US007993378B2
`
`(12) Ulllted States Patent
`Foley et al.
`
`(10) Patent N0.:
`(45) Date of Patent:
`
`US 7,993,378 B2
`*Aug. 9, 2011
`
`(54) METHODS FOR PERCUTANEOUS SPINAL
`SURGERY
`
`(75) Inventors: Kevin Thomas Foley, Germantown, TN
`US ; Maurice Mell Smith, Cordova,
`SYN %US)_ John B‘ Clayton
`SIBYmamOWH’BT/IN (US); ‘giel’hs
`octezuma’ emp 15’
`(U )
`
`(73) Assignee: Warsaw Orthopedic, IN., Warsaw, IN
`(US)
`
`( * ) Notice:
`
`Subject to any disclaimer, the term of this
`patent is extended or adjusted under 35
`U.S.C. 154(b) by 1185 days.
`
`This patent is subject to a terminal dis-
`Claimer'
`
`(56)
`
`(58) Field of Classi?cation Search ........ .. 600/2014246;
`606/86 R, 90, 104, 108, 114, 191, 204, 208,
`606/235, 279
`Sec application ?le for complete search history.
`_
`References Cited
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`Prior Publication Data
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`JUL 5 2007
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`Related US. Application Data
`(62) Division of application No. 10/359,996, ?led on Feb.
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`application NO. 09/449,647, ?led 011 Nov. 30, 1999,
`110W‘ Pat. No. 6,520,907, Which is a division of
`32831032101115; 0'
`1
`0;; zzugdigigs’iolgggti
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`’
`'
`’
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`(51) Int Cl
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`
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`
`Hallet H. Mathews, M.D., Spinal Endoscopy, Evolution, Applica
`tions & Foundations.
`
`(Continued)
`
`.
`.
`Prlrflary Examnier i Thomas C Barrett
`‘4331mm’ Examlw T Larry E Waggle, Jr
`(57)
`ABSTRACT
`A method for accessing the spine includes making an incision
`in the skin of a patient. The skin and tissue can be dilated, and
`a cannula inserted through the dilated skin and tissue. The
`cannula includes a distal end positioned adjacent a ?rst Work
`ing space that includes paraspinous tissue.The cannula can be
`repositioned through the incision to a second Working space
`adjacent the distal end ofthe cannula.
`42 Claims, 7 Drawing Sheets
`
`I50
`
`20
`
`
`
` 1
`
`NUVASIVE 1039
`NuVasive, Inc. v. Warsaw Orthopedic, Inc.
`IPR2013-00206
`IPR2013-00208
`
`

`

`US 7,993,378 B2
`Page 2
`
`US. PATENT DOCUMENTS
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`FOREIGN PATENT DOCUMENTS
`
`DE
`DE
`EP
`EP
`FR
`FR
`GB
`W0
`W0
`WO
`W0
`W0
`
`2 222 979
`39 36 811 A1
`0303 824 A2
`0 528 562 A2
`2701379
`2714 285 A1
`2 234 906
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`8/1993
`8/1993
`8/1995
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`.
`OTHER PUBLICATIONS
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`.
`Laparoscoprc Bone Doyvel Instruments Brochure, Pr(_)pr1et_ary1nstru
`ment set deslgned specl?cally for anter10r end0sc0p1c fus10n proce
`
`.
