Device and system for performing a laparoscopy

Abstract

The invention relates to a device for performing laparoscopy, comprising a first lifting unit 30 for lifting the abdominal wall of a patient P, which is suitable for insertion into the abdominal cavity of a patient, wherein the first lifting unit 30 comprises an insertion channel from the proximal end 32 of the first lifting unit 30 to the distal end 33 of the first lifting unit 30, and a second lifting unit 40 for lifting the abdominal wall of a patient P. The second lifting unit 40 comprises an inflatable support section 44, which is suitable for fixing at least one fixation section 35 of the first lifting unit 30 to the inner surface of a patient's abdominal wall.

Description

[0001] The present invention relates to a device for performing a laparoscopy according to claim 1 and a system for performing the laparoscopy according to claim 10. Technological background

[0002] The invention relates to a complete laparoscopic system with which diagnostic or surgical laparoscopic procedures can be performed without a fixed power supply and without CO2 gas.

[0003] Laparoscopic surgery is a subspecialty of surgery in which abdominal operations are performed without a large abdominal incision. Instead, the necessary surgical instruments, specially developed for laparoscopic surgery, are inserted into the abdominal cavity through small incisions, and the operation is performed laparoscopy using real-time video optics.

[0004] The laparoscopic systems known from the prior art are a complex and very expensive group of devices, collectively referred to as a laparoscopic tower, where each of these devices performs a specific function, such as light source, image acquisition device, image processing device, gas insufflation machine and monitor, in addition to the connecting cables and tubes used to connect these devices to each other and between these devices and the patient, making these devices very complicated to set up and requiring a great deal of space in the operating room, and only persons with appropriate training or expertise are able to operate and set up this system, e.g. installation, cleaning and calibration of light and other functions.As previously mentioned, the currently known systems have a large number of cables and require specialized personnel to manage these devices and handle camera and light cables. This not only places a burden on the surgical procedure due to its complexity, but also takes up valuable space in the operating room because of the numerous components and additional personnel; moreover, they offer a wealth of places where pathogens can be harbored, leading to an increased risk of infection.

[0005] One of the biggest obstacles with laparoscopic devices is insufflation, which requires a CO2 gas cylinder filled with compressed CO2 gas, connected to the insufflator via a gas tube. The insufflator is connected to the patient via another gas tube, which has a gas filter at the outlet of the insufflator to remove pathogens from the gas and reduce the risk of infection.

[0006] In most hospitals, a silicone tube is used to deliver CO2 gas to the patient. This tube is sterilized by heat, which, over time, can develop microscopic cracks from repeated heating, creating a perfect breeding ground for pathogens. This tube needs to be replaced after a certain number of uses, but most hospitals use it until it breaks.

[0007] KR 2018 0068074 A discloses an abdominal wall retractor for laparoscopic surgery. The abdominal wall retractor for laparoscopic surgery comprises: a first tube, both ends of which are open; a second tube, open at both ends and arranged horizontally within the first tube; an air sac arranged at an outer circumferential edge of one end of the first tube; a third tube, both ends of which are open and one end of which is connected to the air sac; and an air inlet connected to the other end of the third tube to transfer air blown in by an external device to the third tube and the air sac.

[0008] The disadvantage of this device is that it uses an air sac that is directly connected to the patient's abdominal wall. This air sac takes up a lot of space in the abdominal cavity, leaving the laparoscope or endoscope with very little room to operate. Description of the invention

[0009] One object of the invention is to avoid at least one of the disadvantages of the prior art. In particular, the present invention aims to provide an improved device or system for performing laparoscopy that does not require a CO2 supply or power supply for operation.

[0010] This problem is solved by the features of the independent patent claims. Advantageous developments are set out in the figures and in the dependent patent claims.

[0011] An inventive device for performing laparoscopy comprises a first lifting unit for raising a patient's abdominal wall, which is suitable for insertion into the patient's abdominal cavity, wherein the first lifting unit comprises an insertion channel from the proximal end of the first lifting unit to the distal end of the first lifting unit, and a second lifting unit for raising a patient's abdominal wall. The second lifting unit comprises an inflatable support section which is suitable for fixing at least one fixation section of the first lifting unit to the inner surface of a patient's abdominal wall.

