US 2032860 A
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March 3, 1935. F 3 A R ET AL 2,@32,86
METHOD FOR ELECTROSURGICAL TREATMENT OF TISSUE Original Filed March 24, 1933 2 Sheets-Sheet l March 3, 19345. F Q WAPPLER ET AL 2,32,86
METHOD FOR ELECTROSURGICAL TREATMENT OF TISSUE Original Filed March 24, 1933 2 Sheets-Shet 2 Patented Mar. 3, 1936 UNITED STATES PATENT OFFICE METHOD FOR ELECTROSURGIOAL TREATMENT OF TISSUE Original application March 24, 1933, Serial No.
662,432. Divided and this application Decemher 7, 1934, Serial No. 756,488
Our present invention relates generally to electrosurgery, and has particular reference to an improved method for severing or cutting tissue.
This application is a division of our copending application Serial Number 662,432, filed March 24, 1933, Patent No. 2,002,594.
While we have herein illustrated and shall hereinafter describe our invention as it may be adapted for effecting severance of adhesions or the like, it will be understood that certain broader phases of our invention are not necessarily restricted to a specific application of this character.
Before proceeding to describe our invention, we will preface by stating that the so-called coagulation and the so-called cutting of tissue, by modern high-frequency electric currents, are two well-recognized and useful phenomena that have won Wide favor of late with the profession. While different types of tissue will react somewhat differently to different currents, it has come to be recognized that, for a given type or body of tissue, coagulation is an effect distinctly different from cutting and requiring different currents. Thus, coagulation is usually effected by means of a relatively blunt electrode; and while it might appear offhand that the coagulating effect is the result of diminished current concentration, the fact is that a true coagulating current will not produce cutting, even though a relatively attenuated electrode be employed. By the same token, cutting is usually effected by means of a thinner or finer electrode,
which no doubt has a valuable current concentrating effect, but it has been demonstrated that a true cutting current will produce sparking and cutting even though an electrode of greater area be employed.
The cutting effect, as this term has been used in the art and as it is referred to by the profession, refers always to an instantaneous-cutting effect, whereby the mere application of the cutting electrode to the tissue produces an immediate sparking and destruction of tissue. While there is a certain amount of coagulation that takes place during the cutting procedure, it is merely incidental and is not as penetrative or as eiiective as the pure coagulation which is customarily resorted to to effect hemostasis.
The foregoing differences between cutting and coagulation are reflected in the development of the art to date. In the development of high-frequency generators, means are usually "providedto permit one adjustment to be made for cutting purposes and other adjustments to be made for coagulating purposes. Various attempts have been made to minimize the necessary adjustments and to simplify the manner in which a single generator can be employed to deliver the twotypes of current which are required. In the development of instruments, separate provisions have usually been made for coagulating and cutting; and where both phenomena are to be available in a single in-,
strument, it has been customary to provide either two separate electrodes (one for one purpose and the other for the other), or to provide a means for interchangeably connecting a single electrode to sources of cutting and coagulating:
Our present invention is predicated upon the discovery that, under certain circumstances, and
body of tissue, and maintained in firm contact. under pressure, and if there is supplied to the electrode a high-frequency current which is greater than a coagulating current and less than an ordinary instantaneous-cutting current, the electrode will automatically effect a graduallyv increasing desiccation and will itself evolve a set of conditions under which it will ultimately sever the tissue with which it is held in contact.
It is because this discovery is of particular importance and utility in connection with the severance of adhesions that we have adapted this phase of our invention, at the outset, in an instrument designed primarily for this specific purpose; and it is this type of instrument which we have herein illustrated and described for the purpose of explaining the nature of our present novel process.
The severance of an adhesion band, for example, in the pleural cavity, is particularly difficult because of the serious consequences resulting from unchecked hemorrhage. It has proven to be unsatisfactory, in many respects, merely to insert a conventional cutting electrode and to cut through an adhesion with an ordinary instantaneous-cutting current. Apart from other diffl:
culties, most adhesions are in a stretched or tensioned condition when the lung is collapsed to effect pneumothorax, and to cut through a tensioned area of this character is precarious because of the danger that the band will tear or divide prematurely, leaving the stumps in a com dition which is not fully hemostatic.