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`
`* cited by examiner
`
`
`
` 2
`
`
`
`

`

`US. Patent
`US. Patent
`
`Aug. 9, 2011
`Aug. 9, 2011
`
`Sheet 1 017
`Sheet 1 of7
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`US 7,993,378 B2
`US 7,993,378 B2
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`|
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`Dl|
`L—— __ —J
`Dol
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`20
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`1—4—1
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`US. Patent
`
`Aug. 9, 2011
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`Sheet 2 of7
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`US 7,993,378 B2
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`60
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`32
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`30
`33 f
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`Fig. 3
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`US. Patent
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`Aug. 9, 2011
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`Sheet 3 of7
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`US 7,993,378 B2
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`6A 84
`r<-—
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`|
`
`85 A
`
`/70
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`"a
`
`78
`
`76
`
`Fig. 4
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`so
`
`90
`
`81
`
`80
`
`A1
`Fig. 4A
`
`85
`5
`m (
`7g
`
`84
`X
`
`90
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`903 B
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`
`81'
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`7a
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`75
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`US. Patent
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`Aug. 9, 2011
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`Sheet 4 of7
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`US 7,993,378 B2
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`120
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`m 120
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`71
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`72
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`110 >
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`A2
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`Flg. 7A
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`110'
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`US. Patent
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`Aug. 9, 2011
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`106
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`120I
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`120
`3 J
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`100 /
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`105
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`Fig. 8
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`US. Patent
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`Aug. 9, 2011
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`Sheet 6 of7
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`US 7,993,378 B2
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`Fig. 10g
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`Fig. 10h
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`Fig. 101'
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`US. Patent
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`Aug. 9, 2011
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`Sheet 7 of7
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`US 7,993,378 B2
`
`1
`METHODS FOR PERCUTANEOUS SPINAL
`SURGERY
`
`CROSS-REFERENCE TO RELATED
`APPLICATION
`
`This application is a divisional of US. patent application
`Ser. No. 10/359,996 ?led on Feb. 6, 2003, and noW aban
`doned, Which is a divisional of US. patent application Ser.
`No. 09/449,647 ?led on Nov. 30, 1999, and noW issued as
`US. Pat. No. 6,520,907; Which is a divisional application of
`US. patent application Ser. No. 08/920,991 ?led Aug. 29,
`1997, noW issued as US. Pat. No. 6,007,487; Which is a
`divisional of US. application Ser. No. 08/620,933, ?led on
`Mar. 22, 1996, noW issued as US. Pat. No. 5,792,044. Each of
`the cross-referenced related applications is hereby incorpo
`rated by reference in its entirety.
`
`FIELD OF THE INVENTION
`
`The present invention relates to devices, instruments and
`methods for performing percutaneous surgeries, particularly
`at locations deep Within the body. One speci?c application of
`the invention concern devices, instruments and techniques for
`percutaneous, minimally invasive spinal surgery.
`
`BACKGROUND
`
`Traditional surgical procedures for pathologies located
`deep Within the body can cause signi?cant trauma to the
`intervening tissues. These open procedures often require a
`long incision, extensive muscle stripping, prolonged retrac
`tion of tissues, denervation and devasculariZation of tissue.
`Most of these surgeries require a recovery room time of
`several hours and several Weeks of post-operative recovery
`time due to the use of general anesthesia and the destruction
`of tissue during the surgical procedure. In some cases, these
`invasive procedures lead to permanent scarring and pain that
`can be more severe than the pain leading to the surgical
`intervention.
`Minimally invasive alternatives such as arthroscopic tech
`niques reduce pain, post-operative recovery time and the
`destruction of healthy tissue. Orthopedic surgical patients
`have particularly bene?ted from minimally invasive surgical
`techniques. The site of pathology is accessed through portals
`rather than through a signi?cant incision thus preserving the
`integrity of the intervening tissues. These minimally invasive
`techniques also often require only local anesthesia. The
`avoidance of general anesthesia reduces post-operative
`recovery time and the risk of complications.
`Minimally invasive surgical techniques are particularly
`desirable for spinal and neurosurgical applications because of
`the need for access to locations deep Within the body and the
`danger of damage to vital intervening tissues. For example, a
`common open procedure for disc herniation, laminectomy
`folloWed by discectomy requires stripping or dissection of the
`major muscles of the back to expose the spine. In a posterior
`approach, tissue including spinal nerves and blood vessels
`around the dural sac, ligaments and muscle must be retracted
`to clear a channel from the skin to the disc. These procedures
`normally take at least one-tWo hours to perform under general
`anesthesia and require post-operative recovery periods of at
`least several Weeks. In addition to the long recovery time, the
`destruction of tissue is a major disadvantage of open spinal
`procedures. This aspect of open procedures is even more
`invasive When the discectomy is accompanied by fusion of
`the adjacent vertebrae. Many patients are reluctant to seek
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`surgery as a solution to pain caused by herniated discs and
`other spinal conditions because of the severe pain sometimes
`associated With the muscle dissection.
