WO2004047653A2

WO2004047653A2 - Surgical instrument

Info

Publication number: WO2004047653A2
Application number: PCT/EP2003/012246
Authority: WO
Inventors: Stephan Koscher; Johann Würtz; Lee L. Swanstrom; Haio Fauser
Original assignee: Stephan Koscher; Wuertz Johann
Priority date: 2002-11-26
Filing date: 2003-11-03
Publication date: 2004-06-10
Also published as: DE10257760A1; AU2003276245A1; WO2004047653A3

Abstract

The invention relates to a surgical instrument for fixing an element, especially an implant, in a body by means of a fixing element. Said fixing element is arranged in or on a carrier (25), especially in a canula, on a traction element and/or a pressure element (4) guided in a guide (3) along a longitudinal axis (A). According to the invention, the carrier (25) can be rotated about the longitudinal axis (A) and/or can be pivoted in relation to the longitudinal axis (A).

Description

Surgical instrument

The present invention relates to a surgical instrument for fixing an element, in particular an implant, in a body by means of a fixing element, the fixing element being arranged in or on a holder, in particular in a cannula, on a pulling and / or pushing element, which is guided in a guide along a longitudinal axis.

Surgical instruments of this type are known and used in a wide variety of forms and designs. They are used, for example, to insert implants, for example in the bloodstream, which are at risk of aneurysms. Such implants are, for example, thin wire meshes, which are usually inserted into a vein or the like in a prestressed state and open at the relevant point in order to expand the vein wall as a kind of additional tube or at least to reinforce and relieve it.

A disadvantage of this type of procedure is that the implant is inserted into the site in question using a surgical instrument, but is not fixed there. This can cause the implant to slip and, particularly if it is a wire mesh to strengthen a bloodstream, break or possibly penetrate the bloodstream, which can lead to internal bleeding and consequently life-threatening situations.

This method has been improved by WO 99/33402 in such a way that the implant, which is located in a vein or the like, is now attached to the wall of the bloodstream or the like by means of a fastening element such as, for example, a T-anchor. This T-anchor is pushed in from outside the bloodstream through the wall of the bloodstream. Inside, the T opens, so to speak, and lies against the implant from the inside with the crossbar. The trunk of the T is fastened, for example twisted, on the outside of the wall of the bloodstream by means of further fastening elements. The cannula can then be pulled out again.

The disadvantage here is that the cannula in which the T-anchor is located cannot be fixed. It moves freely at the end of the instrument and is therefore difficult to guide. The object of the present invention is to prevent the disadvantages mentioned above and to create a surgical instrument which simplifies handling of a holder, in particular a cannula, with a fixing element, in particular a T-anchor, and opens up the possibility of attaching the holder to a specific one Direction and in a certain position to direct and fix there.

To achieve this object, the holder can be rotated about the longitudinal axis and / or pivotable with respect to the longitudinal axis.

If a cannula is selected as the holder, it is guided in a cannula receptacle, which in turn is connected to a main part via a joint. Together they form the cannula insert. The cannula insert is provided at one end with a locking device which, in use, comes into engagement with a receptacle for a pull and push rod or a holding receptacle at the end of the outer tube. The latching device releasably connects the cannula insert to the pulling and pushing element and the outer tube. The tension and compression element, which is preferably a rod, is in turn guided in the outer tube of the surgical instrument.

The Ras.einrichtung is composed in detail of a ball at the end of a pull and push rod section for insertion into the receptacle of the pull and push rod and at least two opposing pins on a guide projection, which in a groove or recess of the holding receptacle at the end of the outer tube. How the snap connection can look in the individual case is of secondary importance. The main thing is that there is a detachable connection between the cannula insert and the outer tube or the pull and push rod. Therefore All the different possibilities of a connection are intended to be encompassed by the present invention.

The pull and push rod of the cannula insert is articulated at its distal end to the cannula holder. Movement of the pull and push rod section, triggered by movement of the pull and push rod in the outer tube, also moves the cannula receptacle and with it the cannula guided therein. The movement takes place at any angle from 0 ° to 90 ° with respect to the longitudinal axis.

