WO1999053851A1

WO1999053851A1 - Surgical retrieval assembly and associated method

Info

Publication number: WO1999053851A1
Application number: PCT/US1998/007620
Authority: WO
Inventors: Naomi L. Nakao; Peter J. Wilk
Original assignee: Wilk And Nakao Medical Technology, Incorporated
Priority date: 1998-04-17
Filing date: 1998-04-17
Publication date: 1999-10-28
Also published as: AU7123098A

Abstract

A surgical instrument assembly (700) for a snare cauterization operation, comprises a tubular member (720) having a diameter sufficiently small so that the tubular member (720) can be inserted through a biopsy channel (704) of a flexible endoscope (706). Multiple endoscopic instruments including a cauterization loop (708), a flexible web member (720) connected to the cauterization loop (708) or to an auxiliary loop (716) so as to form a capture pocket, an elongate flexible fluid feed tube (722) provided at a distal end with a needle point (724) and an aperture (726), are slidably disposed in the tubular member (720). The fluid feed instrument (722) is used to expand a flat or non-projecting polyp prior to severing thereof with the cauterization loop (708) and capture of the severed polyp with the web member (720) or pocket.

Description

1 SURGICAL RETRIEVAL ASSEMBLY AND ASSOCIATED METHOD

Field of the Invention

This invention relates to a surgical instrument assembly for use in removing and

retrieving selected tissues from internal body cavities of a patient. This invention more

specifically relates to an instrument assembly for use in snare cauterization operations. This

invention also relates to an associated method for severing internal organic tissues and

retrieving the severed organic tissues from the patient. More specifically, the present invention

relates to a method for removing polyps.

Background of the Invention

In a conventional endoscopic snare operation, an endoscope is inserted into an internal cavity of a patient, e.g., into the colon, and is used to locate abnormal tissue growths such as

polyps in the internal cavity. Upon the locating of a polyp or other growth which is to be removed, a wire extending through a tube in the biopsy channel of the endoscope is slid in the

distal direction so that a cauterization loop connected to the wire is ejected from the distal end

of the tube and the endoscope. The loop and the endoscope are manipulated from outside of

the patient to pass the loop over the polyp or growth. The wire is then withdrawn in the

proximal direction to tighten the loop around a base region or neck of the polyp. Once the

loop is in contact with the base region of the polyp, an electrical current is conducted through

the loop via the wire. Generally, as the loop is closed about the base region of the polyp,

electrical current is transmitted through the narrowed organic tissues and thereby generates therein heat sufficiently great to cut and cauterize.

Once a polyp is severed by such a snare cauterization technique, it frequently becomes

difficult to capture the polyp and retrieve it from the patient. Sometimes the cauterization loop

is used in an effort to ensnare the polyp. Other capture techniques involve the use of forceps 2 or the application of suction In using forceps, the snare cauterization tube is removed from the biopsy channel of the endoscope and replaced with the forceps In using suction, a vacuum is applied via a suction channel of the endoscope

No matter which specific technique is used, the polyp frequently escapes from the capturing instrumentality and falls away into the colon (or other cavity) Especially in cases

where the polyp is large, the effort and time expended in retrieving the severed polyp may rival

or even exceed the effort and time required to locate and sever the polyp In some cases, the

endoscope must be removed without the polyp and the patient given an enema in an attempt to

flush out the polyp from the colon

Furthermore, there are numerous cases where a severed polyp is never recovered

Sometimes, the polyp is macerated during the retrieval attempt In all such cases, the

pathologist is unable to determine whether the polyp contains carcinoma in situ (localized) or

infiltrative carcinoma (spread) The patient must then undergo a colon resection, sometimes unnecessarily

In any event, the manipulations necessary to remove a severed polyp generally increase

the trauma to the patient, the expense of the surgery and the hospitalization time There is

now a long-felt need to improve the snare cauterization technique to facilitate the capture and

retrieval of severed polyps

U S Patent No 5,201,740 to Nakao et al provides a solution to the above-described

problems in polyp removal Pursuant to the disclosure of that patent, snare cauterization

operations are performed with a surgical instrument assembly comprising a tubular sheath

member carrying a metallic cauterization loop and a metal wire operatively connected to the

loop, the wire passing longitudinally through the sheath An electrical supply is operatively

connectable to the wire, while a flexible web member is connected to the loop to form a J capture pocket, the loop defining a mouth opening of the pocket. During use of the snare

cauterization loop, the web member is passed over and substantially surrounds a polyp. The

pocket captures the polyp at the same time that the cauterization loop is energized to effectuate a severing of the polyp. This cauterization snare assembly with attached pocket is a substantial advance over conventional polyp removal techniques. However, in some cases, the pocket can obscure the polyp from visualization via the endoscope's optical system, making it difficult to obtain an

optimal severing of the polyp. For example, if a polyp is located behind a fold of colonic tissues, it can be difficult to manipulate a cauterization snare to place it around the polyp. If a

pouch is attached to the cauterization loop, the pouch may inhibit effective visualization of the

polyp, thereby increasing the difficulty of the cauterization snare procedure.

Another problem in the removal of polyps occurs where a polyp lies flat against the

wall of the colon or other internal body cavity. In this case it is difficult for the snare to encircle and sever the polyp. Some progress has been made in this regard by injecting saline or

other fluid into the polyp, or into a base region thereof. This injection serves to expand the tissues and elevate the polyp from the internal organic wall, thereby facilitating snare use. The

polyp injection operation is currently performed by a separate instrument which must be

removed prior to the insertion of a cauterization snare.

Summary of the Invention

An object of the present invention is to provide an improved method for the removal of

polyps and other organic tissue parts from patients, particularly a method useful for removing

polyps which lie flattened against the wall of the colon or other internal organ.

A more specific object of the present invention is to provide an improved method for

the performance of a snare cauterization operation, particularly a method useful for removing 4 polyps which lie flattened against the wall of the colon or other internal organ.

A further object of the present invention is to provide an instrument assembly for use in

removing polyps and other tissue clumps from patients, particularly for removing polyps which

lie flattened against the wall of the colon or other internal organ.

Another particular object of the present invention is to provide such an instrument assembly which is simple to manufacture and therefore inexpensive.

A further particular object of the present invention is to provide such an instrument

assembly which is easy to use.

These and other objects are achieved in a surgical instrument assembly for use in snare

cauterization operations comprising, in accordance with an embodiment of the present

invention, a tubular member having a diameter sufficiently small so that the tubular member

can be inserted through a biopsy channel of a flexible endoscope, a cauterization loop, an

electrically conductive wire operatively connected to the cauterization loop, the cauterization

loop and the wire being disposed at least partially in the tubular member, an electrical

connector operatively connected to the wire for feeding an electrical current to the

cauterization loop via the wire, an auxiliary loop, an elongate flexible shifting member

connected at one end to the auxiliary loop, the auxiliary loop and the shifting member being at least partially disposed in the tubular member, a flexible web member connected to the

auxiliary loop so as to form a capture pocket, the auxiliary loop defining a mouth opening of

the pocket, an elongate flexible tube provided at a distal end with a needle point and an

aperture, the flexible tube being disposed at least partially in the tubular member, and a fluid

feed operatively connected to the flexible tube for feeding fluid thereto for ejection through the

aperture.

It is contemplated that the tubular member may be provided with a septum or a 5 plurality of septums defining at least three separate longitudinally extending lumens, the flexible

tubes extending through respective lumens

In use of this instrument assembly during an endoscopic tissue removal operation, the

tubular member is disposed in a biopsy channel of an endoscope which is inserted into a

patient The endoscope is used to visually monitor internal body tissues of the patient. Upon a detection of selected internal tissues to be removed from the patient, the flexible tube is shifted

in the distal direction to eject the needle point from the tubular member, whereupon the needle

point and the aperture are inserted into the selected internal tissues, which are disposed along an internal organic wall of the patient Liquid is then forced through the flexible tube and the

aperture into the selected internal tissues of the patient to expand the tissues and thereby induce the tissues to stand away from the internal organic wall During the operation, the

cauterization loop is shifted in a distal direction relative to the tubular member to eject the

cauterization loop from the tubular member The ejected cauterization loop is at least partially

expanded from a collapsed configuration and passed over the expanded internal tissues of the

patient, whereupon the cauterization loop is closed An electrical current is conducted along

the wire to the closed cauterization loop to sever the expanded internal tissues In addition,

the operation includes the ejection of the auxiliary loop from the tubular member, the opening

of the auxiliary loop from a folded configuration, and the passing of the opened auxiliary loop

over the expanded internal tissues so that the web member substantially surrounds the

expanded internal tissues After the severing of the expanded internal tissues by the cauterization loop and after passing of the auxiliary loop over the expanded internal tissues, the

auxiliary loop is at least partially closed to capture the severed internal body tissues in the

pocket

A surgical instrument assembly for use in snare cauterization operations comprises, in 6 accordance with another embodiment of the invention, a tubular member having a diameter sufficiently small so that the tubular member can be inserted through a biopsy channel of a flexible endoscope, a cauterization loop, an electrically conductive wire operatively connected to the cauterization loop, an electrical connector operatively connected to the wire for feeding an electrical current to the cauterization loop via the wire, a flexible web member connected to

the cauterization loop so as to form a capture pocket, an elongate flexible tube provided at a

distal end with a needle point and an aperture, and a fluid feed operatively connected to the

flexible tube for feeding fluid thereto for ejection through the aperture. The cauterization loop

and the wire, as well as the flexible tube, are disposed at least partially in the tubular member.