`In order to reduce the post-operative recovery time and
`pain associated With spinal and other procedures, micro-sur
`gical techniques have been developed. For example, in micro
`surgical discectomies, the disc is accessed by cutting a chan
`nel from the surface of the patient’s back to the disc through
`a small incision. An operating microscope or loupes is used to
`visualiZe the surgical ?eld. Small diameter micro-surgical
`instruments are passed through the small incision and
`betWeen tWo laminae and into the disc. The intervening tis
`sues are disrupted less because the incision is smaller.
`Although these micro-surgical procedures are less invasive,
`they still involve some of the same complications associated
`With open procedures, such as injury to the nerve root and
`dural sac, perineural scar formation, rehemiation at the sur
`gical site and instability due to excess bone removal.
`Other attempts have been made for minimally invasive
`procedures to correct symptomatic spinal conditions. One
`example is chemonucleolysis Which involved the injection of
`an enZyme into the disc to partially dissolve the nucleus to
`alleviate disc herniation. Unfortunately, the enZyme, chymo
`papain, has been plagued by concerns about both its effec
`tiveness and complications such as severe spasms, post-op
`erative pain and sensitivity reactions including anaphylactic
`shock.
`The development of percutaneous spinal procedures has
`yielded a major improvement in reducing recovery time and
`post-operative pain because they require minimal, if any,
`muscle dissection and they can be performed under local
`anesthesia. For example, US. Pat. No. 4,545,374 to Jacobson
`discloses a percutaneous lumbar discectomy using a lateral
`approach, preferably under ?uoroscopic X-ray. This proce
`dure is limited because it does not provide direct visualiZation
`of the discectomy site.
`Other procedures have been developed Which include
`arthroscopic visualiZation of the spine and intervening struc
`tures. US. Pat. Nos. 4,573,448 and 5,395,317 to Kambin
`disclose percutaneous decompression of herniated discs With
`a posterolateral approach. Fragments of the herniated disc are
`evacuated through a cannula positioned against the annulus.
`The ’3 17 Kambin patent discloses a biportal procedure Which
`involves percutaneously placing both a Working cannula and
`a visualiZation cannula for an endoscope. This procedure
`alloWs simultaneous visualiZation and suction, irrigation and
`resection in disc procedures.
`Unfortunately, disadvantages remain With these proce
`dures and the accompanying tools because they are limited to
`a speci?c application or approach. For example, Jacobson,
`Kambin and other references require a lateral or a posterolat
`eral approach for percutaneous discectomy. These
`approaches seek to avoid damage to soft tissue structures and
`the need for bone removal because it Was thought to be
`impractical to cut and remove bone through a channel. HoW
`ever, these approaches do not address other spinal conditions
`Which may require a mid-line approach, removal of bone or
`implants.
`US. Pat. No. 5,439,464 to Shapiro discloses a method and
`instruments for performing arthroscopic spinal surgeries such
`as laminectomies and fusions With a mid-line or medial pos
`terior approach using three cannulas. Each of the cannulas
`requires a separate incision. While Shapiro discloses an
`improvement over prior procedures Which Were limited to a
`posterolateral or lateral approach for disc Work, Shapiro’s
`procedure still suffers from many of the disadvantages of
`knoWn prior percutaneous spinal surgery techniques and
`
`
`
`10
`
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`

`

`US 7,993,378 B2
`
`3
`tools. One disadvantage of the Shapiro procedure is its
`requirement of a ?uid Working space. Another signi?cant
`detriment is that the procedure requires multiple portals into
`the patient.
