bounded by discreet anatomic structures. Infused gas or liquid, the most common means to create the optical cavity, tend to disperse, leading to collapse of the optical space and loss of visualization. Internal mechanical retractors have been developed, but they require constant application of force by the surgeon or surgical assistant. They cause fatigue for the operator and do not allow precise application of needed retraction. They are also designed to provide force in only one direction; thus, proper counter-traction so important to effective soft tissue dissection, is not possible. External retractor systems also have disadvantages. They may traumatize the skin and provide imprecise retraction. The inadequacy of current instruments to create an optical cavity in unbounded soft tissues makes endoscopic surgery difficult and often impractical.

Surgical tissue dissection during an operation involves five essential elements: retraction, cutting, hemostasis, irrigation, and suction. Retraction moves tissues out of the area being dissected in order to protect them and to allow visualization of the operating field. Cutting tissues separates them from each other. Hemostasis stops blood escaping from open blood vessels by either mechanically occluding the vessel using sutures or metal clips or by cauterizing the vessel by applying either an electrical current or ultrasound. Suction and irrigation remove debris from the surgical field. Most currently available endoscopic instruments are designed to accomplish only one of these functions at a time. Thus, in a complex operation simultaneous use of multiple instruments is usually required. When passed through limited incisions the instruments interfere with each other and impede the progress of the operation. The surgeon also requires additional surgical assistants in order to handle the various instruments. Thus, the use of multiple instruments increases both the complexity and expense of endoscopic surgery.

Problems enumerated in the foregoing are not intended to be exhaustive but rather are among many which tend to impair the effectiveness of previously known surgical techniques. Other noteworthy problems may also exist; however, those presented above should be sufficient to demonstrate that techniques appearing in the art have not been altogether satisfactory.

SUMMARY OF THE INVENTION

In accord with a broad aspect of the present invention, a surgical apparatus includes a hand piece, a shaft, and opposing retractor blades. The shaft has a proximal portion and a distal portion. The proximal portion may be connected to the hand piece. The opposing retractor blades are adjacent the distal portion. The shaft may include at least one channel for communicating one or more associated instruments to the distal portion. An associated instrument may be a camera or another type of operating instrument. Typical operating instruments include endoscopic scissors, clamps, forceps, hemostatic clip appliers, cautery devices, retractors, and sponges. A channel may be an irrigation channel, a suction channel, a video channel, or a tissue extraction channel. The retractor blades may extend from one of the channels.

As another aspect, a subcutaneous surgical instrument includes a hand piece, a shaft, and a plurality of associated instruments. The shaft has a proximal portion connected to the hand piece and a distal portion for subcutaneous placement. The distal portion may include a plurality of channels. Each of the plurality of associated instruments may be associated with one of the plurality channels. The subcutaneous surgical instrument may further include opposing retractor blades extending from the shaft. The retractor blades may be controllably coupled to the hand piece. The hand piece may include a locking mechanism. The hand piece may also include a quick-release mechanism. Further, the hand piece may include a control, such as a push button, for operating at least one of the plurality of associated instruments. The hand piece may be rotatable into an in-line configuration. A typical shaft has a diameter of between about 2 cm and 3 cm and a typical length of between about 28 cm and 32 cm.

As yet another aspect, a device for use in minimally invasive surgery includes a hand piece, a control mechanism, a shaft, a plurality of channels, and opposing retractor blades. The control mechanism is coupled to the hand piece. The shaft has a proximal portion and a distal portion. The shaft may be flexible, and the proximal portion may be connected to the hand piece. The channels are coupled to the shaft for communicating associated instruments to the distal portion. The opposing retractor blades may extend from the distal portion. The opposing retractor blades may be coupled to the control mechanism. The retractor blades may include an optically clear material, and they may include a corridor. The retractor blades typically have a width of between about 1 cm and 4 cm. The retractor blades typically have a thickness of between about 0.3 cm and 1.5 cm. The shaft may be flexible, and it may include one or more segments.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a side view of an embodiment according to the present invention.

FIG. 2 is a side view of an in-line instrument according to an embodiment of the present invention.

FIG. 3 is an axial view of an embodiment according to the present invention.

FIG. 4 is A is a view of a fenestrated multiple blade opposing retractor in a closed position according to an embodiment of the present invention.