The cauterization loop defines a mouth opening of the pocket.

In using this second embodiment during an endoscopic tissue removal operation, the

tubular member is disposed in a biopsy channel of an endoscope which is inserted into a patient. The endoscope is used to visually monitor internal body tissues of the patient. Upon a

detection of selected internal tissues to be removed from the patient, the flexible tube is shifted

point and the aperture are inserted into the selected internal tissues, which are disposed along

an internal organic wall of the patient. Liquid is then forced through the flexible tube and the

aperture into the selected internal tissues of the patient to expand the tissues and thereby

induce the tissues to stand away from the internal organic wall. During the operation, the

cauterization loop and the web member from the tubular member. The ejected cauterization

loop is at least partially expanded from a collapsed configuration and passed, together with the web member, over the expanded internal tissues of the patient, whereupon the cauterization

loop is closed. An electrical current is conducted along the wire to the closed cauterization 7 loop to sever the expanded internal tissues. After the severing of the expanded internal tissues

by the cauterization loop, the severed internal body tissues are disposed in the pocket.

The present invention provides an improved method and an associated instrument assembly for the removal of flat or receding polyps from patients via snare cauterization. A fluid injection needle is introducible into a hollow internal organ together with a snare cauterization and capture pocket assembly, thereby eliminating the necessity of instrument

removal prior to the insertion of another instrument required for the completion of the

operation.

In a method in accordance with the present invention, the severing, capture and

retrieval of flat or nonprojecting polyps are facilitated. An instrument assembly in accordance

with the present invention is simple to use. Accordingly, trauma to the patient and time in

surgery are reduced. More specifically, time under anaesthesia with the accompanying side

effects is reduced. Concomitantly, the expense of hospitalization is decreased.

An instrument assembly in accordance with the present invention allows one to sever a

flat or nonprojecting polyp and then to subsequently capture the severed polyp before it has a chance to roll away. The capture pocket may be placed about the polyp after the cauterization

loop is in place and before cutting occurs. Alternatively, the capture pocket or pouch may be

ejected from the common tubular instrument guide only after the cauterization operation is

completed. In either case, the capture pocket remains out of the way until the cauterization

loop is placed over the polyp and is in place for the cauterization operation.

Brief Description of the Drawing

Fig. 1A is a schematic perspective view of a snare cauterization instrument assembly,

showing a cauterization loop in an ejected, use configuration.

Fig. IB is a schematic longitudinal cross-sectional view of a distal end of the 8 cauterization instrument assembly of Fig 1 A, showing the cauterization loop in a withdrawn or

retracted storage configuration inside the distal end of a tubular member of the instrument

assembly

Fig 2A is a schematic partial cross sectional view of a patient's colon with a polyp,

showing the snare cauterization instrument assembly of Fig 1 A inserted in the biopsy channel

of an endoscope which is itself inserted into the patient's colon, and further showing the

instrument assembly in an initial stage of a snare cauterization procedure

Fig 2B is a schematic partial cross sectional view similar to Fig 2A, showing a loop of

the snare cauterization instrument assembly of Fig 1A being passed around the polyp of Fig

2A

Fig 2C is a schematic partial cross sectional view similar to Figs 2A-2B, showing the

loop of the snare cauterization instrument assembly of Fig 1A completely passed around the

polyp of Fig 2 A

Fig 2D is a schematic partial cross sectional view similar to Figs 2A-2C, showing the

loop of the snare cauterization instrument assembly of Fig 1 A being tightened around a base

or neck of the polyp

Fig 2E is a schematic partial cross sectional view similar to Figs 2A-2D, showing the

loop of the snare cauterization instrument assembly of Fig 1 A in an electrically energized state

for burning through the base or neck of the polyp

Fig 2F is a schematic partial cross sectional view similar to Figs 2A-2E, showing the

polyp severed from the colon wall and captured with the snare cauterization instrument

assembly of Fig 1 A

Fig 2G is a schematic partial cross sectional view similar to Figs 2A-2F, showing the

snare cauterization instrument assembly of Fig 1 A together with the captured polyp drawn 9 towards the distal end of the endoscope

Figs 3-6 are schematic partial side perspective views, showing different specific

embodiments of a snare cauterization instrument assembly

Fig 7 is a schematic side elevational view, on an enlarged scale, of another embodiment

of a snare cauterization instrument assembly, showing a pocket-defining web member on an

auxiliary loop

Fig 8 is a schematic perspective view, also on an enlarged scale, of a modified snare

cauterization instrument assembly, showing an auxiliary loop attached at three points to a cauterization loop

Fig 9 is a schematic top view of another modified snare cauterization instrument assembly, showing an auxiliary loop attached at one point to a cauterization loop

Fig 10 is a schematic partial perspective view, on an enlarged scale, of an additional

snare cauterization instrument assembly

Fig 11 is a schematic partial perspective view, on an enlarged scale, of yet a further

snare cauterization instrument assembly

Fig 12 is a schematic partial cross sectional view of a patient's colon with a polyp,

showing a snare cauterization instrument assembly inserted through the biopsy channel of an

endoscope which is itself inserted into the patient's colon, and further showing an instrument

for depositing color markers on organic tissues

Fig 13 is partially a schematic partial side elevational view and partially a block

diagram of another color deposition instrument alternatively utilizable with the endoscopic

snare cauterization instrument assembly of Fig 12

Fig 14 is partially a schematic partial side elevational view and partially a block

diagram of yet another color deposition instrument alternatively utilizable with the endoscopic 10 snare cauterization instrument assembly of Fig. 12.

Fig. 15 is a schematic partial cross sectional view of a patient's colon with a polyp, showing a snare cauterization instrument assembly inserted through an alternately collapsible

and expandable biopsy channel of an endoscope assembly which is itself inserted into the patient's colon, and further showing an instrument for depositing color markers on organic

tissues.

Fig. 16 is a schematic perspective view of a distal end portion of an endoscopic

cauterization instrument assembly, showing a cauterization loop of the assembly in use to

cauterize and sever a polyp in a patient's colon.

Figs. 17A-17C are schematic side perspective views, partially in cross-section, of another modified cauterization snare and capture pocket, showing three steps in the use of the

device.

Fig. 18 is a schematic side elevational view, partially in cross-section, showing the

cauterization snare and capture pocket of Figs. 17A-17C in a retracted pre-firing insertion

configuration.

Fig. 19 is a schematic side elevation view showing a stage in the assembly of the

cauterization snare and capture pocket of Figs. 17A-17C and 18.

Fig. 20 is a schematic side perspective view, on an enlarged scale, of an endoscopic

surgical instrument assembly.

Figs. 21A-21E are partially schematic cross- sectional views of a colon and partially

schematic side perspective views of an endoscope incorporating the instrument assembly of

Fig. 20, showing successive steps in the performance of an endoscopic operation.

Figs. 22A-22F are partially schematic cross-sectional views similar generally to Figs. 21A-21E, showing an alternative series of successive steps in an endoscopic operation. 11

Fig 23 is a schematic perspective view, on an enlarged scale, of a capture pocket or

pouch, showing the capture pocket or pouch in an opened configuration

Fig 24 is a side elevational view of the capture pocket or pouch of Fig 23, showing the capture pocket or pouch in a substantially closed configuration Fig 25 is a schematic perspective view, on an enlarged scale, of a further capture pocket or pouch, showing the capture pocket or pouch in an opened configuration and attached to a cauterization loop

Fig 26 is a partial schematic perspective view, on a large scale, showing a technique of

fastening the capture pocket or pouch of Fig 25 to the cauterization loop

Fig 27 is a partial schematic perspective view, on a large scale, depicting another

technique of attaching the capture pocket or pouch of Fig 25 to the cauterization loop

Fig 28 is a partial schematic cross-sectional view, on a large scale, illustrating yet

another technique of attaching the capture pocket or pouch of Fig 25 to the cauterization

loop

Fig 29 is a schematic partial perspective view, on an enlarged scale, of an endoscopic instrument assembly for removing flat or nonprojecting polyps, in accordance with the present

invention

Figs 30A-30D are schematic partial perspective views of an endoscope with the

instrument assembly of Fig 29, showing successive steps in the use of the assembly to remove

a flat or nonprojecting polyp, in accordance with the present invention

Fig 31 is a schematic partial perspective view, on an enlarged scale, of another

endoscopic instrument assembly for removing flat or nonprojecting polyps, in accordance with

the present invention

Fig 29 is a schematic partial perspective view, on an enlarged scale, of yet another 12 endoscopic instrument assembly for removing flat or nonprojecting polyps, in accordance with the present invention.