With the object of obviating these difficulties, we have heretofore successfully devised instruments and methods whereby unhurried and thoroughly controllable operations may be performed, under continued and assured illuminated vision, and with minimum danger from the standpoint of hemorrhage. This general type of procedure provides for an efiicient clamping of the adhesion adjacent to the area at which it is to be cut, and a maintenance of this engagement until the operation of severance has been completed. Preferably, the adhesion is grasped at two spaced areas on opposite sides of the area to be cut; the area is preliminarily coagulated; and the cutting is finally accomplished without releasing the resultant stumps.
We are now enabled to provide a method of greatly simplified and improved character. One of the characterizing features of our present invention lies in an ability to employ a single electrode wire which is adapted to be pressed into firm and maintained contact with the body of tissue to be cut, and to Which the application of a sustained supply of a particular type of electric current will automatically bring about, in succession, the effects heretofore produced by separate steps and means. More specifically, the carrying out of our present method involves nothing more than the clamping of the body of tissue at the desired area, and the maintenance of this clamped relationship during the supply of a current to the electrode which is greater than a coagulating current yet less than an instantaneouscutting current. The effects produced are (a) a secure grasp of the tissue under treatment; (b)
adhesion the resultant stumps are held in position for final examination before being released.
In .accordance with the general objects of our invention, a preferred instrument for carrying out the method is provided, in addition to a clamping means and electrode, with a telescopic means; an illuminating means; suitable electric binding posts for establishing the desired connections with a source of high-frequency current;
means for efiiciently insulating the operative electrode wire from the indifferent portions of the instrument; a mechanism for controlling the movements of the clamping means in a simple and reliable manner; a means for permitting removable association of the electrode with the instrument; and means for withdrawing from the area of operation such fumes as may be-generated in the vicinity of the telescope objective. The entire instrument may be mounted and constructed in a unitary form which permits it to beinserted into the pleural cavity through only a single opening provided for this purpose.
The broader phases of our invention, as hereinbefore alluded to, involve an entirely new technique or mode of procedure, which is not necessarily restricted to the particular instrumentality herein described and illustrated.
We achieve the foregoing objects, and such other objects as may hereinafter appear or be pointed out, in the manner illustratively exemplified in the accompanying drawings, wherein- Figure 1 is a perspective view of an instrument that may be used in carrying out our present invention;
Figure 2 is an enlarged longitudinal cross-section through the operative part of the instrument of Figure 1, with certain portions omitted for the sake of clearness;
Figure 3 is a plan view, partly in section, taken substantially along the line 3-3 of Figure 2, with certain parts omitted for the sake of clearness;
Figure 4 is an enlarged cross-sectional view taken substantially along the line 4-4 of Figure 1;
Figure 5 is a longitudinal sideview "similar to the left end of Figure 2, and showing a'step in one mode of use;
Figure 6 is a diagrammatic cross-sectional view.
taken substantially along the line 6-6 of Figure 5;
Figure 7 is a view similar to Figure 5, showing a subsequent step: in the procedure;
Figure 8 is a diagrammatic cross-sectional View taken substantially along the line 8--8 of Figure '7; and
Figure 9 is a view similar to Figure 6on a greatly enlarged scale, illustrating the progressive effect of our present technique.
The endoscopic tube 20 terminates at'itsrear end in the flange 2| and in the attachment sleeve or neck 22. The neck 22 carries the irrigation outlet 23 and also suitable mechanism, such as the clamp 24, for facilitating association with the tube 26 of the interior removable assembly.
The operative assembly consists of the usual plug 25 whose forward portion (.not' shown in Figures 2 and 3) is usually slightly tapered and is adapted to fit snugly into the neck 22.
Extending rearwardly from the plug 25 is the supporting arm 21, terminating in its rear end in a bearing 28 and a suitable clamp 29'adapted to engage and secure the rear end of a'suitable telescopic device 30. The latter is preferably of the character illustrated and described in United States Letters Patent No. 1,680,491, and consists of an eyepiece 3|, suitable terminal bands v3l'for establishing electrical connection with the forward illuminating lamp 33, and an objective lens 3 arranged behind the lamp 33 and commanding an obliquely forward field of vision.
The arm 2? also carries an electric binding post which is mounted in uninsulated relationship, so that all of the parts not specifically insulated from the binding post 26, the arm 21, or the plug 25, are in electrical contact therewith.