[0012] The device is used to lift a patient's abdominal wall and stabilizes it in a desired position. This allows for safe and reproducible surgery. The present invention relates to a laparoscopic device for a complete system that enables diagnostic or surgical laparoscopic procedures to be performed without a fixed power supply or CO2 gas supply. The invention is based on a device for creating, maintaining, and providing a working space for the laparoscopic camera and other instruments, and opens the way for the use of laparoscopy in locations where this was previously impossible, such as in very rural areas of Africa, during rescue operations in remote regions, and in many other scenarios.

[0013] The inflatable support section serves to anchor at least one fixation section of the device to the patient's abdomen. This allows the patient's abdominal wall to be lifted, stabilizing it in the desired position. In this way, the device enables a safe and reproducible procedure. In particular, the second lifting unit is suitable for insertion into the insertion channel of the first lifting unit. This is especially advantageous when, in a particular embodiment, the first and second lifting units are separate components. Thus, the first lifting unit can be placed inside the patient with the abdominal wall open, and then the second lifting unit can be inserted into the insertion channel of the first lifting unit to ensure the fixation of the first lifting unit to the inner surface of the abdominal wall.

[0014] Preferably, the first lifting unit comprises a support element at its proximal end. This support element increases the stability of the first lifting unit. The support element can be a support disc with a central opening, allowing for a symmetrical connection to the first lifting unit. The support element can have at least two connections to facilitate easy connection of the device to an operating table.

[0015] Preferably, the second lifting unit has an insertion channel. This insertion channel is particularly suitable for inserting at least one laparoscope or endoscope for a medical procedure. This provides sufficient space for at least one laparoscope and other instruments to be inserted reproducibly into a patient's abdominal cavity.

[0016] Preferably, the inflatable support section of the second lifting unit is arranged at the distal end of the second lifting unit. The inflatable support section is located near the at least one fixing section of the first lifting unit, which is also located at the distal end of the first lifting unit, and can interact precisely with the at least one fixing section of the first lifting unit.

[0017] Preferably, the at least one fixation section comprises several lifting segments for fixing the first lifting unit to the inner surface of a patient's abdominal wall. The lifting segments are designed to interact with the patient's abdominal wall to lift the patient's abdomen. For example, the lifting segments have lifting sections against which the abdominal wall can rest.

[0018] Preferably, at least one bending edge is arranged on the fixation section of the first lifting unit. This at least one bending edge enables a defined fixation of the first lifting unit in the patient's abdominal cavity. Preferably, the lifting segments are at least partially arranged on the bending edge. By using at least one bending edge, the lifting segments can be moved very precisely from the unlocked position to a locked position in the abdominal cavity.

[0019] Preferably, the inflatable support section of the second lifting unit is arranged adjacent to the at least one bending edge. The inflatable support section can be used to reproducibly move the lifting segments from the unlocked position to a locked position within the abdominal cavity. In particular, the respective lifting section is arranged on the lifting segments such that the lifting sections are spaced apart from the bending edge. This simplifies the transfer of the lifting segments from the unlocked position to a locked position and improves the fixation of the device to the abdominal wall.

[0020] Preferably, at least one supply channel is provided for inflating the inflatable support section of the second lifting unit. This allows the inflatable support section to be inflated. Preferably, air is used to inflate the inflatable support section. Thus, a simple hand pump can be used to inflate the inflatable support section.

[0021] Preferably, the at least one supply channel is arranged on the second lifting unit. This way, the at least one supply channel and the inflatable support section are located in the same area of ​​the device, which makes the manufacture of the device less complex.

[0022] In particular, at least one supply channel is arranged between the first lifting unit and the second lifting unit. This supply channel is securely positioned between the first and second lifting units. The lifting units thus protect the supply channel. Damage to the supply channel can be avoided if the instruments are inserted into one of the insertion channels. This improves safety when using the device.

[0023] Preferably, the first and second lifting units are connected, allowing the patient's abdominal wall to be lifted. This provides a one-piece device with a central insertion channel for introducing a laparoscope or other medical instruments into the abdominal cavity. This device can be attached to the patient's abdominal wall to lift it for surgical procedures. Specifically, the abdominal wall can be lifted by raising both the first and second lifting units. This ensures safe lifting of the abdominal wall and a secure connection between the fixation section and the abdominal wall.