The same elements and organs in the different figures bear the same reference

designations.

Description of the Preferred Embodiments

As illustrated in Fig. 1 A, a snare cauterization instrument assembly comprises a hand held control module 20, a flexible tubular member 22 connected to a distal end of the control

module, and an alternately expandable and closable cauterization loop 24 at the distal tip of the flexible tubular member 22. A flexible sheet or web 26 specifically in the form of a net is

attached to cauterization loop 24 for defining a capture pocket. Loop 24 defines the mouth of

the capture pocket.

Control module 20 comprises a body member or frame 28 which includes a pair of

parallel rails 30a and 30b to which a slider member 32 is reciprocatably secured. Frame 28 has

a thumb hole 31 at a proximal end, whereas slider member 32 has a pair of finger holes 34a and

34b and is fastened to the proximal end of a wire 36 which passes through tubular member 22

and is in turn connected to cauterization loop 24 at the distal end of tubular member 22. Wire 36 is sufficiently flexible to bend with tubular member 22 during the negotiation thereby of

curves or bends in a colon during surgery.

Slider member 32 is also provided with an electrical connector 38 which is couplable to

a source of electrical energy. During a severing step of a cauterization operation, described in

detail hereinafter with reference to Fig. 2E, electrical energy is fed to loop 24 via connector 38

and wire 36.

Capture web 26 is thin and flexible and preferably made of biologically inert flexible

transparent synthetic resin or polymeric material such as polyethylene or nylon. Prior to the 13 beginning of a snare cauterization operation, web 26 is disposed in a closed, folded or

contracted state, together with loop 24, in the distal end of tubular member 22, as illustrated in Fig. IB. Concomitantly, slider member 32 is retracted to the proximal end of rails 30a and 30b

(towards the right side of frame 28 in Fig. 1 A). Tubular member 22 is inserted in a biopsy

channel 40 of an endoscope 42, as shown in Fig. 2A, and the endoscope is inserted into a body

cavity of a patient, such as a colon C.

As illustrated further in Fig. 2A, endoscope 42 is conventionally provided at its distal

end with a pair of apertures 44 and 46 for respectively delivering light to and receiving light

from a surgical site. Upon the discovery of a polyp P within colon C via the use of endoscope 42, the snare cauterization instrument assembly is shifted in a distal direction so that tubular member 22

protrudes from the distal end of biopsy channel 40. Then, slider member 32 is shifted in a

distal direction to eject loop 24 and capture web 26 from tubular member 22. Upon ejection,

loop 24 and capture web 26 expand from a contracted or closed configuration into an at least

partially opened configuration, as shown in Fig. 2A.

Fig. 2B depicts a later stage in the cauterization procedure. The snare cauterization

instrument assembly of Fig. 1 A is manipulated to pass loop 24 around polyp P, with capture

web 26 following. Eventually, loop 24 encircles a base region or neck N of polyp P and the

polyp is surrounded by capture web 26, as shown in Fig. 2C.

At that juncture, slider member 32 is pulled back in the proximal direction, whereby

wire 36 pulls loop 24 partially back into the distal end of tubular member 22, thereby causing

loop 24 to tighten about neck N of polyp P, as illustrated in Fig. 2D.

As indicated in Fig. 2E, electrical current EC is then caused to pass through wire 36

and loop 24. Generally, electric current from loop 24 is conducted through neck N of polyp P, 14 thereby generating in the polyp tissues heat sufficiently great to sever and cauterize neck N. Upon the severing of polyp P at neck N, slider member 32 is pulled farther in the proximal direction, thereby pulling loop 24 further into the distal end of tubular member 22, as shown in

Fig. 2F, to essentially close the loop. Polyp P is now securely trapped in capture web 26. In a further step, depicted in Fig. 2G, the entire snare cauterization instrument assembly including,

in particular, tubular member 22, is shifted in the proximal direction relative to endoscope 42.

However, care is taken not to draw the distal end of tubular member 22 and particularly

capture web 26 with polyp P back into biopsy channel 40 of the endoscope. Polyp P remains

in web or capture pocket 26 outside of tubular member 22 and endoscope 42 during the

withdrawal of endoscope 42 from the patient.

Every polyp severed by a snare cauterization instrument as described and illustrated herein is captured immediately. Thus, the time for the capture and retrieval of severed polyps is reduced to a minimum. Trauma to patient is likewise reduced, as are hospitalization

expenses.

In Figs. 3-6, like structural components bear the same reference designations. Fig. 3

shows a capture web 126 in the form of a net fastened directly to loop 24, while Fig. 4 shows a

capture web 226 in the form of a continuous or solid transparent film fastened directly to loop

24. Fig. 5 illustrates a capture web 326 in the form of a net attached to loop 24 via a

multiplicity of spaced ringlets 328. Loop 24 passes through ringlets 328, which are connected

to a ring-shaped rim element 330 of web 326. Ringlets 328 are preferably made of a metallic

material to facilitate the transmission of electrical current from cauterization loop 24 to the

tissues of a polyp. Fig. 6 shows a capture web 426 in the form of a continuous or solid film of

transparent polymeric material attached to loop 24 via a multiplicity of spaced ringlets 428.

Loop 24 passes through ringlets 428, which are connected to a ring-shaped rim element 430 of 15 web 426

As illustrated in Fig 7, a snare cauterization instrument assembly comprises a flexible

cauterization loop 502, an electrical conductor 504 operatively connected to the cauterization

loop for feeding an electrical current thereto, and a flexible auxiliary loop 506 connected via a fastening element 508 to the cauterization loop only at a distal end thereof An actuator 510 is

operatively connected to cauterization loop 502 and auxiliary loop 506 for alternately

expanding and contracting the two loops in tandem with one another A flexible web member 512 in the form of a net (or a continuous transparent membrane) is connected to auxiliary loop

506 essentially around the circumference thereof to form a capture pocket, auxiliary loop 506

defining a mouth opening of the pocket Preferably, net 512 is fixed to auxiliary loop 506 only

at a distal end and a proximal end (inside a tubular sheath member 514) thereof, the remaining

connections 515 being slidable

Actuator 510 is connected to cauterization loop 502 via conductor 504, which

functions in response to manipulations of actuator 510 to eject cauterization loop 502 from a

collapsed storage position inside the distal end of tubular sheath member 514 and subsequently

to pull cauterization loop 502 back into the sheath member Actuator 510 is coupled to

auxiliary loop 506 via a flexible wire or rod member 516 which like conductor 504 extends

longitudinally through sheath member 514

Cauterization loop 502 and auxiliary loop 506 are disposed in parallel planes P2 and

PI, respectively As depicted in Fig 8, auxiliary loop 506 may be connected at a proximal end

to cauterization loop 502 at two points 518 and 519, as well as to the distal end of the

cauterization loop In that event, wire or rod member 516 may be omitted As further shown

in Fig 8, auxiliary loop 506 is slightly larger than cauterization loop 502 The loops 502 and

506 are close, almost touching one another As described above with reference to Fig 7, web 16 member 512 is fixedly connected to auxiliary loop 506 at a distal end and a proximal end thereof and slidably connected to the auxiliary loop between those ends

Fig 9 shows a cauterization loop 520 and an auxiliary loop 522 connected to one

another at a distal end via a fastener 524 Cauterization loop 520 and auxiliary loop 522 are

essentially coplanar in the expanded configuration illustrated in Fig 9 During an ejection

stroke and a subsequent retraction stroke of cauterization loop 520 and auxiliary loop 522 in response to the manipulations of an actuator (not shown) at a proximal end (not shown) of the instrument assembly, cauterization loop 520 and auxiliary loop 522 expand and contract in unison in essentially a common plane

The embodiments of a cauterization snare instrument assembly illustrated in Figs 7-9

are less expensive to manufacture than the ringlet embodiments of Fig 5 and 6 and enable use

of a wider range of materials for the pocket or web member (512 in Fig 7) than the

embodiments of Figs 3 and 4 In addition, a primary advantage of the particular dual loop

embodiments of Figs 7-9 is that auxiliary loops 506 and 522 are not connected to the

cauterization loops 502 and 520 along operative portions thereof, thereby eliminating any

possible interference that the auxiliary loops or capture nets 512 and 523 (Fig 9) might

otherwise exhibit with respect to the cutting and cauterization operations

As illustrated in Figs 8 and 9, this elimination of possible interference in the cutting and

cauterization operations is furthered by forming cauterization loops 502 and 520 at their distal

ends with respective tongue-like extensions 526 and 528 to which auxiliary loops 506 and 522

are connected Extensions 526 and 528 may be coated with an insulating material (not

illustrated) and serve to separate fasteners 508 and 524 from the site of the cauterization

procedure

Auxiliary loops 506 and 522 are made of electrically nonconductive material preferably 17 in the form of a synthetic resin or polymeric material such as polyethylene or nylon.

