An integrated device for inserting bioactive compound-releasing pellets into the treatment area of ​​subjects requiring treatment.

Abstract

The laparoscopic instrument according to the present invention comprises a shaft having a proximal and distal end, a tip, and a movable part disposed between the distal end and the tip of the shaft, which is attached to both the distal end and the tip and configured to allow movement of the tip relative to the shaft, the tip comprising a cylindrical portion and a tapered portion extending from the cylindrical portion to an exit, the cylindrical portion being attached to the movable part, the cylindrical portion comprising a central channel surrounded by at least two periphery channels, the central channel and the periphery channels extending between the ends of the cylindrical portion of the tip, the central channel comprising a pellet together with a foldable retainer in a folded position, the first periphery channel comprising an opening in the tapered portion, the first periphery channel comprising a first dissection instrument that can protrude from the tip, and a blind-end periphery channel comprising a positioning sensor configured to be detected by an external localizer for continuous positioning of the tip.

Description

Technical Field

[0001] The present disclosure relates to a surgical instrument designed to insert pellets of bioactive molecules into a treatment target area, particularly to a laparoscopic instrument. The present disclosure also relates to a surgical method using such an instrument.

Background Art

[0002] In order to obtain good results in treatments using locally implanted bioactive molecules (for example, in the form of pellet preparations), a plurality of surgical steps are essential, and dedicated laparoscopic instruments need to be sequentially inserted in all of these steps. Furthermore, since the treatment target area is often narrow, in order to accurately administer these molecules, a complex image-guided technique involving continuous 3D positioning of the tip portions of these instruments is required.

[0003] Therefore, such a technique involves inserting and removing a plurality of instruments into or from the patient. Such multiple insertions increase the risk of injury to the patient (particularly in the vicinity of important organs such as the liver or vascular bed). Finally, after inserting the pellet into the correct anatomical position, it is necessary to ensure that the pellet remains in the treatment target area. This final step requires further intervention and additional instruments.

Summary of the Invention

Problems to be Solved by the Invention

[0004] Therefore, there is a need for a single instrument suitable for laparoscopic surgery that can inject bioactive molecules into the treatment target area without involving the removal and reinsertion of multiple instruments within the patient's abdominal cavity. Furthermore, due to the special functionality of this single instrument, this instrument needs to have higher mobility than a single laparoscopic forceps, and as a result, it is essential to have the ability to remotely control the distal end portion.

[0005] The objective of this invention is to provide a single surgical instrument suitable for laparoscopic surgery that can accomplish multiple tasks without the need to remove and reinsert the instrument from the patient. [Means for solving the problem]

[0006] For this purpose, this disclosure relates to a laparoscopic instrument, A shaft having a proximal end and a distal end, The tip and, A movable part disposed between the distal end and the tip of a shaft, which is attached to both the distal end and the tip and is configured to allow the tip to move relative to the shaft. Equipped with, The present invention relates to a laparoscopic instrument, wherein the tip comprises a cylindrical portion and a tapered portion extending from the cylindrical portion to an exit, the cylindrical portion being mounted on a movable portion, the cylindrical portion comprising a central channel surrounded by at least two periphery channels, the central channel and the periphery channels extending between the ends of the cylindrical portion of the tip, the central channel comprising a pellet together with a foldable retainer in a folded position, the first periphery channel having an opening in the tapered portion, the first periphery channel comprising a first dissection instrument capable of protruding from the tip, and the blind-end periphery channel comprising a positioning sensor configured to be detected by an external localizer for continuous positioning of the tip.