[0024] A system according to the invention for performing laparoscopy comprises at least two stabilization units, each comprising a fastening unit for attaching the stabilization unit to a carrier unit, and a device as disclosed herein.

[0025] This invention is based on a mechanical system for creating a space within the abdominal cavity in which the monitors and surgical instruments can operate. The system requires very little space in the operating room and can be operated and set up even by less experienced users. Furthermore, no electrical connections and very little personnel are required to handle the system.

[0026] The stabilization units can consist of metal rods attached to each side of the support unit, e.g., an operating table. These metal rods can have distal openings with a spiral screw that covers the distal end and can be easily unscrewed using the device described herein. These metal rods can be raised or lowered by an internal hydraulic force, controlled either by a foot pump on the floor or electronically by a switch.

[0027] Further advantages, features and details of the invention will become apparent from the following description, in which exemplary embodiments of the invention are described with reference to the drawings.

[0028] The list of reference numerals, like the technical content of the patent claims and figures, forms part of the disclosure. The figures are described coherently and comprehensively. Identical reference numerals denote identical components; reference numerals with different indices indicate functionally identical or similar components.

[0029] The invention is explained in more detail with reference to exemplary embodiments in the following figures. The list of reference numerals forms part of the disclosure.

[0030] Positional references, such as "top", "bottom", "right" or "left", refer to the corresponding representations and are not to be understood as restrictive.

[0031] Although the invention is illustrated and described in detail by means of the figures and the accompanying description, this illustration and detailed description are to be understood as illustrative and exemplary and not as limiting the invention. It is understood that those skilled in the art may make modifications and adaptations without departing from the scope of the following claims. In particular, the invention also includes embodiments with any combination of features mentioned or shown above with regard to various aspects and / or embodiments.

[0032] The invention also includes individual features shown in the figures, even if they are shown there in conjunction with other features and / or are not mentioned above. Furthermore, the term "comprise" and derivatives thereof do not exclude other elements or steps. Likewise, the indefinite article "a" or "an" and derivatives thereof do not exclude a plurality. The functions of several features listed in the claims can be fulfilled by a single unit. The terms "essentially," "approximately," "about," and the like, in conjunction with a property or value, also define precisely that property or value. All reference numerals in the claims are not to be understood as limiting the scope of the claims. Character description

[0033] The figures are described in a coherent and comprehensive manner. Identical reference symbols indicate identical components. They show Fig. Figure 1 shows a first embodiment of a device according to the invention with a first lifting unit and a second lifting unit in a schematic side view, Fig. 2: shows the device according to Fig. 1 with an inflated support section in a schematic side view, Fig. 3: shows the device according to Fig. 1, in which the second lifting unit is arranged in the first lifting unit, in a schematic side view, Fig. 4: shows the device according to Fig. 3 in a schematic top view, Fig. 5: shows a system according to the invention with the device according to Fig. 1, Fig. Figure 6 shows an embodiment of a laparoscope in a schematic side view, and Fig. Figure 7 shows another embodiment of a device in a schematic perspective view. Implementation of the invention

[0034] Fig. 1 and Fig. Figure 2 shows a device 20 for performing laparoscopy, comprising a first lifting unit 30 for raising a patient's abdominal wall, which is suitable for insertion into the patient's abdominal cavity, wherein the first lifting unit 30 includes an insertion channel 31 from the proximal end 32 of the first lifting unit 30 to the distal end 33 of the first lifting unit 30, and a second lifting unit 40 for raising a patient's abdominal wall, wherein the second lifting unit 40 is suitable for insertion into the insertion channel 31 of the first lifting unit 30. The second lifting unit 40 includes an inflatable support section 44, which is suitable for fixing at least one fixing section 35 of the first lifting unit 30 to the inner surface of a patient's abdominal wall. The inflatable support section 44 serves to anchor the device 20 to the patient's abdominal wall.The inflatable support section 44 of the second lifting unit 40 is arranged at the distal end 43 of the second lifting unit 40. The in . Fig. 1 and Fig. The device 20 shown in Figure 2 consists of at least two components, the first lifting unit 30 and the second lifting unit 40. As shown in Figure 2 Fig. 3 and Fig. As shown in Figure 4, the device 20 can also consist of a single component comprising the first lifting unit 30 and the second lifting unit 40.