`Fluid is required in these prior procedures to maintain the
`Working space for proper function of optics ?xed Within a
`prior art cannula and inserted percutaneously. Irrigation, or
`the introduction of ?uid into the Working space, can often be
`logistically disadvantageous and even dangerous to the
`patient for several reasons. The introduction of ?uid into the
`Working space makes hemostasis more di?icult and may
`damage surrounding tissue. Excess ?uid nay dangerously
`dilute the sodium concentration of the patient’s blood supply
`Which can cause seiZures or Worse. The ?uid environment can
`also make drilling di?icult due to cavitation. The requirement
`for a ?uid environment generally increases expenses associ
`ated With the surgery and adds to the complexity of the sur
`gery, due in part to the relatively high volume of ?uid
`required.
`A need has remained for devices and methods that provide
`for percutaneous minimally invasive surgery for all applica
`tions and approaches. A need has also remained for percuta
`neous methods and devices Which do not require a ?uid-?lled
`Working space, but that can be adapted to a ?uid environment
`if necessary.
`A signi?cant need is present in this ?eld for techniques and
`instruments that permit surgical procedures in the Working
`space under direct vision. Procedures that reduce the number
`of entries into the patient are also highly desirable. The ?elds
`of spinal and neurosurgery have particularly sought devices
`and techniques that minimize the invasion into the patient and
`that are streamlined and concise in their application.
`
`SUMMARY
`
`Brie?y describing one aspect of the invention, there is
`provided devices and method for performing percutaneous
`procedures under direct visualiZation, even at locations deep
`Within a patient. In one embodiment, a device for use in
`percutaneous surgery includes an elongated cannula having a
`?rst inner diameter and an outer diameter siZed for percuta
`neous introduction into a patient. The cannula further
`includes a distal Working end and an opposite proximal end
`and de?nes a Working channel betWeen the ends having a
`second diameter Which is equal to the ?rst inner diameter. The
`Working channel is siZed to receive a tool therethrough. The
`device also includes an elongated vieWing element mounted
`inside the cannula adjacent the Working channel. The vieWing
`element has a ?rst end connectable to a vieWing apparatus and
`an opposite second end disposed adjacent the distal Working
`end of the cannula.
`In another aspect, a ?xture is provided for mounting the
`elongated vieWing element to the cannula. The ?xture
`includes a housing attachable to the proximal end of the
`cannula. The housing de?nes a Working channel opening
`therethrough in communication With the Working channel.
`The Working channel opening is siZed to substantially corre
`spond to the second diameter of the Working channel. The
`housing also de?nes an optics bore adjacent the Working
`channel opening. The optics bore is siZed to receive the elon
`gated vieWing element therethrough.
`In some embodiments, the ?xture supports the vieWing
`device for movement Within the optics bore along the longi
`tudinal axis of the bore to extend or retract the lens relative to
`the distal Working end of the cannula. In other embodiments,
`the ?xture supports the vieWing device for rotation Within the
`optics bore about the longitudinal axis of the bore. In some
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`embodiments, the housing is rotatable relative to the cannula
`so that the longitudinal axis of the optics bore is rotatable
`about the longitudinal axis of the Working channel.
`Novel tools are also provided Which are insertable into the
`Working channel of the cannula. A tissue retractor in one
`embodiment includes a body and an integral Working tip
`con?gured to atraumatically displace tissue as the retractor is
`manipulated through tissue. The body-has a convex surface
`con?gured to conform to the inner cylindrical surface of the
`cannula and an opposite concave surface Which does not
`obstruct the Working channel or visualiZation of the Working
`space. Cannulated tissue dilators are also provided Which are
`insertable over a guideWire or another dilator as Well as insert
`able into the Working channel. In some embodiments, the
`tissue dilators include a tapered Working end to displace
`tissue and a gripping portion having a number of circumfer
`ential grooves to enhance gripping and manipulation of the
`dilator.
`According to the methods of this invention, spinal and
`other surgeries can be performed percutaneously With direct
`visualiZation Without the requirement for a ?uid-maintained
`Working space. In another aspect of the inventive surgical
`techniques, all steps of a surgical procedure are conducted
`under direct vision through a single Working channel cannula.
`An optical scope or vieWing device is moved Within the
`Working channel and throughout the Working space from a
`variety of angles and orientations to provide a clear vieW of
`the operative steps.