[0007] Advantageously, the present invention is completed by using the following features individually or in any technically possible combination. The cylindrical portion includes a second peripheral channel equipped with a second cutting tool that can protrude from the tip, and the second cutting tool is configured to perform a different cutting than that performed by the first cutting tool. The first dissection instrument is an electrosurgical dissection instrument, the second dissection instrument is a hydro dissection instrument, and the second periphery channel is configured to guide the hydrojet obtained from a hydrojet generator connected to the laparoscopic instrument. The electrosurgical dissection instrument comprises an electrode protruding from a centering piece that folds within a first periphery channel and unfolds outside the first periphery channel, wherein the electrosurgical electrode is positioned on the top of the centering piece and is always centered relative to the tip when unfolded, and the electrosurgical dissection instrument is configured to extend the electrosurgical electrode outside the tip and retract the electrosurgical electrode into the first periphery channel. This laparoscopic instrument has a first handle configured for operating a first surgical instrument and a second handle configured for controlling pellet release at its proximal end. This laparoscopic instrument has a knob at its proximal end that is configured to control the operation of the tip. The knob is configured to maintain control of the tip without the need for a locking mechanism. The shaft is rigid and has a cavity that extends from the proximal end to the distal end, the cavity housing a guide mechanism for controlling each of the surgical instruments and for controlling the release of pellets. The foldable retainer is designed to fold inside the central channel and unfold when moved outside the device to prevent pellets from returning to the device after pellet release.

[0008] This device can perform the following tasks without requiring removal and reinsertion of the device within the patient. • Even if the tip of a given instrument is bent, preferably the position of the tip of the instrument relative to an external reference is continuously determined. • Using electrosurgical dissection to open up a certain area (e.g., the peritoneal fascia) while preserving the underlying structures. • Hydrocution is used to cut connective tissue surrounding the area to be treated (e.g., around portal vein structures) while preserving nerve tissue or other delicate structures. • Insert the pellet containing the bioactive molecule into the lodge formed in the previous step. • Open the restraint device fixed to the distal part of the pellet to prevent the pellet from falling out.

[0009] According to one embodiment, the instrument is a disposable instrument, partially made from surgical-grade plastic, and requires connection to the following before insertion into a body cavity: • Known electrosurgical generators that can be operated by a foot pedal. A hydrojet generator that can be driven manually or electrically, as the dissection volume is limited to less than 20 / 30 cc (for the size of lodges expected in this application) and the dissection itself is performed on weak connective tissue. • An internal electromagnetic localizer, electromagnetic field generator, mounted on a controllable tip and operating in combination with a patient-placed reference sensor, and software suitable for analyzing signals from the movable and reference sensors in relation to computed tomography images of the treatment area.

[0010] The operation of this surgical instrument is performed using a manual trigger handle, which allows for the withdrawal and retraction of various components of the instrument, along with a manual knob used to control the tip of the instrument. Advantageously, since the instrument is introduced into the patient's body cavity via a laparoscopic cannula and can move significantly relative to the treatment area via the movement of the laparoscopic cannula's shaft, the maneuverability of the tip is limited to two dimensions, thus simplifying the mechanism supported by the aforementioned knob.

[0011] In a preferred embodiment, the present disclosure relates to a laparoscopic instrument designed for inserting a bioactive molecular pellet near the portal vein wall. This bioactive molecule was developed to restore the efficacy of portal glucose sensors, which are significantly reduced in insulin-resistant patients. The instrument facilitates the insertion of the pellet into precise areas that are difficult to reach using a laparoscope without potentially adversely impacting surgical outcomes.

[0012] Other features and advantages of this disclosure will become apparent in the following detailed description. Embodiments of the present invention will be described with reference to the following drawings.

Brief Description of Drawings

[0013] [Figure 1] It is a diagram showing the overall configuration of an instrument according to one embodiment. [Figure 2] It is a diagram showing the tip of an instrument according to one embodiment. [Figure 3] It is a diagram showing an electrosurgical electrode (upper) at a fixed position and an electrosurgical electrode (lower) during pellet release according to one embodiment. [Figure 4] It is a diagram showing the insertion of a pellet and a related method for suppressing the natural removal of the pellet according to one embodiment. [Figure 5] It is a diagram showing the steps of a method for discharging a pellet according to one embodiment.