The pull and push rod in the outer tube is articulated and rotatable at its proximal end in a handle leg of a handle. By moving this handle leg or the handle, the pull and push rod can be moved back and forth in the outer tube. Accordingly, if the cannula insert is connected to the pulling and pushing rod via the latching device, the pulling and pushing rod section can also be moved back and forth when the handle leg is moved, as a result of which the cannula, which is fastened in the cannula holder of the cannula insert, faces the Longitudinal axis can be pivoted.

In order to be able to rotate the cannula preferably by 360 ° about the longitudinal axis, a rotary knob is provided on the surgical instrument, which is connected to the outer tube. Since the pins of the locking device of the cannula insert are firmly locked in the recess of the holder receptacle at the end of the outer tube, not only the outer tube but also the cannula insert connected to the pins can be rotated by turning the rotary knob. Other possibilities of rotating the outer tube or The design of the rotary knob should be encompassed by the present invention.

The present invention also relates to a surgical instrument with an outer tube and at least one working element which is connected to the outer tube.

A disadvantage of such surgical instruments is that, above all, the working element which is attached to the tip of the outer tube is without protection. The outer tube with the working element is inserted into the body and can get caught there due to the lack of protection and possibly cause injuries inside the body or be damaged itself.

It is therefore an object of the present invention to provide a surgical instrument which allows working with a working element without causing injuries inside the body or damaging the working element itself.

To achieve this object, a protective tube is placed on the outer tube, which consists of two telescopically displaceable tube sections, one tube section of which at least partially covers the working element in a removable manner.

A funnel-shaped attachment is assigned to the one protective tube, with which the tube section and thus the protective tube can be arranged on a connecting element of the outer tube. The arrangement of the protective tube is used, for example, a snap ring, which can expand and can therefore be clicked onto the connecting element. Any other connection between the funnel-shaped attachment and the connecting element is conceivable and should be encompassed by the present invention.

The two pipe sections are connected to one another by means of a bayonet-type connection and can be moved into one another.

A knob-like element, which is connected to the inner pipe section by the outer pipe section and is slidable on the latter, serves for better handling when moving the two pipe sections. A different attitude is conceivable.

Behind the bayonet-like connection, a ring can further be provided on one pipe section, which limits the displacement of the other pipe section.

The protective tube is suitable due to its two movable tube sections to protect working elements of different sizes.

Another advantage of the protective tube of the present invention is that it can be easily disassembled, which makes it possible to clean the individual components of the protective tube. If the pipe tapers downwards, the flushing pressure increases and better cleaning is achieved.

The present invention further relates to a surgical instrument with a tension and / or pressure element guided in an outer tube, a fixing device being associated with the tension and / or pressure element. Previous surgical instruments of this type have the disadvantage that, although the tension and / or pressure element can be pushed back and forth in the outer tube as desired, it cannot be determined. As a result, there is no possibility 5 of guiding the cannula insert attached to the pulling and / or pushing element with the cannula and fixing it in a specific position. Direction of the cannula takes place, for example, by contacting an element or the like, which, however, represents only a slight securing 10 of the cannula.

The object of the present invention is therefore also to create a surgical instrument which makes it possible to fix the pull and / or push rod in the outer tube 15 and thus the cannula insert with the cannula in a specific position and position.

To achieve this object, the fixing device has a clamping sleeve which is placed on the tension and / or compression element and whose diameter can be changed.

For this purpose, the clamping sleeve, which encompasses the pull and push rod in the region of the front handle leg of the handle, has a continuous slot with a certain width. Since the clamping sleeve rests on a trough of a cylinder body of a shaft, the width of the slot is reduced when the shaft is rotated by means of a clamping lever, which can reduce the diameter of the clamping sleeve and thus clamp the push and pull element and no more can be moved. The trough in the cylinder body of the shaft is preferably arranged eccentrically and has a sickle shape. Instead of the trough, an element can also be arranged in the shaft, for example, which 5 reduces the width of the shaft by rotating the shaft This causes the adapter sleeve and the pull and push rod is jammed. The different possibilities are intended to be encompassed by the present invention.

