Triangulation apparatus, instrument set, and method for surgeries on the spinal column

Abstract

The invention relates to a triangulation apparatus for at least two instruments for surgeries on the spinal column, wherein the triangulation apparatus comprises at least two first access openings, through each of which the first instrument can be inserted, and at least one second access opening, through which the second instrument can be inserted. The two first access openings are arranged relative to the second access opening such that the trajectories through the two first access openings intersect the trajectory through the second access opening at different distances distally from the triangulation apparatus. The invention also relates to an instrument set having a first instrument, a second instrument, and the triangulation apparatus according to the invention, and to a method for spinal column surgery using the triangulation apparatus according to the invention.

Description

[0001] Triangulation device, instrument set and procedure for surgical interventions on the spine

[0002] The invention relates to a triangulation device for at least two instruments for surgical interventions on the spine, an instrument set with a first instrument, with a second instrument and with the triangulation device as well as a method of a surgical intervention on the spine.

[0003] From US 2022 / 0071645 A1 a triangulation device is known with which a bone drill can be guided at different angles to the facet bone of a vertebral body in order to work on it from several access directions during a spinal surgical procedure. For this purpose the known triangulation device has three access openings with different angles of inclination in order to guide the bone drill to the vertebral body at different angles. A further access opening of the triangulation device is provided for a cannula with which the nerve roots at the process of the vertebral body are to be surrounded in order to protect them during work on the vertebral body. The access openings of the triangulation device are designed in such a way that the bone drill always hits the cannula at the same distance distal to the triangulation device, regardless of the access opening through which it is inserted.This fixed and unchangeable distance, at which the two instruments always meet distal to the triangulation device, means that with a particular triangulation device the facet bone to be treated must always be located at a fixed distance distal to the triangulation device and that if the distance deviates from this the triangulation device can no longer be used because otherwise there is a risk of serious tissue damage. In other words, a particular triangulation device can only be used on patients with a particular body geometry, for example with a particular body mass index (BMI), but not on patients with other body geometries. The applicability of the known triangulation device is severely limited.

[0004] It is therefore the object of the invention to develop a triangulation device with which the disadvantages of the prior art can be eliminated and with which, in particular, an expanded field of application is ensured.

[0005] The object of the invention is achieved with a triangulation device according to claim 1, thus with a triangulation device for at least two instruments for surgical interventions on the spine, with at least two first access openings through which the first instrument can be inserted, with at least one second access opening through which the second instrument can be inserted, wherein the at least two first access openings are arranged relative to the at least one second access opening such that the trajectories through the two first access openings intersect the trajectory through the second access opening at different distances distal to the triangulation device.

[0006] In addition, the object is achieved by an instrument set according to claim 20. The instrument set according to the invention for surgical interventions on the spine has a first instrument, a second instrument and a triangulation device according to the invention, wherein the first instrument can be inserted through the at least two, in particular through all, first access openings and wherein the second instrument can be inserted through the second access opening.

[0007] Furthermore, the object is achieved by a method according to claim 21. The method according to the invention is a surgical intervention on the spine at an intervention site with a triangulation device according to the invention, in particular with an instrument set according to the invention, with the following steps: creating an access to the intervention site, introducing the second instrument through the access to the intervention site, arranging the triangulation device in such a way that the second instrument passes through the second access opening of the triangulation device and introducing the first instrument through one of the first access openings of the triangulation device in a distal direction in such a way that the first instrument essentially comes into operative connection, in particular into contact, with the second instrument.A basic idea of ​​the invention is to expand the applicability of a bipolar access to the intervention site during spinal surgery with the aid of the triangulation device according to the invention. This is made possible by the intersection points of the trajectories of the triangulation device arranged at different distal distances, since, according to the invention, the trajectories through the access openings correspond to the extension directions of the instruments actually arranged therein, so that the intersection points of the trajectories correspond to the points at which the instruments arranged through the access openings intersect.There does not necessarily have to be direct mechanical contact between the instruments, but the distance between the instruments should be so small that the instruments are in an effective relationship with each other, for example when a working instrument is the first instrument at the intervention site and can be visually inspected by an endoscope as the second instrument, with the first instrument being inserted through a first access opening and the second instrument through the second access opening.

[0008] In the context of the invention, such an intervention site is, for example, the vertebral arch (arcus vertebrae) of a vertebral body or its facet joint. The intervention site can be arranged at different distances from the access site, i.e. the site at which instruments are inserted into the patient's body as part of a surgical procedure. This variance in distances depends, among other things, on the individual body geometry of the patient in general, for example depending on the patient's body mass index (BMI), but also on the particular vertebral body of a patient to be treated in particular. Because the triangulation device according to the invention provides intersection points of the trajectories through the access openings, and thus also for the instruments inserted therein, at different distal distances, it is suitable for a variety of anatomical conditions, in particular patient body geometries.

[0009] Due to the intersection points of the trajectories at different distances, the triangulation device according to the invention has corresponding intersection points for the instruments introduced into the access openings at different distances, the latter also being referred to as "kissing points" in order to symbolize the meeting of the instruments, in particular their operative connection in these positions. The target point of an individual instrument at the intervention site is also referred to as the "landing point". Accordingly, the triangulation device according to the invention ensures that the target point of the first instrument coincides with the target point of the second instrument at the common intersection point. In the sense of the invention, a distal direction points towards the patient and a proximal direction towards the surgeon.