Modes for Carrying Out the Invention

[0014] Overview of the Instrument FIG. 1 schematically shows a surgical scene 1 where it is necessary to insert a pellet into a treatment target area R of a patient P. For example, as will be described in detail later, this area for the treatment of the insulin resistance of the patient P and / or the restoration of glucose homeostasis is located near the portal vein. This treatment target area R is accessed by a laparoscope cannula C introduced into the patient P. This cannula C defines a lumen L for introducing a laparoscope instrument 10 that integrates a plurality of functions. In order to control the displacement of the laparoscope instrument 10, an image I of the treatment target area is displayed, and the position of the laparoscope instrument 10 is specified in real time with respect to this image I. Therefore, the instrument is visualized along the image of this area for accurate access to the treatment target area.

[0015] This figure shows the overall configuration of the laparoscopic instrument 10. This instrument 10 includes a distal end portion 100 mounted on the left side to an operable portion 101 (or movable portion) mounted to the shaft 102, and a control set 103 on the right side. From the control set 103, a plurality of connection portions 107, 108, 109 for connecting to the instrument 10 for operation by a surgeon (not shown) extend, and this control set 103 includes a plurality of actuators 104, 105, 106 that are actuated by the surgeon using a handle.

[0016] The shaft 102 includes a proximal end portion 1021 located near the surgeon and a distal end portion 1022 intended to be introduced into the lumen L formed in the patient P by the laparoscopic cannula C. The distal end portion 100 includes a plurality of functions that can be controlled by the surgeon. These functions replace a plurality of instruments prepared for each function.

[0017] In particular, the instrument 10 includes at least one cutting instrument, preferably two cutting instruments, for accessing the treatment target area, and pellets to be released into this area. When the instrument 10 includes two cutting instruments, each cutting instrument is configured to perform a specific type of cutting.

[0018] Preferably, the laparoscopic instrument 10 is a disposable instrument partially made of surgical-grade plastic. This is because the laparoscopic instrument 10 also includes metal parts for purposes such as connecting the instrument. Further, advantageously, the instrument 10 is stored in a sterilization envelope and needs to be connected before insertion into the patient.

[0019] As shown in Figures 2 and 3, the tip 100 comprises a cylindrical portion 1001 and a tapered portion 1002 extending from the cylindrical portion 1001 to the outlet 1003. The cylindrical portion 1001 is mounted on the movable portion 101 and comprises a central channel 1004 surrounded by at least two peripheral channels, preferably three peripheral channels 1005, 1006, and 1007. This central channel 1004 and peripheral channels 1005, 1006, and 1007 extend between the ends of the cylindrical portion 1001 of the tip 100. These channels of the tip 100 are in communication with corresponding channels in the shaft 102.

[0020] One of the peripheral channels is the blind-end peripheral channel 1005. This blind-end peripheral channel 1005 includes a positioning sensor 30 configured to be detected by an electromagnetic field generator 31 acting as an external localizer, and continuously determines the position of the tip 100 relative to a reference sensor 32 placed on the patient P. Therefore, even when the patient is moving, this positioning is performed relative to the reference sensor 32. In particular, the positioning sensor 30 is an electromagnetic localizer. This positioning sensor 30 is connected to a processing unit 33 (connected to a computer, not shown) by a connector 109 that extends through the shaft 102. This processing unit 33 has software suitable for analyzing the signal from the instrument tip positioning sensor 30 and detecting the reference sensor 32. Furthermore, the processing unit is also connected to the external electromagnetic field generator 31. Because positioning is performed in relation to computed tomography images of the patient's treatment area, the tip 100 is displayed in real time during the intervention. By using electromagnetic sensors, it becomes possible to precisely determine the position of the controllable tip.