In order to be able to rotate the shaft by means of the clamping lever, the shaft has a toothed ring which, in the position of use, engages with teeth in a bore in the clamping lever. The shaft can only be rotated as far as the recess on the clamping lever, which cooperates with a pin on the handle, allows. Another possibility for limiting the movement of the clamping lever and thus the shaft in the handle leg of the handle is conceivable and is intended to be encompassed by the present invention. Another arrangement of the clamping lever on the shaft or the rotation of the shaft is also conceivable and should also be encompassed by the present invention.

These elements are also easy to disassemble, which simplifies cleaning of the entire surgical instrument. This can prevent, for example, due to complicated structure, only negligent cleaning, which in the worst case could lead to a dangerous infection in the body if such negligent cleaned devices are used again.

Although protection is also sought separately for the individual elements, the present invention as a whole has created a surgical instrument which considerably simplifies working in the body by rotating the cannula by 360 ° both in the longitudinal axis and at an angle with respect to the longitudinal axis can be pivoted from 0 ° to 90 °. It is also possible to position and fix the cannula in any desired position by actuating the fixing device on the handle. Damage to the cannula itself or injury from the cannula is prevented by the protective tube, which is available in any length due to the two tube sections which can be pushed into one another.

The fact that the surgical instrument can be easily dismantled also enables the individual elements to be optimally cleaned insofar as they, such as the cannula, are not single-use products.

The present instrument is primarily used to repair an anatomical vessel wall or the wall of a hollow organ, such as. B. the esophagus, especially in the human body. It is used in particular as application forceps for a closure element for fixing an implant, such as a stent or stent graft, in a vascular or hollow organ from outside the vessel wall.

Further advantages, features and details of the invention result from the following description of preferred exemplary embodiments and from the drawing; this shows in

1 shows a side view of a surgical instrument according to the present invention with a cannula insert and an associated cannula;

Figure 2 is a front view of the surgical instrument in Figure 1;

Figure 3 is a rear view of the surgical instrument in Figure 1;

Figure 4 is an enlarged view of a connection between the cannula insert and the surgical instrument;

FIG. 5 shows a side view of a protective tube according to the present invention;

FIGS. 6a-6d, views of a clamping lever according to the present invention rotated 90 ° to the right about a longitudinal axis;

Figure 7 is a side view of a shaft for use in the surgical instrument in Figure 1;

FIG. 8 shows a section along the line VIII-VIII through the shaft in FIG. 6;

FIG. 9 shows a side view of an adapter sleeve according to the present invention; Figure 10 is a plan view of the adapter sleeve in Figure 8; and

Figure 11 is a schematic representation of the arrangement of the clamping sleeve on the shaft in the surgical instrument together with the clamping lever.

According to FIG. 1, a surgical instrument 1 has a handle 2, an outer tube 3 connected to it and a pull and push rod 4 guided in the outer tube 3. The handle 2 consists of two handle legs 5 and 6, which are connected to one another via a joint 7. Handle loops 8 and 9 are provided at the respective ends of the two handle legs 5 and 6 in order to facilitate handling of the handle 2.

The end of the handle leg 6 opposite the handle loop 9 has a stop 10 which limits the opening of the two handle legs 5 and 6 of the handle 2.

The end of the handle leg 5 opposite the handle loop 8 is elongated with a curvature. In this curvature of the handle leg 5, a shaft 12 can be seen, which is assigned a clamping lever 13 on the opposite side, that is to say the invisible side. Of this clamping lever 13, however, only a handle 14 can be seen in this view. The shaft 11 is described in more detail below.

At the end of the

Handle leg 5 is one with a not shown

Threaded attachment element 15 arranged. With this, in turn, a rotary knob 16 is rotatably connected to the one Connect the connecting element 17 and a further extension element 18. The outer tube 3 inserted therein can be rotated about a longitudinal axis A by means of the rotary knob 16.

The end of the outer tube 3 opposite the extension element 18 is provided with a holder receptacle 19.

The pull and push rod 4, which is articulated and rotatably supported at one end in the handle leg 6 of the handle 2, extends further through the curvature of the handle leg 5 and the outer tube 3 and the holder receptacle 19.