FIG. 4B is a view of a fenestrated multiple blade opposing retractor in an open position according to an embodiment of the present invention. FIG. 5A is a view of a non-fenestrated pair of opposing retractor blades in a closed position according to an embodiment of the present invention.

FIG. 5B is a view of a non-fenestrated pair of opposing retractor blades in an open position according to an embodiment of the present invention.

FIG. 6A is a view of a fenestrated pair of opposing retractor blades in a closed position according to an embodiment of the present invention.

FIG. 6B is a view of a fenestrated pair of opposing retractor blades in an open position according to an embodiment of the present invention.

FIG. 7 is a side view of an instrument having a flexible shaft according to an embodiment of the present invention.

FIG. 8 is a side view of an instrument having a flexible, segmented shaft according to an embodiment of the present invention.

DESCRIPTION OF ILLUSTRATIVE EMBODIMENTS

The present invention comprises a subcutaneous endoscopic dissecting instrument. It is designed to allow minimally invasive surgery in anatomic locations not amenable to usual endoscopic techniques in addition to use in standard endoscopic surgery. For example, the present invention is intended to facilitate endoscopic dissection in the subcutaneous space to allow harvest of tissue flaps and other features such as nerves and veins. As such, it would be very useful for reconstructive surgery, which requires these specialized tissues.

The present invention is intended to overcome the above-described problems of the prior art. Specifically, the present invention allows controlled formation of an optical space and proper application of mechanical traction and counter-traction on tissues in a way that does not fatigue an operating surgeon or assistant. Further, the present invention concentrates multiple elements of operation into a single hand-held device.

The present invention permits various components of a surgical operation to be concentrated at a small space located at the end of a single instrument. It is intended to provide a way for the surgeon to use a single hand to control different tasks, such as retraction, visualization, suction, irrigation, and electrocautery in deep tissues. Consequently, the present invention advantageously reduces fatigue on the hands and arms of a surgeon and may eliminate or reduce the dependence on one or more assistants during an operation. There may be multiple channels extending through or along a shaft of the instrument, which allow introduction of endoscopic cameras and other various instrumentation. The channels may communicate different instrumentation to the distal end of the shaft. More specifically, the channels may communicate various instrumentation to the distal end and ultimately to subcutaneous planes. Adjacent to the distal end of the instrument are expanding jaws which retract and counter-tract tissue, allowing dissection to occur in the tissue planes. The jaws provide mechanical traction and counter-traction on tissues in a manner which minimizes fatigue on the surgeon or assistant. The retractor jaws may be controlled by a hand piece which is connected to a proximal side of the shaft. Other instruments may similarly be activated and controlled through or along the shaft by adding other appropriate control mechanisms to the hand piece.

Turning first to FIG. 1 there is shown an exemplary embodiment of the present invention. The subcutaneous surgical instrument 10 essentially comprises a hand piece 20, a shaft 30 having a proximal portion 35 and a distal portion 36, and opposing retractor blades 40 adjacent to the distal portion 36. The proximal portion 35 is connected to the hand piece 20. The connection between the proximal portion 35 and the hand piece 20 may be achieved in any well known manner, such as by one or more screws, clips, glues, welds, or the like. Alternatively, the hand piece 20 may be connected to the shaft 30 as an integral unit. For instance, the hand piece 20 and shaft 30 may be fabricated as a single piece from materials such as, but not limited to, plastic or one or more metal alloys (e.g., a stainless steel alloy).

In an exemplary embodiment, shaft 30 may be between about 15 cm and 45 cm long, and more preferably between about 28 cm and 32 cm. The shaft diameter may be between about 1.5 cm and about 4 cm, and more preferably between about 2 cm and 3 cm. The shaft may be constructed of any of a number of materials, including, but not limited to metals or plastics. Additionally, the shaft may be made flexible. In an exemplary embodiment, a flexible shaft may have a length of approximately 40 cm. A flexible shaft may be constructed with a series of segments which can be made to bend into different positions, thus permitting placement of the shaft into hard-to-reach subcutaneous areas. The shaft 30 may contain a plurality of channels (not shown in FIG. 1) for communicating at least one associated instrument (not shown in FIG. 1) to distal portion 36. As used herein, channels may refer to openings running along the inside of shaft 30. For instance, a channel may be a hollowed-out region of various shapes within shaft 30. Further, a channel may run along an outer surface of a shaft. Still further, a channel may be a site for interior or exterior attachment to shaft 30. For example, instrumentation may be fixed to shaft 30 at a channel consisting of an attachment site to the external body of shaft 30. Channels may be used to house and/or guide instrumentation down shaft 30, to distal portion 36, and further, subcutaneously into a patient. The channels are designed so that different associated instruments needed for a specific task may all be used simultaneously by a single surgeon or assistant with minimal fatigue to the hands and forearm. Moreover, the channels are designed to reduce or eliminate interference between different instruments, for the channels can guide and keep separate each different piece of equipment associated with different channels.