The arm 21 also carries the insulated terminal lock 35, preferably secured by the threaded-stem 36 v of the binding post 26, as illustrated most clearly in Figure 2. The block 35 carries'aninsulated binding post 31.
Secured to the plug 25 and projecting forward- 1y therefrom is the elongated stem '38 provided with the upper guide channel or tube 39, 'the lower guide channel or tube 40, and the lateral guide tubes 4|. The telescope 30 is adapted to be accommodated in the upper tube 39, and it will be understood that the plug 25 and th'e bloclc 35 are provided with suitable bores through which this telescope may slidably extend.
At the forward end of the stem 38 we mount the stationary or fixed jaw 42, which consists preferably of two spaced parallel arms substantially aligned with the axis of the stem 38. These arms are preferably joined at the forward end, so that the jaw is substantially U-shaped when viewed in a horizontal plane.
Pivoted to the rear of the fixed jaw 42, as at the pivot points 43, is a similarly constructed 2-armed movable jaw 44. This jaw is adapted to be rocked or pivoted from the open full-line position of Figure 1 into the closed full-line position of Figure 2, and this is accomplished by a pair of control rods 45 which are slidably accommodated in the guide tubes 4| and are pivoted at their forward ends to the rear of the movable jaw 44, as at the pivot points 46. These rods extend rearwardly through the tubes 4 I, thence through suitably prepared bores in the plug 25, and are secured at their rear ends to a member 41 which is under the control of the scissors-like control mechanism 48.
The fixed handle of the latter mechanism is rigidly secured, as at 49, to the plug 25; and the movable handle is pivoted, as at 50, to the fixed handle and has its free end pivotally articulated, as at to the member 41. When the handles 48 are drawn toward each other, the member 41 is advanced forwardly, and this advances the control rods 45 and forces the movable jaw 44 toward its closed position. When the handles 48 are separated by a slight degree, the rods 45 are correspondingly retracted, and the movable jaw is opened into the dot-and-dash position of Figure 2.
The electrode member comprises the elongated conductive member 52 which merges at its forward end with the longitudinal electrode wire 53. At its forward end, the wire 53 doubles back upon itself to provide a journal piece 58 arranged substantially along a line parallel to the axis of the instrument.
A sheath of insulation 55 envelops the conductive member 52, terminating short of the wire 53 at the forward end, and short of the extreme rear end of the member 52. The insulation 55 is in turn enclosed in an outer metallic sheath 56 which is somewhat shorter.
The electrode member is preferably removably applicable to the instrument, so that the electrode wire 53 is mounted in fixed relation to the fixed jaw 42. The means for accomplishing this comprises a clamp at the rear of the instrument adjacent to the binding post 31 for engaging the rear end of the electrode member, and a bearing carried by the fixed jaw and adapted to engage the forward end of the electrode wire.
The articulation of the journal piece 58 with the jaw 42 is preferably accomplished by providing a longitudinal bearing 59 between the arms of the jaw 42, the bearing being provided with an insulating lining 68.
The engagement of the rear end of the electrode member preferably consists in providing Thesejaws thereby engage or disengage the rear portion of the sheath 56, as shown most clearly in Figure 3.
Embedded in'the block 35 is a conductive element 64, and this element is provided with a longitudinal bore adapted toreceive the rear uninsulated end of the conductive member 52. The interior conductive portion of the binding post 31 is in electrical connection with the element 64, preferably by forming the element 64 with an exteriorly projecting threaded stud 65 onto which the binding post 31 may be screwed and tightened, as shown in Figure 3. Access to the parts,"
for purposes of assembly and/or repair, may be had through the large opening on the opposite side of the block 35, this opening being normally closed by the threaded plug 65'.
The electrode member is applied to the instru firm locked relationship. The withdrawal is accomplished in the opposite manner.
By virtue of this manner of mounting the electrode member, it is obvious that the electrode wire 53 is brought into electrical connection with the interior of the binding post 31, and is at the" same time thoroughly and completely insulated from all other portions of the instrument.
The member 41 is provided with a suitable bore or channel in its upper portion to permit passage of the telescope 30, and the rear portion of the electrode member serves as an efficient guide for *the member 41 during the reciprocal movements of the latter.