[0035] The inflatable support section 44 is located near the fixation section 35 of the first lifting unit 30, which is situated at the distal end 33 of the first lifting unit 30. The fixation section 35 comprises several lifting segments 37 for attaching the first lifting unit 30 to the inner surface of a patient's abdominal wall. The lifting segments 37 are designed to interact with the patient's abdominal wall to lift it. A bending edge 38 is located on the fixation section 35 of the first lifting unit 30. The bending edge 38 enables defined fixation of the first lifting unit 30 to the patient's abdominal wall. The lifting segments 37 are located on the bending edge 38.

[0036] The use of the bending edge 38 makes it possible to remove the lifting segments 37 from an unlocking position ( Fig. 1) into a locking position ( Fig. 4) to be brought within the abdomen. The inflatable support section 44 of the second lifting unit 40 is arranged adjacent to the bending edge 38. The inflatable support section 44 is used to move the lifting segments 37 from the unlocking position to the locking position within the abdominal cavity. In the unlocking position, the lifting segments 37 are oriented in the same direction as the longitudinal extent of the first lifting unit 30. In the locking position, the lifting segments 37 are aligned in the transverse extent of the first lifting unit 30, e.g., horizontally.

[0037] The first lifting unit 30 includes a support disc 34 at the proximal end 32 of the first lifting unit 30. The support disc 34 includes two connections 39 for easy connection of the device 20 to an operating table.

[0038] The second lifting unit 40 comprises an insertion channel 41 extending from the proximal end 42 of the second lifting unit 40 to the distal end 43 of the second lifting unit 40. The insertion channel 41 is suitable for inserting at least one laparoscope for a medical procedure.

[0039] The second lifting unit 40 includes a supply channel 45 for inflating the inflatable support section 44 of the second lifting unit 40. For this device, air is used to inflate the inflatable support section 44, which is supplied to the inflatable support section 44 via the supply channel 45.

[0040] Fig. Figure 5 shows a further aspect of the invention, a system 100 for performing laparoscopy, comprising at least two stabilization units 102, 112, each of which includes a fastening unit 103, 113 for attaching the stabilization unit 102, 112 to a support unit 120, as well as a device 20 disclosed herein, which is placed in the abdominal cavity of a patient P. The stabilization units 102, 112 may include metal rods 104, 114 on each side of the support unit 120. The support unit 120 may be an operating table.

[0041] The device 20 shown comprises the first lifting unit 30 and the second lifting unit 40 as nested and connected tubes, one inside the other, extending from the outside of the abdominal wall Aw into the abdominal cavity of the patient P. The first lifting unit 30 consists of a solid tube section with a disc 34 attached to its proximal end 32, and this disc 34 has locations where the fastening units 103, 113 are attached, which serve to lift the lifting units 30, 40, and according to this lifting action, the position of the distal end 33 of the first lifting unit 30 inside the abdominal cavity of the patient P is determined.The second lifting unit 40 is a solid tube equipped at its distal end 43 with an inflatable support section 44, located directly beneath the solid section of the first lifting unit 30. This inflatable support section 44 is attached only to the outer wall of the second lifting unit 40, leaving the interior empty for the insertion of instruments into the abdominal cavity. The inflatable support section 44 is positioned directly beneath the lifting segments 37, preventing them from falling. Thus, once the setup is complete, the lifting segments 37 are wedged between the inner surface of the anterior abdominal wall and the inflatable support section 44, appearing as a single unit when the outer tube is lifted by means of the fastening units 103, 113.

[0042] At the start of the operation, the surgeon creates an opening in the anterior abdominal wall, preferably using the open technique, and holds the anterior abdominal wall up with forceps, as is usually done until the inflatable support section 44 is inflated, to keep the distal end 33 of the first lifting unit 30 away from the intestine and to prevent accidental entrapment of intra-abdominal tissue between the lifting segments 37. The rigid lifting segments 37 begin to move from the horizontal to the vertical position, and then the surgeon inserts both lifting units 30, 40 into the abdominal cavity and advances them downward until the massive tubular portion of the first lifting unit 30 passes the inner wall of the abdominal cavity just below the peritoneum.Then the surgeon begins to inflate the inflatable support section 44 of the second lifting unit 40 using an air source 115 and the supply channel 45 attached to the second lifting unit 40, and when the inflatable support section 44 inflates, he begins to push the rigid lifting segments 37 of the first lifting unit 30 away from each other and form a fan-like shape that lies vertically under the anterior abdominal wall, and the inflatable support section 44 fixes them in a horizontal position.