[0010] The first instrument, to which the at least two first access openings are assigned, can be a working instrument for the surgical procedure which is designed to process or to be guided through human tissue. In this respect, the first instrument can be at least one member of the following group: needle, guide rod, guide tube, dilator, working sleeve, drill, milling cutter. The diameters of the first access openings can be designed to accommodate a plurality of first instruments one after the other, such that the diameters of the first access openings essentially correspond to the outer diameter of the largest first instrument to be inserted therein. A guide rod and / or a guide tube can serve as a guide means for further instruments to be inserted to the intervention site during the surgical procedure.A dilator dilates human tissue as atraumatically as possible before introducing additional, particularly larger, instruments. A working sleeve allows for the insertion of additional instruments, such as an endoscope or other instruments, which are inserted through the working sleeve to protect the surrounding tissue.

[0011] The outer diameters of the first access openings are in particular adapted to the first instrument in such a way that the latter can be inserted into the first access openings in a longitudinally displaceable manner, preferably with a tight fit.

[0012] The second instrument can be an inspection instrument, in particular an endoscope. In this respect, the diameter of the second access opening can be matched to the diameter of the second instrument such that the second instrument can be inserted into the second access opening in a longitudinally displaceable manner, in particular with a tight fit.

[0013] Preferably, the at least two first access openings each have a circular and / or oval base area. In particular, all of the first access openings have a circular and / or oval base area. A circular base area can be useful in order to insert the first instrument, which can have a circular base area, into the triangulation device with as little lateral play as possible and to hold it in its current position relative to the triangulation device. In particular, when a working instrument is the first instrument within the meaning of the invention, this avoids the risk of tissue injury due to unintentional movement of the working instrument. In an advantageous development of the invention, at least one first access opening can be designed as a bore and / or an elongated hole. Preferably, all of the first access openings are designed as elongated holes.The extension direction of the elongated hole of a first access opening can be arranged parallel to the direction of a connecting line between the first access opening and the second access opening. The elongated hole of the first access opening can have a length between 1.5 mm and 20 mm, preferably 12 mm, and / or a width between 1.5 mm and 6.5 mm, preferably 2.5 mm.

[0014] The triangulation device preferably has two, three, four, or at least four first access openings. It can be provided that the trajectories through two first access openings intersect the trajectory through the second access opening distal to the triangulation device at different angles. In this way, it can be provided that the first instrument approaches the "kissing point," i.e., the point of intersection with the second instrument inserted through the second access opening, at different angles. This increases the processing options at the intervention site using the first instrument, while ensuring that, regardless of which first access opening the first instrument is inserted through, it reaches the intervention site at the intended distal distance from the triangulation device. Incorrect positioning of the first instrument, particularly along the proximal-distal direction, is thereby avoided.

[0015] Preferably, at least one first access opening is arranged at an angle of inclination other than 0° relative to the vertical. According to the invention, the angle of inclination of an access opening corresponds to the angle formed by the trajectory through this access opening relative to the vertical. In a further development of the invention, at least two, in particular all, of the first access openings are arranged at an angle of inclination other than 0° relative to the vertical. This ensures that the first instrument is guided to the intervention site at an angle that excludes, as far as possible, unwanted tissue damage in the region of the spine, in particular to nerve structures. The triangulation device according to the invention can therefore be used for interventions on the spine from a lateral direction.

[0016] Preferably, the angle of inclination of at least one first access opening relative to the vertical is between 20° and 50°, in particular between 20° and 46°, preferably between 22° and 43°, in particular 34°. This applies in particular to the angle of inclination of all first access openings. All first access openings can have the same angle of inclination. In a further development of the invention, it can be provided that the angle of inclination of at least two first access openings, in particular of all first access openings, are different from one another.

[0017] Preferably, the angle of inclination of the first access opening facing the second access opening is greater than the angle of inclination of the first access opening facing away from the second access opening. In particular, it can be provided that the angle of inclination of the first access opening facing the second access opening is the greatest and / or that the angle of inclination of the first access opening facing away from the second access opening is the smallest. In the vicinity of a first access opening, the triangulation device can have information which corresponds to the angle of inclination of the first access opening and / or the distance of the intersection point of the trajectory through the first access opening with the trajectory through the second access opening from the triangulation device.

[0018] Preferably, the at least two first access openings, in particular all first access openings, are arranged along a straight connecting line, wherein the connecting line is aligned in particular parallel to a directional component of the trajectory through one of the first access openings. The connecting line can run through the at least one second access opening, wherein the connecting line runs in particular through all first access openings and all second access openings and thus corresponds to a connecting line between the access openings.