As can be seen in FIG. 4, the end of the pull and push rod 4 has a receptacle 20 for docking a cannula insert 21. The cannula insert 21 is composed of a latching device 22, a main part 23 and a cannula receptacle 24. The cannula receptacle 24 serves to receive a cannula 25 with an associated slide 26 which can be inserted into the cannula 25 at one end. The cannula 25 is guided at one end in a bore (not shown in detail) in the cannula receptacle 24 and at the other end is provided with an obliquely tapering tip.

For the slide 26, a trough 27 is provided on the top of the main part 23 behind the cannula receptacle 24, in which the slide 26 lies when it enters a human body or the like (see FIG. 1) and cannot be bent if for example, a protective tube 40 is pushed from behind over the entire cannula insert 21.

The cannula receptacle 24 is connected via a joint 28 to the main part 23, to which the locking device 22 is assigned on the opposite side. The locking device 22 of the cannula insert 21 has on the one hand a ball 29 for insertion into the receptacle 20 of the pull and push rod 4 and on the other hand two opposing pins 30 for insertion into a groove 31 in the holding receptacle 19 at the end of the outer tube 3 engage the pin 30 in a corresponding recess 32 at the end of the groove 31.

The ball 29 is connected via a stop 33 to a pull and push rod section 34 which is guided in a guide projection 35 on the main part 23. The pins 30 are arranged opposite one another on the guide projection 35.

In a manner not shown, the pulling and pushing rod section 34 sliding in the main part 23 is connected to a joint 39 outside the longitudinal axis A on the cannula receptacle 24, as a result of which, as will be described below, the cannula receptacle 24 can be pivoted about the joint 28 ,

Furthermore, according to FIG. 1, a protective tube 40 is placed on the outer tube 3 and on the extension element 18 and the connecting element 17. The protective tube 40 consists of two telescopically movable tube sections 41 and 42 (see FIG. 5), the tube section 42 being guided in the tube section 41 and being manageable by means of a knob-like element 43.

At one end of the pipe section 41 there is a stop 44 which cooperates with the knob-like element 43, so that the pipe section 42 cannot be moved beyond the end of the pipe section 41. The other end of the pipe section 41 has a funnel-shaped attachment 45, which in the use position is placed on the attachment element 18 and the connecting element 17 and is fastened thereon, for example, via a snap ring (not shown in more detail). In this way, the protective tube 40 can be fixed and easily removed again.

The pipe sections 41 and 42 form a bayonet-like connection 55 with one another. The elements required for this are a pin 56 and a channel 57. The pin 56 is arranged in the interior of the knob-like element 43 at the end of the pipe section 42 and the channel 57 in the pipe section 41. The pin 56 is guided in the channel 57. The trough 57 is S-shaped, i.e. their respective ends 58 and 59 are curved in a hook shape. Due to the bayonet-like connection 55, the total length of the protective tube 40 can be changed as desired.

As can be seen from FIGS. 2 and 3, a connecting nipple 46 protrudes laterally from the attachment element 17, on which a head 48 provided with an external thread 47 is arranged. Via the external thread 47 of the head 48, for example, a liquid supply can be connected to the connection nipple 46, so that liquid reaches the surgical instrument 1 through the connection nipple 46, for example to flush away blood when used in the body. It is also conceivable to connect compressed air to form cavities in the body, for example.

According to FIG. 3, the arrangement of the clamping lever 13 on the handle leg 5 of the handle 2, which is not visible here, is also shown. As shown in FIGS. 6a to 6d, the clamping lever 13 is a P-shaped structure, the upper region 49 of which has a bore 50, the inner surface of which has individual teeth 51 is provided. In the position of use, these teeth 51 are in engagement with a ring gear 52 of the shaft 12 (see FIG. 7).

Furthermore, a recess 53 is provided in the upper region 49 of the P-shaped clamping lever 13, which in use serves to receive a pin 54 on the handle leg 5 of the handle 2. The pin 54 (see FIG. 3) serves to limit the movement of the clamping lever 13.

The grip 14 of the clamping lever 13 is flattened and widened, in particular for better handling of the clamping lever 13, in contrast to the upper region 49, and projects slightly to the side from the upper region 49 of the clamping lever 13.