In using the snare cauterization instrument assemblies of Figs. 7-9, cauterization loop 502 or 520 and auxiliary loop 506 or 522 are expanded from a collapsed configuration inside

the distal end of sheath member 514 to an expanded configuration. In the expanded

configuration, auxiliary loop 506 or 522 is preferably larger than cauterization loop 502 or 520

and essentially parallel thereto. A special case of parallelism is found where the cauterization

loop and the auxiliary loop are coplanar.

Pursuant to additional steps in the procedure, pocket or web member 512 or 523 is opened during the expansion of cauterization loop 502 or 520 and auxiliary loop 506 or 522

and the expanded loops are passed over a selected polyp or other internal tissue agglomeration to be removed, so that web member 512 or 523 substantially surrounds the polyp. Cauterization loop 502 or 520 is then closed by pulling it into the distal end of sheath member

514 or 525 (Fig. 9). The closure of cauterization loop 502 or 520 around a base region of the

polyp while the cauterization loop is energized with electrical current serves to severe the

polyp at its base. Maintaining web member 512 or 523 surrounding the polyp during the

cauterization procedure serves to capture the severed polyp at the instant of its severance.

As illustrated in Fig. 10, a modified snare cauterization assembly includes a

cauterization loop 530 surrounded along a substantial portion of its length by a tubular jacket or sleeve 532 to which a flexible pocket-defining web member 534 is connected. Jacket or

sleeve 532 is made of a heat-conductive and electricity-conductive material enabling

cauterization to proceed through the medium of the sleeve. In addition, sleeve 532 is provided

with a coating or layer 535 of a biocompatible dye or ink material of a predetermined color.

Color from coating 535 is transferred from the cauterization loop and particularly from sleeve

532 during the conduction of current through the loop. Coating 535 may be a liquifiable solid 18 or a powder. Such a color-transferable coating or layer may be provided directly on any of the cauterization loops described herein. The deposition of a common color on a severed polyp and an unsevered neck or base area serves to facilitate a locating of the polyp's original situs upon a subsequent identification of the polyp as being malignant or a carcinoma. This is

especially advantageous where several polyps are caught in the same procedure (see Fig. 15).

As illustrated in Fig. 11, another modified snare cauterization assembly comprises a cauterization loop 536 enclosed along essentially its entire length by a tubular jacket or sleeve

538 to which a flexible pocket-defining web member 540 is coupled. Sleeve 538 is provided

along an inner side with a plurality of longitudinally extending windows 542 for facilitating or

enabling the conduction of heat and/or electrical current from cauterization loop 536 to

organic tissues of a polyp or other cell mass to be removed from a patient's body.

As shown in Fig. 12, a surgical instrument assembly for use in a snare cauterization operation comprises an endoscope assembly 550 including a biopsy channel 552 and a light outlet 554 at a distal end of an endoscope insertion member 556 for delivering light to a

surgical site inside a patient. The distal end of the endoscope insertion member 556 is further

provided with a light inlet 558 for receiving light reflected from a surgical site. Light outlet

554 and light inlet 558 are located at the distal ends of a fiber optic illumination guide (not

shown) and a fiber optic image guide (not shown), respectively, which extend longitudinally

through endoscope insertion member 556.

As further illustrated in Fig. 12, a tubular sheath member 560 is inserted through biopsy

channel 552, while a metal wire 562 passes longitudinally through the sheath 560 and is

operatively connected at a distal end to an alternately expandable and collapsible metallic

cauterization loop 564. An electrical supply (not shown in Fig. 12) is operatively connected to

wire 562 for feeding an electrical current to loop 564 via the wire. A manually actuatable 19 shifter (not illustrated in Fig 12) is operatively connected to wire 562 at a proximal end

thereof for longitudinally sliding the wire along sheath 560 in alternately opposite directions A flexible web member 566 is connected to loop 564 to form a capture pocket, the loop

defining a mouth opening of the pocket Web member 566 is attached to loop 564 in a manner

so as to expose the loop to enable effective cauterization of organic tissues by the loop

Also extending through biopsy channel 552 is a tubular member 568 connected at a

proximal end to a pressurizable dye or color source 570 such as a hypodermic syringe filled

with a biocompatible liquid of a predetermined hue A distal end portion of tubular member

568 is ejected from biopsy channel 552 upon arrival of the distal end of endoscope assembly

550 at an internal surgical site where a polyp PO is detected via light outlet 554 and light inlet

558 of endoscope assembly 550 Colored fluid is squirted from tubular member 568 to place

recognizable markers Ml and M2 on polyp PO and a lower portion of a polyp neck PN by

which polyp PO is connected to a colon wall CW of a patient Markers Ml and M2 enable

subsequent identification of the original location of polyp PO upon a medical analysis of the polyp after it has been severed and removed from the patient in accordance with procedures

described herein and other steps known to those skilled in the art

Upon an insertion of endoscope insertion member 556 into a patient's colon, endoscope

assembly 550 is used to visually monitor internal body tissues of the patient, including the

internal surface of colon wall CW Upon detecting selected internal body tissues (e.g., polyp

PO) to be removed from the patient, loop 564 and web member 566 are ejected from a distal

end of biopsy channel 552 Loop 564 and web member 566 are at least partially expanded

from a collapsed configuration upon their ejection from biopsy channel 552. Loop 564 is

manipulated from outside of the patient, e g , via endoscope assembly 550 and more

particularly via wire 562 or sheath 560, to pass the expanded loop over the polyp PO so that 20 web member 566 substantially surrounds the polyp. Subsequently, loop 564 is closed to

engage the polyp PO around a base region thereof. Closure is effectuated by sliding sheath

560 in a distal direction so that a proximal part of loop 564 is retracted into the sheath. An

electrical current is conducted through the closed or partially closed loop 564 to burn through

the base region of polyp PO, thereby severing the polyp PO at the base region. Loop 564 is

closed further upon a completed burning of the loop through the base of the polyp PO, thereby capturing the severed polyp in web member or pocket 566.

Polyp PO and neck PN may be marked with a biocompatible dye or ink by tubular member 568 prior to the cauterization procedure. Alternatively, at least the neck portion PN

may be marked after polyp PO has been severed by loop 564 and captured in web member

566. Tubular member 568 operates to spray a determinable quantity of liquid dye or ink onto

the surfaces of polyp PO and neck or base PN.

As illustrated in Fig. 13, another instrument 572 utilizable with endoscope assembly

550 to mark organic tissues inside a patient comprises a tubular member 574 operatively

connected at a proximal end to a pressurized or pressurizable supply 576 of a biocompatible

fluidic dye material. At a distal end, tubular member 574 is provided with a needle 578 for use

in injecting the dye material below the surface of polyp PO and neck PN.

As shown in Fig. 14, another instrument 580 utilizable with endoscope assembly 550 to

mark organic tissues inside a patient comprises a tubular member 582 operatively connected at

a proximal end to a pressurized or pressurizable supply 584 of a biocompatible fluidic dye

material. At a distal end, tubular member 582 is provided with a brush 585 for use in applying

or painting the dye material on the surface of polyp PO and neck PN.