[0021] The central channel 1004 houses a pellet 20 and a foldable retainer 21 fitted to a release wire 126 to allow control of the release of the pellet into the patient. The pellet 20 has, for example, a length of 10 mm and a diameter of 4.6 mm. The release of the pellet 20 is made possible by the release wire 126 located within the central channel 1004, which can be actuated by a first handle 106 located at the proximal end 1021 of the instrument 10. The diameter of the central channel 1004 is adapted to the size of the pellet 20. The length of the release wire 126 is such that the release of the pellet 20 and the retainer 21 is permitted. The retainer 21 prevents the pellet 20 from returning to the instrument 10 after it has been pushed out of the instrument 10 and released into the patient. In particular, the retainer 21 is designed to remain folded until it reaches a resting size to prevent the pellet 20 from detaching from the treatment area. The retainer 21 has a foldable shape made of shape memory wire, and can be stored in a small volume.

[0022] The first peripheral channel 1006 has an opening 1008 in the tapered portion 1002 and houses a first cutting tool 12 that can protrude from the tip portion 100. In a preferred embodiment, the second peripheral channel 1007 has an opening 1009 and houses a second cutting tool 13 that can protrude from the tip portion 100.

[0023] The first dissection instrument 12 is an electrosurgical dissection instrument, and the second dissection instrument 13 is a hydro-dissection instrument. These dissection instruments allow for different types of dissection depending on the area to be dissected. In particular, the type of dissection is determined by the hardness of the area to be dissected, the anatomical structures surrounding the area to be dissected, etc. For example, fascia F (which constitutes the mesenteric portion of the peritoneum) is hard and can be dissected with an electrosurgical dissection instrument, while connective tissue can be dissected with a hydro-dissection instrument. Furthermore, this hydro-dissection instrument is also used when there are important structures around the area to be treated. This is especially true when dissecting connective tissue located around the portal vein, which must not be damaged.

[0024] According to one embodiment, the electrosurgical dissection instrument 12 is capable of protruding from a first peripheral channel 1006. According to one embodiment, the electrosurgical dissection instrument is initially located outside the peripheral channel 1006 and can be retracted into the peripheral channel 1006 only after use of the instrument. The electrosurgical dissection instrument 12 comprises an electrosurgical electrode 120, the insulator of which protrudes from a centering piece 121. The centering piece 121 is folded when positioned inside the first peripheral channel 1006 and unfolded outside the first peripheral channel 1006. The electrosurgical electrode 120 is positioned on the top 124 of the centering piece 121 and is always centered relative to the tip 100 when unfolded. The electrosurgical electrode 120 is connected by a connector 107 to a conventional electrosurgical generator operated by a foot pedal (not shown). Furthermore, the second handle 105 is connected to the electrosurgical electrode 120, allowing the electrode to extend from the instrument and retract into the instrument.

[0025] The first peripheral channel 1006 is larger than the second peripheral channel 1007. Therefore, the second peripheral channel 1007 is smaller than the first peripheral channel 1006 and is dedicated to the hydro-cutting device, and in particular to the hydro-jet flow obtained from a hydro-jet generator connected to the device 10 by a flexible tube 108.

[0026] The tapered portion 1002 of the tip 100 serves to center the various extensible elements housed within the central and periphery channels. The hollow interior of the tapered portion 1002 facilitates the expansion or retraction of the centering piece 121 of the electrosurgical electrode and the partial extension of the retainer 21. The opening 1003 of the tip 100 is preferably 100 μm larger than the pellet size to facilitate insertion into the treatment area.

[0027] The device 10 is equipped with a knob 104 at its proximal end 1021 for controlling the operation of the tip 100, and as a result the movable part 101 is controlled by the knob 104. For example, the tip 100 is attached to the movable part 101 by two wires that are wound and unwound onto the same reel after the operation of the knob 104. The knob 104 is designed to be at a 90° angle with respect to the longitudinal axis of the shaft 102, and is connected to the reel either directly or via a 90° mechanism so that the shaft 102 extends along this longitudinal axis. The frictional force of the knob 104 is designed so that the knob 104 itself maintains the angle set on the movable part 101 without requiring a locking mechanism after the operation of the knob 104. In one embodiment, the movable part 101 is composed of a conventional entangled semi-hardened tube made of flexible plastic suitable for one-dimensional motion, preferably in a direction perpendicular to the longitudinal axis A.