[0019] In a further development of the invention, it can be provided that at least three first access openings are provided. The distance from a first access opening to a second first access opening can be equal to the distance from the second first access opening to the third first access opening. All first access openings can be arranged so as to be evenly distributed, in particular on the proximal end face and / or on the distal end face of the triangulation device. In particular, in the case that all first access openings are arranged at an angle of inclination other than 0° to the vertical, they can be arranged so as to be evenly distributed on the proximal end face of the triangulation device, but this does not necessarily have to apply to the arrangement of the first access openings on the distal end face of the triangulation device.The same applies conversely, i.e. an evenly distributed arrangement of the first access openings on the distal end face does not necessarily require their evenly distributed arrangement on the proximal end face. The at least two first access openings, in particular all of the access openings, can be arranged in a region of the triangulation device between its flat center and a side edge of the triangulation device. The triangulation device can therefore be spatially functionally divided and have a first region which is assigned to the first access openings, and a second region which is assigned to the second access opening, wherein the first region does not overlap with the second region.In a further development of the invention, the first access openings can be arranged such that the intersection points of the trajectories through the first access openings with the trajectory through the second access opening are each equidistant from one another, which applies in particular to their distal distances.

[0020] Preferably, only a second access opening is formed. The second access opening can be designed to accommodate an inspection instrument, in particular an endoscope, as the second instrument. The base area of ​​the second access opening can essentially correspond to the base area of ​​the second instrument.

[0021] Preferably, the diameter of the second access opening is larger than the diameter of at least one first access opening, in particular larger than the diameter of all the first access openings. The base area of ​​the second access opening can be larger than the base area of ​​a first access opening, in particular larger than the base area of ​​all the first access openings.

[0022] The second access opening is preferably designed as an elongated hole. Particularly when the second instrument has a circular base, this enables fine adjustment of the second instrument inserted into the second access opening during the procedure, wherein the second instrument is held in the second access opening but can be tilted, for example, along one axis. The slight mobility of the second instrument made possible by the geometry of the second access opening creates an improved opportunity for visual inspection of the procedure site when the second instrument is an inspection instrument. The second instrument can still be easily moved in the optimal viewing direction. The second access opening can have a length between 6.5 mm and 20 mm, preferably 9.0 mm, and / or a width between 5 mm and 10 mm, preferably 6.5 mm.

[0023] Preferably, the angle of inclination of the second access opening is smaller than the angle of inclination of one of the first access openings, in particular smaller than the angle of inclination of all of the first access openings. This ensures that, for example, an inspection instrument as a second instrument can reach the intervention site via the most direct route possible and inspect the first instrument there, while still minimizing tissue damage and trauma caused by the insertion of the second instrument because anatomical conditions on the way to and at the intervention site are taken into account. For the first instrument, a greater angle of inclination than the second instrument is generally recommended in order to guide the first instrument to the intervention site from a desired direction.

[0024] Preferably, the angle of inclination of the second access opening relative to the vertical is not equal to 0° and is in particular between 10° and 40°, in particular between 10° and 20°, preferably substantially 15°. This ensures that the second instrument can be introduced for visual inspection at the surgical site at an angle that is as safe as possible during spinal surgery.

[0025] Preferably, the intersection angle between the trajectory through the first access opening and the trajectory through the second access opening is between 30° and 70°, in particular between 35° and 60°, preferably between 40° and 60° or between 45° and 55°, in particular approximately 49° or 50°. This applies in particular to all intersection angles between the trajectories through the first access openings and the trajectory through the second access opening.Taking into account the geometry of the patient at the intervention site, this enables the introduction of both the first instrument and the second instrument during spinal surgery at a risk-free angle to the intervention site, in particular during an interlaminar, lateral, and especially post-lateral access to the spinal canal of a patient, in particular taking into account the safety zone known as the "Kambin triangle" in the area of ​​an intervertebral foramen (foramen intervertebrale). The intersection angle between the trajectory through the first access opening and the trajectory through the second access opening can be the sum of the angles of inclination of the two trajectories relative to the vertical.

[0026] The intersection points of the trajectories through the first access openings with the trajectory through the second access opening are preferably arranged distal to the triangulation device at distances of 15 mm to 100 mm, in particular from 15 mm to 25 mm or from 22.5 mm to 85 mm, preferably 20 mm. This ensures that the intersection points of the trajectories are always in the area in which the intervention site is spaced from the skin surface of the patient, onto which the triangulation device according to the invention can be placed as intended. The intersection points of the trajectories can be arranged axially aligned with one another, wherein a connecting line of the intersection points can be aligned normal to the front side of the triangulation device. In a further development of the invention, it can be provided that the intersection points are arranged offset from one another laterally, i.e. parallel to the front side of the triangulation device.

[0027] Preferably, the triangulation device is movable into an open position and a closed position, wherein the access openings are at least partially exposed in the open position and closed in the closed position. The triangulation device can be opened for inserting and adjusting the instruments and closed for locking the instruments. The triangulation device can be opened and closed repeatedly.

[0028] The triangulation device preferably comprises at least two parts that are movable relative to one another and / or are connected to one another in a captive manner. The two parts can be pivotable relative to one another, in particular about a pivot axis that can be oriented normal to the surface of the proximal end face of the triangulation device and / or laterally offset from a connecting line of the access openings.