Instrument 572 of Fig. 13 or instrument 580 of Fig. 14 may be inserted through biopsy

channel 552 of endoscope assembly 550. Alternatively, tubular member 568 or marking 21 instrument 572 or 580 may be inserted through an alternately expandable and collapsible biopsy channel 586 provided on a sheath 588 surrounding an endoscope insertion member 590,

as illustrated in Fig 15 Such an endoscope sheath 588 may take the form described and

illustrated in U S Patents Nos 4,646,722 and 5,025,778, the disclosures of which are hereby

incorporated by reference

Sheath 588 is provided with other alternately expandable and collapsible biopsy

channels 592 and 594, one of which receives a sheath 596 of a cauterization instrument

assembly 598 As depicted in Fig 15, an expanded web member 600 at a distal end of

instrument assembly 598 carries a pair of polyps PI and P2 which have already been marked

with respective colors and severed Fig 15 shows a third polyp P3 being marked by instrument 572 (Fig 13) prior to cauterization and severing by a loop 602 to which web member 600 is attached in a manner to enable cauterization by the loop

As shown in Fig 16, another assembly for use in severing and removing an organic

tissue sample TS from inside a patient comprises a cauterization loop 604 which in an

expanded configuration has a bent configuration which arcs at 606 laterally from a plane PLN

in which the loop opens and closes Arc or curvature 606, inherent in the prestressed or

spring-biased construction of loop 604, facilitates the capture of polyps by facilitating the

encirclement thereof, as indicated in Fig 16 The curved design of Fig 16 may be used in any

of the snare embodiments described herein, as well as in prior art cauterization loops without

an attached capture pocket or web Loop 604 is provided with a capture pocket 608 and is

operatively connected to an electrical energy source (not shown) via an elongate wire 610

extending longitudinally through a sheath 612 in turn extending through a biopsy channel 614

of an endoscope insertion member 616

It is to be noted that colored staples may be used to mark a polyp and/or its base, the 22 staples being applied via an endoscopic stapling instrument as disclosed in U.S. Patents Nos. 5,015,249 and 5,049,153 and 5,156,609, the disclosures of which are hereby incorporated by

reference. The staples may be applied to the base or neck of a severed polyp either before or after a cauterization procedure.

Figs. 17A-17C illustrate steps in using a modified snare including a cauterization loop

782 with a capture pocket 784 attached by burnable ringlets 786 to the loop. The two most

proximal ringlets 788 are connected via respective threads 790 to an inner surface or side 794

of a deployment sheath 792. Points of connection 796 of threads 790 to sheath surface 794

are located at a distance dl from the distal tip 798 of sheath 792 approximately equal to half of

the length LI of loop 782.

Upon an extension of loop 782 from sheath 792, as illustrated in Fig. 17 A, threads 790 pull ringlets 788 in a proximal direction to the proximal side of loop 782, thereby stretching

capture pocket 784 out to an optimally opened configuration. Of course, threads 790 also limit the extent to which loop 782 may be distanced from the distal end of sheath 792.

Fig. 17B shows the sliding of ringlets 786 and 788 in a distal direction relative to loop

782 upon a retraction of the loop into sheath 792, after loop 782 and pocket 784 have been

placed about a polyp (not shown). In the event that the user endoscopist decides that an

adjustment of the snare relative to the polyp is desired, loop 782 is pushed in a distal direction

relative to sheath 792. This movement may be accomplished, of course, by pulling sheath 792

in a proximal direction relative to loop 782. Upon a sufficient ejection of loop 782 from sheath

792, threads 790 again pull ringlets 788 in a proximal direction to the proximal side of loop

782 to thereby open capture pocket 784.

If the user endoscopist decides that loop 782 is propitiously positioned relative to the

subject polyp, loop 782 is pulled further into sheath 792, as illustrated in Fig. 17C. Ringlets 23 786 and 788 are severed from loop 782 via a burning process, thereby freeing capture pocket

784 from loop 782 The polyp cauterization assembly of Figs 17A-17C may be provided with

a purse string for ensuring closure of capture pocket 784 upon completion of a polyp severing operation As shown in Fig 18, in packing loop 782 and pocket 784 inside sheath 792, pocket

784 may be disposed distally of loop 782, thereby facilitating the packaging process

Fig 19 illustrates a step in a manufacturing operation Sheath 792 includes a distal

segment 800 which is attached to a body portion 802 of the sheath via ultrasonic welding,

adhesive, heating, or other process Threads 790 extend through segment 800 and are

sandwiched between segment 800 and body portion 802 upon connection of those sheath

elements to one another Threads 790 may be provided additionally with knots 804 which are

located outside of the sheath 792 upon completion of manufacturing Knots 804 serve as

anchors, preventing dislodgement of threads 790 during use of the cauterization snare

assembly

As illustrated in Fig 20, a surgical instrument assembly 890 for use in snare cauterization operations comprises a tubular instrument guide member 892 defining a plurality

of separate longitudinally extending lumens 894 and 896. Lumens 894 and 896 have

semi-circular cross-sections Tubular member 892 has a diameter sufficiently small so that the

tubular member can be inserted through a biopsy channel 898 of a flexible endoscope insertion

member 900 (Figs. 21A-21E) Instrument assembly 890 further comprises a cauterization loop

902 and an auxiliary loop 904 which is provided with a flexible web member 906 defining an

alternately expandable and contractible capture pocket Auxiliary loop 904 defines a mouth

opening of the pocket

An electrically conductive wire 908 is connected to cauterization loop 902, 24 cauterization loop 902 and wire 908 being disposed at least partially in lumen 896 of tubular

member 892. An electrical supply 909 is operatively connected to wire 908 via a coupling 910

for feeding an electrical current to cauterization loop 902 via wire 908. An elongate flexible

shifting member 912 (e.g., a wire) is connected at one end to auxiliary loop 904. Auxiliary

loop 904 and wire 912 are at least partially disposed in lumen 894 of tubular member 892. A

handle assembly 914 is provided at the proximal end of wire 912 for facilitating the maneuvering of auxiliary loop 904 from outside the patient. Handle assembly 914 may also be

connected to cauterization loop 902 to facilitate the manipulation of the loop to eject the loop

from lumen 896 and to place the loop about a polyp PLP (Fig. 21A). Handle assembly 914 is

operatively connected to cauterization loop 902 and auxiliary loop 904 so as to allow those two elements to be ejected independently from tubular member or catheter 892.

Web member 906, whether a net or a continuous film of polymeric material, may be

connected to auxiliary loop 904 at a plurality of spaced locations, e.g., via ringlets (not

shown). Tubular member 892 is preferably flexible so that it may pass along bends in

endoscope insertion member 900 upon a deployment thereof during an endoscopic

investigation.

As depicted in Fig. 21 A, upon introduction of endoscope insertion member 900 into a

patient's colon CLN and use of the endoscope assembly to visually monitor internal body tissues of the patient to locate polyp PLP, tubular member 892 is moved in a distal direction

through biopsy channel 898 of endoscope insertion member 900 to eject a distal end portion of

the tubular member from the biopsy channel.

Subsequent steps of an endoscopic surgical procedure are depicted in Fig. 2 IB.

Cauterization loop 902 is shifted in a distal direction relative to ejected tubular member 892 to

eject the cauterization loop from the tubular member. Upon ejection, ejected cauterization 25 loop 902 is expanded from a collapsed configuration inside tubular member 892 to an opened configuration. Cauterization loop 902 is then manipulated from outside of the patient to pass the expanded cauterization loop over polyp PLP which is to be removed from the patient.

As illustrated in Fig. 21C, cauterization loop 902 is at least partially closed to engage

polyp PLP around a base region or neck NK thereof. This closure is effectuated by shifting

tubular member 892 and cauterization snare relatively towards one another to thereby at least

partially withdraw or retract cauterization loop 902 into tubular member 892. Upon closure of

cauterization loop 902 about polyp neck NK, an electrical current is conducted through wire

908 and cauterization loop 902 to burn through polyp PLP at base region or neck NK thereof, thereby severing the polyp at the neck.

Upon a severing of the polyp PLP at the neck NK, cauterization loop 902 is retracted into tubular member 892. Then, auxiliary loop 904 is ejected from tubular member 892, the

auxiliary loop and web member or capture pocket 906 being opened from a folded

configuration inside lumen 94 of tubular member 892 to an at least partially expanded or

opened configuration, as illustrated in Fig. 2 ID. Subsequently, auxiliary loop 904 is

maneuvered from outside the patient to pass the opened auxiliary loop 904 over the severed

polyp PLP so that web member or pocket 906 substantially surrounds the polyp. At that

juncture, auxiliary loop 904 is at least partially closed to capture the severed polyp PLP in web

member or pocket 906, as shown in Fig. 21E. As further indicated in Fig. 21E, the closing of

auxiliary loop 904 includes shifting tubular member 892 and the auxiliary loop relatively

towards one another to thereby at least partially withdraw auxiliary loop 904 into tubular

member 892. After capture has been effectuated, polyp PLP is removed from the patient

together with auxiliary loop 904 and the capture pocket 906.