The shaft 12, which is shown clearly in FIG. 7, has, in addition to the ring gear 52, a cylinder 60 which has a smooth outer surface 61. A recess 62 is embedded in the lateral surface 61, which, as can be seen in the cross section A-A, is crescent-shaped and eccentrically arranged and extends only around part of the circumference of the cylinder 60 of the shaft 12.

The trough 62 serves to receive a clamping sleeve 63, which is composed of a sleeve section 64 which is chamfered at one end and tapering and a ring 65. An outer diameter a _{x of} the ring 65 is larger than an outer diameter a _{3 of} the sleeve section 64, whereas an inner diameter a _{2 of} the ring 65 is equal to an inner diameter a _{4 of} the sleeve section 64. This results in a uniform bore 66 through the clamping sleeve 63. Both the ring 65 and the sleeve section 64 of the clamping sleeve 63 are traversed by a slot 67 on one side, as can be seen in FIG. 10. The slot 67 has a width b. The ring 65, which has more material than the sleeve section 64, counteracts the closing of the slot 67, so that the slot 67 opens automatically even after a longer closing.

According to FIG. 11, the arrangement or the position of the shaft 12 in a transverse bore 11 in the handle leg 5 of the handle 2 and the arrangement of the clamping sleeve 63 in the trough 62 of the shaft 12 are shown. Furthermore, the arrangement of the clamping lever 13 on the ring gear 52 of the shaft 12 is indicated by an arrow 68.

The operation of the present invention is as follows:

In order to make the surgical instrument 1 functional, it must first be connected to the cannula insert 21 and the cannula 25. For this purpose, the two tube sections 41 and 42 of the protective tube 40 are completely shifted into one another along the bayonet-like connection 55, so that the holder receptacle 19 is exposed at the end of the outer tube 3. The cannula insert 21 is then inserted into the holder receptacle 19. This is done as follows.

First, the handle legs 5 and 6 of the handle 2 are completely opened, so that the pull and push rod 4 moves as far as possible out of the holder receptacle 19. The ball 29 of the latching device 22 is then inserted or hung into the receptacle 20 of the pull and push rod 4 from the side. The stop 33 behind the Ball 29 abuts an edge 69 of the pull and push rod 4.

The two handle legs 5 and 6 of the handle 2 are then completely closed again. As a result, the pull and push rod 4 together with the cannula insert 21 is pulled backwards. When the two handle legs 5 and 6 are completely closed, the two pins 30 simultaneously move into the grooves 31 or snap into the recesses 32 of the holder receptacle 19. The cannula insert 21 is now securely connected to the surgical instrument 1, but the pull and push rod section 34 remains axially movable.

Due to the mounting of the pins 30 in the recess 32 of the holder receptacle 19 of the outer tube 3, by rotating the rotary knob 16, which rotates the outer tube 3, the holder receptacle 19, with it, the pins 30 which are latched in here and thus the entire cannula insert 21 Longitudinal axis A are rotated.

In addition to the rotation and movement of the cannula insert 21 and about the longitudinal axis A, the cannula receptacle 24 in which the cannula 25 is arranged can also be connected by means of a wire 38 or the like connecting element which connects to the invisible end of the pull and push rod 34 is connected to pivot about the joint 28 and with respect to the longitudinal axis A.

In order to protect the cannula insert 21 or the cannula 25 itself, for example, when entering a body and also to prevent injuries from the cannula 25, the tube section 42 of the protective tube 40 is again attached to the surgical instrument 1 after the cannula insert 21 has been attached extended. This will rotated on the knob-like element 43. The pins 56 arranged on the inside of the knob-like element 43 are thus moved out of the respective curvature 58 or 59 at the respective end of the channel 57 of the bayonet-type connection 55 and are displaced along the channel 57, where they then turn into the curve 58 by renewed rotation of knob-like element 43, this time in the opposite direction. In this position, the tube section 42 is extended so far beyond the cannula insert 21 that the cannula 25 is well protected.