[0029] Preferably, the at least two first access openings and / or the at least one second access opening are arranged along the contact surface of the two parts, in particular when the triangulation device is in the closed position. This makes it particularly easy for the instruments to be received in the access openings and locked therein by a corresponding movement of the two parts of the triangulation device. In particular, all access openings are arranged along the contact surface of the two parts, which can therefore correspond at least in sections to the connecting line of the access openings. The triangulation device can be designed such that all instruments can be inserted into the access openings in a clampable manner. The contact surface of the two parts can run at least in sections parallel to a directional component of at least one trajectory through an access opening.Preferably, the pivot axis of the parts of the triangulation device that can be pivoted relative to one another is arranged between the second access opening and the side wall of the triangulation device facing the second access opening. As a result, the pivot axis is arranged near the second instrument, which, as already mentioned, can be an endoscope. When the triangulation device is opened by a pivoting movement of the two parts relative to one another and the resulting release of the access openings, the access openings are not released to the same extent. By arranging the pivot axis near the second access opening, it is ensured that the first access openings are largely released first, which allows, for example, readjustment of the first instruments, while at the same time the second instrument remains relatively firmly locked in the second access opening.The pivot axis can be arranged at a distance from the contact surface of the two parts of the triangulation device. The pivot axis is in particular placed on the side of the triangulation device associated with the second access opening, which side can also be referred to as the endoscope side, which enables easy opening of the opposite side, which is associated with the first access openings, in order to make scalpel cuts, for example when using a scalpel as the first instrument. The pivot axis can be arranged at a distance from the contact surface of the two parts of the triangulation device. In a particular embodiment of the invention, the pivot axis can be defined by a pin which is in particular fixedly connected to one part of the triangulation device and rotatably and in particular captively connected to the other part of the triangulation device.Preferably, the triangulation device can be locked in the closed position, in particular clamped, to prevent accidental tasting of the instruments. The triangulation device can be locked in the open position. For locking, the triangulation device can have a clamping means, which can be designed as a clamping screw, which in particular penetrates both parts of the triangulation device. The clamping screw can have knurling on a lateral surface and / or a surface of 300 mm. 2 up to 1000 mm 2 , preferably 550 mm 2, have. The knurling makes the clamping screw easier to operate. The clamping screw can have a diameter of between 12 mm and 18 mm, preferably of approximately 15 mm, and / or a height of between 8 mm and 16 mm, in particular of approximately 12 mm. A recess in the triangulation device which is assigned to the clamping screw and through which the clamping screw extends when the triangulation device is in the closed position, can preferably be designed as a slot so that the triangulation device can be opened even if the clamping screw is slightly loosened. The clamping means can be arranged in a region of the triangulation device between a first access opening, in particular the first access opening facing away from the second access opening, and a side edge of the triangulation device facing this first access opening.

[0030] The triangulation device can have an outwardly projecting, in particular convexly curved, projection on a side wall in order to simplify handling of the triangulation device, in particular its opening. The projection can be arranged on the side wall facing the first access opening. The projection can be arranged approximately at the height of the clamping means, so that both the clamping screw can be easily loosened and the triangulation device can then be easily opened. Instead of the projection, or as an alternative thereto, the lateral outer wall can have a recess, in particular a concavely curved recess.

[0031] At least one first access opening and / or at least one second access opening is assigned information on the triangulation device, which information can correspond to the intersection point of the trajectory through the first access opening with the trajectory through the second access opening distal to the triangulation device. The information corresponds in particular to the distal distance of the intersection point from the triangulation device and / or its lateral position with respect to the proximal end face of the triangulation device. In order to facilitate orientation of the triangulation device and / or the instruments inserted therein, even during an X-ray inspection, the triangulation device can have at least one X-ray marker.

[0032] The triangulation device may have a length between 50 mm and 180 mm, preferably 110 mm, and / or a width between 25 mm and 75 mm, preferably 50 mm, and / or a height between 5 mm and 20 mm, preferably 12 mm.

[0033] The first instrument can be inserted through all of the first access openings. The second instrument can be designed as an endoscope and, in particular, have a working diameter of between 5 mm and 10 mm, in particular of 6.5 mm or a maximum of 4 mm. The first instrument and / or the second instrument can have an atraumatic distal end to avoid tissue injuries during the procedure.

[0034] The arrangement of the triangulation device within the scope of the method according to the invention can provide that the triangulation device is pushed in the open position from proximal to distal over the second instrument, for example the endoscope, which is in particular already arranged in the patient, wherein the second instrument is received in the second access opening and then the triangulation device is moved into the closed position. Furthermore, it can be provided that the creation of access to the intervention site takes place initially via the first access opening using a needle and a wire arranged in this, which is also known as the Seldinger method. After the wire has been inserted, the needle can be removed again. The second instrument can be guided to the intervention site over the wire or without a previously placed needle or a previously placed wire. The endoscope can have an obturator.When inserting the first instrument, a plurality of dilators, in particular those arranged coaxially to one another and guided one above the other, can be inserted as first instruments. The first instrument can be a guide rod, a guide sleeve, a plurality of guide sleeves, at least one dilator and / or a working sleeve. When inserting the first instrument through the first access opening of the triangulation device, the first access opening can be selected depending on the desired angle and / or the desired distance of the intersection point with the second instrument already inserted through the second access opening. The first instrument can be moved independently of the second instrument. In particular, when the first instrument makes a tissue incision, this can be done efficiently and with relatively large instruments, particularly when the triangulation device is open.The bipolar access to the intervention site provided by the invention allows the first instrument to be moved independently of the second instrument at the intervention site, which provides improved flexibility in handling the instruments and thus improved performance of the intervention. Furthermore, compared to a monoportal access, an access with a reduced diameter is provided, since the instruments used for the intervention are not guided through a single access point and the instruments do not have to be designed for combined use.