[0028] Preferably, the shaft 102 has a rigid cavity having six subchannels. Of these subchannels, two are for wires used to enable tip manipulation, one for a movable electrosurgical electrode, one for a hydrojet dissection channel, one for a wire used to acquire position data from a positioning sensor, and one for a wire used for extracting pellets and pellet retainers, such as umbrella-shaped retainers.

[0029] On the surgeon's side, the instrument 10 is preferably made of plastic and comprises a casing 103 connected to the shaft 102, which holds all of the maneuverable tip connection and mechanism, and handles 105, 106.

[0030] Figure 3 shows the extension and retraction of the electrosurgical electrode (upper part) and the extension procedure of the retainer (lower part) in the form of a pellet and a restraining umbrella. The electrosurgical electrode 120 can be ejected after the second handle 105 of the instrument 10 is actuated. Since the electrode 120 has a diameter significantly smaller than the diameter of the pellet 20, when it is no longer stored in the instrument body, it needs to be centered using a centering piece 121 in the form of a flexible cage that expands by the elasticity of a plastic wire (shape memory) (see bottom of Figure 3). Preferably, the size of the centering piece 121 is a compromise between the size required for adequate centering and the size required for adequate visibility of the electrode tip 120 by the surgeon.

[0031] After the tip 100 of the instrument 10 is inserted into the treatment area and careful hydro-dissection of the connective tissue is performed, the pellet 20 is pushed out of the storage container together with the foldable inverted umbrella-shaped part 21.

[0032] Figure 4 shows the pellet insertion step before instrument removal. The pellet 20 is inserted into the treatment area 130 (e.g., near the portal vein PV), preferably into the surrounding connective tissue C located within the volume 132 formed by hydrojet dissection. This is achieved by applying an electrosurgical current with the electrode tip protruding, and then partially inserting the tip of the instrument into the treatment area. The extrusion of the pellet is accompanied by expanding a retainer 21, which is an inverted umbrella-shaped anchor preferably composed of a shape memory wire. Due to the helical shape of the fixing wire, it expands both perpendicular to the pellet and within the longitudinal axis of the pellet. This provides a limited storage volume suitable for laparoscopic instruments, while also ensuring sufficient fixation.

[0033] Method for releasing pellets using laparoscopic instruments During the procedure, and with respect to Figure 5, the surgeon introduces the instrument 10 into the laparoscopic cannula as described above (step E1). During the intervention, the tip 100 of the instrument 10 is continuously positioned (step E2), and the instrument 10 is manipulated by the handle 105 and knob 104 to precisely position the tip 100 (step E3).

[0034] Once the instrument 10 is introduced near the treatment area, the surgeon controls the extension of the electrosurgical electrode 120 (see top of Figure 3) (step E4) and begins dissecting the surrounding tissue of the treatment area while manipulating the instrument 10 via the handle 105 (step E5). Alternatively, step E4 is not performed if the electrosurgical electrode 120 is already located outside the tip 100. For example, fascia F (see Figure 1) is dissected by the electrosurgical electrode 120.

[0035] Once the surrounding tissue of the target area is separated, the surgeon retracts the electrosurgical electrode 120 (step E6, see bottom of Figure 3).

[0036] Next, the surgeon begins hydrolectomy of connective tissue C (see Figure 1) to define the area where the pellet needs to be inserted (step E7). As shown in Figure 1, connective tissue C surrounds the portal vein PV.

[0037] After hydrocution of the connective tissue, access to the treatment area becomes possible, and the surgeon begins extruding the pellet 20 using handle 106 (step E8, see Figure 4).

[0038] Next, the device 10 is removed (step E9).