It is to be noted that the electrode wire 53 is arranged in such a manner that it projects through the arms of the movable jaw 44 when the jaws are closed. Stated otherwise, the electrode wire is arranged in a longitudinal plane passing through the axis of the fixed jaw 42, the wire being offset from the plane of this jaw in the" direction of the movable jaw. Accordingly, when any body is clamped by the forward portion of the instrument, it comes first into engagement with the movable jaw 44, on one side, and with the electrode wire 53, on the opposite side. The jaw 44 may, therefore, be said to constitute a member which is adapted to press a body into firm engagement or contact with the electrode wire 53.
The manner in which the instrument herein before described embodies the features of the broader phases of our invention, and permits us to carry out our new technique, is illustrated most clearly in Figures 5-9. The procedure illustrated in these figures consists in electrosurgi-' cally coagulating and cutting through a growth, such as an adhesion band 66.
The band is first engaged as illustrated in Figures 5, 6, and 9, at the area at which the severance is to take place. The engagement is effected between the movable jaw 44 and the electrode wire 53, and this may be accomplished under illuminated vision, as will be readily understood. The engagement is a firm and tight err-3 gagement which embeds the electrode wire 53 well into the surface of the band 66, as illustrated most clearly in Figures 6 and 9. Figure 9 is a view on an enlarged scale, but is not grossly exaggerated, since body tissue readily yields iii "the'manner shown when it issubjected to the and/or tissue juices.
squeezing pressure described.
It will be noted, upon viewing Figure 9, that when the clamping is first effected the electrode wire 53 is almost completely surrounded by tissue We have illustratively shown a slight amount of the tissue juices at 61 to illustrate this fact.
- A current of the character hereinbefore alluded to is now caused to be supplied to the electrode wire 53. This is preferably accomplished by connecting an indifferent terminal of a suitable frequency current is preferably of the character source of high-frequency current to the binding post 26, and by connecting an active terminal of said source to the binding post 31. The highgenerated by an apparatus of the kind which is shown in Letters Patent No. 1,962,796, the current being an undamped sustained high-frequency current.
The particular current which is fed to the electrode wire 53, in accordance with our invention,
is one which is greater than a coagulating current yet less than an instantaneous-cutting ourchanges whatsoever in connections, electrodes, or
'vantageous and useful.
site sides of the line of cleavage.
rent, and the connections are maintained during a maintenance of the clamped relationship illustrated in Figures 6 and 9. The effect is one which we believe to be new in the art, and highly ad- A desiccation begins to take place, manifested by the generation of steam bubbles at the area of contact, and as the desiccation continues the area around the wire 53 becomes dryer and dryer. The juices 6'! are boiled off, and the juices incorporated in the surrounding tissue are also gradually eliminated, so that a virtual cooking of the tissue takes place. The result is that the area around the electrode wire 53 commences to shrink, and the action is progressive, so that ultimately the tissue assumes the relative position shown by the dot-and-dash line 68. Obviously, as the tissue shrinks and becomesdesiccatedfthearea in contact with the electrode wire 53 becomes smaller and smaller;
and this fact, coupled with the gradually increasing resistance of the desiccated or coagulated tissue, results in automatically bringing about a set of conditions which ultimately are conducive to actual cutting. In other words, when the tissue has reached the dried and shrunken state indicated by the dot-'and-dash line 68, the resistance has increased to such an extent, and the area in contact (along the bottom of the wire 53) has become so small, that a maintenance of the very same current will suddenly bring about a spark ing effect at the electrode wire 53, culminating in 7 an actual electrosurgical severance of the tissue.
Progressive desiccation and coagulation may take, for example, about thirty seconds or so. Without altering any of the characteristics of the generating circuit, and without making any .theband 66, and that the latter is nevertheless efficiently and firmly clamped at areas on oppo- This leavesv the opposed stumps in a clamped condition, holding them available for careful, unhurried inspection by the operator, and for such further treatment as may be necessary to prevent any hemorrhage after they are finally released.
wire, and holding it in desired maintained contact; and both jaws serve the mechanical function of engaging the opposed resultant stumps as thecutting isaccomplished. It is preferable,-
however, to employ these jaws, collectively, as the indifferent clamping electrode, inasmuch as the .modeof procedure is thereby greatly simplified and rendered more efficient.