Biopsy channel 898 of endoscope member 900 may be located in a sheath disposed on the 26 endoscope, as described in U.S. Patent No. 5,217,001, the disclosure of which is hereby

incorporated by reference.

It is to be noted that the device or instrument assembly of Fig. 20 includes a cauterization wire disposed simultaneously with a separate capture pocket in a common

tubular instrument guide member.

Figs. 22A-22E depict a sequence of steps in another endoscopic polyp removal

procedure. Fig. 22 A is identical to Fig. 21 A and shows endoscope insertion member 900

inserted into colon CLN. Insertion member 900 is used to visually monitor internal body

tissues of the patient to locate polyp PLP. Upon locating polyp PLP, the endoscopist moves

tubular member 892 in a distal direction through biopsy channel 98 of endoscope insertion

member 900 to eject the distal end portion of the tubular member from the biopsy channel.

Fig. 22B is identical to Fig. 21B and illustrates subsequent steps of the endoscopic polyp removal procedure. Cauterization loop 902 is shifted in a distal direction relative to ejected tubular member 892 to eject the cauterization loop from the tubular member. Upon

ejection, ejected cauterization loop 902 is expanded from a collapsed configuration inside

tubular member 892 to an opened configuration. Cauterization loop 902 is then manipulated

from outside of the patient to pass the expanded cauterization loop over polyp PLP which is to

be removed from the patient.

As illustrated in Fig. 22C, cauterization loop 902 is maneuvered to encircle polyp PLP

around base region or neck NK thereof. Prior to completing a closure of cauterization loop

902 about polyp PLP, auxiliary loop 904 and capture pocket 906 are ejected from tubular

member 892 and are opened from a folded configuration inside lumen 894 of tubular member

892 to an at least partially expanded or opened configuration. As illustrated in Fig. 22D, auxiliary loop 904 is then maneuvered from outside the patient to pass the opened auxiliary

B32-002 27 loop 904 and capture pocket 906 over the polyp PLP so that web member or pocket 906

substantially surrounds the polyp. At that juncture, tubular member 892 on the one hand and

cauterization loop 902 and auxiliary loop 904 on the other hand are shifted relatively towards

one another to thereby effectuate a partial closure of the loops about polyp PLP, particularly about neck region NK thereof, as shown in Fig. 22E.

Upon closure of cauterization loop 902 about polyp neck NK, an electrical current is conducted through wire 908 and cauterization loop 902 to burn through polyp PLP at base

region or neck NK thereof, thereby severing the polyp at the neck. Simultaneously with the

current flow, cauterization loop 902 is drawn into tubular member 892. The severed polyp is

automatically or naturally captured within pocket 906, as illustrated in Fig. 22F. After capture

has been effectuated, polyp PLP is removed from the patient together with auxiliary loop 904

and the capture pocket 906.

Figs. 23 and 24 illustrate an improvement in a loop and pouch assembly which may be

incorporated into the assembly of Fig. 20. The assembly comprises a tubular member 920

defining at least one longitudinally extending lumen 922. Tubular member 920 has a diameter

sufficiently small so that the tubular member can be inserted though a biopsy channel of a flexible endoscope. An elongate flexible shifting member 924 is connected at one end to a

flexible loop 926, the loop and the shifting member being at least partially disposable in lumen

922. A flexible web member 928 is connected to loop 926 so as to form a capture pocket or

pouch. Loop 926 defines a mouth opening of pocket 928. At least one flexible tensile member

or tether 930 and preferably two flexible tensile members 930 and 932 are connected to flexible

web member or pocket 928 at proximal end points 934 and 936 thereof. Flexible tensile

members 930 and 932 are also connected to tubular member 920 at a pair of holes 938 and 940

formed in tubular member 920 at points spaced from a distal end thereof. Tensile members 28 930 and 932 extend from flexible web member 928 into lumen 922 of tubular member 920.

Tensile members 930 and 932 are segments of a single flexible tensile tether member

942 which extends through holes 938 and 940 in tubular member 920. A patch 944 is disposed

on an outer surface of tubular member 920 over holes 938 and 940 and over a bight portion

946 of tensile member 942 which is located outside the tubular member. Patch 944 is a thin

film of polymeric material which is heat shrunk tightly over the tubular member 920. Patch

944 ensures that bight portion 946 of tensile member or thread 942 is not snagged on possible protuberances inside the endoscope channel.

When loop 926 is ejected from tubular member 920, web member or capture pocket

928 slides along loop 926, staying outside of the tubular member, as illustrated in Fig. 24. In

the event that the loop 926 is subsequently ejected again from the distal end of tubular member

920, tensile segments 930 and 932 hold the proximal end of capture pocket 928 so that the

pocket slides back along the emerging loop 926 to become repositioned along the loop as

illustrated in Fig. 23.

The specific embodiment of the invention illustrated in Figs. 24 and 25 ensures that the

pocket 928 can remain outside the tubular member 920 and yet can be reopened or

repositioned in the event it is necessary or desirable to eject the loop 926 again. If tensile segments 930 and 932 were attached to loop 926 or shifting member 924, as it is in some prior

art pouches, a polyp contained in capture pocket 928 would be mashed owing to a dragging of

the pocket and its contents into tubular member 920.

As illustrated in Fig. 25, an endoscopic surgical instrument for use in snare

cauterization operations comprises a tubular sheath member 950, an alternately expandable and

contractible cauterization loop 952, and an electrically conductive wire 954 operatively

connected to the loop. Generally, wire 954 is thicker than loop 952 and is crimped thereto at 29

955 via a swaging procedure.

Wire 954 is slidable longitudinally through sheath member 950, while the sheath is

longitudinally insertable through a biopsy channel of an endoscope insertion member (not

shown). A flexible web member 956 is connected to loop 952 essentially around a circumference thereof to form a capture pocket, loop 952 defining a mouth opening of the

pocket. More specifically, web member 956 is slidably attached to loop 952 along a proximal

portion 958 thereof via a plurality of spaced thread ringlets 960. Web member 956 is fixedly

but removably attached to loop 952 along a distal portion 962 thereof to enable at least a

substantial separation of web member 956 from loop 952 upon a proximally directed cutting stroke of wire 954 during a cauterizing phase of an endoscopic polyp removal operation. As

illustrated particularly in Fig. 25, web member 956 is fixed to distal end portion 962 at a plurality of discrete points 964 along a radially outer surface of loop 952. Those attachment

points 964 are severable or rupturable, e.g., by the heat of cauterization, so that web member

956 is separated from loop 952 during cauterization.

As further illustrated in Fig. 25, a purse string 966 is attached to web member or pouch

956 along a ring shaped locus proximately to the mouth opening, that is, proximately to loop

952. Purse string 966 is attached at a proximal end to at least one of wire 954 and tubular

member 950, as described hereinabove with reference to Figs. 17A-17C, and 23-24. Purse

string 966 is made of a heat-resistant material such as quartz and is attached to wire 954 proximally to the point of connection 955 of loop 952 to wire 954. Because quartz is prone to

fracture, it is fixed to wire 954 via a reservoir of adhesive activated by ultraviolet radiation. It

is to be noted that the length of purse string 966 must be selected so that the purse string does

not close too early during a retraction of loop 952 into tubular sheath member 950. It is to be

further noted that the embodiment of Fig. 25 is advantageously provided with the tether 930, 30 932, 942 of Fig. 23. The tether is omitted in Fig. 25 for purposes of clarity of illustration.

As depicted in Fig. 26, where cauterization loop 952 comprises a plurality of metal

strands or filaments 968 wound, woven or braided to one another, web member or capture pouch 956 may be attached to the loop via threads 970 inserted under individual strands or filaments 968 of loop 952. Alternatively, as shown in Fig. 27, web member or capture pouch

956 may be attached to loop 952 via threads 972 and minute metal ringlets 974. Ringlets 974

may become virtually integral with loop 952. In yet another attachment method, indicated in

Fig. 28, web member or capture pouch 956 is attached to the radially outer surface of loop 952

along distal portion 962 thereof via an adhesive layer 976.

Generally, it is contemplated that distal portion 962 extends approximately one-third

the length of loop 952, while proximal portion 958 extends approximately two-thirds the length of loop 952. Prior to the cutting and cauterizing phase of a polyp removal procedure,

thread ringlets 960 slide back and forth along loop 952 as the loop is alternately extended and retracted into tubular sheath member 950 during attempts to properly position loop 952

relative to a polyp. During the cutting and cauterizing phase of the procedure, only distal

portion 962 of loop 952 comes into contact with a polyp; the proximal portion 958 is retracted

into tubular member 950 prior to the conduction of cauterization current.