[0039] Use of a device for inserting bioactive compound-releasing pellets near the portal vein to treat insulin resistance and / or restore glucose homeostasis in subjects requiring treatment. Postprandial glucose homeostasis depends on the coordinated glucose sensing mechanisms in the portal vein (Soty et al., 2017). This sensor is significantly impaired in preclinical models of insulin resistance due to decreased expression of the GLP-1r receptor, which is essential for glucose sensing (Malbert et al., 2021). Restoration of GLP-1r density can be achieved by locally administered dihydrotestosterone at concentrations less than 1 / 10th of parenteral hormone concentrations. More importantly, restoration of GLP-1r density at the peri-portal level is associated with restoration of insulin sensitivity in the same preclinical models of insulin resistance.

[0040] Achieving favorable therapeutic outcomes using locally administered bioactive molecules requires multiple surgical steps, all of which involve the sequential insertion of specialized laparoscopic instruments. Furthermore, due to the narrowness of the portal vein structure requiring GLP-1r recovery, image guidance of the instrument tip is necessary throughout the procedure. This solution makes the use of flexible laparoscopic instruments impossible due to the high uncertainty of tip position. This makes the insertion of pellets containing bioactive molecules somewhat technically difficult, as the portal vein structure and instrument shaft are nearly parallel (or have a limited angle to each other), hindering the easy insertion of the forceps tip holding the pellet. Another pitfall in pellet insertion around the portal vein concerns the formation of a suitable surgical lodge for pellet insertion. This procedure requires the use of a dissection instrument, but its tip is not easily visualized, potentially leading to dangerous consequences, especially in fragile structures such as the portal vein. Furthermore, dissection performed under conditions where direct visualization is not possible may damage the complex neural network located along the connective tissue surrounding the portal vein structure. Finally, the movement of the portal system due to the repositioning of the gastrointestinal tract after feeding is strong enough to dislodge pellets from surgically prepared lodges. Therefore, it is essential to close the internal peritoneal layer supporting the periportal connective tissue. This closure is difficult when using surgical sutures that cannot adequately hold the inherently very thin peritoneal layer. The alternative option used so far has been to attach a Dacron mesh using surgical adhesive to seal the peritoneal opening and thereby prevent unwanted pellet dislodgement.

[0041] Furthermore, by using a laparoscopic cannula capable of accommodating a large-diameter shaft (up to 30 mm) without causing significant gas leakage, the use of the aforementioned disposable laparoscopic instruments becomes possible.

[0042] As previously stated, the object of this disclosure is to provide a single surgical instrument suitable for laparoscopic surgery and capable of performing the following tasks without removal and reinsertion from the abdominal cavity. • Continuously determine the position of the tip of a given instrument relative to an external reference, even if the tip of the instrument is bent. • Using electrosurgical drying to release the peritoneal fascia while preserving the underlying structures. • Using hydro-dissection to preserve nerve tissue while dissecting the connective tissue surrounding the portal vein structure. This is made possible by inserting the tip of the instrument into the tear in the peritoneal fascia created during the previous step (after retracting the electrosurgical tip). • Insert the pellet containing the bioactive molecule into the lodge formed in the previous step. • Open the restraint device fixed to the distal part of the pellet to prevent the pellet from falling out. (References) [Explanation of Symbols]

[0043] 1. Surgical Scene 10 Laparoscopic instruments 12. First dissection instrument, electrosurgical dissection instrument 13. Second dissection device, hydro dissection device 20 pellets 21 Foldable retainer, foldable reversible umbrella-shaped part, retainer 30 Location-determining sensors 31 Electromagnetic field generator 32 Reference Sensor 33 Processing Units 100 Tip 101 Controllable parts, movable parts 102 Shaft 103 Control set, casing 104 Actuator, Knob 105 Actuator, second handle 106 Actuator, first handle 107 Connection part 108 Connection part, flexible tube 109 Connection part 120 Electrosurgical Electrodes 121 Centering Piece 124 Top 126 Discharge wire 130 Treatment Areas 132 Volume section 1001 Cylindrical section 1002 Tapered section 1003 Exit, opening 1004 Central Channel 1005 Blind-end periphery channel 1006 First peripheral channel 1007 Second peripheral channel 1008 Aperture 1009 Aperture 1021 Proximal end 1022 Distal end A Longitudinal axis C. Laparoscopic cannula, connective tissue F Fascia Image I L lumens P patient PV portal vein R: Target area for treatment