[0035] Further steps of the procedure can be carried out after the first instrument has been inserted through the first access opening of the triangulation device. The method can, for example, provide that at least one, in particular a plurality of dilators are moved as first instruments through the first access opening to the intervention site. It can then be provided that a working sleeve, as a further, in particular first, instrument, is moved through the first access opening to the intervention site over the dilator already arranged at the site of use. The at least one dilator, in particular all of the dilators located inside the working sleeve, can then be removed from the intervention site. According to the invention, a working channel, which is assigned to the first instrument, is designed to be spatially separate from an inspection channel, which is assigned to the second instrument.After the procedure, all instruments and the triangulation device according to the invention can be removed.

[0036] Further advantages and features of the invention emerge from the claims and from the following description, in which exemplary embodiments of the invention are explained in detail with reference to the drawings. In the drawings:

[0037] Fig. 1 shows a triangulation device according to the invention in a schematic plan view,

[0038] Fig. 2 shows the triangulation device of Fig. 1 in a longitudinal section along the section line XX in Fig. 1,

[0039] Fig. 3 shows the triangulation device of Fig. 1 in a view from below,

[0040] Fig. 4 shows a cross section through the triangulation device of Fig. 3 along the section line BB in Fig. 3,

[0041] Fig. 5 shows a further embodiment of the triangulation device according to the invention in a plan view,

[0042] Fig. 6 shows the triangulation device of Fig. 5 in a longitudinal section along the section line AA in Fig. 5,

[0043] Fig. 7 shows the triangulation device of Fig. 5 in a view from below, Fig. 8 shows a cross section through the triangulation device of Fig. 7 along the section line BB in Fig. 7 and

[0044] Fig. 9 shows an instrument set according to the invention with a triangulation device according to the invention during a surgical procedure on the spine and with a first instrument and with a second instrument, both of which pass through the triangulation device.

[0045] Fig. 1 shows a triangulation device 1 according to the invention for surgical interventions on the spine 36 in a schematic plan view of its proximal end face 2. The triangulation device 1 has a rectangular base with rounded corners and has a length of 110 mm, a width of 50 mm and a height of 12 mm.

[0046] The proximal end face 2 of the triangulation device 1 has, in a left-hand area in Fig. 1, four first access openings 4, 5, 6, 7 arranged linearly one behind the other, each with a circular base, which are each matched to a first instrument 34 (not shown in Fig. 1) in order to guide the first instrument 34 through the first access openings 4, 5, 6, 7 to an intervention site. Working instruments for inserting into or processing tissue, for example needles, guide rods, guide tubes, dilators, working sleeves and / or bone drills or bone milling cutters, can be used as first instruments 35. The first access openings 4, 5, 6, 7 are arranged at different distances from one another on the proximal end face 2 of the triangulation device 1. In a right-hand area 8 of the triangulation device 1 in Fig. 1, a second access opening 9 is designed as an elongated hole.The second access opening 9 is arranged in alignment with the first access openings 4, 5, 6, 7, and thus lies on a connecting line 10 which connects the first access openings 4, 5, 6, 7 to one another and which in Fig. 1 coincides with the section line XX shown there. From the illustration in Fig. 1 it is already clear that the second access opening 9 has an angle of inclination a with respect to the vertical V of not equal to 0°, which will be discussed later. The diameters of the first access openings 4, 5, 6, 7 are each smaller than the diameter of the second access opening 9; the same applies to the areas of the access openings 4, 5, 6, 7, 9. The second access opening 9 is designed for a second instrument 35, for example an inspection instrument, for example an endoscope, which can be inserted through the second access opening 9 and moved to the intervention site 37.

[0047] The triangulation device 1 comprises two parts 11, 12, a first part 11 arranged at the top left in Fig. 1 and a second part 12 arranged at the bottom right in Fig. 1. The triangulation device 1 is movable between a closed position shown in Fig. 1 and an open position not shown in Fig. 1 by pivoting the two parts 11, 12 relative to one another. The pivoting movement takes place by means of a pin 13, hidden in Fig. 1, which is fixedly connected to the second part 12 and movably but captively connected to the first part 11. The pivoting movement thus takes place about a pivot axis 14 aligned normal to the proximal end face 2, the position of which pivot axis is determined by the pin 13. The pivot axis 14 is located in Fig. 1 offset upwards to the connecting line 10 of the access openings 4, 5, 6, 7, 9 and is arranged between the second access opening 9 and the side wall 15 of the triangulation device 1 facing it.In the closed position of the triangulation device 1, its parts 11, 12 are in contact with one another and form a contact surface 16, with all access openings 4, 5, 6, 7, 9 being arranged at least along a portion of the contact surface 16. As a result, instruments 34, 35 inserted into the access openings 4, 5, 6, 7, 9 are held in the closed position of the triangulation device 1 without the application of external force, in a form-fitting manner perpendicular to their direction of extension and in a force-fitting manner along their direction of extension, thus preventing accidental movement of the instruments 34, 35 and thus incorrect fitting.When the triangulation device 1 is moved from the closed position to the open position, the first access openings 4, 5, 6, 7, and thus the first instrument 34, are initially released due to the arrangement of the pivot axis 14 in a region 17 facing the second access opening 9, while the second instrument 35 is still comparatively fixed in the second access opening 9 and is only released upon continued movement of the triangulation device 1 into the open position.