When the cannula 25 has reached its place of use, the two tube sections 41 and 42 can be pushed back into one another. Now the channel 25 can be freely pivoted and rotated. However, once it has reached its desired position and position, there must be the possibility of being able to determine the cannula 25. This is necessary, on the one hand, to enable the cannula 25 to work precisely and, on the other hand, to prevent damage to the cannula itself or damage to surrounding tissue parts by it.

For this purpose, the cannula 25 can be fixed on the handle leg 5 of the handle 2 by means of the clamping lever 13. This is done by setting the pull and push rod 4, since the pull and push rod 4 is guided in the clamping sleeve 63, which rests in the handle leg 5 of the handle 2 on the trough 62 in the cylinder 60 of the shaft 12.

If the pull and push rod 4 and thus the cannula 25 are to be fixed, the clamping lever 13, which is seated on the ring gear 52 of the shaft 12 in a rotationally fixed manner by means of the teeth 51, is moved to the left or right. As a result, the shaft 12 and thus the depression 62 of the cylinder 60 also move. The pin 54 on the handle leg 5 of the handle 2 cooperates with the recess 53 of the clamping lever 13 in order to limit the rotation of the clamping lever 13 in one direction or the other.

By rotating the trough 62, the width b of the slot 67 of the clamping sleeve 63 is reduced due to the crescent shape of the trough 62. With increasing rotation of the clamping lever 13 and thus the shaft 12, the width b of the slot 67 is thus reduced to such an extent that the pull and push rod 4, which is guided in the clamping sleeve 63, is clamped. The pull and push rod 4 and consequently also the cannula insert 21 can no longer be moved forwards or backwards and can no longer be rotated. Furthermore, the cannula 25 can no longer be pivoted with respect to the longitudinal axis A and, together with the cannula insert 21, is fixed in its desired position.

Then, for example, a T-anchor located in the cannula can be ejected from the cannula 25 by means of a further instrument, not shown here, by pressing this instrument from behind on the slide 26, whereupon the latter in turn moves into the cannula 25 and the T - Anchor or the like.

If the fixing of the cannula insert 21 is to be undone, only the clamping lever 13 has to be turned in the opposite direction. This increases the width b of the slot 67 of the clamping sleeve 63 and a movement of the pull and push rod 4 is possible again.

Detaching the cannula insert 21 from the surgical

Instrument 1 after the application is done in the opposite way, using the two handle legs! 5 and 6 the handle 2 are opened again as far as possible. As a result, the resistance which is present due to the pins 30 of the latching device 22 which are engaged in the recess 32 of the holder receptacle 19 is overcome by the pressure of the pull and push rod 4. The pins 30 are pressed out of the groove 31 of the holder receptacle 19 by the pull and push rod 4 and the ball 29 of the latching device 22 can be removed from the receptacle 20 of the pull and push rod 4. The connection between the cannula insert 21 and the surgical instrument no longer exists.

DR. PETER WEISS & DIPL.-ING. A. BRECHT

European patent attorney

Case number: P 2841 / PCT Date: 10/28/2003 W / HE

Position Number List

Claims

1. Surgical instrument for fixing an element, in particular an implant, in a body by means of a fixing element, the fixing element being arranged in or on a holder (25), in particular in a cannula, on a pulling and / or pushing element (4) , which is guided in a guide (3) along a longitudinal axis (A),

characterized,

that the holder (25) is rotatable about the longitudinal axis (A) and / or pivotable relative to the longitudinal axis (A). is.

2. Surgical instrument according to claim 1, characterized in that the holder (25) between 0 ° to 90 ° relative to the longitudinal axis (A) is pivotable.

3. Surgical instrument according to claim 1 or 2, characterized in that the holder (25) around

3.60 ° is rotatable.

4. Surgical instrument according to one of claims 1 to 3, characterized in that the cannula (25) is guided in a cannula holder (24).

5. Surgical instrument according to claim 5, characterized in that the cannula receptacle (24) is connected via a joint (28) to a main part (23) of a cannula insert (21).

6. Surgical instrument according to claim 6, characterized in that the main part (23) of the cannula insert (21) is assigned a pull and push rod section (34) and this via a latching device (22) detachably with the pull and / or push element (4th ) connected is.