Claims

1. Laparoscopic instruments (10), A shaft (102) having a proximal end (1021) and a distal end (1022), The tip (100) and A movable part (101) disposed between the distal end (1022) and the tip (100) of the shaft (102), wherein the movable part (101) is attached to both the distal end (1022) and the tip (100) and is configured to allow movement of the tip (100) relative to the shaft (102), and Equipped with, The tip portion (100) comprises a cylindrical portion (1001) and a tapered portion (1002) extending from the cylindrical portion (1001) to an outlet (1003), the cylindrical portion (1001) being mounted on the movable portion (101), the cylindrical portion (1001) comprising a central channel (1004) surrounded by at least two peripheral channels (1005, 1006, 1007), the central channel (1004) and the peripheral channels (1005, 1006, 1007) extending between the ends of the cylindrical portion (1001) of the tip portion (100), and the central channel Laparoscopic instrument (10), wherein the channel (1004) comprises a pellet (20) together with a foldable retainer (21) in a folded position, the first periphery channel (1006) comprises an opening (1008) in the tapered portion (1002), the first periphery channel (1006) comprises first dissection instruments (12, 13) that can protrude from the tip portion (100), and the blind end periphery channel (1005) comprises a positioning sensor (30) configured to be detected by an external localizer (31) for continuously positioning the tip portion (100).

2. The laparoscopic instrument according to claim 1, wherein the cylindrical portion comprises a second peripheral channel (1007) having a second dissection instrument (12, 13) that can protrude from the tip portion (100), and the second dissection instrument (13) is configured to perform a dissection different from the dissection performed by the first dissection instrument.

3. The laparoscopic instrument according to claim 2, wherein the first dissection instrument is an electrosurgical dissection instrument (12), the second dissection instrument is a hydro dissection instrument (13), and the second peripheral channel (1007) is configured to guide a hydrojet obtained from a hydrojet generator connected to the laparoscopic instrument.

4. The laparoscopic instrument according to claim 3, wherein the electrosurgical dissection instrument (12) comprises an electrode (120) protruding from a centering piece (121) that is folded within the first peripheral channel (1006) and unfolded outside the first peripheral channel (1006), the electrosurgical electrode being positioned on the top (124) of the centering piece (121), the electrosurgical electrode (120) being always centered relative to the tip (100) when unfolded, and the electrosurgical dissection instrument is configured to extend the electrosurgical electrode (120) outside the tip (100) and retract the electrosurgical electrode (120) into the first peripheral channel.

5. The laparoscopic instrument according to any one of claims 1 to 4, comprising a first handle (106) configured for operating a first surgical instrument and a second handle (105) configured for controlling the release of the pellet (20) at the proximal end (1021).

6. The laparoscopic instrument according to any one of claims 1 to 5, wherein the proximal end (1021) is provided with a knob (104) configured to control the operation of the tip (100).

7. The laparoscopic instrument according to claim 6, wherein the knob (104) is configured to maintain the control of the tip without using a locking mechanism.

8. The laparoscopic instrument according to any one of claims 1 to 7, wherein the shaft (102) is rigid and comprises a cavity (1023) extending between the ends of the shaft (102) from the proximal end (1021) to the distal end (1022), the cavity (1023) housing a guide mechanism for controlling each of the surgical instruments and for controlling the discharge of the pellet.

9. The laparoscopic instrument according to any one of claims 1 to 8, wherein the foldable retainer (21) is configured to fold inside the central channel and unfold when moved outside the instrument to prevent the pellet from returning to the instrument after the pellet has been released.

Images