Associated instruments include any instrumentation which may be needed during a specific surgical procedure. For instance, a video or still camera is an associated instrument which may be housed in or on a channel of shaft 30. In fact, various operating instruments including, but not limited to, retractors, cautery devices, endoscopic scissors, clamps, forceps, hemostatic clip appliers, and sponges may be communicated to the distal portion 36 by means of one or more channels.

Different channels of the present subcutaneous surgical instrument 10 may serve different functions. For instance, one channel may be used as an irrigation channel. Specifically, an irrigation device may be inserted into such a channel and be communicated through or on shaft 30 for irrigating an optical cavity or tissues during surgery. Similarly, one channel may be a suction or video channel. A suction channel may house or guide a suction device appropriate for a certain procedure while a video channel may house or guide cables, a camera, and associated electronics needed to operate the camera. Additionally, one channel may be used as a general accessory channel to house or guide instruments or equipment which serve as accessories to other instruments. Also, one channel may be used as a tissue extraction channel. One may use such a channel to withdraw harvested tissue (e.g., a saphenous vein or nerve) up through or along the instrument during a procedure. Again, the channels allow one to operate several instruments at once while comfortably holding a hand piece without experiencing any undue interference between different individual instruments.

The subcutaneous endoscopic dissector 10 may include one or more control mechanisms coupled to hand piece 20 for controlling one or more associated instruments. Shown in FIG. 1 are some examples of typical control mechanisms including retractor control ring 25, finger control ring 28, and thumb-operated push button 38. As one moves retractor control ring 25, retractor blades 40 move accordingly. Moving retractor control ring 25 causes an extension member 27 to engage a locking mechanism 100. When a user stops moving retractor control ring 25, locking mechanism 100 locks the position of retractor control ring 25, thereby locking the position of retractor blades 40. Locking mechanism 100 may be connected to hand piece 20 in any well known manner. Although shown in FIG. 1 as a ratchet-type device, any suitable design may be employed that will serve to lock a position of retractor blades 40. Also shown in FIG. 1 is a quick-release trigger 105 connected to hand piece 20. Quick release trigger 105, when activated, completely unlocks the position of opposing retractor blades 40, allowing a user to further adjust the blades as needed. As shown here, the trigger acts by swinging away locking mechanism 100, thereby freeing retractor control ring 25; however, other appropriate designs will be apparent to one of ordinary skill in the art. Thus, according to the present invention, a surgeon or assistant may, with one hand, open or close a retractor to create a sufficient optical cavity, lock the retractor in place, and subsequently release the lock to further adjust the retractor.

Other control mechanisms may include one or more push buttons, such as push button 38. Push button 38 may operate different instruments residing in or upon different channels. For instance, push button 38 may operate irrigation or suction functions through an irrigation or suction channel, respectfully. If a cautery device is to be used, it may be controlled by a control mechanism such as finger control ring 28 adjacent to hand piece 20. Control ring 28 may be linked to the cautery device by a wire system running the length of the shaft. By moving finger control ring 28 back and forth, a cautery device may be made to move back and forth, side to side, or in any other suitable manner. For instance, movement of the control ring 28 may move a cautery blade in a circular pattern in a horizontal plane through various tissues. The surgeon may use a foot pedal (not shown in FIG. 1) to control activation of current to the cautery blade. It is contemplated that finger control ring 28 may also be configured to control other types of instrumentation besides a cautery device, such as a retractor. Control mechanisms may be designed for right or left-handed individuals.

FIG. 2 shows an embodiment of the present invention in an in-line position. The in-line position allows the device to be placed in a more compact position, so that there is less intrusion to the surgeon. The in-line configuration is achieved by rotating hand piece 20 along path 33 relative to shaft 30. Although shown here as an in-line configuration, the present invention contemplates that hand piece 20 may be locked to any suitable angle relative to shaft 30. Such locking may be accomplished by any suitable means, such as by a locking hinge mechanism.