`The techniques of the present invention also encompass
`passing multiple tools and instruments through the single
`Working channel cannula and manipulating the instruments
`and tools Within the Working space. In one speci?c embodi
`ment, a tissue retractor is provided that extends through the
`Working channel Without signi?cantly reducing the dimen
`sions of the channel.
`It is an object of the invention to provide devices and
`methods for percutaneous spinal surgery for all applications
`and approaches. One advantage of this invention is that per
`cutaneous procedures can be accomplished in a dry environ
`ment because a ?uid Working space is not required for the
`proper function of the optics. One bene?t of this invention is
`that it provides instruments and methods Which reduce the
`cost, risk, pain and recovery time associated With surgery.
`These and other objects, advantages and features are accom
`plished according to the devices and methods of the present
`invention.
`
`BRIEF DESCRIPTION OF THE FIGURES
`
`FIG. 1 is a side elevational vieW of a device according to
`this invention.
`FIG. 2 is a top elevational vieW of a ?xture for supporting
`a vieWing device Within a cannula according to this invention.
`FIG. 3 is a side cross-sectional vieW of the ?xture shoWn in
`FIG. 2.
`FIG. 4 is a side elevational vieW of a retractor according to
`one embodiment of this invention.
`FIG. 4A is an end cross-sectional vieW of the retractor of
`FIG. 4 taken along lines A-A.
`FIG. 5 is a top elevational vieW of the retractor shoWn in
`FIG. 4.
`FIG. 6 is an end elevational vieW of the retractor shoWn in
`FIGS. 4 and 5.
`FIG. 7 is a side elevational vieW of a retractor according to
`another embodiment of this invention.
`FIG. 7A is an end cross-sectional vieW of the retractor of
`FIG. 7 taken along lines A-A.
`
`
`
`11
`
`
`
`

`

`US 7,993,378 B2
`
`5
`FIG. 7B is an end cross-sectional vieW of the retractor of
`FIG. 7 taken along lines B-B.
`FIG. 8 is a top elevational vieW of the retractor shown in
`FIG. 7.
`FIG. 9 is a side elevational vieW of a dilator according to
`this invention.
`FIG. 10(a)-(i) depicts the steps of a method according to
`this invention.
`FIG. 11 is a side cross-sectional vieW of a device according
`to one embodiment of this invention.
`FIG. 12 is a side cross-sectional vieW of an aspiration cap
`as shoWn in FIG. 11.
`
`DESCRIPTION OF THE ILLUSTRATED
`EMBODIMENTS
`
`For the purposes of promoting an understanding of the
`principles of the invention, reference Will noW be made to the
`embodiments illustrated in the draWings and speci?c lan
`guage Will be used to describe the same. It Will nevertheless
`be understood that no limitation of the scope of the invention
`is thereby intended, such alterations and further modi?ca
`tions in the illustrated devices and described methods, and
`such further applications of the principles of the invention as
`illustrated therein being contemplated as Would normally
`occur to one skilled in the art to Which the invention relates.
`The present invention provides instruments and methods
`for performing percutaneous surgery, including spinal appli
`cations such as laminotomy, laminectomy, foramenotomy,
`facetectomy or discectomy, With a single Working channel
`endoscope. The present inventors have discovered that many
`percutaneous surgeries may be performed Without a ?uid
`Workspace through the use of optics Which move indepen
`dently of the cannula. The present invention contemplates
`techniques and instruments that can be implemented With or
`Without a ?uid environment.
`This invention also brings the advantages of percutaneous
`procedures to applications that previously required open sur
`gery. One advantage is based upon the further discovery that
`bone Work can be performed percutaneously through a large
`Working channel. Another advantage is realiZed in the use of
`a single portal Within the patient to perform a Wide range of
`simultaneous procedures.