The snare assembly of Figs. 25-28 is designed to solve a problem arising with other

snare designs where the web member or pouch is woven onto the cauterization loop. In use,

when such a snare closes upon a polyp, the attachment ringlets or threads of the pouch slide

towards the distal end of the snare and are interposed between the cauterization loop and the

polyp. Thus, the cauterization loop has to cut through the attachment ringlets or threads of the

pouch while cutting through the polyp. This may occasionally hinder a polypectomy operation. In the design of Figs. 25, 26 and 28, web member or pouch 956 is attached to loop 952 31 only along an outer surface thereof at distal portion 962 This attachment of web member or

pouch 956 to the cauterization loop 952 cannot interfere with the cutting and cauterizing of a

polyp Where fine metal loops or filaments 974 are used to attach pouch 956 to cauterization

loop 952 (Fig 27), the metal filaments do not interfere with the cauterization process The sliding attachment of web member or pouch 956 to proximal portion 958 of

cauterization loop 952 enables a repositioning of the snare relative to a polyp More specifically, after loop 952 has been partially drawn back into tubular member 950, the loop

can be shifted again in a distal direction relative to tubular member 950 to enable an adjustment

in the position of the snare relative to the polyp Web member or capture pouch 956 slides

along the proximal portion 958 of loop 952 during these adjustments

Accordingly, in the design of Figs 25, 26 and 28, a clean cut is obtained through a

polyp, the snare may be repositioned relative to the polyp, and pouch 956 remains outside of

tubular member 950 after severing of the polyp Pouch 956 is severed from cauterization loop

952 during the polypectomy operation The heat generated during the procedure severs ringlets 960 and releases pouch 956 occurs so that the pouch is held only by purse string 966

As illustrated in Fig 29, an endoscopic instrument assembly 700 for use in severing and

retrieving a flat or nonprojecting polyp from a wall of a colon or other internal organ

comprises a tubular member 702 having a diameter sufficiently small so that the tubular

member can be inserted through a biopsy channel 704 of a flexible endoscope 706 (Figs 30A-

30D) Assembly 700 includes a cauterization loop 708 and an electrically conductive wire 710

operatively connected to the cauterization loop, the cauterization loop and the wire being

disposed at least partially in tubular member 702 An electrical connector 712 is operatively

connected to wire 710 for feeding an electrical current from a current source 714 to

cauterization loop 708 via the wire Assembly 700 further includes an auxiliary loop 716 32 provided at a distal end of an elongate flexible shifting member 718. Auxiliary loop 716 and

shifting member 718 are at least partially disposed in tubular member 702. A flexible web

member 720 is connected to auxiliary loop 716 so as to form a capture pocket, the auxiliary

loop defining a mouth opening of the pocket. Assembly 700 also includes an elongate flexible

tube 722 provided at a distal end with a needle point 724 and an aperture 726. Tube 722 is

disposed at least partially in tubular member 702 and is provided at a proximal end with a fluid

feed connector 728 for coupling the tube to a pressurizable liquid supply 730, whereby fluid is fed to tube 722 for ejection through aperture 726.

Figs. 30A-30D depict successive steps in the use of instrument assembly 700 during an endoscopic tissue removal operation. Tubular member 702 is slidably disposed in biopsy

channel 704 prior to or after the insertion of endoscope 706 into a colon CNN of a patient.

Endoscope 706 and particularly an illumination guide 732 and fiber-optic image guide 734

thereof are used to visually monitor internal body tissues along the wall WC of colon CNN.

Upon a detection of what appears to be a flat or nonprojecting polyp FP along colon wall WC,

tubular member 702 is shifted in the distal direction to eject a distal end portion of the tubular

member from biopsy channel 704. In addition, tube 722 is shifted in the distal direction to

eject needle point 724 from tubular member 702. As shown in Fig. 30A, needle point 724 and

aperture 726 are inserted into the polyp FP, for example, at the base thereof. Liquid is then transferred through tube 722 from supply 730 and forced out through aperture 726 into polyp

FP to expand the polyp and thereby induce the polyp to stand away from colon wall WC, as

shown in Fig. 30B.

After polyp FP is induced to stand away from wall WC, tube 722 is retracted back into

tubular member 702 and cauterization loop 708 is ejected, expanded from a collapsed

configuration and placed about the expanded polyp, as shown in Fig. 30B. Cauterization loop 33 708 is then closed, by moving tubular member 702 further in the distal direction to draw a portion of loop 708 back into the tubular member. Subsequently, an electrical current is conducted from source 714 along wire 710 to cauterization loop 708 to sever the expanded

polyp FP. After the severing of polyp FP, cauterization loop 708 is pulled in the proximal

direction, relative to tubular member 702, to retract the cauterization loop back into tubular

member 702. Then, shifting member 718 is pushed distally to eject auxiliary loop 716 and web

member or pocket 720 from tubular member 702, as illustrated in Fig. 30B. Auxiliary loop

716 opens naturally in response to internal spring biasing forces, whereupon loop 716 and web or pocket member 720 is placed about severed polyp FP. Alternatively, it is possible to place

the auxiliary loop 716 and web member 720 about polyp FP prior to the severing thereof by cauterization loop 708. In either case, after the severing of the expanded polyp FP by

cauterization loop 708, auxiliary loop 716 is at least partially closed to capture the expanded

and severed polyp in the pocket. Loop 716 is closed by pushing tubular member 702 in the

distal direction about a proximal end portion of the auxiliary loop.

As depicted in Fig. 29, the different instruments of assembly 700 are disposed in

respective lumens (not designated) of tubular member 702 defined by a plurality of septums

736, 738 and 740 joined to one another in a Y configuration. In an alternative construction,

shown in Fig. 31, wire 710 and shifting member 718 are slidably disposed in respective ancillary tubes 742 and 744 in turn slidably disposed in an outer tubular member 746. Tubular

member 746 need not be provided with septums 736, 738 and 740 (Fig. 29). Although tubes

722, 742 and 744 could be disposed directly in biopsy channel 704 (Figs. 30A-30D) without

tubular member 746, transportation, storage and use of the instrument assembly of Fig. 29 are

facilitated if tubular member 746 is included. 34 As illustrated in Fig. 32, another surgical instrument assembly 750 for use in snare

cauterization operations comprises a tubular member 752 having a diameter sufficiently small so that the tubular member can be inserted through a biopsy channel of a flexible endoscope. Tubular member 752 is provided with a diametric and longitudinally extending septum 754

defining a pair of lumens 756 and 758. Lumen 756 is slidably traversed by an electrically

conductive wire 760 operatively connected at a distal end to a cauterization loop 762, while

lumen 758 is slidably traversed by a flexible fluid feed tube 764 provided at a distal end with a

needle point 766 and a fluid outlet aperture 768. Wire 760 is provided at a proximal end with

an electrical connector 770 operatively connected to an electrical current source 772. A

flexible web member 774 is connected to cauterization loop 762 so as to form a capture

pocket. A fluid feed connector 776 couples tube 764 to a pressurizable fluid supply 778 such

as a syringe. Prior to an operation, cauterization loop 762 and needle point 766 are disposed

within their respect lumens 756 and 758.

The use of instrument assembly 750 during an endoscopic polyp removal operation is a variation of that described above with reference to Figs. 30A-30D, the variation resulting from

the attachment of web member or capture pocket 774 to cauterization loop 762. Web member

or capture pocket 774 is disposed about the expanded polyp FP simultaneously with the

placement of cauterization loop 762 about the polyp. Pocket 774 is closed about polyp FP by

the same distal motion of tubular member 752 that closes cauterization loop 762. The polyp is

automatically captured upon severing of the polyp.

It is to be noted that web members or capture pockets 720 and 774 may be provided

with one or more flexible tensile members 930 and 932 (Figs. 23 and 24) as described above,

for purposes of facilitating a repeated extension of auxiliary loop 716 or cauterization loop 762

from the respective tubular member and a concomitant opening and partial closing of web 35 members or capture pockets 720 and 774, to enable optimal positioning of the loops about the

polyp FP prior to a cauterization and severing procedure.

It is to be noted that the liquid used to expand a flat polyp, as described above with

reference to Fig. 29 et seq. may have a color or hue so that the liquid also functions as a marker for purposes of correlating severed polyps with their respective locations on the wall of

the colon prior to removal. Where two or more polyps are to be removed from the colon, the polyps (and their necks or stalks) are marked with respective colors to differentiate them from each other. The tube which is used to inject the dyes is flushed out with transparent saline

between successive marking (and possible polyp expanding) operations.