Turning now to FIG. 3, there is shown an axial view of another embodiment of the present invention. As shown in FIG. 3, the shaft 30 may communicate various associated instruments through the interior or along the exterior of shaft 30, out towards the distal portion, and perhaps, ultimately, subcutaneously. The channels may include, for example, a video channel 90, an operating instrument channel 85, a wiring channel (not shown in FIG. 3), a suction channel 75, and irrigation channel 80. The suction channel 75 may be tubing, and may be made of a material such as synthetic plastic or rubber (e.g., silicone) that is used to provide desired suction at the distal portion 36 of the shaft 30. The suction channel 75 may be controlled by push button 38 or 39 on hand piece 20. The irrigation channel 80 may be tubing, and may be made of a material such as synthetic plastic or rubber (e.g. silicone) that is used to provide desired irrigation at the distal portion 36 of the shaft 30. The irrigation channel 80 may be controlled by push button 38 or 39 on hand piece 20. The video channel 90 permits a miniature video camera to be located at the distal portion 36 of the shaft 30. Such miniature video cameras are well known in minimally invasive surgery. Cables connecting the video camera to a monitor may pass through video channel 90 and exit through a standard video connection (not shown in FIG. 3) at the rear portion of the shaft 30. A camera may be controlled by a control mechanism adjacent to hand piece 20.

Although channel sizes may vary according to the application, a typical channel may have a diameter between about 5 mm and 10 mm. A typical suction and irrigation channel may each have a diameter of between about 2 mm and 5 mm. It is to be understood that the present invention contemplates the use of more or fewer channels as desired. For example, one may employ a tissue extraction channel, a wiring channel for housing or guiding wires associated with an instrument, or an accessory channel for accessory instruments and equipment. An extraction channel may have an enlarged diameter — in an exemplary embodiment, an extraction channel may have a diameter of 15 mm. As shown in FIG. 3, there may be additional channels 88 on each side of shaft 30 to guide other instruments down the shaft of the endoscopic dissector into the operating field without requiring direct visualization. These channels allow a surgeon to place the tip of an instrument (e.g., scissors) into the open groove to be guided into an optical cavity. Once in the optical cavity, the surgeon can see the instrument on a video monitor and begin to use it. It is to be understood that more or fewer of such open grooves may be employed as a certain procedure may warrant.

The mechanism of retraction involves retractor blades 40 that open inside tissues, pushing them apart, to create an optical space that can be quickly shifted to the exact site of the dissection. The opposing retractor blades 40 provide traction and counter-traction to afford consistent visualization, and they place the tissues under proper tension to make a dissection efficient. In an exemplary embodiment, the opposing retractor blades 40 may be fashioned from optically clear material to allow visualization even when the instrument is advanced through the tissues with the blades in a closed position. Opposing retractor blades 40 may be constructed from a material able to withstand sterilization, such as the polycarbonate material LEXAN. Again, opposing retractor blades 40 may be controlled by a control mechanism such as retractor control ring 25 and locked by locking mechanism 100. The control mechanism for opposing retractor blades 40 may be connected through a retractor channel to the opposing retractor blades 40. Additionally, retractor blades may be coupled to shaft 30 (e.g., within a channel) for subcutaneous placement.

Shown in FIG. 4A is a close-up view of a fenestrated multiple blade opposing retractor 200 in a closed position. Retractor 200 includes corridor 210 and blade portions 205. A corridor, or fenestration, refers to an area where opposing surfaces of the opposing retractor blades do not coapt completely — this allows passage of an instrument, piece of tissue, or any other material through the blades even when they are in a closed position. Such a feature advantageously allows for, for example, advancement of the instrument along a length of a piece of tissue being harvested and withdrawn through a channel in the shaft. As the retractor jaws advance in a closed position, the corridor prevents injury to tissue. Shown in FIG. 4B is a close-up view of fenestrated multiple blade opposing retractor 200 in an open position. Although shown in FIGS. 4 as having three blades 205 in a somewhat-circular design, the present invention contemplates use of more blades arranged in different configurations.

Shown in FIG. 5A is a close-up view of a non-fenestrated pair of opposing retractor blades 220 in a closed position. Shown in FIG. 4B is a close-up view of a non-fenestrated pair of opposing retractor blades 220 in an open position. It is contemplated that the retractor of FIGS. 5 may be different shapes or designs, including, for example, curved or pointed ends.