7. Surgical instrument according to claim 6, characterized in that the latching device (22) has opposing pins (30) and a ball (29).

8. Surgical instrument according to claim 7, characterized in that the ball (29) on the pull and push rod section (34) and the pins (30) are arranged on a guide projection (35) on the main part (23).

9. Surgical instrument according to claim 9, characterized in that the ball (29) with a

Recording (20) at the distal end of the pull and push rod (4) is engaged.

10. Surgical instrument according to claim 8 or 9, characterized in that the pin (30) with grooves

(31) or recesses (32) of a holder receptacle (19) are engaged on ^• the distal end of the outer tube (3).

11. Surgical instrument according to at least one of claims 6 to 10, characterized in that the other end of the pull and push rod section (34) is articulated to the cannula receptacle (24).

12. Surgical instrument according to at least one of claims 1 to 11, characterized in that the pull and push rod (4) is coupled at the other end to a handle leg (6) of a handle (2).

13. Surgical instrument according to claim 12, characterized in that the pull and push rod (4) by means of the handle leg (6) is axially movable.

14. Surgical instrument according to at least one of claims 1 to 13, characterized in that on the guide designed as an outer tube (3) a rotary knob (16) for rotating the outer tube (3) and thus the cannula (25) about the longitudinal axis (A ) is provided.

15. Surgical instrument with an outer tube (3) and at least one working element (21) which is connected to the outer tube (3), characterized in that a protective tube (40) is placed on the outer tube (3), which consists of two telescopically there are mutually displaceable pipe sections (41, 42), of which a pipe section (42) envelops the working element (21) at least partially removably.

16. Surgical instrument according to claim 22, characterized in that the two tube sections (41, 42) are connected to one another by means of a bayonet-like connection (55).

17. Surgical instrument according to claim 15 or 16, characterized in that one end of the tube section (41) with a funnel-shaped Attachment (45) for placement on a connecting element (17) is provided.

18. Surgical instrument according to one of claims 15 to 17, characterized in that an opposite end of the tube section (41) is provided with a stopper (44) which prevents the movement of the

Pipe section (42) limited when extending.

19. Surgical instrument according to at least one of claims 15 to 18, characterized in that the tube section (42) is connected at one end to a knob-like element (43) which slides on the tube section (41).

20. Surgical instrument according to claim 19, characterized in that the knob-like element (43) is provided in its interior with at least one pin (56) via which it is connected to the tube section (42).

21. Surgical instrument according to claim 20, characterized in that the pin (56) is guided in curvatures (58, 59) or in a channel (57) in the tube section (41).

22. Surgical instrument with a tension and / or pressure element guided in an outer tube (3)

(4), wherein the tension and / or pressure element (4) is assigned a fixing device, characterized in that the fixing device has a clamping sleeve (63) placed on the tension and / or pressure element (4), the diameter (a _x to a ₄ ) are changeable.

23. Surgical instrument according to claim 22, characterized in that the clamping sleeve (63) has a sleeve section (64) and a cow (65).

24. Surgical instrument according to claim 23, characterized in that an outer diameter (ai) of the ring (65) is larger than the outer diameter (a ₃ ) of the sleeve section (64).

25. Surgical instrument according to claim 23 or 24, characterized in that an inner diameter (a ₂ ) of the ring (65) is equal to the inner diameter (a ₄ ) of the sleeve section (64).

26. Surgical instrument according to claim 23, characterized in that a slot (67) in the sleeve portion (64) and the ring (65) is formed.

27. Surgical instrument according to at least one of claims 22 to 26, characterized in that the clamping sleeve (63) lies in a trough (62) of a cylinder (60) of a shaft (12).

28. Surgical instrument according to claim 27, characterized in that the trough (62) is arranged eccentrically and sickle-shaped.

29. Surgical instrument according to claim 28, characterized in that the shaft (12) has a ring gear (52) which engages with a toothed (51) bore (50) on a head (49) of a clamping lever (13) stands.

30. Surgical instrument according to claim 29, characterized in that the clamping lever (13) has a recess (53).

31. Surgical instrument according to claim 30, characterized in that the recess (53) serves to receive a pin (54) on the handle leg (5) of the handle (2).