[0043] When the surgeon begins to raise the first lifting unit 30 with the help of the fastening units 103, 113 attached to the sides of the operating table, the lifting segments 37 push the abdominal wall Aw upwards, then the surgeon stabilizes the fastening units 103, 113 in the desired position according to his preference, and when the surgeon has to remove the device 20 after completion of the operation, he simply lets the air out of the inflatable support section 44 and begins to pull the device 20 upwards, whereby the lifting segments 37 gradually return to their original, vertical position and can be easily removed.

[0044] Fig. Figure 6 shows a laparoscopic camera 70 with a body 71 and an arm 72 extending from it. The body 71 represents the proximal end 73, which remains outside the patient's body during surgery. The distal end 74 is located at the tip of the arm 72.

[0045] A camera 75 and a light source 80 are located at the tip and proximal end 74, respectively, of the arm 72 of the camera 75. The images received by the camera are forwarded to a main interface 85 with a processor (not shown) for processing the still or video images received from the camera. The processor delivers the images to a communication interface 86, which in turn forwards the images to an interface 87. The images from the camera 75 can be transmitted via a communication device 76 through this interface. Additionally or alternatively, the communication interface 86 can display the images on a display 88 on the camera, allowing a user to control the camera's configuration via a control interface 89, preferably via the interface.The camera 75 is independent and can process and store the images received by the camera 75 and enable the recording and removal of images from the camera 75 via the memory card 84.

[0046] The light sources 80 on the side of the arm 72 can be selectively illuminated. For example, the light source 80 can be illuminated only when it has entered the cavity of a patient into which the camera 75 is inserted. If the light source 80 is provided at a multitude of points on the circumference, in the cross-section, of the arm 72, the light sources 80 can be controlled so that they shine only in the direction toward which the camera 80 is focused or which is of interest to the operator. The camera 70 can be provided with a lens 77 that compensates for the distortion caused by the trocar tip and thus improves the light received by the camera 75. The laparoscopic camera 70 can be inserted into one of the insertion channels 31, 41 of the device 20, which are located in the Fig. Numbers 1 to 4 are shown.

[0047] Fig.Figure 7 shows another embodiment of the device 220. This device 220 consists of a stretchable and liftable leather or polyester or other non-stretchable material that is applied to the anterior abdominal wall and forms a film 221 that separates the abdominal wall from a metal disc 222 that sits over this film 221. This non-stretchable film has a central opening 223 that allows the passage of the L-shaped retractors and the camera 75 into the interior of the abdomen, but this opening is smaller than the size of the metal disc 222 in order to prevent the metal disc 222 from slipping inside the abdomen. This non-stretchable film 221 includes two fastening units 203, 213, one on each side, for attaching it to the lateral operating table. These fastening units 203, 213 have many holes 207, 217 that are spaced apart to allow the use of the perfect length for different patients.These holes 207, 217 have hollow pins 208, 218 (e.g. short cylinders), one in each hole 207, 217, to allow the screw to be inserted into the side bed bars to fix them.

[0048] The metal disc 222 has a central opening 223 which is used as a way for the camera to be inserted into the abdomen.

[0049] The metal disc 222 has four small holes 224 on its side to allow the passage of the four L-shaped retractors 225, which are used to lift the abdomen from the inside, thus creating the space. In one aspect, this small hole 224 is connected to a flat, larger round space 226, which is used to lock the distal end of the L-shaped retractors 225, which terminate as large spheres; in another aspect, this flat space is rectangular and the distal end of the L-shaped retractors 225 is rectangular.

[0050] In one aspect, these L-shaped retractors 225 must be at an angle of less than 90 degrees between the transverse and vertical segments, so that when pressure is applied by lifting the non-stretchable cloth 221 and the metal disc 222, the likelihood of these L-shaped retractors 225 slipping out and always lifting the abdominal wall is low. In another aspect, the vertical segment of the L-shaped retractors 225 can be long or short depending on the patient.