Shown in FIG. 6A is a close-up view of a fenestrated pair of opposing retractor blades 240 in a closed position. Retractor 240 includes a fenestration 250. Again, this allows passage of an instrument, piece of tissue, or any other material through the jaws even when they are in a closed position. Shown in FIG. 6B is a close-up view of a fenestrated pair of opposing retractor blades 240 in an open position. The retractors of FIGS. 6 may exhibit different designs or configurations according to the needs of the user.

The dimensions of the opposing retractor blades may vary according to the specific procedure being performed and the number of retractor blades being used, but they are typically between about 1 cm and 4 cm in width and between about 0.3 cm and 1.5 cm in thickness. In a typical embodiment, the retractor blades may open to about 5 cm. However, they may be designed to open to a greater or lesser extent according to the needs of a user.

Turning now to FIG. 1, there is shown an instrument 300 according to an embodiment of the present invention having a flexible shaft 310. Flexible shaft 310 may be constructed of any suitable flexible material such as synthetic plastic or rubber. The flexible design of instrument 300 advantageously allows for performing minimally invasive surgery around complex structures and in otherwise hard-to-reach areas.

Shown in FIG. 8, there is shown an instrument 400 according to an embodiment of the present invention have a flexible, segmented shaft 410. Segmented shaft 410 may be constructed from a series of rigid or semi-rigid segments such as segment 420 joined together with flexible joints such as joint 430. Shaft 410 may be made to be rigid by tightening a tension cable running through the shaft (not shown in FIG. 8). This gives a surgeon great versatility to place the instrument in an optimal configuration to facilitate an operation. This feature is especially important for procedures to harvest long subcutaneous structures such as saphenous veins or nerves. Thus, shaft 410 may be adjusted to take on a myriad of different shapes. Specifically, it may snake around complex structures, allowing a surgeon to reach what may otherwise be an impossible location.

The present invention may be made of different sizes for operating in more confined places (e.g., for harvest of nerve or vein grafts on an extremity). The device may be designed to be either disposable or may be disassembled for cleaning and sterilization.

The instrument is an improvement over previous methods of minimally invasive surgery because it offers a better method to create an optical space and reduces the number of instruments required to perform an endoscopic procedure. Previous instruments retracted in only one direction and depended upon constant force exerted by the surgeon. These prior art instruments fatigued the surgeon, provided inconsistent visualization, and did not consistently place the tissues under proper tension. The present invention creates an optical space with more ease, consistency, and mobility. Such an optical space may be more easily enlarged as the controlled mechanical retraction places tissues at the margins under proper tension. Further, there is less operator fatigue as compared to prior art instruments, because constant force by the surgeon is not required. The number of instruments is also reduced by concentrating the necessary elements of operation into a single instrument. The present invention allows for subcutaneous dissection in a more natural way than possible with prior art instruments. Using the present device, a surgeon may use her hands in a more intuitive manner ~ in a manner similar to that used in convention surgical procedures. Thus, the present invention will be easier to master and be more efficient than prior art devices. Allowing for a flexible design, the present invention makes endoscopic dissection around complex surfaces straightforward, whereas using prior art devices, such a task would be difficult if not impossible.

The principle of design of this instrument may be used to yield a family of products to enable endoscopic dissection in unbounded tissue spaces. Examples of common procedures that may be performed using this type of instrument (or modifications of it) include muscle harvest including latissimus dorsi (especially for breast reconstruction), rectus abdominis, pectoralis major, gracilis, serratus anterior, trapezius, tensor fasciae latae, gastrocnemius, and soleus (Miller et al. , 1994, 1995 ; Robb and Miller; Staley et al. , 1994; Ota et al. , 1996). Also, the present invention may be used for harvesting other tissues, such as the saphenous vein (for cardiovascular reconstruction) and the sural nerve (for peripheral nerve reconstruction).

Further, the present invention may be used for lymph node biopsy and dissection, biopsy and/or ablation (i.e. excision, cryotherapy, cauterization, ultrasound) of subcutaneous tumors (including breast), peripheral neuroma exploration, placement of tissue expanders and breast implants, lipectomy for body contouring, and abdominoplasty, among other procedures.