[0048] The triangulation device 1 can be locked in the closed position shown in Fig. 1, thus preventing unintentional opening of the triangulation device 1. For this purpose, a clamping screw is provided as a clamping means 18, which is arranged in a lower left area of ​​the triangulation device 1 in Fig. 1. The clamping screw 18 is located below the connecting line 10 of the access openings 4, 5, 6, 7, 9 and in an area 3 between the first access opening 4 facing away from the second access opening 9 and the side wall 19 of the triangulation device 1 facing this. For improved handling, the clamping screw 18 has a knurling (not shown in Fig. 1) on its outer surface 20 and passes through the first part 11 and the second part 12 of the triangulation device 1, so that by actuating the clamping screw 18 the first part 11 is connected to the second part 12 in a force-fitting manner.In order to facilitate the opening of the triangulation device 1 after a manual actuation of the clamping screw 18, the area of ​​the side wall 19 of the first part 11 facing the clamping screw 18 has a convexly curved projection 21, by means of which a surgeon can manually carry out the opening pivoting movement during the procedure in a simple, quick and reliable manner.

[0049] Fig. 2 shows the triangulation device 1 of Fig. 1 in a longitudinal section along the section line XX in Fig. 1, which, as already mentioned, corresponds to the connecting line 10 of the access openings 4, 5, 6, 7, 9. This illustration shows that all access openings 4, 5, 6, 7, 9 are each arranged at an inclination angle α of not equal to 0° with respect to the vertical V. Accordingly, all trajectories 22, 23, 24, 25, 26 through the access openings 4, 5, 6, 7, 9, shown in dashed lines in Fig. 2, have an angle α of not equal to 0° with respect to the vertical V, which angle α corresponds to the inclination angle α. In the embodiment shown, the first access openings 4, 5, 6, 7, coming from left to right in Fig. 2, have angles of inclination a relative to the vertical V of approximately 22°, 25°, 30° and 43°.The second access opening 9 has an angle of inclination a of approximately 15°, which is thus smaller than all of the angles of inclination a of the first access openings 4, 5, 6, 7. The angle of inclination a of the first access opening 7 facing the second access opening 9 is greater than the angles of inclination a of the other first access openings 4, 5, 6 and is also greater than the angle of inclination a of the second access opening 9. All trajectories 22,.

[0050] 23, 24, 25, 26 through the access openings 4, 5, 6, 7, 9 each have a directional component which is arranged parallel to the direction of the connecting line 10 of the access openings 4, 5, 6, 7, 9.

[0051] Due to the arrangement of the first access openings 4, 5, 6, 7 and their angle of inclination a, the first access openings 4, 5, 6, 7 emerge from the distal end face 27 of the triangulation device 1 arranged at the bottom in Fig. 2 at equal distances from one another, while, as already mentioned, they are not arranged at equal distances from one another on the proximal end face 2 of the triangulation device 1.

[0052] The intersection points 28, 29, 30, 31 of the trajectories 22, 23,

[0053] 24, 25 through the first access openings 4, 5, 6, 7 with the trajectory 26 through the second access opening 9 are located distal to the triangulation device 1 at different distances therefrom and are arranged offset laterally from one another, i.e. parallel to the end face 27 of the triangulation device 1. The trajectory 25 through the first access opening 4 facing the second access opening 9 intersects the trajectory 26 through the second access opening 9 at a distal distance of 22.5 mm at an intersection angle ß of approximately 58°. The trajectory 22 through the first access opening 4 facing away from the second access opening 9 intersects the trajectory 26 through the second access opening 9 at a distance of 85 mm at an intersection angle ß of approximately 37°. The component of the triangulation device 1 shown in Fig. 2 top right has the same hatching as the first part 11 arranged top left, but corresponds to the second part 12, as can also be seen from Fig.1 emerges.

[0054] Fig. 3 shows the triangulation device 1 in a bottom view of its distal end face 27. This also shows the arrangement of the first access openings 4, 5, 6, 7 at equal distances from one another, as well as the inclined arrangement of the second access opening 9 relative to the vertical V. It is also shown that the clamping screw 18 passes through the two parts 11, 12 of the triangulation device 1, and the pivot axis is formed by a pin 13 connected to the second part 12 and engaging the first part 11. Both parts 11, 12 are captively connected to one another.