[0051] When the operation begins, the surgeon must make an opening in the abdominal wall through the navel, then place the non-stretchable drape 221 over the anterior abdominal wall and connect it horizontally to the operating table. Next, the surgeon begins inserting the L-shaped retractors 225, ensuring that each retractor 225 is attached to the metal disc 222 as the vertical leg of the L-shaped retractors 225 is as short as possible. The surgeon then pushes the metal disc 222 downward until it rests on the non-stretchable drape 221 and presses the vertical leg of the L-shaped retractors 225 downward to hold them just above the metal disc 222.If the height is not suitable, the surgeon can always adjust the height by pressing a button at the distal end of the L-shaped retractor 225, which releases the locking mechanism and also allows the removal of the L-shaped retractors 225 at the end of the operation.

[0052] Once the metal disc 222 is in place and the L-shaped retractors 225 have reached the perfect length, the surgeon begins to raise the side table rods by pumping the hydraulic mechanism into these rods, and as they raise, they also raise the middle disc 222 over the non-stretchable cloth 221. Reference symbol list 20 Device 30 first lifting unit 31 Introduction channel 32 proximal end 33 distal end 34 Support disc 35 Fixation section 37 lifting segments 38 Bending edge 39 connections 40 second lifting unit 41 Introduction channel 42 proximal end 43 distal end 44 inflatable support section 45 Supply channel 70 laparoscopic camera 71 bodies 72 Arm 73 proximal end 74 distal end 75 Camera 76 Communication device 77 lens 80 light source 84 memory card 85 Main interface 86 Communication interface 87 Interface 88 Display 89 Control interface 100 System 102 stabilization units 103 fastening units 104 metal rods 112 stabilization units 113 fastening units 114 metal rods 115 Air source 120 carrier units 220 Device 203 Fastening unit 207 holes 208 pens 213 Fastening unit 217 holes 218 pens 221 cloth 222 Metal disc 223 central opening 224 holes 225 L-shaped retractors Room 226 Patient Aw abdominal wall QUOTES INCLUDED IN THE DESCRIPTION

[0000] This list of documents cited by the applicant was automatically generated and is included solely for the reader's convenience. The list is not part of the German patent or utility model application. The DPMA accepts no liability for any errors or omissions. Cited patent literature

[0000] KR 2018 0068074 A

[0007]

Claims

[1] Device (20) for performing laparoscopy, comprising a first lifting unit (30) for lifting a patient's abdominal wall, which is suitable for insertion into the abdominal cavity of a patient, wherein the first lifting unit (30) comprises an insertion channel from the proximal end (32) of the first lifting unit (30) to the distal end (33) of the first lifting unit (30), a second lifting unit (40) for lifting a patient's abdominal wall, characterized by , that the second lifting unit (40) comprises an inflatable support section (44) suitable for fixing at least one fixation section (35) of the first lifting unit (30) to the inside of a patient's abdominal wall. [2] Device according to claim 1, characterized by , that the second lifting unit (40) has an insertion channel (41) which is particularly suitable for inserting at least one laparoscope for a medical procedure. [3] Device according to claim 1 or 2, characterized by , that the inflatable support section (44) of the second lifting unit (40) is arranged at the distal end (43) of the second lifting unit (40). [4] Device according to any one of the preceding claims, characterized by , that the at least one fixation section (35) comprises several lifting segments (37) for fixing the first lifting unit (30) to the inside of a patient's abdominal wall. [5] Device according to any one of the preceding claims, characterized by , that at least one bending edge (38) is arranged on the fixing section (35) of the first lifting unit (30). [6] Device according to claim 5, characterized by , that the inflatable support section (44) of the second lifting unit (40) is arranged adjacent to the at least one bending edge (38). [7] Device according to any one of the preceding claims, characterized by, that at least one supply channel (45) is provided for inflating the inflatable support section (44) of the second lifting unit (40). [8] Device according to claim 7, characterized by , that the at least one supply channel (45) is arranged at the second lifting unit (40) and in particular between the first lifting unit (30) and the second lifting unit (40). [9] Device according to any one of the preceding claims, characterized by , that the first lifting unit (30) and the second lifting unit (40) are connected to each other so that the abdominal wall of a patient can be lifted, in particular by lifting both the first lifting unit (30) and the second lifting unit (40). [10] System (100) for performing laparoscopy, comprising at least two stabilization units (102, 112), each comprising a fastening unit (103, 113) for fastening the stabilization unit (102, 112) to a carrier unit, and a device (20) according to one of the preceding claims.

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