Further modification and alternative embodiments of this invention will be apparent to those skilled in the art in view of this description. Accordingly, this description is to be construed as illustrative only and is for the purpose of teaching those skilled in the art the manner of carrying out the invention. It is to be understood that the forms of the invention herein shown and described are to be taken as the presently preferred embodiments. Various changes may be made in the shape, size, and arrangement of parts. For example, equivalent elements or materials may be substituted for those illustrated and described herein, and certain features of the invention may be utilized independently of the use of other features, all as would be apparent to one skilled in the art after having benefit of this description of the invention.

REFERENCES

The following references, to the extent that they provide exemplary procedural or other details supplementary to those set forth herein, are specifically incorporated herein by reference.

Miller and Robb, "Endoscopic Technique For Free Flat Harvesting," Clinics Plastic Surg., 22(4):755-773, 1995. Miller et al., "Harvest of Jejunum, Rectus Abdominis, and Omentum," In: Endoscopic Plastic

Surgery of the Breast, Trunk and Extremities, Ch. 15, pp 488-509. Miller et al, "Jejunum and Omentum Harvest," Ch. 29, pp 302-308. Miller, "Minimally Invasive Techniques of Tissue Harvest in Head and Neck Reconstruction," Clinics Plastic Surg, 21(1):149-159, 1994. Ota et al, "Small Intestinal Resection," In: Operative Laparoscopy and Thoracoscopy, Ch. 41, pp 729-737, 1996. Robb and Miller, In: Muscle Harvest, Ch. 30, pp 309-318. Staley et al, "Laparoscopic Intracorporeal Harvest of Jejunal Tissue for Autologous Transplantation," Surg. Laparoscopy Endoscopy, 4(3): 192- 195, 1994.

Claims

1. A surgical apparatus, comprising: a hand piece; a shaft having a proximal portion and a distal portion, said proximal portion being connected to said hand piece; and opposing retractor blades adjacent said distal portion of said shaft.

2. The apparatus of claim 1, wherein said shaft comprises at least one channel for communicating one or more associated instrument to said distal portion.

3. The apparatus of claim 2, wherein said associated instrument comprises a camera.

4. The apparatus of claim 2, wherein said associated instrument comprises an operating instrument.

5. The apparatus of claim 4, wherein said operating instrument is selected from the group consisting of endoscopic scissors, a clamp, forceps, a hemostatic clip applier, a cautery device, a retractor, and a sponge.

6. The apparatus of claim 2, wherein said at least one channel comprises an irrigation channel.

7. The apparatus of claim 2, wherein said at least one channel comprises a suction channel.

8. The apparatus of claim 2, wherein said at least one channel comprises a video channel.

9. The apparatus of claim 2, wherein said at least one channel comprises a tissue extraction channel.

10. A subcutaneous surgical instrument, comprising: a hand piece; a shaft having a proximal portion connected to said hand piece and a distal portion for subcutaneous placement, said distal portion comprising a plurality of channels; and a plurality of associated instruments, each of said plurality of associated instruments being associated with one of said plurality of channels.

11. The instrument of claim 10, further comprising opposing retractor blades extending from said shaft and controllably coupled to said hand piece.

12. The instrument of claim 11, further comprising a locking mechanism connected to said hand piece.

13. The instrument of claim 12, further comprising a quick-release mechanism connected to said hand piece.

14. The instrument of claim 10, wherein said hand piece includes a control for operating at least one of said plurality of associated instruments.

15. The instrument of claim 14, wherein said control comprises a push button.

16. The instrument of claim 10, wherein said hand piece is rotatable into an in-line configuration with said shaft.

17. The instrument of claim 10, wherein said shaft has a diameter of between about 2 cm and 3 cm.

18. The instrument of claim 10, wherein said shaft has a length of between about 28 cm and 32 cm.

19. A device for use in minimally invasive surgery, the device comprising: a hand piece; a control mechanism coupled to said hand piece; a shaft having a proximal portion and a distal portion, said proximal portion being connected to said hand piece; a plurality of channels coupled to said shaft for communicating associated instruments to said distal portion; and opposing retractor blades extending from said distal portion, said retractor blades being coupled to said control mechanism.

20. The device of claim 19, wherein said retractor blades are comprised of an optically clear material.

21. The device of claim 19, wherein said retractor blades comprise a corridor.

22. The device of claim 19, wherein said retractor blades have a width of between about 1 cm and 4 cm.

23. The device of claim 19, wherein said retractor blades have a thickness of between about 0.3 cm and 1.5 cm.

24. The device of claim 19, wherein said shaft is flexible.

25. The device of claim 24, wherein said shaft comprises one or more segments.