[0055] Fig. 4 shows the triangulation device 1 according to Fig. 3 in a cross-section along the section line BB shown there, which is perpendicular to the connecting line 10 of the access openings 4, 5, 6, 7, 9 and arranged at the level of the clamping screw 18. The clamping screw 18 passes through a recess 32, designed as a slot, in the first part 11 and a recess 33 in the second part 12, the latter being provided with a thread not shown in Fig. 4. The clamping screw 18 projects beyond the proximal end face 2 at a distance of 12 mm and, in the screwed-in state in which the triangulation device 1 is locked, is flush with the distal end face 27 of the triangulation device 1. Fig. 5 shows a further embodiment of the triangulation device 1 according to the invention in a plan view of its proximal end face 2. The embodiment shown here, in contrast to that according to Fig.1 has two first access openings 4, 5 arranged one behind the other, which are designed as elongated holes. The orientation of the elongated holes 4, 5 is parallel to the connecting line 10 of the access openings. The width of the elongated holes 4, 5 corresponds approximately to the diameter of the first access openings 4, 5, 6, 7 according to the embodiment of Fig. 1. Further features of the triangulation device 1 according to Fig. 1 are also implemented in the embodiment according to Fig. 5, in particular the second access opening 9, the clamping screw 18, and the pivot axis 14.

[0056] Fig. 6 shows a section through the triangulation device 1 according to Fig. 5 along the section line AA shown there, which corresponds to the connecting line 10 of the access openings 4, 5, 9. From this, it can be seen that the first access openings 4, 5 each have the same angle of inclination α with respect to the vertical V, which in the exemplary embodiment shown is approximately 34° in each case. The distance between the two first access openings 4, 5 on the proximal end face 2 of the triangulation device 2 therefore corresponds to their distance on the distal end face 27 of the triangulation device 1. The angles of inclination α of the first access openings 4, 5 are each greater than the angle of inclination α of the second access opening 9, which incidentally corresponds to the angle of inclination α of the second access opening 9 of the embodiment according to Fig. 1 and is approximately 15°.Since both first access openings 4, 5 each have the same inclination angle α, the trajectories 22, 23 through the first access openings 4, 5 intersect the trajectory 26 through the second access opening 9 at the same intersection angle β, here approximately 49°. The two intersection points 28, 29 are arranged at different distal distances from the triangulation device 1 and laterally offset from each other.

[0057] Fig. 7 shows the triangulation device 1 according to Fig. 5 in a view from below of its distal end face 27 and thus in particular the positions of the access openings 4, 5, 9 emerging from this as well as the clamping screw 18 and the pin 13.

[0058] Fig. 8 shows a cross-section through the triangulation device according to Fig. 7 along the section line XX drawn there, which is arranged corresponding to the section line BB according to Fig. 3. In this respect, this representation corresponds to Fig. 4, so that to avoid repetition, reference is made to the above explanations.

[0059] Fig. 9 shows an instrument set 42 according to the invention with a triangulation device 1 according to the invention during a surgical procedure on the spine 36 of a patient, arranged at the bottom in Fig. 9. The triangulation device 1 is in the closed position. The triangulation device 1 rests on the skin surface (not shown in Fig. 9 for reasons of clarity) at a predefined position such that a

[0060] 9 shows the first instrument 34 arranged on the left, which is designed as a working instrument, which passes through the first access opening 4 of the triangulation device 1, which is covered in perspective in FIG. 9, and reaches the intervention site 37. In addition, a second instrument 35, designed as an endoscope in the exemplary embodiment shown, passes through the second access opening 9 of the triangulation device 1, which is also covered in FIG. 9. The first instrument 34 is thus aligned at an angle of inclination relative to the vertical which corresponds to the angle of inclination of the first access opening 4. The same applies to the second instrument 35, whose angle of inclination corresponds to the angle of inclination of the second access opening 9. For reasons of clarity, the angles of inclination and the trajectories of the access openings are not shown in FIG. 9.

[0061] The triangulation device 1 is designed such that the intersection point 28 of the trajectory through the first access opening 4 with the trajectory through the second access opening 9 corresponds to the intersection point 37 of the first instrument 34 with the second instrument 35. The intersection point 37 corresponds to the intervention site 37, is axially spaced from the triangulation device 1 by a predefined value, and essentially results from the arrangement and orientation of the access openings 4, 9. At the intersection point 37, tissue 38 is processed by means of the first instrument 34, which—arranged radially one above the other—has a working sleeve 39, a dilator 40 for expanding the patient's tissue 38, and a radially inner bone drill 41. At the same time, a visual inspection of the intervention site 37 takes place through the endoscope as the second instrument 35.The instrument set 42 according to the invention comprises the triangulation device 1 according to the invention, the first instrument 34, including its individual components 39, 40, 41, and the second instrument 35, including any individual components present therein. Since the first instrument 34 and the second instrument 35 are

[0062] Intervention site 37 is insofar as it is in an effective connection, this location is also called the "kissing point" due to the proximity of the two instruments 34, 35.

Claims

Patent claims 1. Triangulation device (1) for at least two instruments (34, 35) for surgical interventions on the spine (36), with at least two first access openings (4, 5, 6, 7) through which the first instrument (34) can be inserted, with at least one second access opening (9) through which the second instrument (35) can be inserted, wherein the at least two first access openings (4, 5, 6, 7) are arranged relative to the at least one second access opening (9) such that the trajectories (22, 23, 24, 25) through the two first access openings (4, 5, 6, 7) intersect the trajectory (26) through the second access opening (9) at different distances distal to the triangulation device (1).