Although the invention has been described in terms of particular embodiments and

applications, one of ordinary skill in the art, in light of this teaching, can generate additional

embodiments and modifications without departing from the spirit of or exceeding the scope of

the claimed invention. Accordingly, it is to be understood that the drawings and descriptions

herein are profferred by way of example to facilitate comprehension of the invention and should not be construed to limit the scope thereof.

Claims

36 WHAT IS CLAIMED IS:

1. A surgical instrument assembly for use in snare cauterization operations, comprising: a tubular member;

a cauterization loop;

an electrically conductive wire operatively connected to said cauterization loop, said

cauterization loop and said wire being disposed at least partially in said tubular member;

an auxiliary loop;

an elongate flexible shifting member connected at one end to said auxiliary loop, said auxiliary loop and said shifting member being at least partially disposed in said tubular member;

a flexible web member connected to said auxiliary loop so as to form a capture pocket, said auxiliary loop defining a mouth opening of said pocket; and

an elongate flexible tube provided at a distal end with a needle point and an aperture,

said flexible tube being disposed at least partially in said tubular member.

2. The instrument assembly defined in claim 1, further comprising a first additional

flexible tube and a second additional flexible tube each extending slidably through said tubular

member, said cauterization loop and said wire being disposed at least partially in said first

additional flexible tube, said auxiliary loop and said shifting member being at least partially

disposed in said second additional flexible tube.

3. The instrument assembly defined in claim 2 wherein said tubular member is provided

with septum means defining at least three separate longitudinally extending lumens, the flexible

tubes extending through respective ones of said lumens.

37 4. The instrument assembly defined in claim 1 wherein said tubular member is provided with septum means defining at least three separate longitudinally extending lumens, said cauterization loop and said wire being disposed at least partially in a first one of said lumens,

said auxiliary loop and said shifting member being at least partially disposed in a second one of

said lumens, said flexible tube being disposed at least partially in a third one of said lumens.

5. The instrument assembly defined in claim 1, further comprising at least one flexible

tensile member connected to said flexible web member at a proximal end thereof and to said

tubular member at a point spaced from a distal end thereof.

6. The instrument assembly defined in claim 1 wherein said web member is slidably connected to said auxiliary loop at a plurality of spaced locations.

7. The instrument assembly defined in claim 1 wherein said flexible web member is a

net.

8. The instrument assembly defined in claim 1 wherein said flexible web member is a

continuous film of polymeric material.

9. The instrument assembly defined in claim 1 wherein said web member is disposed in

a collapsed configuration together with said auxiliary loop inside said tubular member.

10. The instrument assembly defined in claim 1 wherein said tubular member has a

diameter sufficiently small so that said tubular member can be inserted through a biopsy 38 channel of a flexible endoscope.

11. The instrument assembly defined in claim 1 wherein electrical means are operatively

connected to said wire for feeding an electrical current to said cauterization loop via said wire.

12. The instrument assembly defined in claim 1 wherein fluid feed means are

operatively connected to said flexible tube for feeding fluid thereto for ejection through said

aperture.

13. A surgical instrument assembly for use in snare cauterization operations,

comprising:

a tubular member;

a cauterization loop;

cauterization loop and said wire being disposed at least partially in said tubular member; a flexible web member connected to said cauterization loop so as to form a capture

pocket, said cauterization loop defining a mouth opening of said pocket;

said flexible tube being disposed at least partially in said tubular member.

14. The instrument assembly defined in claim 10, further comprising an additional

flexible tube extending slidably through said tubular member, said cauterization loop and said

wire being disposed at least partially in said additional flexible tube. 39

15. The instrument assembly defined in claim 11 wherein said tubular member is

provided with septum means defining at least two separate longitudinally extending lumens, the

flexible tubes extending through respective ones of said lumens.

16. The instrument assembly defined in claim 10 wherein said tubular member is

provided with septum means defining at least two separate longitudinally extending lumens, said cauterization loop and said wire being disposed at least partially in a first one of said

lumens, said flexible tube being disposed at least partially in a second one of said lumens.

17. The instrument assembly defined in claim 10 wherein said tubular member has a

diameter sufficiently small so that said tubular member can be inserted through a biopsy

channel of a flexible endoscope.

18. The instrument assembly defined in claim 10 wherein electrical means are operatively connected to said wire for feeding an electrical current to said cauterization loop

via said wire.

19. The instrument assembly defined in claim 10 wherein fluid feed means are

aperture.

20. A method for removing a selected portion of internal body tissues of a patient,

comprising the steps of:

providing (I) a flexible conductive cauterization loop, (II) a flexible tube provided at a 40 distal end with a needle point and an aperture, and (III) a flexible auxiliary loop to which a

flexible web member is connected to define an expandable pocket, said cauterization loop, said

flexible tube and said auxiliary loop being disposed in a common tubular member, said common

tubular member in turn being disposed in a biopsy channel of an endoscope; inserting said endoscope into a patient;

using said endoscope to visually monitor internal body tissues of the patient after

insertion of said endoscope into the patient;

upon detecting selected internal tissues to be removed from the patient, shifting said flexible tube in the distal direction to eject said needle point from said tubular member; inserting said needle point and said aperture into the selected internal tissues of the

patient, the selected internal tissues being disposed along an internal organic wall of the

patient;

forcing liquid through said flexible tube and said aperture into the selected internal

tissues of the patient to expand the tissues and thereby induce the tissues to stand away from

said internal organic wall;

shifting said cauterization loop in a distal direction relative to said tubular member to

eject said cauterization loop from said tubular member;

upon ejection of said cauterization loop from said tubular member, at least partially

expanding said cauterization loop from a collapsed configuration;

manipulating the expanded cauterization loop from outside of the patient to pass the

expanded cauterization loop over the expanded internal tissues of the patient;

upon a passing of the expanded cauterization loop over the expanded internal tissues,

closing the cauterization loop about the expanded internal tissues;

conducting an electrical current along said wire and to the closed cauterization loop to 41 sever the expanded internal tissues; ejecting said auxiliary loop from said tubular member;

upon ejection of said auxiliary loop from said tubular member, at least partially opening

said auxiliary loop from a folded configuration;

maneuvering the opened auxiliary loop from outside of the patient to pass the opened

auxiliary loop over the expanded internal tissues so that said web member substantially

surrounds the expanded internal tissues; and

upon the severing of the expanded internal tissues by said cauterization loop and upon

maneuvering of the auxiliary loop over the expanded internal tissues, at least partially closing said auxiliary loop to capture the severed internal body tissues in said pocket.

21. The method defined in claim 20, further comprising the ejecting of said tubular

member from said biopsy channel prior to ejection of said needle point, said cauterization loop

and said auxiliary loop from said tubular member.

22. The method defined in claim 21 wherein the closing of said cauterization loop

about the expanded internal tissues is effectuated by a relative motion of said tubular member

and said cauterization loop towards one another and a resultant partial drawing of said

cauterization loop into said tubular member.

23. The method defined in claim 21 wherein the closing of said auxiliary loop about the

expanded internal tissues is effectuated by a relative motion of said tubular member and said

auxiliary loop towards one another and a resultant partial drawing of said auxiliary loop into

said tubular member. 42

24. A method for removing a selected portion of internal body tissues of a patient,

comprising the steps of: providing (I) a flexible conductive cauterization loop to which a flexible web member is connected to define an expandable pocket, and (II) a flexible tube provided at a distal end with a needle point and an aperture, said cauterization loop, said flexible tube and said web member

being disposed in a common tubular member, said common tubular member in turn being

disposed in a biopsy channel of an endoscope;

inserting said endoscope into a patient;

insertion of said endoscope into the patient;

upon detecting selected internal tissues to be removed from the patient, shifting said

flexible tube in the distal direction to eject said needle point from said tubular member; inserting said needle point and said aperture into the selected internal tissues of the

patient, the selected internal tissues being disposed along an internal organic wall of the patient;

said internal organic wall;

eject said cauterization loop from said tubular member;

expanding said cauterization loop and said web member from a collapsed configuration;

expanded cauterization loop and the expanded web member over the expanded internal tissues 43 of the patient;

upon a passing of the expanded cauterization loop and the expanded web member over

the expanded internal tissues, closing the cauterization loop about the expanded internal

tissues; and conducting an electrical current along said wire and to the closed cauterization loop to sever the expanded internal tissues.

25. The method defined in claim 24, further comprising the ejecting of said tubular

and said web member from said tubular member.

26. The method defined in claim 25 wherein the closing of said cauterization loop

and said cauterization loop towards one another and a resultant partial drawing of said cauterization loop into said tubular member.