`According to one embodiment of the present invention, as
`depicted in FIG. 1, a device 10 is provided for use in percu
`taneous surgery Which includes an elongated cannula 20 hav
`ing a ?rst inner diameter D I and an outer diameter D O siZed for
`percutaneous introduction into a patient. The cannula 20 also
`includes a distal Working end 21 and an opposite proximal
`end 22. The cannula de?nes a Working channel 25 betWeen
`the ends 21, 22 having a second diameter d2 equal to the ?rst
`inner diameter D I siZed for receiving a tool therethrough. The
`cannula has a length along its longitudinal axis L that is siZed
`to pass through the patient from the skin to an operative site or
`Working space. In some cases, the Working space may be
`adjacent a vertebra or disc, or in the spinal canal.
`An elongated vieWing element 50 is mountable inside can
`nula 20 adjacent the Working channel 25. The vieWing ele
`ment 50 has a ?rst end 51 connectable to a vieWing apparatus,
`such as an eyepiece or camera, and an opposite second end 52
`disposed orpositionable adjacent the distal Working end 21 of
`the cannula 20. The particular elongated vieWing element 50
`is not critical to the invention. Any suitable vieWing element
`is contemplated that creates an optical or image transmission
`channel. In one embodiment, the elongated vieWing element
`50 includes a ?ber optic scope 54 and a lens 55 at the second
`end 52. Preferably, the ?ber optic scope includes illumination
`
`20
`
`25
`
`30
`
`35
`
`40
`
`45
`
`50
`
`55
`
`60
`
`65
`
`6
`?bers and image transmission ?bers (not shoWn). Altema
`tively, the vieWing element may be a rigid endoscope or an
`endoscope having a steerable or bendable tip.
`One advantage of this invention is that it provides optics
`Which are movable relative to the cannula 20. Because the
`optics are movable, it is not necessary to provide a ?uid
`maintained Work space. The optics can be removed, cleaned
`and replaced While the cannula is percutaneously positioned
`Within the patient over the Working space. Any con?guration
`Which alloWs the optics to be movably supported adjacent the
`Working channel 25 is contemplated. In one embodiment,
`shoWn in FIGS. 1-3, a ?xture 30 is provided for mounting the
`elongated vieWing element 50 to the cannula 20. Preferably,
`the ?xture 30 includes a housing 31 attachable to the proximal
`end 22 of the cannula 20. The Working channel opening 35 is
`siZed to substantially correspond to the second diameter d2 of
`the Working channel 25 to receive tools. The ?xture 30
`includes a housing 31 Which de?nes a Working channel open
`ing 35 arranged to communicate With the Working channel 25
`When the ?xture 30 is mounted to the cannula 20. The Work
`ing channel opening 35 is siZed to receive tools therethrough
`for passage through the Working channel 25. In the embodi
`ments shoWn in FIGS. 1-3, the ?xture 30 is con?gured to
`mount the vieWing element 50 Within the Working channel 25.
`The housing 31 also de?nes an optics bore 60 adjacent the
`Working channel opening 35. The optics bore 60 has a longi
`tudinal axis 1 that is preferably substantially parallel to the
`axis L of the cannula and Working channel. The optics bore 60
`is preferably siZed to removably receive the elongated vieW
`ing element 50 therethrough. The ?xture 30 preferably sup
`ports the vieWing element 50 for movement Within the optics
`bore 60 along the longitudinal axis 1 of the bore 60 to extend
`or retract the lens 55 relative to the distal Working end 21 of
`the cannula 20. The retractable/extendable feature of the
`optics of this invention provides an advantage over prior
`endoscopes because it eliminates the requirement for a ?uid
`Workspace. While the device 10 and its vieWing element 50
`can be easily used in a ?uid environment, the ?uid is not
`essential for the system to operate, contrary to prior systems.
`Furthermore, many of the prior endoscopes Were not suited to
`access certain areas because of their large diameters. For
`example, prior endoscopes could not access the spinal canal.
`HoWever, With this invention, access to the spinal canal is not
`limited by the diameter of the channel or cannula. The can
`nula 20 can be left behind in the soft tissue or supported by the
`lamina While the second end 52 of the elongated vieWing
`element 50 can be advanced into the spinal canal along With
`any spinal instruments Which have been inserted into the
`Working channel 25.