2. Triangulation device (1) according to claim 1, characterized in that the at least two first access openings (4, 5, 6, 7) each have a circular and / or an oval base area.

3. Triangulation device (1) according to one of claims 1 or 2, characterized in that two, three, four or at least four first access openings (4, 5, 6, 7).

4. Triangulation device (1) according to one of the preceding claims, characterized in that at least one first access opening (4, 5, 6, 7) is arranged with an angle of inclination (α) of not equal to 0° with respect to the vertical (V).

5. Triangulation device (1) according to claim 4, characterized in that the angle of inclination (a) of at least one first access opening (4, 5, 6, 7) relative to the vertical (V) is between 20° and 46°, in particular between 22° and 43°, in particular 34°.

6. Triangulation device (1) according to one of the preceding claims, characterized in that the angle of inclination (α) of the first access opening (5, 7) facing the second access opening (9) is greater than the angle of inclination (α) of the first access opening (4) facing away from the second access opening (9).

7. Triangulation device (1) according to one of the preceding claims, characterized in that the at least two first access openings (4, 5, 6, 7), in particular all of the first access openings (4, 5, 6, 7), are arranged along a straight connecting line (10), wherein the connecting line (10) is aligned in particular parallel to a directional component of the trajectory (22, 23, 24, 25) through the first access opening (4, 5, 6, 7).

8. Triangulation device (1) according to one of the preceding claims, characterized in that only a second access opening (9) is formed.

9. Triangulation device (1) according to one of the preceding claims, characterized in that the diameter of the second access opening (9) is larger than the diameter of at least one first access opening (4, 5, 6, 7), in particular larger than the Diameter of all first access openings (4, 5, 6, 7) .

10. Triangulation device (1) according to one of the preceding claims, characterized in that the second access opening (9) is designed as a bore and / or elongated hole.

11. Triangulation device (1) according to one of the preceding claims, characterized in that the angle of inclination (a) of the second access opening (9) is smaller than the angle of inclination (a) of one of the first access openings (4, 5, 6, 7), in particular smaller than the angle of inclination (a) of all the first access openings (4, 5, 6, 7).

12. Triangulation device (1) according to one of the preceding claims, characterized in that the angle of inclination (a) of the second access opening (9) relative to the vertical (V) is not equal to 0° and in particular is between 10° and 20°, in particular 15°.

13. Triangulation device (1) according to one of the preceding claims, characterized in that the intersection angle (ß) between the trajectory (22, 23, 24, 25) through the first access opening (4, 5, 6, 7) and the trajectory (26) through the second access opening (9) is between 40° and 60°, in particular between 45° and 55°, in particular approximately 49°.

14. Triangulation device (1) according to one of the preceding claims, characterized in that the Intersection points (28, 29, 30, 31) of the trajectories (22, 23, 24, 25) through the first access openings (4, 5, 6, 7) with the trajectory (26) through the second access opening (9) distal to the triangulation device (1) are arranged at distances of 15 mm to 100 mm, in particular of 22.5 mm to 85 mm.

15. Triangulation device (1) according to one of the preceding claims, characterized in that the triangulation device (1) is movable into an open position and into a closed position, wherein the access openings (4, 5, 6, 7, 9) are at least partially exposed in the open position and closed in the closed position.

16. Triangulation device (1) according to one of the preceding claims, characterized in that the triangulation device (1) has at least two parts (11, 12) which are connected to one another in a movable and / or captive manner relative to one another, in particular pivotable relative to one another.

17. Triangulation device (1) according to claim 16, characterized in that the at least two first access openings (4, 5, 6, 7) and / or the at least one second access opening (9) are arranged along the contact surface (16) of the two parts (11, 12).

18. Triangulation device (1) according to one of claims 16 or 17, characterized in that the pivot axis (14) of the parts (11, 12) of the triangulation device (1) which are pivotable relative to one another is located between the second access opening (9) and the side edge (15) facing this triangulation device (1) is arranged.

19. Triangulation device (1) according to one of claims 15 to 18, characterized in that the triangulation device (1) can be locked, in particular clamped, in the closed position.

20. Instrument set (42) for surgical interventions on the spine with a first instrument (34), with a second instrument (35), and with a triangulation device (1) according to one of claims 1 to 19, wherein the first instrument (34) can be inserted through at least one, in particular through all of the first access openings (4, 5, 6, 7) and wherein the second instrument (35) can be inserted through the second access opening (9).

21. A method for surgical interventions on the spine (36) at an intervention site (37) with a triangulation device (1) according to one of claims 1 to 19, in particular with an instrument set (42) according to claim 20, comprising the following steps: Creating access to the intervention site (37), introducing the second instrument (35) through the access to the intervention site (37), Arrangement of the triangulation device (1) such that the introduced second instrument (35) passes through the second access opening (9) of the triangulation device (1) and insertion of the first instrument (34) through one of the first access openings (4, 5, 6, 7) of the triangulation regulation device (1) distally such that the first instrument (34) comes into operative connection with the second instrument (35).

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