It will also be understood that the present method, while admirably adapted for the treatment of an adhesion band or the like, is not necessarily restricted in its use to a treatment of this character. It may, for example, be used in cutting through a neoplasm or growth which is not strictly in'the form of an adhesion. In the latter case, the resultant stump of the growth will be engaged by one pair of opposed jaw arms, while the excised masswill be engaged by the opposite pair of opposed jaw arms. By slightly releasing the jaws, the stump may be released, without at the same time releasing the excised mass; and the jaws may thenbe clamped together again to withdraw the excised mass rearwardly from the interior of the body.
Other electrodes, of varying configurations, depending upon the particular uses to which they are to be put, may be employed, and the member illustrated has been shown merely by way of a preferred example to explain the nature and general capabilities of the invention. The essential characteristic of the electrode is that it consists of an elongated conductive member securely held in fixed relationship and against which a body of tissue may be pressed in firm maintained contact, preferably in a manner which embeds the electrode well into the body, as hereinbefore described.
All of the foregoing procedures are, of course,
capable of accomplishment under illuminated vision, as will be obvious from the arrangement and construction of the telescope illustratively shown in the present drawings. The formation of the jaws 42 and 44 with two spaced parallel arms permits unimpeded vision of the electrode wire and of the area which is the subject of treatment. The irrigation outlet 23 may be conveniently employed as an aspirating outlet for drawing fumes rearwardly through the instrument and hence out of the path of the objective of the telescope.
Under certain circumstances, we contemplate eliminating one of the control arms 45 and utilizing the empty guide tube 4| for purposes of irrigation, either liquid or gaseous.
' It will also be observed that, from certain aspects, the fixed jaw 42 is not always essential. That is,'so far as the clamping of a body against the electrode wire is concerned, the movable jaw 44 is in itself a-sufiicient instrumentality for effecting this purpose.
We have found the present method useful for the treatment and severance of adhesions generally, both pulmonary and abdominal; also in the treatment and removal of growths andpro:v
trusions in the rectum, lower bowels, trachea, bronchi, and esophagus; and in the general treatment, cutting, and excision of a variety of neoplastic and papillomatous growths and masses.
The characterizing feature of our invention lies in the fact that a single current, and a single electrode, are employed to accomplish, automatically and in succession, a predetermined progressive desiccation and coagulation and an ultimate true cutting; and, more especially, in the employment of a current which is greater than a. coagulating current yet less than an ordinary instantaneous-cutting current; whereby the proper conditions to accomplish the foregoing ends are automatically brought about.
In general, it will be understood that changes in the details, herein described and illustrated for the purpose of explaining the nature of our invention, may be made by those skilled in the art without departing from the spirit and scope of the invention as expressed in the appended claims. It is, therefore, intended that these details be interpreted as illustrative, and not in a limiting sense.
Having thus described our invention, and illustrated its use, what we claim as new and desire to secure by Letters Patent is- 1. The method of electrosurgically severing a body of tissue, which consists in clamping the body between two mutually insulated electrodes, one of which is relatively attenuated, and directing through said body, from one electrode to the other, a high-frequency current which is greater than a coagulating current yet less than an instantaneous-cutting current, the passage of current thereby automatically effecting a progressive desiccation and an ultimate severance of the clamped body by said attenuated electrode.
2. The method of electrosurgically severing a body of tissue, which consists in clamping the body between two mutually insulated electrodes, one of which is relatively attenuated, directing through said body, from one electrode to the other, a high-frequency current which is greater than a coagulating current yet less than an instantaneous-cutting current, and continuously clamping the electrodes toward each other as the resultant desiccation and ultimate severance of the body progresses.
3. The method of electrosurgically severing a body of tissue, which consists in clamping the body between two mutually insulated electrodes, one of which is relatively attenuated, directing through said body, from one electrode to the other, a high-frequency current which is greater than a coagulating current yet less than an instantaneous-cutting current, and clamping the body on opposite sides of the attenuated electrode as the resultant desiccation automatically eventuates into a severance of the body by said attenuated electrode.
4., The herein-described method of cutting tissue by means of high-frequency electric current, which consists in applying an attenuated electrode to the tissue to be cut, supplying to the electrode a current which is greater than a coagulating current yet less than an instantaneouscutting current, and maintaining said electrode, under pressure, in firm contact with said tissue to allow the resultant desiccation to effect a gradual increase in current concentration and thus automatically evolve an ultimate condition under which cutting will eventually take place.
FREDERICK CHARLES WAPPLER. FREDERICK CHARLES WAPPLER, Administrator of Reinhold H. Wappler, Deceased.