`Preferably the ?xture 30 also supports the vieWing element
`50 for rotation Within the optics bore 60 about the longitudinal
`axis 1 of the bore 60. The lens 55 of the vieWing element 50
`de?nes an optical axis A0. As in many endoscopes, the optical
`axis A0 can be offset at an angle relative to the longitudinal
`axis 1 of the optics bore 60. This feature alloWs the optical
`axis A0 of the lens to be sWept through a conical ?eld of vieW
`F for greater visibility of the Working space. The ?xture 30
`can further be con?gured so that the vieWing element 50 is
`rotatable relative to the cannula 20. In this embodiment, the
`housing 31 is rotatable relative to the cannula 20 so that the
`second longitudinal axis 1 of the optics bore 60 rotates about
`the longitudinal axis L of the Working channel 25. The rotat
`able features of this invention alloWs visualiZation of the
`entire Working space. This feature also aids in simplifying the
`surgical procedure because the optics 50 and accompanying
`?ttings can be moved out of the Way of the surgeon’s hands
`and tools passing through the Working channel.
`
`
`
`12
`
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`

`US 7,993,378 B2
`
`7
`In one embodiment depicted in FIG. 3, the housing 31
`de?nes a receiver bore 40 having an inner diameter d I slightly
`larger than the outer diameter D0 of the cannula 20. In this
`con?guration, the proximal end 22 of the cannula 20 can be
`received Within the receiver bore 40 so that the housing 31 can
`rotate about the proximal end 22 of the cannula 20. As shoWn
`in FIG. 3, the housing 31 also includes an upperbore 41 Which
`is contiguous With the Working channel opening 35 and the
`receiver bore 40. In one embodiment, the optics bore 60 is
`disposed Within the upper bore 41 of the housing 31.
`In a preferred embodiment depicted in FIG. 2, the optics
`bore 60 is de?ned by a C-shaped clip 61 disposed Within the
`upper bore 41. Preferably, the C-shaped clip 61 is formed of
`a resilient material and the optics bore 60 de?ned by the clip
`61 has an inner diameter D,- that is slightly less than the outer
`diameter of the elongated vieWing element 50. When the
`vieWing element 50 is pushed into the optics bore 60 it resil
`iently de?ects the C-shaped clip 61. The resilience of the clip
`61 provides a gripping force on the element 50 to hold it in the
`desired position, While still alloWing the element 50 to be
`repositioned.
`Alternatively, the optics bore 60 can have an inner diameter
`larger than the outer diameter of the vieWing element. In this
`instance, the vieWing element 50 can be supported outside the
`device 20, either manually or by a separate support ?xture.
`Preferably the device 10 provides engagement means for
`securely yet rotatably engaging the ?xture 30 to the cannula
`20. Most preferably, the ?xture 30 is con?gured to engage a
`standard cannula 20. Engagement means can be disposed
`betWeen the housing 31 and the cannula 20 When the ?xture
`30 is mounted to the proximal end 22 of the cannula 20 for
`providing gripping engagement betWeen the housing 31 and
`the cannula 20. In one embodiment depicted in FIG. 3 the
`engagement means includes a number of grooves 32 Within
`the receiver bore 40 and a resilient sealing member, such as an
`O-ring (see FIG. 11) disposed in each groove 32. The sealing
`members, or O-rings, disposed betWeen the housing 31 and
`the outer diameter D0 of the cannula 20 rotatably secure the
`?xture 30 to the cannula 20. The O-rings provide suf?cient
`resistance to movement to hold the ?xture 30 in a selectable
`position on the cannula. In another embodiment, the housing
`31 de?nes a receiver bore 40 Which has an inner diameter d,
`Which is only slightly larger than the outer diameter D0 of the
`cannula 20 so that the housing 31 can rotate freely about the
`cannula 20.
`The Working channel 25 and the Working channel opening
`35 are both siZed to receive a tool or instrument therethrough.
`Preferably, the Working channel opening 35 of the housing 31
`has a diameter DW Which is substantially equal to the i